Enhancing satisfaction and respect for health care personnel: a mixed-methods case study of a community-based intervention.

Health care personnel (HCP) face violence as a result of lack of satisfaction and respect among community members. It is imperative for HCP to engage in social work by involving communities for enhancing satisfaction and respect for them. This study attempted to provide insight on this phenomenon by using a mixed-methods concurrent embedded approach. Communities were selected based on modified Solomon four-group design from Karachi in southern province and from three cities of northern province, Khyber Pakhtunkhwa of Pakistan. Focus group discussions and in-depth interviews took place for formulating the quantitative tool. Six hundred pretests were done prior to introducing low-cost community-based interventions followed by 601 posttests. We found increased levels of satisfaction in both provinces, whereas level of respect increased significantly in Karachi in the southern province only. Qualitative interviews revealed the important role played by media and religious leaders. These findings suggest that satisfaction and respect for HCP can be enhanced through community support, involvement of religious leaders, and effective media campaigns.

Effect of low-cost interventions to reduce the incidence of violent events in two public sector tertiary-care emergency departments, Pakistan.

Background: Violence against health care workers has been widely reported in Pakistan. Aims: This study, from September 2019 to April 2020, aimed to determine the effect of low-cost interventions to reduce violent events in two tertiary-care emergency departments in Karachi and Peshawar, Pakistan. Methods: In phase one, a surveillance system was established in each department and information on violent events was recorded for three months. In phase two, low-cost interventions designed to reduce violent events were introduced, e.g. awareness-raising material on violence for patients, training for health care workers and visitor identification cards. Violent events were then recorded for another three months and the percentage difference in number of violent events was calculated. Results: In Karachi, 256 violent events occurred before the intervention and 225 after the intervention, a 12.1% reduction. Physical violence events decreased significantly by 42.9% (P = 0.044). The number of events perpetrated by health care workers decreased by 61.9% (P = 0.016) while those perpetrated by patients decreased only by 5.7% (P = 0.538). In Peshawar, 90 violent events occurred before the intervention and 45 events after, a 50.0% reduction (P = 0.009). The number of events perpetrated by health care workers was the same in both phases. Events perpetrated by patients or their companions decreased significantly by 59.72% (P = 0.001). Conclusion: Violence against health care workers can be reduced significantly by improving their prevention and de-escalation skills. Client educational interventions, supplemented with hospital regulations and patient guidance, can also help reduce the incidence of violent events.

Managing violence against healthcare personnel in the emergency settings of Pakistan: a mixed methods study.

OBJECTIVES: The primary objective of this study was to evaluate the effectiveness of a half-day training on de-escalation of violence against healthcare personnel regarding prevention and management of violence incidents versus a similar tertiary-level hospital with no such training. Secondary objectives were to compare the overall satisfaction, burnout, fear of violence and confidence in coping with patients' aggression of the healthcare personnel in the two hospitals. DESIGN: Mixed method design, with a comparative cross-sectional (quantitative) and focus group discussions (qualitative) components. SETTING: Emergency departments of the two tertiary care hospitals in district Peshawar over 6 months starting from May 2018. PARTICIPANTS: Healthcare personnel in the emergency departments of the two hospitals (trained vs untrained). OUTCOME MEASURES: Violence exposure (experienced/witnessed) assessed through a previously validated tool in the past 5 months. Burnout, confidence in coping with patient aggression and overall job satisfaction were also assessed through validated tools. The qualitative component explored the perceptions of healthcare personnel regarding the management of violence and the importance of training on de-escalation of violence through focus group discussions in the two hospitals. RESULTS: The demographic characteristics of the healthcare personnel within the two hospitals were quite similar. The de-escalation training did not lead to a reduction in the incidences of violence; however, confidence in coping with patient aggression and the overall satisfaction were significantly improved in the intervention hospital. The de-escalation training was lauded by the respondents as led to an improvement in communication skills, and the healthcare personnel suggested for scale-up to all the cadres and hospitals. CONCLUSION: The study found significant improvements in the confidence of healthcare personnel in coping with patient aggression, along with better job satisfaction and less burnout in the intervention hospital following the de-escalation training.

Prevalence and determinants of violence against health care in the metropolitan city of Peshawar: a cross sectional study.

BACKGROUND: Violence against healthcare personnel is a major public health problem. Healthcare personnel are at the frontline dealing with people in stressful and unpredictable situations. Therefore, this study was conducted to determine the prevalence and associated factors of violence against health care personnel. METHODS: A cross sectional study was conducted in the district Peshawar. Healthcare personnel from public and private sectors working in both the primary and tertiary levels of healthcare were invited to participate. Violence was assessed through a structured questionnaire previously used in Pakistan and was defined as experiencing and/or witnessing any form of violence in the last 12 months. Mental health was assessed through the General Health Questionnaire. Logistic regression was used to estimate the association of violence against healthcare personnel with psychological distress and demographic characteristics. Data entry and analysis were conducted in STATA 14. RESULTS: A total of 842 healthcare personnel participated in the study. The prevalence of violence experienced and/or witnessed by healthcare personnel in Peshawar was 51%. Verbal violence remained the predominant form of violence and almost half of the healthcare personnel (45%) were exposed to it. A quarter of the respondents (24%) reported physical violence alone or in combination with other forms of violence. In almost two third of the incidents the perpetrators were either attendants, relatives or the patients. The emergency unit and wards within healthcare facilities were the most common places where violent events took place. The major factors responsible for the violent incidents were communication failure, unreasonable expectations and perceived substandard care. No uniform policy/procedure existed to manage the incidents and the healthcare personnel adopted different responses in the wake of violent events targeting health care. Working in public healthcare facilities and having a larger number of co-workers/colleagues significantly increased the risk of violence in the healthcare settings while being a paramedic significantly reduced the risk as compared to physicians. CONCLUSIONS: Violence against healthcare personnel is a serious public health issue and the prevalence is quite high. A holistic effort is needed by all stakeholders including healthcare community, the administration, lawmakers, law enforcement, civil society, and international organizations.

Assessment of a mass media campaign on giving way to ambulances in five cities of Pakistan.

OBJECTIVE: To determine the contribution of a mass media campaign towards encouraging more vehicles to give way to ambulances, and to identify the factors associated with higher likelihood of giving way to ambulances. METHODS: The three-phase observational study was conducted from December 2017 to March 2018 in Karachi, Lahore, Rawalpindi, Islamabad and Peshawar cities of Pakistan. Six road sites in different areas of each city were selected for observation. The surveys in each city were supervised by academic partners, including APPNA Institute of Public Health, Karachi, University of Health Sciences, Lahore, Al-Nafees Medical College, Rawalpindi and Islamabad, and Khyber Medical University, Peshawar. Three observation surveys were carried out before, during and after the media campaign on right of way for ambulances. Only those ambulances were observed which were rushing through and seeking space. The behaviour of only those vehicles was observed which had the space to change the lane when the space was sought from them. The association of the outcome of vehicles giving way to ambulances immediately or in a few seconds with the campaign was determined using logistic regression analysis. RESULTS: After adjustment for city of observation, timing of the day and type of vehicle, vehicles during and after the campaign were significantly more likely give space to ambulance (p<0.05) compared to cars, buses and vans were significantly less likely to give space (p<0.05). CONCLUSIONS: Media campaign produced better results in encouraging vehicle-owners to give right of way to ambulances to ensure timely medical assistance.

The magnitude and determinants of violence against healthcare workers in Pakistan.

Objectives: To determine the magnitude and determinants of violence against healthcare workers (HCWs) and to identify the predominant types and causes of violence experienced by them. Methodology: A cross-sectional survey based on structured questionnaire adopted from previous surveys and qualitative data was conducted in 4 large cities and 12 districts in 3 provinces of Pakistan. The survey covered 8579 from all cadres of HCWs, including doctors, nurses, technicians, support staff, ambulance workers, vaccinators, lady health visitors, midwives and lady health workers (LHWs). The predictors of overall violence experienced, physical violence experienced and verbal violence experienced were separately analysed for tertiary care hospitals, secondary care hospitals, primary care hospitals and field-level HCWs. Logistic regression was used to compute adjusted ORs with 95% CIs for the association of different factors with the violence experienced. Results: More than one-third (38.4%) reported having experienced any form of violence in the last 6 months. Verbal violence was the most commonly experienced form (33.9%), followed by physical violence (6.6%). The main reasons for physical violence were death of patients (17.6%), serious condition of patients (16.6%) and delay in care (13.4%). Among the different types of field HCWs, emergency vehicle operators were significantly more likely to experience verbal violence compared with LHWs (adjusted OR=1.97; 95% CI 1.31 to 2.94; p=0.001). Among hospital HCWs, those working in private hospitals were significantly less likely to experience physical violence (adjusted OR=0.52; 95% CI 0.38 to 0.71; p=0.001) and verbal violence (adjusted OR=0.57; 95% CI 0.48 to 0.68; p=0.001). Conclusion: Violence against HCWs exists in various forms among all cadres and at different levels of care. The gaps in capacity, resources and policies are evident. Specific strategies need to be adopted for different types of HCWs to protect them against violence.*The study was conducted under the framework of ICRC's Healthcare in Danger Initiative for protection of healthcare against Violence.

Breaking Bad News: A contextual model for Pakistan.

OBJECTIVES: The purpose of the study was to identify the sequence of violence that ensues after breaking bad news and develop a contextual model of breaking bad news and develop a model contextual for Pakistan. METHODS: A qualitative exploratory study was conducted using Six FGDs and 14 IDIs with healthcare providers working in the emergency and the obstetrics and gynecology departments of tertiary care hospitals of Karachi, Pakistan. Data was transcribed and analyzed to identify emerging themes and subthemes using thematic content analysis. RESULTS: Impatience or lack of tolerance, lack of respect towards healthcare providers, unrealistic expectations from healthcare facility or healthcare staff were identified as main reasons that provoked violence after breaking bad news. A conceptual five step model was developed to guide communication of bad news by the health care providers. On initial testing the model was found to be effective in de-escalation of violence. CONCLUSION: Communication of bad news requires application of specific approaches to deal with contextual challenges for reducing violence against healthcare.