In April 2020, an aggravated mob attacked two female doctors and hurled stones at them in Indore, India, where they were screening a woman for COVID-19 in a densely populated area, as described in the news.1 This was not a singular incident from a single country, but one of several thousands of cases reported around the world every year. In its 73rd assembly, the World Medical Association noted that violence against healthcare workers (HCWs) has risen over the past decade and increased drastically during COVID-19. A 2019 meta-analysis conducted by Liu et al. that included studies from Asia, Europe, North America, Australasia, Africa, and Latin America estimated the prevalence of workplace violence (WPV) against healthcare workers by patients and visitors.2 The study found that 61·9% (95% CI: 56·1% to 67·6%) HCWs faced WPV, with 24·4% (95% CI: 22·4% to 26·4%) reporting experiencing physical violence over the last 12 months. While this analysis focused on violence perpetrated by patients and visitors, studies from across world regions document co-workers and supervisors as perpetrators of WPV as well.3,4
While WPV affects all HCWs - and some evidence suggests that male HCWs are more at risk of violence in some contexts2 – a large number of female HCWs are affected by it in part because of the sheer number of women in healthcare. Women form 70 percent of the health and social sector workforce,5 and female HCWs form the majority of the nursing, midwifery, and community health worker cadres,6 where they are responsible for outreach health services, and are at a greater risk of violence.7
Female HCWs – especially those who face additional bias or discrimination because of age, race, socioeconomic position, or other factors – operate in settings with high gender inequity in representation at the top levels, devaluation of female HCWs, and pay gap.
Most women work primarily under men (who form more of the higher-level roles in health systems) within systems where those above wield power over those below them.6 These factors shape the normalization of violence in the workplace and affect women's reporting and addressing of such cases.7
Additionally, gender norms continue to assign doctors and specialists – who cure – more value than nurses and community health workers – who care. Such norms further devalue female HCWs, who comprise the bulk of the care providers in health systems globally.6 This devaluation also reinforces economic hierarchies in medical institutions, with Labor Force Survey (LFS) data from 21 countries showing that a gender wage gap of 11% persists in the healthcare sector after adjusting for occupation and working hours.5 The devaluation of caregiving roles and economic uncertainty of women HCWs can reduce women's professional autonomy and contribute to the normalization and under-reporting of violence.6,7
Gender power dynamics and norms thus both make women a target of violence and make it difficult for them to address it. Continuous exposure to violence and the lack of ability of health systems to redress the issue leads to severe psychological and emotional impacts among female HCWs who already work in high-stress situations.8
WPV also impacts population health. Exposure to violence hinders HCWs from providing quality healthcare services to the communities.6 Moreover, psychological and emotional stresses due to exposure to violence lead to absenteeism and attrition.7,8 Health systems cannot afford to have female HCWs leave. The WHO Global Strategy on Human Resources for Health estimates a global shortfall of almost 18 million health workers by 2030.
There are things we can do right now.
There are effective interventions to de-escalate workplace violence against nurses, ranging from standalone training and structured education programs to multicomponent interventions that include organizational changes such as violence reporting systems.9 While all such programs had a positive effect, the impact of standalone training and educational programs has been limited; changes must include organizational policies and work environments.9
Such changes also need to be backed by gender-responsive legislation. For example, the World Health Organization (WHO) and The International Labour Organization (ILO) have recently published new guidelines around stronger occupational health and safety programs for health workers. The guidelines call for policies and measures for zero tolerance of workplace violence and recommend programs to be gender-responsive, non-discriminatory, and inclusive.10
We also need to make deeper shifts in societies to change the gender and power norms that underpin the persistence and growth of violence. We know gender biases heighten the risk for violence against female HCWs. We also know that violence against HCWs is normalized as ‘part of the job.’
As we slowly emerge from the pandemic, we must work to create health systems where female HCWs are celebrated for their contributions and where violence against HCWs is not tolerated.
Contributors
All authors contributed to conceptualization, writing, reviewing, and editing and have read and agreed to the published version of the manuscript.
Declaration of interests
All the authors received a grant (# INV-018007) from Bill and Melinda Gates Foundation. The authors have no other conflicts to disclose.
References
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