Violence against healthcare: current practices to prevent, reduce or mitigate violence against healthcare

VIOLENCE
AGAINST
HEALTH CARE:
Current practices to prevent,
reduce or mitigate violence
against health care
I. Executive summary
II. Introduction
1. The issue of violence against health care
2. Why conduct this survey?
3. Methodology and limitations
4. Introductory findings
III. Main findings
1. Overview of the responses – measures to counter violence against health care
2. Security
3. Work environment
4. Mental health and well-being
5. Communication
6. Coordination with others
IV. Case studies
Bulgarian Medical Association
ICRC Colombia
Italian Nurses Association
Taiwan Nurses Association
Portuguese Association for Hospital Development
V. Conclusion
VI. Annexes
1. About the organizations
2. Methodology
3. Survey questions
VII. Acknowledgements
Contents
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I. Executive summary
Violence against health personnel and facilities has been documented more often in recent years,
affecting all regions of the world both in war and in peacetime, undermining the very foundations of
health systems, impeding the right to health and impacting critically on outcomes achievable by
health systems. In war, it also constitutes a severe infringement of international humanitarian law –
which prohibits targeted attacks on medical facilities, health personnel and medical transport – and
of international human rights law. With the health emergency linked to the coronavirus pandemic, a
worrying upward global trend in reported incidents has emerged.
From May to July 2021, the International Council of Nurses, the International Committee of the Red
Cross, the International Hospital Federation and the World Medical Association – four international
umbrella organizations which are members of the global Community of Concern of the Health Care in
Danger initiative – carried out a joint survey to evaluate the perceptions of violence against health
care during the early stages of the pandemic and to identify good practices implemented to prevent,
reduce or mitigate incidents according to country’s circumstances and health personnel’s
perspectives.
The members of the four partner organizations replied to the survey voluntarily, based on their
specific knowledge of the location. The analysis proposed in this report focused on qualitative data
around good practices shared by the members across countries with differing Human Development
Index values.
Results demonstrate the persistence of violence against health personnel in all responders’
locations, with a higher frequency of incidents after the coronavirus pandemic started. The incidents
also impacted negatively on a wide range of health care services, from emergency care to
programmatic preventive activities. It documents practical solutions initiated by health entities to
tackle violence at community level in the areas of security, promote safer work environments, care
for staff’s mental health and well-being, and address gaps in communication and coordination.
We hope that the good practices presented in this report will spur the global health community to
take action, to share further positive experiences and to advocate for meaningful strategies to
protect health personnel and address the scourge of violence against health care.
1
II. Introduction
The issue of violence against health care
1.
Violence against health care has been a recurrent problem over the years across the globe. The
coronavirus (COVID-19) pandemic has appeared to worsen the situation, with a documented
increase of incidents in many countries. Health personnel and their patients are persistently subject
to acts of violence in all regions of the world.
The World Health Organization (WHO) defines attacks against health care as “any act of verbal or
physical violence or obstruction or threat of violence that interferes with the availability, access and
delivery of curative and/or preventive health services during emergencies. Types of attacks vary
across contexts and can range from violence with heavy weapons to psychosocial threats and
intimidation”. [1]
Besides attacks on health care in emergency settings, violence against health care can also happen
in times of peace, during times of regular work in health care systems with significant variations
depending on the geographical locations and types of attacks. Violence targets health personnel [2]
or patients, health facilities [3] or health transport. [4]
Violence against health care may happen amidst war and in other violent scenarios and may include
violent acts – such as intentional or reckless violent behaviour towards, or wielding weapons against,
health care personnel and assets – or blockages or denial of care. Outside of these exceptional
scenarios, violence against health care may derive from tensions at the workplace, from a lack of
socially or culturally adequate health responses or even from criminal acts, such as robbery and
intentional damage to health material. Coercion and threats to compel health personnel to work
against ethical principles are considered a form of violence against health care, as well as any act
intended to prevent care from being provided. In addition, the situation has evolved since the start
of the COVID-19 pandemic. Some countries have reported violence and aggression against health
care driven by the pandemic, for example, health care personnel being discriminated against,
harassed and targeted for violence. The pandemic has added further pressure and risk to the already
overwhelmed health care workforce.
Since 2011, the Health Care in Danger (HCiD) initiative from the International Committee of the Red
Cross (ICRC) has shed light on the problem and offers resources to raise awareness and promote
action to change this reality. The International Council of Nurses (ICN), the International Hospital
Federation (IHF) and the World Medical Association (WMA) have been members of the global
Community of Concern of the HCiD initiative since its beginning, advocating for the safety of health
personnel and protection of health care around the globe with strong and sustainable actions by
decision makers.
[1] WHO, “Stopping attacks on health care”, WHO, Geneva, 2022: https://www.who.int/activities/stopping-attacks-on-health-care, all links
accessed 11 June 2022.
[2] Health care encompasses activities that aim to preserve or restore health through the prevention, diagnosis, treatment, cure, recovery
and/or rehabilitation of any physical and/or mental health condition. The term might also refer to the organized system through which
these activities are carried out. “Health care service” refers to the provision of care at various levels and within particular scopes (such as
a pre-hospital health care service, a primary health care service or a rehabilitation service), while a health care provider is the agent
responsible for that activity – a medical or a non-medical agent, which can be either an individual or a group.
[3] Health facilities include hospitals, laboratories, clinics, first-aid posts, blood-transfusion centres, forensic medical facilities, and the
medical and pharmaceutical stores of these facilities. Health personnel include doctors, nurses, paramedic staff, first-aiders, forensic
medical staff and support staff assigned to medical functions. The term also encompasses the administrative staff of health care
facilities and ambulance personnel.
[4] Health vehicles include ambulances, medical ships and aircraft, whether military or civilian, and any other vehicles transporting medical
supplies or equipment.
2
2. Why conduct this survey?
Considering the need to protect all people from violence within the health care context, the ICN,
the ICRC, the IHF and the WMA carried out a joint collaborative survey from May to July 2021 to
understand the perceptions of violence against health care during the first year of the COVID-19
pandemic and to identify good practices implemented to prevent, reduce or mitigate violence, with
a focus on (but not limited to) those measures implemented during the early stage of the
pandemic.
An invitation was sent to a focal point in each member organization of the ICN, ICRC, IHF and
WMA to participate in the survey about their perception of levels and types of violence
surrounding their work in health care, and the practices implemented at the organizational and
national level to counter the violence. The goal of the survey was to collect experiences from
member organizations – giving consideration to their specific location while facing different types
of violence – to highlight the negative impact of violence and to share this knowledge with a
broader community, compiling meaningful suggestions for action in order to support replication,
adaptation or expansion of such measures and protect health care from harm.
3. Methodology and limitations
The survey was shaped to collect the perceptions and experiences of health personnel in various
categories and was circulated within the membership base of the four partner organizations.
Responses to the survey were voluntary. It consisted of 31 questions and was purposely
designed with multiple-choice answers and parallel open questions to capture qualitative data.
Participants were free to answer the questions they desired. To ensure consistency in the
responses and avoid duplication, only one representative answered the survey on behalf of each
member organization. The survey was translated into three languages (English, French and
Spanish) and the responses were collected through an online platform.
A sample of over 120 responses was received. The survey responses were reviewed for
consistency, completeness and data entry errors. Responses with missing information, such as
the organization’s name or contact details, and blank or duplicated responses were removed from
the analysis. [5]
The main limitations of the study are due to its voluntary approach: some questionnaires were
only partially answered, and a low number of members engaged in the effort. The complexity of
the situation around the pandemic surely impacted member organizations’ ability to respond to
the survey. Those limitations reduced the survey’s capacity to present quantitative information
and make generalizations. To counterbalance this fact, we propose a qualitative analysis, linked
to suggestions for action that come from a broader list of recommended material, to complement
the great examples that surfaced in the good practices submitted.
The final sample of responders is distributed geographically (Figure 1) and across the Human
Development Index (HDI) [6] (Figure 2). Categorizing responses based on HDI allows a fuller
picture of the responders’ national level of human development, and the analysis showed that
[5] Please refer to the annex for the detailed explanation of the number of responses and validation process.
[6] The HDI is a composite index of three dimension indexes: life expectancy, education (mean years of schooling completed and
expected years of schooling for children of school-entering age) and gross national income per capita. (Source: United Nations
Development Programme, “Human Development Index (HDI)”, United Nations Development Programme, New York, 2022:
https://hdr.undp.org/data-center/human-development-index#/indicies/HDI.)
3
there was diverse representation from responders and geographic locations. The higher response
rate coming from very high-HDI countries might be related to their available resources to respond to
diverse institutional needs during the pandemic.
Figure 1. Geographic distribution of responders
Figure 2. Distribution of countries according to Human Development Index (HDI)
4. Introductory findings
Only answers reporting events of violence (33 responses) have been selected for analysis. [7] In
most cases, violence against health personnel was reported to already occur before the pandemic
and close to 10% of the organizations received reports of attacks related to the COVID-19
pandemic. In addition, such attacks have continued to escalate and close to 60% of the responders
[7] See Annex 2, “Methodology”.
4
Very high
61%
Low
18%
High
15%
Middle
6%
perceived an increase in reported cases of violence against health care since the beginning of the
pandemic. The survey shows that violence against health care affects all responding organizations,
regardless of their countries’ economic and security situations.
Occurence of reported cases of violence against health care personnel,
patients or facilities
Figure 3. Occurence of reported cases of violence against health care before and during
the pandemic
Perceived increase in reported cases after the pandemic started
Figure 4. Percieved increase in reported cases
Forms of violence perceived by responders
In this report, violence is classified in four main categories: verbal aggression, physical aggression,
damage or loss (e.g. destruction or theft) of assets, and obstruction of care. All answers mentioned
the occurrence of verbal aggression. Threats were mentioned by 82% of the organizations, and the
same percentage mentioned physical aggression.

It can [happen] in different places (hospitals,
practices), it can be done by patients or those
close to them. Verbal or physical aggression is
not always predictable.

5
91% 9%
Violence occuring since before the pandemic
Violence only occuring in connection with the pandemic
Yes
58%
No
30%
Unsure
12%
Perceived frequency of violence against health care
Responders were asked to indicate how often they perceived violence occurring, and their answers
seem to vary across the categories, as shown in Figure 6. Attacks carried out with guns and other
means of physical or destructive violence are perceived as occurring much less frequently than
violence perpetrated verbally. [8] Differing frequencies of violent incidents against health care were
mentioned. In most answers, events were perceived as occurring at least once a month.
Perceived aggressors
Violence against health staff can be perpetrated by different actors. Patients and family members
were often perceived as the main source of violence.
[8] An important limitation of the study is that responders who are more affected by violence could have felt more compelled to answer.
As the focus of this survey is on the practices generated by members to counter violence, please refer to the following report for a
discussion of the prevalence of violence: ICRC, Gathering Evidence-Based Data on Violence Against Health Care, ICRC, Geneva, 2020:
https://healthcareindanger.org/wp-content/uploads/2021/03/4513_002-ebook.pdf.
Figure 5. Type of violence reported
6
Verbal aggression, 100%
Physical aggression, 82% Discrimination, 35%
Verbal threats, 82%
Destruction of assets,
vandelism, 48%
Stealing of assets, 42%
Obstruction of
care, 36%
Threatening with
weapons, 27%
Killing or severely
wounding a health
care worker or
patient, 21%
Targeting
with
shelling,
15%
Targeting
with
stones,
12%
Arson, 6%
When there is a health worker who is
wounded or arrested, clinical services will be
disrupted, as well as the continuity of care
Services affected
As shown in Figure 7, emergency care is by far perceived as the service most affected by violence.
Surgery or intensive care, vaccination services (especially during a pandemic), and mental health and
psychosocial support services are also widely perceived as being affected.
Figure 6. Percieved aggressors
Figure 7. Services affected
7
Unknown aggressors, 9%
Military or security forces, 15%
Other, 24%
People using the services (patients), 54%
Family members accompanying the patients, 76%
Physical and rehabilitation services, 18%
Care for newborns and children, 18%
Storage of medical items, 21%
Preventative care, health promotion and outreach activities, 21%
Prenatal and maternal care, including deliveries, 33%
Programmatic clinical services, 33%
Referrals and other types of medical transportation services, 33%
Vaccination services, 42%
Surgery or intensive care, 42%
Mental health, psychosocial care services, 45%
Clinical services – emergency care, 45%
Overview of the responses – measures to counter violence against
health care
Communication, security and work environment were referred to the most frequently across
all levels of HDI.
Security and work environment seem to be more frequently referenced for countries with
lower HDI values.
Mental health support and communication are less frequently mentioned in low-HDI countries.
1.
The data collected makes it possible to draw up a list of five main themes in line with the practices
and/or measures reported countering the occurrence of violence: security, work environment,
mental health and well-being, communication and coordination.
A distribution for each topic was developed according to the frequency of references in open
answers. [9] The following points regarding HDI were observed with this thematic analysis:
Decision to intervene on the issue of violence against health care
In more than half of the responses, the decision to intervene was made either through a holistic
approach related to well-being or a specific initiative from management. The reasons mentioned for
not implementing measures were: 1) a low reported number of violent incidents against health
personnel; 2) lack of time to implement measures; and 3) the current political and security situation
in the country.
Response to violence in the organizations
Communication skills, reporting, risk assessments, enhanced accountability protocols, coordination
with other stakeholders and the further development of security items at the workplace are
mentioned in 60% of the answers. [10] Development of new legislation has also been mentioned,
albeit less frequently.
The responses were mostly multidimensional, with seven different types of measures cited on
average, and eight responses composed of at least ten measures. The full frequency of mentions
can be seen in Figure 9.
[9] See Annex 2 for the methodology of the qualitative analysis.
[10] See question 15 in the questionnaire (Annex 3).
III. Main findings
Figure 8. Decision to intervene
8
Comprehensive approach to
improve well-being in the
workplace, 43%
Initiative from the
management, 15%
Pressure from the staff, 9%
None, 9%
Both pressure from the staff and
response to a serious incident, 3%
Response to a specific, very serious incident,
21%
Target population of the measures to prevent violence
Measures to prevent violence against health care usually target staff, as mentioned in nearly all
responses. However, the patients and the community are mentioned in around half of the answers.
This finding also aligns with the question about perceived aggressors of violent incidents. Close to
80% of reported violence against health care is perpetrated by family members accompanying the
patients, which explains why the responders also consider the community and patients as targets of
the measures. Around one-third of responses focus on all three presented categories, and another
third exclusively on the staff.
Armed groups were mentioned only once as a specific target of the response.
The following sections address the content of the answers provided in each thematic category, with
suggestions for action at the end of each topic.
Figure 9. Types of interventions
Figure 10. Target population
9
Staff, 40%
Staff, community and patients, 37%
Staff and patients, 10%
Staff and community, 10%
Community, 3%
Ensuring time and space for all staff to rest, 27%
Enhancing transparency, 27%
Enhancing visibility and identification of the staff and the
facility, 37%
Implementing contingency plans, 40%
Ensuring ethical provision of care, 50%
Providing mental health and psychosocial support
to the staff, 53%
Ensuring access for al staff to protective
measures, 57%
Implementing security items at the workplace, 70%
Implementing reporting and monitoring of violent incidents, 70%
Training in communication skills and de-escalation techniques, 70%
Assessing and managing risks, 67%
Enhancing accountability, 67%
Coordination with other stakeholders, 67%
2. Security
General security-related measures
The deployment of efficient security staff is suggested as a requirement to improve security. In
addition, new recruitment of security staff and changes to the current organization have been
mentioned.
The security staff need to be responsive and easily reachable in case of a problem, the speed of its
intervention being of the upmost importance.
The engagement of security focal points within the health facility is very important to ensure a quick
reaction to incidents. Security agents outside the facility, in a nearby neighbourhood, can also
intervene if needed to provide in-house security.
Finally, clear identification of health personnel inside the facility (with, for example, new dedicated
jackets) and signage on the facility itself (such as a “no weapons allowed” sign) could deter potential
aggressors from performing aggressive acts against health personnel. Many examples also
displayed the good results from existing tools and the integration of the results in a training session.
57% of responses included
“Protocols to ensure access of all staff to
protective measures”
37% of responses included
“Procedures to enhance
visibility and identification of
the staff and the facility”
67% of responses included
“Procedures to assess and
manage risks”
Identify security focal points in the staff
Employ responsive security staff
Use clear protocols for communication at the organizational level and between the focal points
in case of emergency
Clearly identify the health personnel
Suggestions for action
Train specific or health personnel in each team on the issue of security, including on the
necessary steps to be performed to de-escalate violence or trigger a contingency plan,
with protocols always enabling communication with the security service.
The security staff should be trained to be responsive, as the speed of their intervention is an
mmimportant factor.
Such protocols should be put in place through official means for the whole security
process (walkie-talkies, official applications for chatting in groups).
In countries with a higher level of violence, use distinguishable items to identify the staff, such
mmas bright jackets, specific ID cards or other elements that cannot be easily copied.
10
Measures on passive security and/or equipment
Security equipment items in the workplace entail a reinforcement of general security in and around
the facility. This can range from building security walls or reinforcing fences to secure high-risk areas
and provide the possibility to lock down an area. The use of technology, such as installation of
cameras, can also strengthen general security by ensuring better access control. It was also
mentioned that risk assessments can provide pertinent solutions.
70% of responses included “Security items
at the workplace”
Secure the high-risk areas with access control
Secure the space around the facility
Assess the risks
Analyse the reported cases of violence against health personnel
Train the staff
Suggestions for action
Using adapted means – either with technology to control access and limit it to patients and
the needed staff (e.g. ID badge management, camera) or without such technology (simple ID
cards, human checks) – ensure that entry and exit areas, as well as restricted circulation
areas, are properly marked and that staff are always identifiable.
Elevate external walls, ensure lighting around the health facility and remove blind spots, patrol
the area around the health facility and coordinate with local security authorities.
Perform a risk assessment in and around the health facility, with the involvement of the
various segments of staff and users of the service. Implement measures to limit the risks,
including topersonnel, be it at the workplace or during transport (e.g. ambulance, referral).
Maintaining compliance with personal data protection rules, provide protocols to document
the cases, enabling the collection of relevant information about the violent event and its
consequences.
Share protective information with staff through informative and participative training sessions.
After the installation of the walls,
a reduction of armed people entering
the facility was noted, as well as a
reduction of verbal aggression (…)
between users and staff
11
Identification of most affected areas,
perpetrators of the events, and type of
events – thanks to the detailed and
systematic documentation system
3. Work environment
Managerial measures
Strong management protocols were mentioned in the survey as critical to preventing, responding to
and reporting on acts of violence. These protocols include measures through which direct actions
may be triggered when violence occurs and when staff are trained in a previously defined
contingency safety plan. Dedicated staff can monitor the post-incident situation to avoid possible
retaliation against the personnel in their daily life. Frequent reminders and training sessions are
incentives for all to follow a procedure, including ethical standards and national norms. In
emergencies a clear definition of roles and responsibilities frequently is missing or fails, which
increases the overall pressure on health personnel.
To reduce workplace violence, solutions mentioned ranged from the existence of a workplace-
violence prevention committee to the recruitment of dedicated staff monitoring the situation.
The respect of health care’s ethical principles is key to building a culture of trust with patients and
their family members. Not respecting those norms will only worsen the situation. Some responses
also mentioned including the staff in discussions, to make them agents in their own safety.
50% of all responses included
“Protocols to ensure ethical
provision of care”
40% included “Development and
training of contingency plans”
Develop a contingency plan
Train the staff on procedure and norms
Strengthen internal communication
Suggestions for action
Establish clear responsibilities through a contingency plan for situations of violence, with
frequent reminders to the staff. The plan should be intersectoral, with the involvement of local
authorities if possible. It should also consider different levels of violence or types of threats.
The procedures and norms can be evolving or changing with time. Regular updates should be
proposed.
Organize frequent meetings between the direction and the staff and involve the staff in
decisions concerning their security.
Technical measures – reporting, monitoring and references
Beyond the lack of awareness of violence against health personnel, the main reason for not
reporting incidents might be the absence of a unified system for collecting occurrences of violence
(mentioned by five different countries). Some answers mentioned reporting a case directly to the
management of the facility, but most of the time information seems to be kept locally. Having a
national database with thorough procedures to ensure transparency, and limit intermediaries
between the moment of complaint and its resolution, was said to facilitate and guarantee the
communication of violent incidents to decision makers and prevent under-reporting.
[The issue of violence] was discussed in
weekly and monthly meetings
12
Guidelines from the ministry of health are sometimes provided to the staff, but the means to
implement them can be lacking. The distance between the law and the reality in the field may also be
explained by the lack of regional procedures.
Develop national procedures and systems of reporting
Link with the justice department
Adapt the guidelines to the reality in the field
Hold awareness sessions on violence against health personnel for both staff and the community
Provide complete support to victims of violence
Suggestions for action
Advocate with the national authorities to create a specific mechanism for reporting violent
incidents against health personnel, accompanied by clear procedures and training courses
in this system in all health facilities. Documentation and analysis should be performed
whenever possible.
The justice department should be included in these procedures to ensure a direct action or
simplified procedure for health personnel to complain formally about violent incidents.
Provide various levels of guidelines for better and concrete implementation, with detailed
methods and solutions according to the location.
Working conditions
The lack of awareness of the issues of violence against health personnel is not only a social problem;
it concerns the staff itself. Many answers display the need for awareness sessions on violence for
both the staff and, separately, the community. A healthy working environment should be inclusive
and team-friendly.
However, a few cases of violence between health personnel themselves have been reported.
Respondents often mentioned the need for legal support provided by the management to staff
members exposed to violence, including with the intention of accompanying the person through the
complaint system. Setting up a mechanism enabling direct reporting to the prosecutor’s office was
mentioned. The legal implications of aggression towards health personnel can be dissuasive to some
of the aggressors. The support offered to health personnel who are victims of violence can include
mental health support, counselling as well as legal advice and incentives to report incidents.
Suggestions for action
Organize both internal and public sessions to raise awareness on the matter. Display information
at the entrance of the health facility. Encourage reporting of violent events.
The support must include legal help for an official complaint, counselling on how to cope with the
situation and mental health and psychosocial support.
70% of all responses included
“Procedures to report and monitor the occurrence
of violence in the health care setting”
Sometimes, the health staff is not aware
that violence against health care should be
addressed as a problem, so creating
awareness also makes the reporting rise
13
4. Mental health and well-being
Mental health support presents a double challenge, as it concerns both health personnel and some
patients suffering from the situation. The responses to the survey suggest that countries with a low
HDI reported fewer mental health and psychosocial support (MHPSS) measures when compared to
the others.
Psychosocial support to health personnel is often a neglected theme, even in difficult situations
such as the pandemic. Staff might feel exhausted mentally, if not physically, sometimes resulting in
necessary breaks from work. The same is even more true in conflicts, as the long-term exposure to
violence will only increase the need for MHPSS. Solutions reported range from establishing
psychosocial teams (when none previously existed) to the creation of a hotline available at any time
and moderated by professionals specifically trained in the subject.
When the internet connection is reliable, support can consist of virtual sessions with specialized
teams. If physical meetings are prioritized, collaboration with other organizations with the necessary
capacities was mentioned as another possible solution.
53% of all responses mentioned
“Protocols to provide MHPSS to the
staff are available”
27% of all responses included
“Protocols to ensure resting time and
space for all staff”
Ensure time and space for all staff to rest
Create MHPSS teams or collaborate with other organizations that can provide MHPSS expertise
Create and train a remote team of professionals on MHPSS
Provide free access and sessions for all the staff
Encourage team-building and peer support
Suggestions for action
Shifts not only need to be scheduled in ways that allow for sufficient rest, but the workplace
should also provide space for short breaks and private areas where people can get away from
the working atmosphere.
Hire and train professionals in mental health to provide the needed support. If that is not
possible, collaborate with organizations and foundations that can provide support in the
workplace.
The team should be accessible through virtual tools and/or a hotline. They should be trained
specifically in violence against health care and in the advantages and drawbacks of online
consultations.
All staff should have access to this support through free sessions. It is important also to give
access to staff’s family members or others who might suffer indirectly from the situation.
To strengthen awareness and build team spirit, group activities based on realistic scenarios
could feature in a practical way the challenges that the team could face during an event.
The losses for those who suffer an attack
are not only material issues (…) these
attacks generated fear of being attacked
14
5. Communication
With the community
The survey pointed out an expectation from the civilian authorities to communicate widely on
violence against health care and raise awareness in the community, while encouraging respect
towards health personnel and informing of the legal consequences of violence. Some respondents
reported cases where civilian authorities on the contrary provoked miscommunication during the
pandemic. The need for a good communication strategy targeting the right groups, including arms
bearers, is essential.
It was suggested to launch official media campaigns at the national level (which should not prevent
initiatives at the local level) in order to guarantee wide-reaching communication to the population.
This can be done through posters and flyers, meeting with journalists or social media.
Communicate through media campaigns
Disseminate information through the civilian authorities
Suggestions for action
Communication campaigns should be planned – targeting the right group (community,
mmovulnerable groups, youth, religious leaders, etc.) and using the right media (radio, SMS,
mmonewspapers, social platforms, etc.) – and have a clear objective of preventing and reducing
mmothe violence.
Reach out to civilian authorities to promote the large-scale dissemination of key messages on
respect for health personnel and to raise awareness of the legal consequences for those
attacking them.
With patients and family members
Communication with patients and their family members, often perceived as the main aggressors,
has been prioritized by many organizations in their response to the violence.
The main solution suggested is training staff in de-escalation methods, to keep the situation under
control. Informational items handed over to the patients, including on their legal responsibilities,
were also mentioned.
67% of all responses included
“Procedures to enhance accountability
towards the public, including patients
and family members”
Acknowledgement that there’s a need to
publicly communicate in the protocols (what
is new in the response to the pandemic), key
message on stigma and discrimination
against health workers
15
Finally, the patient feedback form, while a tool used mainly for accountability to the public, enables
better communication between the staff and the patients by promoting learning from past
situations.
It was mentioned that, during the pandemic, some people have insisted on access to vaccines while
not belonging to the target groups. Better communication would be helpful in this type of situation.
Provide staff with training in communicating with patients
Communicate priority groups for triage or specific health interventions at the entrance of
Improve transparency and accountability
Educate staff continuously
Suggestions for action
Train all the staff with frequent interactions with patients or their family members in
communication skills, such as de-escalation methods and non-violent communication. Train all
staff in violence prevention.
the facility
Print posters displaying the current rule. Appoint dedicated staff to remind visitors of the rules,
answer questions and ensure application of the protocols.
Create a patient feedback form or any other tool allowing the patients or their family members to
either report their frustration in a peaceful way or to propose ideas to improve the overall relation
b between staff and patients.
eduEducation should be developed through a variety of means (i.e. through initial studies, on-the-
eduspot training, continuous education) to include reminders about the ethical principles of health
educare and norms, in order to ensure better transparency and accountability.
70% of all responses included
“Development of
communication skills and de-
escalation training”
27% of all responses included
“Procedures to enhance
transparency regarding
provision of care”
16
Accountability to the users of the service

Tools have been developed to enhance accountability, such as patient feedback forms, performance
appraisals and attendance and punctuality records. They are meant to exhibit effective work
interactions and improve communication and transparency. It is also important to establish
protocols and accountability mechanisms for ethical questions that might be triggering violence
and/or overburdening carers in their daily duties.
6. Coordination with others
Civilian authorities
Coordination with civilian authorities, from local partners to the ministry of health is often seen as an
important measure to reduce the problem of violence against health personnel. Support to improve
dialogue may be needed in some cases, while in others, authorities will readily help spread the
message within the community.
Finally, two different approaches regarding how coordination should be realized were reported. In one
case with a conflict between two belligerents, coordination is mentioned as being always
confidential. In the second case, the creation of a task force including several entities, such as
health authorities, non-governmental organizations and security forces, allowed for a unified
message and the dissemination of better practices.
Engage in dialogue with local authorities to ensure safe provision of care
Coordinate in special situations, especially when a contingency plan is activated
Suggestions for action
Prioritize what is necessary in each scenario and ask for support when needed. The safe passage
oooof ambulances should, for example, be respected by all parties.
Foster cooperation between the various parties, including health organizations. If they do not
agree to communicate with each other, coordinate bilaterally to ensure safety within the health
facility and of health personnel.
67% of all responses included
“Coordination with other stakeholders, such
as the police, EMT teams, firefighters or
other health care organizations”
Coordination with community
leaders is vital
17
Training

De-escalation training has been part of the response more often than not. It has not been
implemented in the same way throughout the world, and countries with a lower HDI mentioned a low
rate of training.
In conflict-affected countries, several solutions have been implemented, e.g. training medical
students, awareness sessions with the staff and community, training in national norms and
programmes to teach ethical standards in providing care.
A few specified examples of de-escalation techniques used are non-violent communication
methods, crisis training and specific programmes about care-team support. A proactive method has
been the inclusion of a violence-management course in continuing medical education and through
group sessions or webinars with staff.
Establish focal points within the security forces
Implement a no-weapons policy at the health facility
Speak with all weapon bearers
Military or security forces
The analysis of the answers showed that in countries with low and medium HDI values, unknown
aggressors and military and security forces are perceived as more common aggressors when
compared to the other categories.
Responders indicated that coordinating with military forces can be a difficult process, with potential
conflicting interests that can threaten the respect of medical impartiality when providing care.
Ensuring timely and adequate access to all by implementing suitable procedures throughout the
military hierarchy was suggested as a way to help solve these difficulties.
A strong and respectful relationship with the police, through focal points, has helped in resolving
some situations. It has led to positive results, such as officers leaving weapons outside the facility
when they enter for security operations. The double security-focal-point system, in which both
trained health personnel and local security forces cooperate, can also create a better relationship
and prevent such operations.
Suggestions for action
The security forces should be connected to the focal points inside the health teams to ensure
quick intervention.
Ensure that the health facility and health transport are free of weapons, to avoid direct
targeting but also accidental discharge of weapons and coercive behaviour.
It is important to discuss the issue with all weapon bearers, even informally, to achieve safety
for all health personnel.
18
All signals and
complaints received
or found by the
Bulgarian Medical
Association and the
ministry of health are
forwarded to the head
of the cabinet of the
prosecutor’s office
and are acted upon
immediately
IV. Case studies
Bulgarian Medical Association
Strengthen relations with the justice department
with a functioning workflow of identification and
analysis of violent incidents against health
personnel. Identify the various target groups and a
suitable strategy.
Use TV campaigns with a recognized actor for
older populations (identify an actor who is keen to
participate in charity events). For younger groups,
streaming live on social media such as Facebook
and YouTube will be more engaging.
GOOD PRACTICES
FOCUS – COORDINATION
The Bulgarian Medical Association, the ministry of
health and the prosecutor’s office concluded an
agreement with the aim to cooperate on prevention,
detection and investigation of violence against health
personnel in the course of, or in connection with, the
performance of their duties.
All signals and complaints received or found by the
Bulgarian Medical Association and ministry of health
are forwarded to the head of the cabinet of the
prosecutor’s office and are acted upon immediately.
FOCUS – 2019 MEDIA CAMPAIGN
The need for a media campaign has long been noted
(since 2002). The Bulgarian Medical Association
launched the campaign “Good words heal” in 2019 in
order to keep public attention focused on the issue of
violence, raise awareness among health personnel and
ultimately reduce these acts of violence.
The association recruited a famous Bulgarian actor
and photographer, Vladimir Karamazov, to promote the
campaign. The actor had already participated in other
charity initiatives, with UNICEF for example.
CONTEXT
Violence against health care is systemic
in Bulgaria, and, although the pandemic
does not seem to have worsened deeply
an already-complicated situation, more
than a case of violence per week is still
reported.
The violence is of multiple kinds and mid-
level intensity and includes verbal
threats, physical aggression, obstruction
of care and destruction of assets.
Specific services have been affected:
emergency care, surgery or intensive
care, vaccination services and maternal
health care. Staff availability has also
suffered from the situation. The main
perceived aggressors against health
personnel are patients and family
members but also the media.
The initiative included security items at the
workplace and procedures to report and
monitor the occurrence of violence in the
health care setting in coordination with the
ministry of health and the prosecutor’s office.
19
ICRC Colombia
spread the relevant information on
protecting health care from violence,
targeting the general public (via campaigns
and social media), specific communities,
security forces, armed groups and health
care staff
increase accountability to the public with
specific staff training in the national norms
on protecting health care
provide psychosocial and mental health
support to the staff (both as crisis
interventions and through a structural Help
the Helpers programme)
enhance the visibility and identification of
staff and facilities, making them clearly
identifiable to all
report, monitor and analyse the violence
through a well-structured documentation
system led by the health ministry and
complemented by ICRC documentation of
confidential cases
engage in dialogue with all stakeholders,
including armed groups, to ensure respect
for health care and support health services
and the provision of health care, particularly
for communities affected by violence.
APPROACH
The ICRC addresses the problem using a
comprehensive, multidimensional approach
targeting all stakeholders, in close coordination
with the highly developed national health
ministry system and the high-performing
Colombian Red Cross. The aims are to:
CONTEXT
Violence against health care is systemic in
Colombia. It has grown in parallel with the
increase in recent years in the intensity of the
conflict and its consequences, and it has
worsened since the beginning of the pandemic.
The violence includes various types of
incidents, from verbal threats to physical
aggression, retention of health care staff to be
taken away to care for members of non-state
armed groups, attempts to kill wounded
patients in hospitals and ambulances, wounding
of staff and destruction of assets.
There have been times when violence has led to
mass resignations by staff in some health care
facilities, and repeated exposure to attacks
surely imposes a severe burden on well-being
and mental health, especially in those areas
affected most by armed conflict. Violence has
affected health care in a range of ways,
reducing the provision of life-saving or time-
sensitive services and hindering preventive and
clinical health care, staff availability and drug
storage.
While mainstream patients and family members
are the most frequently identified aggressors
against health personnel, according to the
official register from the ministry of health, the
armed groups, and less frequently the security
forces, have also been identified as
perpetrators of violence.
Empower and help the ministry of health to develop, sustain and improve a comprehensive system
for protecting health care.
Advocate for, and support, the implementation of a normative framework to protect health care
(through domestic legislation and policies).
Collaborate with all stakeholders, as they all have a role to play in the protection of and respect for
health care.
Support coordination to develop and implement intersectoral plans of action to protect health care.
Engage in separate dialogues if stakeholders can’t coordinate together. This may include
confidential dialogue to respect each stakeholder’s needs and respect medical confidentiality.
Develop a risk assessment based on robust data analysis, systematic case documentation and
qualitative analysis.
GOOD PRACTICES
20
ICRC Colombia continued
FOCUS – MONITORING AND ANALYSIS
To develop an effective risk analysis and
improve daily operations, the detailed
documentation of events is compiled in the
comprehensive documentation system, which
identifies high-risk areas, the type of violence
suffered by the staff and its consequences.
This monitoring tool is run by the local health
ministry, with technical support from the ICRC.
The quantitative analysis of the data from the
documentation system is complemented by a
qualitative analysis taking into account the
severity and impact of the attacks, as well as
the number of unreported events (due to fear)
of which the ICRC has knowledge through
confidential dialogue with health care staff and
communities.
support to, and coordination with, the
robust normative framework and
documentation system from the ministry of
health on protecting health care, in
cooperation with the Colombian Red Cross
communication on protecting health care
and how to ensure safe provision of care;
support and coordination between health
authorities
communication with armed groups on
protecting health care; confidential dialogue
with armed groups in response to specific
incidents of violence
coordination with stakeholders on real-time
interventions to enable safer passage of
ambulances, mobile vaccination teams or
health care teams.
FOCUS – COORDINATION
The dialogue with the various stakeholders in
Colombia can be challenging. The ICRC has
therefore divided its actions accordingly,
focusing on what can realistically be achieved
with each of them. This includes:
OUTCOMES
The community is more respectful of health
workers, and both the armed groups and the
security forces officially accept the importance
of protecting health personnel, even if the
reality can pose challenges to maintaining the
respect and protection needed.
Health care staff understand better what the
problem is and cooperate with the measures
taken, improving both their own security and the
capacity to cope with the violence. Finally, an
analysis of the frequency and nature of violent
events allowed for a description of the most
affected areas and the type of incidents as well
as improved responses or planning of
interventions.
Collaborate with all
stakeholders, as they
all have a role to play
in the protection of
and respect
for health care
21
Italian Nurses Association
Create or update a specific law on violence
against health personnel with dissuasive
legal implications.
Establish good and functioning working
environments.
Provide continuous training and support to
minimize the frequency of the events and
their possible impact.
FOCUS – NEW LEGISLATION
In September 2020, the Italian parliament
approved a new law to address violence against
health professionals. This law includes the
constitution of a National Observatory on the
Safety of the Health and Socio-Health
Professions under the ministry of health, which
promotes studies for reducing health
professionals’ exposure to risk factors,
monitors the implementation of safety
measures, including video-surveillance tools,
and promotes best practices and specific
training for health professionals.
Furthermore, the legal consequences and
implications for people aggressing health
personnel verbally or physically have been
strengthened. The law extended prison
sentences (from 4 to 16 years) for individuals
who cause serious or very serious personal
injuries to health personnel, including in
emergency settings. Also, it increased the
administrative penalty (from €500 to €5,000)
for an action that, short of constituting a crime,
involves violence, abuse, offence or
harassment towards health care workers.
The law also enjoins the ministry of health to
promote knowledge of the importance of
respecting health professionals. In addition, a
National Day of Education and Prevention of
Violence against Health Personnel (12 March)
was created to raise awareness on the subject.
GOOD PRACTICES
CONTEXT
Violence against health care was happening in
Italy before the pandemic and the current high
frequency of events is not perceived to have
worsened with the pandemic. According to the
survey, the source of violence is mainly family
members accompanying patients and, to a
lesser degree, patients themselves. Reported
incidents mostly include verbal threats, stealing
or destruction of assets, with some cases of
physical aggression. Emergency care, mental
health and psychological care, and outreach
services were highlighted as negatively
impacted by episodes of violence.
Interventions and initiatives were developed
after specific incidents reported intensively by
the media, especially on a few cases of gender-
based and physical aggression. Most measures
are targeted at training staff in communication
skills, mental health and psychosocial support,
as well as protocols to ensure ethical provision
of care and security in the workplace.
Additionally, new legislation was implemented
to target patients and communities.
FOCUS – WORKING CONDITIONS
Training courses focusing on how to manage
difficult or violent situations were added to
continuing education for health professionals.
The need for more support for staff who are
victims of violent episodes has been
documented widely. A national approach is in
development to resolve the issue of under-
notification of violent events. Particular
attention should be paid to all professionals
who work in the community. They visit clients
and patients at home, putting them at high risk,
as they are often alone and without any support
from colleagues or security staff.
This has led to the development of a number of
support and counselling services led by local
non-profit organizations aimed at meeting
health and social care professionals’ need for
mental health support to cope with the impact
of these events.
This law shows that it is necessary to
take care of and defend from
violence the health and well-being of
those professionals who spend their
lives protecting and taking care of
others’ health in every setting, such
as family and home care. 22
Taiwan Nurses Association
FOCUS – WORK ENVIRONMENT
A reporting mechanism for violent incidents in
hospitals has been established. Regular
collection of incidents targeting health
personnel in and out of the hospital facilitates
robust analysis, which, after review, can be
incorporated into safety-management
practices and staff education and training.
The Medical Care Act was announced in 2014
and amended in 2017. It stipulates that “no
person shall use violence, coercion, intimidation
or other illegal methods to disrupt the order of a
medical institution or to obstruct the execution
of medical care practice”. The revision added
public insults to the list of legally actionable
offences against providers of medical services,
making verbal abuse against medical personnel
by members of the public punishable by a fine of
NT$ 30,000–50,000 (about USD 1,000–1,700).
Additionally, this revision enjoined the national
governing authority to establish a formal
reporting mechanism and to issue regular public
announcements regarding the content and
prosecution results of related cases. The
revision also includes emergency health
personnel as a protected category, ensuring
their rights while on duty.
In addition, the Ministry of Health and Welfare
has developed: standard procedures for
reporting and managing disturbances to medical
order or obstruction of medical practice in
hospitals; guidelines for response procedures,
education and training; and standards for
response evaluation.
Management also provides appropriate
psychological support, counselling, and support
for related legal claims or other assistance to
employees who have been injured.
Encourage reporting and develop standard
procedures to facilitate it.
Include all possible information in the risk
assessment, analyse the results and
include them in the training sessions.
CONTEXT
Violence against health care occurred before
the pandemic but only infrequently, with the
estimation of one reported case per month. The
aggressors are mostly the patients and their
family members. Workplace violence has also
been reported among health personnel.
Reported incidents include verbal threats,
physical aggression and targeting of assets,
with damage to both the isolation room and
equipment such as chairs, doors or computer
screens. Various services have been affected
including life-saving or emergency services,
activities outside health facilities, vaccination,
and mental health services.
FOCUS – SECURITY
To ensure medical personnel’s safety, the
prevention of violence against health care has
been included in the hospital accreditation
process. Medical institutions first performed a
detailed risk assessment by establishing
criteria to identify high-risk sites, such as the
emergency departments. They then tightened
access to these areas. Security was
strengthened by installing monitors and
facilitating communication with the police
through a common procedure.
OUTCOME
In addition to the existing health violence
prevention and occupational disaster-
management procedures, the new measures
strengthen the protection of health personnel
providing care in an epidemic.
GOOD PRACTICES
Some people had a fight owing to
personal disagreements in the
process of seeking medical
treatments in a medical institution.
The health care workers were
violently attacked in the process of
handling the dispute.
23
Portuguese Association for Hospital Development
FOCUS – SECURITY
To overview the assessment and management
of security conditions to reduce violence
against health care, a security office was set up
at the Ministry of Health, with a hierarchical
organization comprising more than 200 focal
points appointed in the different structures of
the national health service: regional focal and
institutional focal points in hospitals, local
health units and health centre groups – at least
one for each institution. At the same time,
points of contact in the security forces have
been identified to support these focal points. A
collaborative network was created with all the
actors mentioned above to strengthen the
procedures and clarify the objectives.
To discern and investigate the phenomenon of
violence in the health sector and promote the
identification, notification, and analysis of
cases of violence, the organization conducted a
security survey of all the national health
institutions (INQSEG2020), with quantitative
and qualitative research methodologies to
highlight the main findings that were shared
broadly. It also defined a template for the risk
assessment and organized security visits in
order to implement the recommendations.
The national online platform for reporting cases
of violence on health professionals (Notific@)
was used to analyse the episodes of violence.
Based on the conclusions of the analysis, the
security literacy in the health sector was
strengthened.
Pilot projects with innovative solutions for the
prevention and mitigation of violence in the
health sector have been encouraged through
training of personnel. Results of some of the
projects were already presented.
The Action Plan for the Prevention of Violence in
the Health Plan for the Prevention of Violence in
the Health Sector was reinforced in 2022 with a
Resolution of the Council of Ministers of
Portugal (No. 1/2022 of January 5) which places
measures related to violence on health
professionals as one of the priorities for
investment and improves the coordination of
cross-sectoral work and between ministries.
CONTEXT
Violence against health care is a recurrent
problem in Portugal, happening since before the
pandemic and with very frequent occurrences,
with more than a case per week. However, the
frequency of events has been reduced from 9
to 4 cases per 1.000 workers in the year since
the beginning of the pandemic compared to the
prior one. These specific values are collected
thanks to an online reporting system used for
the last 14 years. Violence is mainly produced
by patients and their family members, and
ranges from verbal threats to physical
aggression and from discrimination to the
destruction of assets.
Mental Health, emergency care, and other
programmatic clinical services have all been
affected by the absence of the staff suffering
violence. The comprehensive approach
developed targeted the staff, the patients, and
the community. It included various measures:
security protocols, management, support to the
staff, communication towards the public,
trainings, coordination, etc.
FOCUS – MENTAL HEALTH & WELL-BEING
Occupational safety and health measures are
implemented to promote well-being and prevent
violence as an occupational risk. Directives to
create a safe and healthy environment in the
Health Sector in terms of interpersonal
relationships, structures, work organization,
equipment, and circuits have been developed.
The support to health professionals who are
victims of violence has been conceived through
the creation of optimized circuits in the legal,
clinical, and psychological support areas, where
an improved interconnection with the justice
sector is still ongoing.
Finally, a dedicated telephone support service
was set up, with psychologists specifically
trained to act in cases of violence against
health professionals for crisis intervention and
follow-up at national level. The service is
available 24 hours a day, every day of the year. 24
Portuguese Association for Hospital Development continued
Create a remote system (hotline, video
calls) available 24/7 with trained specialist
to support the staff.
Identify a security focal point in the staff
to coordinate with security officers, while
ensuring they are first and foremost
following the ethical principles of health
care.
OUTCOME
IWith a consolidated system and workflow in
place, the number of recorded violent
episodes has fallen, even though there is a
strong incentive to report them. It also allows
everyone concerned to develop ideas on how
to keep improving with the already mentioned
innovative pilot project, changes to the online
registered system or coordination with even
more actors.
GOOD PRACTICES
“We thought that having a
clearer governance model
now (the current one
has been in place for about a
year), optimized circuits and
training will provide the
necessary guidance to
achieve better results.”
25
V. Conclusion
This survey focused on qualitative data, and the responses display very consistent answers.
Answers show that violence against health care has long been present and the COVID-19 pandemic
has worsened the situation, with a higher frequency of violent events.
Despite the persistent presence of this violence, it is clear that practical solutions to prevent it do
exist: from raising awareness in communities about violence against health personnel, to the
development of new legislation to protect them, the survey shows that much can be done. The
frequent under-reporting of incidents of violence documented in the study indicates that
awareness-raising does also concern the health personnel themselves. A better and more robust
system for reporting, monitoring and analysing data is required to allow for a better understanding of
the magnitude of this phenomenon and to take appropriate decisions.
The survey also shows the importance of improving relations between health personnel and patients
and their family members, who are perceived as the main aggressors. The display of ethical and
accountable behaviour was mentioned as a suggested response; however the most mentioned
measure was training health personnel in communication skills for de-escalating potentially violent
situations.
This survey has presented the perception of many complementary points of view and has collected
operational strategies to cope with critical situations, emphasizing the need for guidelines in order
to prevent, reduce and manage the violence against health personnel. Strategies should be as
comprehensive as needed to engage at all stages of the process: from prevention to mitigation of
the consequences of violence. At the same time, proper evaluation of the interventions might
support pinpointing those that are the most effective in specific contexts, or to respond to
particular problems. Such evaluations are largely missing.
The authors of this report strongly hope that the good practices presented here will encourage all
those concerned to take action to prevent and mitigate violence against health care, and to share
further positive experiences with those facing similar issues.
The HCiD initiative recommends additional good practices related to the pandemic, [11] legal
support [12] and health-facility security assessment. [13]
Ethical Principles of Health Care, [14] endorsed in June 2015 by civilian and military health care
organizations, aims toguide health personnel when providing health care to patients.
[11] ICRC, Safer COVID-19 Response: Checklist for Health-Care Services, ICRC, Geneva, 2020: https://healthcareindanger.org/wp-
content/uploads/2020/05/4469_002_Safer_COVID-19_Response-Checklist_for_Health-care_Services-Lr_1.pdf.
[12] ICRC, Security Survey for Health Facilities, ICRC, Geneva, 2020: https://www.icrc.org/en/publication/4315-security-survey-health-
facilities.
[13] ICRC, Protecting Health Care from Violence: Legislative Checklist, ICRC, Geneva, 2021: https://healthcareindanger.org/wp-
content/uploads/2021/05/legislative_checklis_on_protecting-health-care-from_-violence_web-1.pdf.
[14] WMA et al.,Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies, WMA, Ferney-Voltaire, France, 2015:
https://www.wma.net/wp-content/uploads/2016/11/4245_002_Ethical_principles_web.pdf.
26
VI. Annexes
About the organizations
1.
The International Council of Nurses (ICN) is a federation of more than 130
national nurses’ associations, representing more than 27 million nurses
worldwide. Founded in 1899, ICN is the world’s first and widest-reaching
international organization for health professionals. Operated by nurses and
leading nurses internationally, ICN works to ensure quality nursing care for
all, sound health policies globally, the advancement of nursing knowledge
and the worldwide presence of a respected nursing profession and a
competent and satisfied nursing workforce.
The International Committee of the Red Cross (ICRC) is an independent,
neutral organization ensuring humanitarian protection and assistance for
victims of armed conflict and other violence. It takes action in response to
emergencies and at the same time promotes respect for international
humanitarian law and its implementation in national law.
Established in 1929, the International Hospital Federation (IHF) is
a global not-for-profit, non-governmental membership
organization. Headquartered in Geneva, Switzerland, the IHF is the
global voice of hospitals and health systems. The IHF provides its
members with a platform for knowledge exchange and
networking with different actors in the health sector, to improve
the standard, quality and level of service delivery.
The World Medical Association (WMA) is a global federation of 115
national medical associations, representing millions of physicians
worldwide. Acting on behalf of patients and physicians, the WMA
promotes the highest possible standards of medical care, ethics,
education and health-related human rights for all. The WMA has a
long-standing commitment to protecting health care, in line with
the principles of humanity and impartiality and international
humanitarian and human rights law.
27
global (33)
global but only to analyse qualitative answer (1)
Philippines health facilities (22)
Philippines but only to analyse qualitative answers (10).
2. Methodology
The survey was carried out from May to July 2021.
The responses analysed in this report have been selected from the overall list of responses,
according to the following criteria: Responses which provided incomplete information (such as the
absence of the organization’s title or contact details and/or data-entry errors) were not retained for
the study. Only one representative answered the survey on behalf of each member organization,
except multiple responses submitted by the hospitals in the Philippines.
Owing to a limited number of answers, most of the numbers are not disaggregated in the report to
prevent challenges associated with statistical tests at this scale.
From a total number of 129 responses collected, 11 were removed due to either duplication or
missing values. An additional 55 responses were either incomplete or duplicated entries from the
hospitals in the Philippines. These responses have been removed from the analysis.
For some of the remaining responses, the missing organization name was able to be recovered using
the official email address of the respondent or other means. The final sample is composed of 63
answers, separated into four groups:
The global sample is the one used for all numbers in this report.
Topics classification
For open answers, the method used detection of some initial keywords for each topic (e.g. “media” or
“journalist” for communication to the public), finding new related keywords (“campaign”). It then
defined a value for each word related to a topic. For example, the detection of the word “equipment”
in a sentence cannot be related directly to the “security equipment” subtopic, or to “destruction of
material equipment”. Manual validation was performed in the end to ensure coherence in the
categories.
Every quantitative answer has been linked to a topic and graded according to the level of relevance,
using a score from zero to two. For example: “How often did you perceive this violence as
happening?” would get a higher grade depending on the frequency, from zero for “In very few
moments over the past 12 months” up to two for “More than once a week”.
As the available number of points for every topic was different, the categories have been normalized
to achieve a denominator of 100, permitting simple percentages, e.g. a score of 14 in the topic
“mental health” (out of 18 available points) becomes 78%, while a score of 14 in “security” (out of
48) is only 29%.
28

Question Response type
Identification Name of the organization Open

Country where the organization
is based
Open
Description
Have your members reported
cases of violence against health
care personnel, patients or of
facilities and ambulances being
a target of violence in any way?
No / Yes, and it has
occurred since before the
pandemic / Yes, but this is
only connected to the
pandemic response 

Does your organization or
association perceive there has
been an increase in reported
cases of violence against health
care since the start of the
pandemic?
Yes / No / Unsure –
Unknown

What type of violence has
occurred? (check all that apply)
Verbal aggressions / verbal
threats / physical
aggressions / threatening
with weapons / obstruction
of care / destruction of
assets (vandalism) /
stealing of assets /
targeting people, the facility
or the vehicle with stones /
targeting people, the facility
or the vehicle with shelling /
arson-burning / killing or
severely wounding a health
care worker or patient /
discrimination / other
(describe)
3. Survey questions
29

Question Response type

Who are the aggressors? –
Family members accompanying
the patients
1 (most frequent) to
5 (least frequent)

Who are the aggressors? –
Persons using the services
(patients)
1 (most frequent) to
5 (least frequent)

Who are the aggressors? –
Unknown aggressors
1 (most frequent) to
5 (least frequent)

Who are the aggressors? –
Military or security forces
1 (most frequent) to
5 (least frequent)

Who are the aggressors? –
Other
1 (most frequent) to
5 (least frequent)

If you selected Other, please
specify here
Open

How often did you perceive this
violence as happening?
More than once a week
/Once a week /More than
once a month /Once a
month /Less than once a
month, sporadically / In very
few moments over the past
12 months

Share, if possible, an
approximate number of cases
reported per month:
Open
30

Question Response type

What were the services
negatively impacted by the
episodes of violence? (check all
that apply)
Clinical services –
programmatic / clinical
services – emergency
care/clinical services –
pre-natal and maternal
health care, including
facility-assisted
deliveries/ surgery or
intensive unit
care/preventive care and
health promotion –
outreach activities
outside a health facility
/preventive and clinical
care – activities targeting
newborn and child care/
referrals and other types
of medical transportation
services /mental health
and psychosocial care
services /physical
rehabilitation services/
vaccination
services/storage of drugs
and other medical
equipment/human
resources – availability of
health care workers

If you wish, you can use the box
to further describe the impact –
for example, you can tell us
more if a service was fully
interrupted or suspended for
some hours, if there was
damage to infrastructure, etc.
Open
31

Question Response type
Response
Was there any intervention to
respond to the situation of
violence?
Yes/No

How was the decision to
intervene on that violence
taken?
It came as a pressure
from the staff / It was an
initiative from the
management / It was a
response after a specific
very serious incident /It
was part of a
comprehensive approach
to generate well-being at
the workplace

If you wish, you can use the box
for further explanations
Open
32

Question Response type

What does the
measure(s) to protect
health care from
violence entails?
(check all that apply)
Development and training of communication
skills and de-escalation techniques / security
items at the workplace / procedures to assess
and manage risks / protocols to ensure ethical
provision of care / procedures to enhance
accountability towards the public, including
patients and family members / protocols to
ensure resting time and space for all staff /
protocols to ensure access of all staff to
protective measures / procedures to report
and monitor the occurrence of violence at the
health care setting / procedures to enhance
transparency regarding provision of care /
procedures to enhance visibility and
identification of the staff and the facility /
development and training of contingency plans
/ protocols to coordinate with other
stakeholders, such as the police, the EMT
teams, firefighters or other health care
organization / protocols to provide mental
health and psychosocial support to the staff

If you wish, you can
share further
explanations on the
measures taken
Open

Who was the target
population of the new
measure(s)? (check all
that apply)
The staff / the patients / the community
as a whole / other

Can you describe in
more detail the new
measure(s) and its
implementation?
Yes/No
33

Question Response type

Please comment on the new
measure(s) and its
implementation
Open

Do you have any perceived or
measured outcome from the
new measure(s)?
Yes/No

Please comment on the
perceive or measured outcome
from the new measure(s)
Open

In your opinion, what was the
main reason to not develop
measures to respond to the
issue of violence?
Lack of guidance on what
to do / lack of financial
resources / lack of
dedicated staff / lack of
time / other

If you wish, you can use the box
for further information
Open

Did you feel like you had all the
information you needed to
design and implement the
measure(s) to respond to
violence against
health care?
Yes/No

Please comment on the
information you needed to
design and implement the
measure(s) to respond to
violence against health care
Open
34

Question Response type
Resources
Do you have a public report, a
news article or other public
document that has presented
the events of violence you have
mentioned in this survey?
Yes/No

If you wish, you can use this box
to add links of public report,
news article or other public
documents to be sent to survey
coordinators.
Open

Has your organization or
association published any
resources or guidance materials
on violence against health care
that can be shared with us?
Yes/No

If you wish, you can use this box
to add links of resources or
guidance materials on violence
against health care to be sent to
survey coordinators.
Open

How would you like to hear back
from the results of this survey?
(check all that apply)
Dissemination of the
report through
newsletters and the
websites from the
participating
organizations / webinar to
discuss the results /
recommendations or
guidance publication
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VII. Acknowledgements
Ana Elisa Barbar, adviser to the Health Unit, Health Care in Danger initiative, ICRC
Clarisse Delorme, senior policy advisor, WMA
Hoi Shan Fokeladeh, policy advisor, ICN
Sara Perazzi, senior partnership and programme manager, IHF.
This report is the result of the collective work of:
Consultant for data analysis: Olivier Papadakis
Editing and proofreading: Katherine Bennett, communications and engagement manager, IHF.
We thank our colleagues in charge of communication, research and advocacy for their valued
contributions.
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Published: July 2022