Prevalence and Risk Factors Associated With Workplace Violence Against General Practitioners in Hubei, China

Abstract

Objectives. To assess the prevalence and factors associated with physical and nonphysical violence in a sample of general practitioners (GPs).

Methods. We used a cross-sectional design to collect data from December 2014 to March 2015 with a structured self-administered questionnaire from 1015 GPs in Hubei Province, Central China (response rate, 85.6%). We used a multivariable logistic regression model to identify the predictors associated with workplace violence toward GPs.

Results. Of the respondents, 62.2% of respondents reported exposure to workplace violence in the preceding year, including 18.9% and 61.4% who encountered physical and nonphysical violence, respectively. Multivariable logistic regression analysis suggested that GPs who were male, at a higher professional level, and who had a lower average monthly income were more likely to experience physical violence. Male GPs, less-experienced GPs, and those with administrative responsibility were more likely than their counterparts to encounter nonphysical violence.

Conclusions. This study shows that the prevalence of workplace violence against GPs is high in Hubei, China. Creating a prevention strategy and providing safer workplace environments for GPs should be urgently prioritized.

Violence against health care workers, who are often at high risk of being abused, is a global concern.¹ Apart from injury, workplace violence has been associated with reduced job satisfaction and poor quality of life, as well as increased stress, burnout, and sleep disturbance.^2–4 In addition, workplace violence has been found to affect the retention of health professionals and the quality of medical care.⁵ Therefore, primary prevention of such violence worldwide is a considerable public health priority.

The latest round of nationwide systemic health care reform in China, launched in 2009, aimed to provide affordable, equitable access to quality basic health care for all citizens by 2020. Building and strengthening primary health care infrastructure was the core task of the reform. In 2011, the China State Council announced the instructional advice on establishing the general practitioners (GPs) system and provided instructions on training qualified and excellent GPs in a variety of ways. In 2015, the State Council articulated the establishment of a health care grading system to strengthen primary health care infrastructure.

Previous studies have been conducted to investigate workplace violence and its determinants in general practice in developed countries.^6,7 Current Chinese health care reform emphasizes strengthening the primary health institutions. A high rate of workplace violence against Chinese GPs could threaten the stability of primary health care workers and lower health care delivery quality and productivity, with negative effects on China’s health care system reform. To date, there has been no research on the 1-year prevalence of physical and nonphysical violence toward GPs in the primary health care setting or of its risk factors. We conducted this study to address these issues among GPs who worked in the grass roots communities in Hubei, Central China.

METHODS

We conducted a cross-sectional study between December 2014 and March 2015 in Wuhan, Hubei Province. We used a stratified sample design in the study. According to the China Health Statistics Yearbook 2013,⁸ there were 2325 primary health institutions (community health centers and township health centers) in 17 prefecture-level cities of Hubei province, all of which were included in this study. According to the number of GPs and scales of primary health institutions, from each sampled primary health institution, we randomly selected 30% of the on-post GPs with at least 1 year of work experience for inclusion in the sample. Of 3752 eligible GPs, we randomly selected 1186 to attend the health service quality training meeting organized by the Hubei provincial general practice training center, and then these GPs were asked to complete a self-reported questionnaire. Altogether, 1049 filled out the survey; we excluded 34 questionnaires because information on workplace violence was missing. Ultimately, we included 1015 eligible questionnaires in this analysis, yielding a response rate of 85.6%.

We used the Chinese version of the Workplace Violence Scale developed by Wang et al.⁹ consisting of 5 items with a 4-point ordinal scale ranging from 0 (never) to 3 (more than 3 times/year). Workplace violence included physical violence (physical and sexual assaults) and nonphysical violence (verbal abuse, threats, and sexual harassment). Participants were asked whether they had experienced physical or nonphysical workplace violence within the previous year from external sources (i.e., patients, patients’ family, or visitors).

In the descriptive analyses, we treated the dependent variables (physical and nonphysical workplace violence) as binary variables. Predictive variables included demographic characteristics (gender, age, marital status), socioeconomic factors (education level, average monthly income), and work-related factors (practice setting, work tenure, professional level, contract status, and management responsibility). We used stepwise multivariable logistic regression analysis to determine predictors of physical and nonphysical violence (level for selection and elimination: P = .05 and P = .10, respectively). We performed analyses by using SAS version 9.2 (SAS Institute, Cary, NC), and all tests were 2-sided with a significance level of .05.

RESULTS

The main characteristics of the participants (n = 1015; 65.0% men) are shown in Table A. The mean age of the participants was 38.7 years (SD = 6.7). The mean duration of health care practice was 16.3 (SD = 7.9) years, with more than half located in urban community health centers. In total, 62.2% of the respondents experienced workplace violence in the preceding year; 18.9% encountered physical and 61.4% nonphysical violence. Verbal abuse (54.4%) was the most common form of violence, followed by threats (33.8%), sexual harassment (22.7%), physical assault (18.9%), and sexual assault (7.6%).

The results of the univariate and multivariable analyses are shown in Table 1. Those GPs who were male (odds ratio [OR] = 3.4), at a higher professional level (OR = 1.7), and who had lower income (OR = 3.0) were more likely to have experienced physical violence. The GPs with management responsibility were 1.5 times more likely to have experienced nonphysical violence than those without management responsibility. More-experienced GPs encountered less nonphysical violence risk for each additional 10 years of general practice (OR = 0.8).

TABLE 1—

Results of Univariate and Multivariable Analyses for Physical and Nonphysical Violence Against General Practitioners: Hubei, China, December 2014–March 2015

	Physical Violence			Nonphysical Violencea
Characteristic	Yes, No. (%) or Mean ±SD	Univariate OR (95% CI)	Multivariable-Adjusted Model OR (95% CI)b	Yes, No. (%) or Mean ±SD	Univariate OR (95% CI)	Multivariable-Adjusted Model OR (95% CI)b
Number of participants	192 (100.0)			623 (100.0)
Age, y	40.0 ±5.7	1.4 (1.1, 1.8)c		38.5 ±6.4	0.9 (0.8, 1.1)c
Work tenure, y	17.8 ±6.9	1.3 (1.1, 1.6)c		16.1 ±7.4	0.9 (0.8, 1.1)c	0.8 (0.7, 0.9)c
Male (Ref = female)	167 (87.0)	4.5 (2.9, 7.0)	3.4 (2.1, 5.6)	446 (71.7)	2.1 (1.6, 2.8)	2.6 (1.7, 3.0)
Educational level
Associate’s degree or vocational diplomad	97 (51.1)	1 (Ref)		295 (47.8)	1 (Ref)
Bachelor’s degree or higher	93 (49.0)	0.9 (0.6, 1.2)		322 (52.2)	1.0 (0.8, 1.3)
Marital status
Unmarried, widowed, or divorced	7 (3.6)	1 (Ref)		44 (7.2)	1 (Ref)
Married	183 (96.3)	2.1 (0.9, 4.7)		571 (92.9)	1.2 (0.7, 2.1)
Contract status
Temporary	43 (22.5)	1 (Ref)		168 (27.3)	1 (Ref)
Permanente	148 (77.5)	1.3 (0.9, 1.9)		448 (72.7)	0.9 (0.7, 1.3)
Professional title
Elementary or lessf	73 (38.2)	1 (Ref)	1 (Ref)	297 (48.1)	1 (Ref)
Intermediate or higherg	118 (61.8)	1.6 (1.2, 2.3)	1.7 (1.2, 2.5)	321 (51.9)	1.0 (0.8, 1.3)
Practice setting
THC	116 (60.4)	1 (Ref)		300 (48.2)	1 (Ref)
CHC	76 (39.6)	0.45 (0.3, 0.6)		323 (52.8)	0.7 (0.5, 0.9)
Average monthly income, ¥
≥ 3500	20 (10.5)	1 (Ref)	1 (Ref)	113 (18.3)	1 (Ref)
2500 to < 3500	93 (49.0)	2.1 (1.3, 3.5)	2.4 (1.4, 4.1)	284 (46.0)	1.1 (0.8, 1.5)
< 2500	77 (40.5)	2.5 (1.5, 4.3)	3.0 (1.7, 5.4)	116 (35.7)	1.3 (0.9, 1.9)
Has management responsibility
No	101 (54.9)	1 (Ref)		372 (61.8)	1 (Ref)	1 (Ref)
Yes	83 (45.1)	1.8 (1.3, 2.5)		230 (38.2)	1.6 (1.2, 2.2)	1.5 (1.1, 2.0)

Note. CHC = community health center; CI = confidence interval; GP = general practitioner; OR = odds ratio; THC = township health center.

^aNonphysical violence includes threats, sexual harassment, and verbal abuse.

^bAdjustment for age (continuous), educational level (associate’s degree or vocational diploma, bachelor’s degree or higher), marital status (unmarried or widowed or divorced, married), contract status (permanent, temporary), practice setting (CHC, THC), and other variables in the models.

^cOR for additional 10 years of work tenure.

^dGPs who have acquired associate’s degree or vocational diploma. An associate’s degree required 3 years of education in college after graduation from senior middle school (grade year 10 to year 12) or 5 years of education in college after graduation from junior middle school (grade year 7 to year 9). A vocational diploma requires 2 years of education in vocational school after graduation from senior middle school or 3 years of education in vocational school after graduation from junior middle school.

^eWages and welfare of GPs would be paid by the Chinese government public health services expenditure. GPs were unable to be freely fired by health institutions.

^fGPs were with junior or without any technical title.

^gGPs were with middle or senior professional title.

DISCUSSION

This study showed that 62.2% of Chinese GPs reported exposure to workplace violence during the previous 12 months, which is roughly in the middle of reported prevalence rates found in western countries (e.g., Australia, New Zealand, and the United Kingdom) ranging from 49.5% to 90.3%.^6,7,10

Our findings revealed that the predicting factors of different types of workplace violence were not exactly the same. It suggested that the significant factors associated with physical violence were being male, lower average monthly income, and higher professional level. Being male, longer work tenure, and management responsibility were independently associated with nonphysical violence. These results suggest that interventions aiming to reduce violence against GPs need to take into account differences in particular types of violence, GPs’ sociodemographics and work-related characteristics, and other predicting factors.

The study’s findings can be interpreted in context of findings in the previous literature. Male GPs were more easily influenced by the work-related aspects of the job, but female GPs were affected more by the job interfering with their family life.¹¹ A lower risk of workplace violence toward female GPs may partly reflect a greater likelihood of their adoption of specific personal risk-reduction measurements compared with their male counterparts. Gender differences also may be related to differences in exposure.

Furthermore, GPs with longer work experience were found to be at lower risk of nonphysical violence. One possible explanation for this finding was that, compared with older GPs, younger GPs had less work experience and fewer chances to improve their work skills and effectiveness, which might lead to errors in patient care. They may have fewer communication skills with patients when handling difficult cases, which can result in workplace violence. In addition, the higher the professional level of GPs may mean the heavier workload they undertook, which affected the health of GPs and quality of their services. Patients had much higher expectations of higher-ranking physicians. Patients tended to seek high-level medical service even for minor, self-limiting conditions. Thus, the heavy load of patients increased work pressure on physicians, resulting in long-term overwork, which may lead to rushing, indifference and disrespect to patients, which was a major cause of doctor–patient tension.¹²

PUBLIC HEALTH IMPLICATIONS

Actions such as increasing government investment in the health system, establishing alarm and monitoring systems, ensuring adequate staffing, improving doctor–patient relationships, developing education and training programs on coping with violence, and enforcing appropriate policies and legislation are urgently needed to minimize violence toward GPs in order to maintain the primary health care system.