Verbal and physical violence against health care workers in the Eastern Mediterranean Region: a systematic review

Özgür Önal,1 Fatma Y. Evcil,1Kıymet Batmaz,1 Betül Çoban1 and Edanur Doğan1

1Suleyman Demirel Universitesi, Tip Fakultesi [Faculty of Medicine, Suleyman Demirel University], Isparta, Türkiye (Correspondence to Fatma Y. Evcil: This email address is being protected from spambots. You need JavaScript enabled to view it.).

Abstract

Background: Workplace violence is a serious public health problem threatening health care workers worldwide.

Aim: We aimed to determine the prevalence of physical and verbal violence over the previous year and during the career of health workers in countries of the WHO Eastern Mediterranean Region and Türkiye.

Methods: The databases MEDLINE (via PubMed), Cochrane Library, Scopus, Science Direct, Web of Science and ProQuest were explored along with reference lists from selected articles. Inclusion criteria were: studies carried out in the WHO Eastern Mediterranean Region or Türkiye, staff working in hospitals and primary health care services, studies on health workers exposed to verbal and/or physical violence by patients/relatives. We initially identified 3513 articles. After further review, 75 studies conducted during 1999–2021 were eligible. These were analysed using MetaXL, version 5.3, and STATA, version 16.

Results: The study covered 69 024 health care professionals from 22 countries. Meta-analysis showed that 63.0% (95% CI: 46.7–79.2) of health care professionals had experienced verbal violence and 17.0% (95.0% CI: 14.0–21.0) physical violence. There was no difference for sample size, professional group, quality score or response rate. The frequency of physical and verbal violence in the subgroup analysis was statistically significantly different for country and year.

Conclusion: A variety of questionnaires and time intervals had been used, making it difficult to calculate a standard severity prevalence and compare subgroups. Examining the temporal trend of workplace violence by country and determining how country-specific social factors and policies affect it would be valuable in future studies.

Keywords: verbal violence, physical violence, health care workers, Eastern Mediterranean Region, systematic review, meta-analysis

Citation: Önal Ö, Evcil FY, Batmaz K, Çoban B, Doğan E. Verbal and physical violence against health care workers in the Eastern Mediterranean Region: a systematic review. East Mediterr Health J. 2023;29():xxx–xxx. https://doi.org/10.26719/emhj.XXXX Received: 23/12/22, accepted: 03/03/23

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).


Introduction

Workplace violence is a serious public health problem that threatens health care workers worldwide. Health care workers are an occupational group at high risk of workplace violence (1). The World Health Organization (WHO) has reported that at least 3 out of every 5 health care workers had been exposed to violence over the previous year (2,3). Violence negatively affects the health of all employees working in health institutions, from cleaning staff to doctors. Workplace violence is defined as threats, abuse and attacks that occur in work-related conditions and may affect the health of employees (4). All kinds of behaviours, from threats and insults to murder, are considered within the scope of workplace violence (5).

Violence in the workplace is examined under 2 main headings: physical and psychological. Physical violence is defined as the use of physical force that causes physical, psychological or sexual problems in the exposed person. Many situations, such as pushing, kicking, hitting, slapping and injuring with an object, can be given as examples (4). According to WHO, health workers are exposed to physical violence at rates ranging from 8% to 38% throughout their careers (1). It has been reported that 24.4% of health care workers have been exposed to physical violence in the previous year (3).

Psychological violence is any behaviour that causes the individual to be negatively affected psychologically (4). Verbal violence, such as insulting, shouting, threatening, swearing, etc., is the most common subdimension of psychological violence (6–9). According to WHO, health care workers are exposed to verbal violence at a much higher rate than physical violence (2). A recent meta-analysis in China found that 61.2% of health care workers were exposed to verbal violence in the last year (10).

Violence has a negative mental, physical and social impact. Violence against health care workers is known to cause a number of health issues, including psychological harm, injuries and death. Decreased job satisfaction and staff quitting their positions are also among the consequences (11). Therefore, violence in the health sector is a significant issue that has a direct impact on the health of employees and an indirect impact on the health of patients.

Determining the frequency of the violence that health care workers are exposed to is important for protecting the health of both employees and society. Studies have been conducted on the prevalence of violence among health care workers in different regions, however, we did not find any systematic review or meta-analysis that reported the frequency of violence (physical or verbal) among health care workers in the Eastern Mediterranean Region which compared different subgroups (country, occupation, time interval, sample size, study year, quality score, response rate). One meta-analysis conducted worldwide on this subject examined a specific subgroup and the prevalence of physical violence experienced in the previous year only (12). Detailed examination of health violence in the Eastern Mediterranean Region, as in our study, will reveal the regional dimensions of the problem.

In this study, we aimed to determine the prevalence of physical and verbal violence experienced by health care workers during one year and throughout their careers in countries with sociocultural similarities in the Eastern Mediterranean Region.

Methods

Study design

This study was conducted in accordance with the Preferred Reporting Elements for Systematic Reviews and Meta-analyses (PRISMA) (13) and was registered in the International Prospective Systematic Review Registry (PROSPERO) under the code CRD42022314256.

This meta-analysis was conducted following the checklist of the Meta-Analysis of Observational Studies in Epidemiology guidelines for the design. The specified guideline includes recommendations on reporting background, search strategy, methods, results, discussion and conclusions (14).

Search strategy

We searched 6 academic databases, MEDLINE (via PubMed), Cochrane Library, Scopus, Science Direct, Web of Science and ProQuest, with words arranged in accordance with MeSH terms. Search strategies for each database are shown in Table 1. The following search terms were used “physical violence”, “verbal violence”, “workplace violence”, “nurse”, ”doctor”, “health care professional”, “prevalence” and “incidence”.

Study selection and selection criteria

We carried out the research and selection of the studies in line with previously defined inclusion criteria. Studies were included if they met the following criteria: conducted in the countries of the WHO Eastern Mediterranean Region and Türkiye due to their sociocultural proximity; participants working in hospitals and primary health care services; and studies conducted on health workers exposed to verbal and/or physical violence by patients and their relatives. Only observational studies reporting prevalence of violence were included in the systematic review and meta-analysis. Only studies whose language of publication was English were selected.

Studies were excluded if they met the following criteria: randomized controlled trials and systematic reviews; studies whose main research topic was mobbing and burnout; studies in which the cause of violence was conflict and chaos in the country; and studies dealing with only sexual violence in health care professionals.

All the data detected in the literature search were transferred to Excel, and duplicates were removed. Scanning of titles and abstracts for these studies was done by referees (ÖÖ, FYE). Unclear titles/summaries were scanned by another reviewer (KB, BÇ, ED) and discussed by the reviewers until approval for inclusion or exclusion was obtained. All reviewers independently scanned full-text articles using a standardized search tool according to eligibility criteria such as country of study, study design, type of publication and sample studied. Studies meeting all criteria were included in the review. When contradictory conclusions were reached about inclusion or exclusion, these were resolved by discussion.

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for the systematic review and selection of studies to be included in the meta-analysis.

Quality assessment

Loney criteria (8 items) were used for the quality scoring of the studies evaluated in this review (15). The criteria were: sampling method (random sample or whole population), sampling frame (defining the study population), sample size (< 355 or ≥ 355), questioning the violent event (using standard measurement form/other), unbiased measurement, response rate (< 70% or ≥ 70%), confidence intervals (CIs) and subgroup details and study subject. The total score was calculated by giving a score to the studies for each item; the overall scores ranged from zero (0) to 8 points, with higher scores indicating higher quality.

Statistical analysis

Data were analysed using MetaXL, version 5.3, and STATA, version 16. Small-study effects and publication bias were examined using the Luis Furuya-Kanamori (LFK) index, the Doi plot and the funnel plot (16). The Doi plot has been reported to be more intuitive and the LFK index more robust than the traditionally used Egger’s regression-intercept test (17). An LFK index value > 1 or 2 or < 2 indicate major asymmetry. For optimal interpretation, at least 5 studies are required, therefore only the LFK index and Doi plots relating to the prevalence of physical and verbal violence in the last year and during the career period were prepared for the subgroups. The LFK index was calculated by applying double arcsin, logit, and no transformation to the prevalence data, and the value with the least asymmetry was used in the analysis. Graphics and tables related to this subject are available from the authors on request.

Both the Cochran Q test and the I2 statistics were used to test the heterogeneity of the data (18). Significant heterogeneity between studies was assumed to be P 50% (19). If significant heterogeneity was observed between studies, a random effects model was adopted to calculate the prevalence of physical and verbal violence; otherwise, a fixed effects model was adopted. The same procedure was followed to generate meta-analytically derived national estimates of the prevalence of workplace violence (physical and verbal) based only on studies available from each country. Meta-analytical estimates could not be calculated for countries with < 2 studies (20). Prevalence estimates for the countries where the studies were conducted (Bahrain, Egypt, Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Morocco, Pakistan, Palestine, Saudi Arabia, Syrian Arab Republic, Türkiye), the year of study (2010 and before vs 2011 and later) and sample size (< 355 and ≥ 355) were analysed by subdividing the professional group (physicians only, nurses only, all health care workers), quality score (< 6 vs ≥ 6) and response rate (< 70% and ≥ 70%). Statistical significance was set at P < 0.05.

Results

Study selection and study characteristics

For the systematic review and meta-analysis, a keywords search was carried out on the 6 academic databases, and 3513 articles were identified (Figure 1). After removing duplicates, 2675 articles were scanned for titles and abstracts. The remaining 274 full texts were reviewed, and we included 75 studies that met the eligibility criteria.

The selected studies were examined under 2 separate headings according to the type of violence, physical and verbal. Prevalence of violence was evaluated in 2 groups according to the time interval as “last year of the study (last year, last 6 months, last 2 months)” and “during career”. From the meta-analysis, 69 (92.0%) studies covered the prevalence of physical violence, 18 (24.0%) covered the frequency of physical violence encountered throughout the career, and 51 (68.0%) covered the frequency of physical violence encountered in the last year. Also from the meta-analysis, 71 (94.7%) studies included the prevalence of verbal violence, 17 (22.7%) the frequency of verbal violence encountered throughout the career, and 54 (72.0%) the frequency of verbal violence in the last year.

The studies included in the systematic review and meta-analysis were conducted between 1999 and 2021. Although violence was examined through the questionnaires in these studies, there was no standard measurement tool used in all of the studies. While the scale developed by WHO/ILO was used in 22 (29.4%) studies, other scales were used in 6 (8.0%) studies. In 47 (62.7%) studies, the questions were created by the researchers, i.e. they did not use any standard scales. The total number of health care workers examined in all studies was 69 024. Among the studies examining physical violence, 50 (66.7%) were from 2011 and later. Data from a total of 61 241 health care workers were assessed in studies on the frequency of physical violence. Fifty (66.7%) studies evaluating the prevalence of verbal violence were conducted in 2011 and later. The total number of health care workers covered in the studies examining verbal violence was 62 261. The countries that had the greatest number of studies on both physical and verbal violence were Türkiye and Saudi Arabia.

The mean quality score (Loney score) for the 75 studies reviewed was 5.2, with 34 (45.4%) scoring ≥ 6 (Table 2). Of the studies reporting the frequency of physical violence, 12 (16.0%) were conducted on physicians only and 23 (30.7%) on nurses only. Ammong those studies reporting the prevalence of verbal violence, 10 (13.4%) included only physicians and 27 (36.0%) included only nurses. An equal number of studies evaluated more than one occupational group for both physical and verbal violence. Since the frequency of verbal violence was examined in many categories in the one (1.4%) study included, and the participants could choose more than one proposition, the net frequency of this type of violence could not be calculated, and only the frequency of physical violence was included in the meta-analysis for that study (21).

For the calculation of the frequency of verbal violence in another study, the category sexual violence, which had been included with non-physical violence, was not included in the frequency of verbal violence (22), which we calculated as 57.9% for that study.

Publication bias was checked using a funnel plot. In the funnel plot analysis, although the prevalence of physical and verbal violence was symmetrical in the studies included in the meta-analysis, mean differences were widely spread. This may have occurred due to variations in sociodemographic characteristics. It was observed that the studies concentrated on a low level of standard errors, an indication that the sample size in most studies was satisfactory.

All studies included in the systematic review, along with their characteristics and the number of violent incidents, are presented in Table 3. The prevalence values obtained from the studies were transformed in accordance with the LFK index scores: transformation with the lowest LFK index was applied. The transformations applied in this framework are detailed in Table 4.

Prevalence of physical violence against health care workers

We analysed 18 studies to determine the prevalence of physical violence encountered by health care workers in the Eastern Mediterranean Region throughout their careers, in the last year, in the previous 6 months, and in the last 2 months (Figure 2). The estimated frequency was 23.4% (95% CI: 16.1–32.0) (Table 5). There was significant heterogeneity among the studies reviewed (Q = 1224.4, P < 0.001, I2 = 99%). The prevalence of physical violence in the last year was calculated at 19.0% (95% CI: 15.4–22.6) by pooling the data reported from 51 studies showing high heterogeneity (Q = 4024.39, P < 0.001, I2 = 99%).

Studies reporting the frequency of physical violence encountered throughout the career were conducted in the Islamic Republic of Iran, Iraq, Jordan, Morocco, Saudi Arabia and Türkiye. Prevalence varied between 8.0% (95% CI: 0.5–15.5) and 39.5% (95% CI: 0.1–97.3) by country, with a statistically significant difference between countries for the prevalence of physical violence (P < 0.027) (Table 5). The prevalence of physical violence in the last year was reported in more studies, and the estimates ranged from 10.6% (95% CI: 2.2–19.1) to 42.2% (95% CI: 33.3–51.1). The frequency of being exposed to physical violence in the last year also differed significantly between countries (P < 0.001).

When the studies were analysed according to the occupation of the health care professionals, the highest frequency of physical violence throughout the career was reported in studies involving only physicians (31.0%; 95% CI: 9.5–52.5). For studies reporting physical violence during the previous year, the highest prevalence (23.4%, 95% CI: 17.0–29.9) was reported in those that included only nurses. There was no statistically significant difference between the frequency of physical violence according to the occupational group for both time intervals investigated (during career, P = 0.412; for the last year, P = 0.147).

For studies examining the frequency of physical violence throughout the career, the prevalence calculated for those conducted in 2011 and later (29.7%; 95% CI: 17.9–41.4) was statistically significantly higher than that for studies conducted over the previous years (15.6%; 95% CI: 10.3–21.0) (P = 0.033). In studies examining the frequency of physical violence during the previous year, there was no significant difference in prevalence between studies conducted in in these 2 periods (P = 0.564).

Studies included in the meta-analysis were further divided into subgroups based on sample size (< 355 and ≥ 355), response rate (< 70% and ≥ 70%) and quality score ( 0.05).

Prevalence of verbal violence against health care workers

We analysed 71 studies to determine the prevalence of verbal violence. Data from 17 studies reporting the frequency of exposure to verbal violence during the professional career were pooled and the frequency of verbal violence was estimated at 73.7% (95% CI: 67.8–80.4) (Table 5). The frequency of exposure to verbal violence in the last year was calculated at 59.9% (95% CI: 54.7–65.1) (data from 54 studies). Heterogeneity was found between studies examined for both time intervals (during career Q = 784.76, P < 0.001, I2 = 98%; Q = 10 150.03, P < 0.001, I2 = 99%). The prevalence of verbal violence encountered during the career, in the last year, last 6 months, and last 2 months, and heterogeneity between studies are shown in Figure 3.

When analysed by country of study, the frequency of verbal violence throughout the career ranged from 63.0% (95% CI 46.7–79.2) to 87.0% (95% CI 82.0–92.0) (Table 5). Data obtained from studies conducted in the Islamic Republic of Iran, Iraq, Jordan, Saudi Arabia and Türkiye showed a statistically significant difference (P < 0.001). The frequency reported from studies examining verbal violence over the last year ranged from 45.0% (95% CI 30.7–59.4) to 85.0% (95% CI 83.0–87.0) by country (Table 5). The highest prevalence, 85.0%, was reported from the Syrian Arab Republic, followed by the Islamic Republic of Iran, 80.7%, and Bahrain, 78.0%. There was also a significant difference between the countries included in the meta-analysis for prevalence of verbal violence in the last year (P < 0.001).

Studies that included only physicians reported the highest frequency of verbal violence throughout the career, with a prevalence of 77.0% (95% CI: 67.1–86.8) (Table 5). The frequency of verbal violence reported in the last year was highest in studies that included only nurses (65.5%; 95% CI: 56.9–74.1). However, there was no significant difference between the frequency of verbal violence according to occupational group for both time intervals (during career, P = 0.799; for the last year (P = 0.099).

The frequency of encountering verbal violence throughout the career was higher in studies conducted diring or after 2011. However, the difference was not statistically significant (P = 0.201) (Table 5). For studies conducted in 2010 and before reporting on encountering verbal violence during the last year, the frequency (67.9%; 95% CI: 58.3–77.4) was statistically significantly higher than in studies conducted in 2011 and after (55.9%; 95% CI: 50.1–61.7) (P = 0.035) (Table 5).

Studies included in the meta-analysis were divided into subgroups based on sample size (< 355 and ≥ 355), response rate (< 70% and ≥ 70%) and quality score ( 0.05).

Supplementary materials, including Doi plots and funnel plots, are available from the authors on request.

Discussion

In this study, we pooled the prevalence estimates of physical and verbal violence in the workplace against health professionals reported in 75 studies published from 1999 to 2021. A total of 69 024 health care professionals from 22 countries in the WHO Eastern Mediterranean Region and Türkiye having similar sociocultural characteristics were included in the study. Our meta-analysis revealed that 63.0% (95.0% CI: 58.0–68.0) of health care workers in the Eastern Mediterranean Region experienced verbal violence and 17.0% (95.0% CI: 14.0–21.0) were exposed to physical violence. During their career, 3 out of every 5 health professionals had been exposed to verbal violence and 1 out of 5 had been subjected to physical violence.

This study provides the first quantitative estimate of the prevalence of physical and verbal violence perpetrated against health professionals in the countries of the WHO Eastern Mediterranean Region. The prevalence estimates presented are based on a pool of 75 studies on health care professionals at all levels of care and various types of profession conducted in many countries in the Region.

Although studies from all countries in the Region were eligible for inclusion, there were none on the prevalence of physical and verbal violence from 10 countries, Afghanistan, Djibouti, Libya, Oman, Qatar, Somalia, Sudan, Tunisia, United Arab Emirates and Yemen. In addition, more than half of the eligible studies were reported from Türkiye (20 studies), Saudi Arabia (12 studies) and the Islamic Republic of Iran (11 studies). It is clear that more studies are needed from the low- and middle-income countries of the Region.

We determined the frequency of physical violence to be 23.4% throughout the career and 19.0% during the last year. Some reviews we examined focused on the prevalence of physical violence in the workplace for health professionals; a wide range of frequencies (2% to 32%) was reported (3,23,24). Li et al., who presented the prevalence estimates of physical violence in all WHO regions and the world in 2018, determined the prevalence of physical violence in the last year in the Eastern Mediterranean Region at 17.1% (12). Corresponding results for other WHO regions were: Africa 20.7%; America 23.6%; Europe 26.4%; Western Pacific 14.5%; Southeast Asia 5.6%; and worldwide 19.3%. Our estimation for the Eastern Mediterranean Region was similar to the world value and higher than some regions (Western Pacific and Southeast Asia) reported by Li et al.

We found the frequency of verbal violence against health care providers was 73.7% during the career and 59.9% for the last year. Previous meta-analyses have reported the frequency of verbal violence from different regions or the frequency of verbal violence experienced by a specific health care profession group in the Eastern Mediterranean Region (25,26). In a 2019 meta-analysis, which included studies from 5 regions of the world, the frequency of exposure to non-physical violence in the last year was 42.5%. The highest frequency was reported from North America (58.7%), followed by Asia (45.5%) and Australia (38.7%). In the same study, the most common subtypes of non-physical violence were 57.6% for verbal abuse and 33.2% for threats (3). In an umbrella review and meta-analysis examining violence against health care professionals, the prevalence of verbal violence was 66.8% (27). In a meta-analysis encompassing studies in China, the frequency of verbal abuse was 61.2% and the frequency of threat 39.4% (10). In all the meta-analyses cited above, the frequency of verbal violence was freater than that of physical violence (3,10,27), similar to our own findings.

In the subgroup analysis, we found no statistically significant relationship between the prevalence estimates for physical and verbal violence that health professionals were exposed to during the career and in the last year or less and sample size, response rate, quality score or professional group. The meta-analysis by Li et al. reported that the prevalence estimates were significantly higher in studies with a sample size ≤ 500, a quality score < 5 or a low response rate (12). However, it has also been found that studies with fewer participants may be associated with higher prevalence estimates that could be attributed to selection bias and publication bias (28). In a 2019 systematic review that evaluated workplace violence as physical and non-physical, nurses had the highest exposure to any type of violence, followed by doctors and other health professionals (3). In another systematic review, nurses were exposed to physical violence more frequently than doctors (12). It is clear that further studies are needed to provide more evidence about violence against health professionals in the workplace.

Our findings indicated that there was a significant difference between countries in terms of the frequency of verbal and physical violence, both throughout the career and during the last year. Data on the frequency of verbal and physical violence throughout the career were available from only 6 countries. Only one study covering 2 countries (Iraq and Jordan) was included in the meta-analysis. These findings suggest that more studies are needed to examine the frequency of physical and verbal violence throughout the career in countries in the Region. The frequency of verbal violence in the last year has been reported in more countries and more studies, however, analysis of publication bias revealed major asymmetry between studies. The results reporting the prevalence of violence in the last year should be carefully evaluated due to the small number of countries involved, the results relating to the frequency of violence throughout the career, and the major asymmetry from publication bias. It should, however, be taken into account that each country has its own particular working environment and conditions and geographical and cultural differences in the perception of violence, and that any standard definition and measurement of violence are not included in the studies.

We found that the year of publication was correlated with the prevalence estimates. In studies conducted in 2011 and later, physical violence throughout the career was significantly more prevalent than in those conducted in 2010 and before. For verbal violence, frequency in the last year was 67.9% in studies published in 2010 and before. This was significantly higher than the results for later years. In contrast, in our study we did not find any significant relationship reported in other systematic reviews on violence in health settings (3,12). The fact that more recent studies reported a higher prevalence of violence in our meta-analysis may be due to the increase in violence in the last decade, or it may be a result of an increase in awareness about workplace violence. Also, the number of studies conducted on violence in health has seen an increase over the past decade, with only 23 of the 75 studies dating from 2010 or earlier.

Our study had certain strengths and weaknesses. There was no standard measurement method in studies conducted to evaluate workplace violence among health professionals. There were definitional differences in terms of severity and typs. The time intervals in which violence was investigated differed in the studies we included. For this reason, we need to consider bias in recall studies that assess long-term violence (for example, throughout the career). The studies examined were analysed according to characteristics such as sample size, quality score and year of study; even so, it should be considered that many other factors may affect the frequency of violence when examining the results. For example, the frequency of violence encountered throughout the career may be greater in older participants, and some participants may not report the violence they have been exposed to for fear of losing their job. A particular behaviour perceived as violence in one society may be perceived as normal in another; a circumstance that may be misleading when comparing results.

Along with these limitations, our research also had some strengths. As far as we know, this is the first study in which physical and verbal violence related to the Eastern Mediterranean Region, which covers a vast geographical area and many countries, are examined together.In addition, within the scope of the study, the frequencies of both physical and verbal violence were discussed separately during the whole career and in the last year. This has allowed the frequency of violence to be discussed for specific time intervals.

Conclusion

Different questionnaires and different time intervals were used in the studies examined. This makes it difficult to calculate a standard severity prevalence and compare subgroups. Using a standard questionnaire in future studies would provide clearer results. In addition, practical interventions in the health sector are still urgently needed. In future research, it would be helpful to examine the temporal trend of workplace violence by country to determine how country-specific social factors and policies affect it and to investigate the causes of violence and methods for prevention.

Funding: None.

Competing interests: None declared.

References

1. Preventing violence against health workers. Geneva: World Health Organization; 2022 (https://www.who.int/activities/preventing-violence-against-health-workers, accessed 1 April 2023).

2. Violence and harassment. Geneva: World Health Organization; 2022 (https://www.who.int/tools/occupational-hazards-in-health-sector/violence-harassment, accessed 1 April 2023).

3. Liu J, Gan Y, Jiang H, Li L, Dwyer R, Lu K, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med. 2019; 76(12):927–37. doi:10.1136/oemed-2019-105849.

4. Framework guidelines for addressing workplace violence in the health sector/Joint Programme on Workplace Violence in the Health Sector. Geneva: International Labour Office, International Council of Nurses, World Health Organization, Public Services International; 2002 (https://apps.who.int/iris/handle/10665/42617, accessed 1 April 2023).

5. Jenkins L. Current intelligence bulletin 57. Violence in the workplace. Risk factors and prevention strategies. Cincinnati: Centers for Disease Control and Prevention/NIOSH; 1996 (Publication No. 96-100; https://www.cdc.gov/niosh/docs/96-100/, accessed 1 April 2023).

6. Li P, Xing K, Qiao H, Fang H, Ma H, Jiao M, et al. Psychological violence against general practitioners and nurses in Chinese township hospitals: incidence and implications. Health Qual Life Outcomes. 2018;16(1):1–10. doi:10.1186/s12955-018-0940-9

7. Xing K, Zhang X, Jiao M, Cui Y, Lu Y, Liu J, et al. Concern about workplace violence and its risk factors in Chinese Township Hospitals: a cross-sectional study. Int. J. Environ. Res. Public Health. 2016;13(8):811. doi:10.3390/ijerph13080811

8. Cetinkaya F, Dur N, Akbulut Z, Korkmaz M. Evaluation of the violence experienced by nurses of different generations and their strategies for coping with the stress resulting from violence. Int J Caring Sci. 2018;11(3):1756–62 (https://internationaljournalofcaringsciences.org/docs/48_centicaya_original_11_3.pdf, accessed 10 April 2023).

9. Work-related violence and its integration into existing surveys. Geneva: International Labour Organization, Department of Statistics; 2013:13. (https://www.ilo.org/public/libdoc//ilo/2013/113B09_220_engl.pdf, accessed 16 November 2022).

10. Lu L, Dong M, Wang S bin, Zhang L, Ng CH, Ungvari GS, et al. Prevalence of workplace violence against health-care professionals in China: a comprehensive meta-analysis of observational surveys. Trauma Violence Abuse. 2020;21(3):498–509. doi:10.1177/1524838018774429

11. Violence: occupational hazards in hospital. Cincinnati: Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; 2002 (https://www.cdc.gov/niosh/docs/2002-101/pdfs/2002-101.pdf?id=10.26616/NIOSHPUB2002101, accessed 18 November 2022).

12. Li YL, Li RQ, Qiu D, Xiao SY. Prevalence of workplace physical violence against health care professionals by patients and visitors: a systematic review and meta-analysis. Int J Environ Res Public Health. 2020;17(1):299. doi:10.3390/ijerph17010299

13. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement. J Clin Epidemiol. 2021 Jun;134:103–12. doi: 10.1016/j.jclinepi.2021.02.003

14. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000 Apr 19;283(15):2008–12. doi: 10.1001/jama.283.15.2008

15. Loney PL, Chambers LW, Bennett KJ, Roberts JG, Stratford PW. Critical appraisal of the health research literature: prevalence or incidence of a health problem. Chronic Dis Can, 1998;19(4): 170–6. PMID:10029513

16. Furuya-Kanamori L, Barendregt JJ, Doi SA. A new improved graphical and quantitative method for detecting bias in meta-analysis. Int J Evid Based Healthc. 2018;16(4):195–203. doi:10.1097/XEB.0000000000000141

17. Lin L, Chu H. Quantifying publication bias in meta-analysis. Biometrics. 2018;74(3):785–94. doi:10.1111/biom.12817

18. Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, Botella J. Assessing heterogeneity in meta-analysis: Q statistic or I2 index? Psychol Methods. 2006;11(2):193. doi:10.1037/1082-989X.11.2.193

19. Erickson L, Williams-Evans SA. Attitudes of emergency nurses regarding patient assaults. J. Emerg. Nurs. 2000;26(3);210–5. doi:10.1016/S0099-1767(00)90092-8

20. Valentine JC, Pigott TD, Rothstein HR. How many studies do you need? A primer on statistical power for meta-analysis. J Educ Behav Stat. 2010;35(2):215–47. doi:10.3102/1076998609346961

21. Bayram B, Cetin M, Oray NC, Can IO. Workplace violence against physicians in Turkey’s emergency departments: a cross-sectional survey. BMJ Open. 2017;7,e013568. doi:10.1136/bmjopen-2016-013568

22. Kitaneh M, Hamdan M. Workplace violence against physicians and nurses in Palestinian public hospitals: a cross-sectional study. BMC Health Serv Res. 2012;12:469. doi:10.1186/1472-6963-12-469

23. Hahn S, Zeller A, Needham I, Kok G, Dassen T, Halfens RJG. Patient and visitor violence in general hospitals: A systematic review of the literature. Aggress Violent Behav. 2008;13(6):431–41. doi:10.1016/j.avb.2008.07.001

24. Nikathil S, Olaussen A, Gocentas RA, Symons E, Mitra B. Workplace violence in the emergency department: A systematic review and meta-analysis. Emerg Med Australas. 2017;29(3):265–75. doi:10.1111/1742-6723.12761

25. D’Ettorre G, Mazzotta M, Pellicani V, Vullo A. Preventing and managing workplace violence against healthcare workers in emergency departments. Acta Biomed. 2018;89(4-S):28–36. doi:10.23750/abm.v89i4-S.7113

26. Aljohani B, Burkholder J, Tran QK, Chen C, Beisenova K, Pourmand A. Workplace violence in the emergency department: a systematic review and meta-analysis. Public Health. 2021;196:186–97. doi:10.1016/j.puhe.2021.02.009

27. Sahebi A, Golitaleb M, Moayedi S, Torres M, Sheikhbardsiri H. Prevalence of workplace violence against health care workers in hospital and pre-hospital settings: an umbrella review of meta-analyses. Front Public Health. 2022;10:895818. doi:10.3389/fpubh.2022.895818

28. Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, et al. Prevalence of depression and depressive symptoms among resident physicians: systematic review and meta-analysis. JAMA. 2015; 314(22):2373–83. doi:10.1001/jama.2015.15845

References for studies included in this review

Abbas MAF, Fiala LA, Rahman AGA, Fahim AE. Epidemiology of workplace violence against nursing staff in Ismailia Governorate, Egypt. J Egypt Public Health Assoc. 2010;85(1):16. PMID:21073846

Abdellah RF, Salama KM. Prevalence and risk factors of workplace violence against health care workers in emergency department in Ismailia, Egypt. Pan Afr Med J. 2017;26:21. doi:10.11604/pamj.2017.26.21.10837

Abou-ElWafa HS, El-Gilany AH, Abd-El-Raouf SE, Abd-Elmouty SM, El-Sayed Hassan El-Sayed R. Workplace violence against emergency versus non-emergency nurses in Mansoura university hospitals, Egypt. J Interpers Violence. 2015;30(5):857–72. doi:10.1177/0886260514536278

AbuAlRub RF, Khalifa MF, Habbib MB. Workplace violence among Iraqi hospital nurses. J Nurs Scholarsh. 2007;39(3):281–8. doi:10.1111/j.1547-5069.2007.00181.x

AbuAlRub RF, Al-Asmar AH. Psychological violence in the workplace among Jordanian hospital nurses. J Transcult Nurs. 2014;25(1):6–14. doi:10.1177/1043659613493330

Acik Y, Deveci SE, Gunes G, Gulbayrak C, Dabak S, Saka G, vd. Experience of workplace violence during medical speciality training in Turkey. Occup Med. 2008;58(5):361–6. doi:10.1093/occmed/kqn045

Adib SM, Al-Shatti AK, Kamal S, El-Gerges N, Al-Raqem M. Violence against nurses in healthcare facilities in Kuwait. Int J Nurs Stud. 2002;39(4):469–78. doi:10.1016/s0020-7489(01)00050-5

Ahmed AS. Verbal and physical abuse against Jordanian nurses in the work environment. East Mediterr Health J. 2012;18(4):318–24. doi:10.26719/2012.18.4.318.

Akbolat M, Sezer C, Unal O, Amarat M, Durmus A. The effects of direct violence and witnessed violence on the future fear of violence and turnover intention: A study of health employees. Curr Psychol. 2021;40(9):4684–90. doi:10.1007/s12144-019-00410-x

Alameddine M, Kazzi A, El-Jardali F, Dimassi H, Maalouf S. Occupational violence at Lebanese emergency departments: prevalence, characteristics and associated factors. J Occup Health. 2011;53(6):455–64. doi:10.1539/joh.11-0102-oa

Alameddine M, Mourad Y, Dimassi H. A national study on nurses’ exposure to occupational violence in Lebanon: prevalence, consequences and associated factors. PLOS ONE. 2015;10(9):e0137105. doi:10.1371%2Fjournal.pone.0137105

Al Anazi RB, AlQahtani SM, Mohamad AE, Hammad SM, Khleif H. Violence against health-care workers in governmental health facilities in Arar City, Saudi Arabia. Sci World J. 2020 Mar 20;2020:6380281. doi:10.1155/2020/6380281

AlBashtawy M, Al-Azzam M, Rawashda A, Batiha AM, Bashaireh I, Sulaiman M. Workplace violence toward emergency department staff in Jordanian hospitals: a cross-sectional study. J Nurs Res. Mart 2015;23(1):75–81. doi:10.1097/jnr.0000000000000075

Albashtawy M. Workplace violence against nurses in emergency departments in Jordan. Int Nurs Rev. 2013;60(4):550–5. doi:10.1111/inr.12059

Algwaiz WM, Alghanim SA. Violence exposure among health care professionals in Saudi public hospitals. A preliminary investigation. Saudi Med J. Ocak 2012;33(1):76–82. PMID:22273653

Alhamad R, Suleiman A, Bsisu I, Santarisi A, Owaidat AA, Sabri A et al. Violence against physicians in Jordan: An analytical cross-sectional study. PLOS ONE. 2021;16(1):e0245192. doi:10.1371/journal.pone.0245192

Alharbi FF, Alzneidi NA, Aljbli GH, Morad SA, Alsubaie EG, Mahmoud SA et al. Workplace violence among healthcare workers in a tertiary medical city in Riyadh: a cross-sectional study. Cureus. 2021;13(5). doi:10.7759/cureus.14836

Al-Omari H. Physical and verbal workplace violence against nurses in Jordan. Int Nurs Rev. 2015;62(1):111–8. doi:10.1111/inr.12170

Al-Omari H, Khait AA, Al-Modallal H, Al-Awabdeh E, Hamaideh S. Workplace violence against nurses working in psychiatric hospitals in Jordan. Arch Psychiatr Nurs. 2019;33(5):58–62. doi:10.1016/j.apnu.2019.08.002

Alqahtani MA, Alsaleem SA, Qassem MY. Physical and verbal assault on medical staff in emergency hospital departments in Abha City, Saudi Arabia. Middle East J Fam Med. 2020;18(2):94–100. doi:10.5742MEWFM.2020.93753

Alsaleem SA, Alsabaani A, Alamri RS, Hadi RA, Alkhayri MH, Badawi KK, vd. Violence towards healthcare workers: A study conducted in Abha City, Saudi Arabia. J Fam Community Med. 2018;25(3):188–93. doi:10.4103/jfcm.JFCM_170_17

Al-Shaban ZR, Al-Otaibi ST, Alqahtani HA. Occupational violence and staff safety in health-care: a cross-sectional study in a large public hospital. Risk Manag Healthc Policy. 2021;14:1649–57. doi:10.2147/RMHP.S305217

Alshahrani M, Alfaisal R, Alshahrani K, Alotaibi L, Alghoraibi H, Alghamdi E et al. Incidence and prevalence of violence toward health care workers in emergency departments: a multicenter cross-sectional survey. Int J Emerg Med. 2021;14(1):1–8. doi:10.1186/s12245-021-00394-1

Al-Shamlan NA, Jayaseeli N, Al-Shawi MM, Al-Joudi AS. Are nurses verbally abused? A cross-sectional study of nurses at a university hospital, Eastern Province, Saudi Arabia. J Fam Community Med. 2017;24(3):173–80. doi:10.4103/jfcm.JFCM_45_17

Alsmael MM, Gorab AH, AlQahtani AM. Violence against healthcare workers at primary care centers in Dammam and Al Khobar, Eastern Province, Saudi Arabia. Int J Gen Med. 2020;13:667–76. doi:10.2147/IJGM.S267446

Arafa A, Shehata A, Youssef M, Senosy S. Violence against healthcare workers during the COVID-19 pandemic: a cross-sectional study from Egypt. Arch Environ Occup Health. 2021;1–7. doi:10.1080/19338244.2021.1982854

Atawneh FA, Zahid MA, Al-Sahlawi KS, Shahid AA, Al-Farrah MH. Violence against nurses in hospitals: prevalence and effects. Br J Nurs. 2003;12(2):102–7. doi:10.12968/bjon.2003.12.2.11049

Ayranci U. Violence toward health care workers in emergency departments in west Turkey. J Emerg Med. 2005;28(3):361–365. doi:10.1016/j.jemermed.2004.11.018

Ayranci U, Yenilmez C, Balci Y, Kaptanoglu C. Identification of violence in Turkish health care settings. J Interpers Violence. 2006;21(2):276–96. doi:10.1177/0886260505282565

Baig LA, Shaikh S, Polkowski M, Ali SK, Jamali S, Mazharullah L et al. Violence against health care providers: A mixed-methods study from Karachi, Pakistan. J Emerg Med. 2018;54(4):558–66. doi:10.1016/j.jemermed.2017.12.047

Baykan Z, Oktem İS, Cetinkaya F, Nacar M. Physician exposure to violence: a study performed in Turkey. Int J Occup Saf Ergon. 2015;21(3):291–7. doi:10.1080/10803548.2015.1073008

Bayram B, Cetin M, Oray NC, Can IO. Workplace violence against physicians in Turkey’s emergency departments: a cross-sectional survey. BMJ Open. 2017;7(6):1–10. doi:10.1136/bmjopen-2016-013568

Belayachi J, Berrechid K, Amlaiky F, Zekraoui A, Abouqal R. Violence toward physicians in emergency departments of Morocco: prevalence, predictive factors, and psychological impact. J Occup Med Toxicol. 2010;5(1):1–7. doi:10.1186/1745-6673-5-27

Boz B, Acar K, Ergin A, Erdur B, Kurtulus A, Turkcuer I, et al. Violence toward health care workers in emergency departments in Denizli, Turkey. Adv Therapy. 2006;23(2):364–9. doi:10.1007/BF02850142

Cevik M, Gumustakim RS, Bilgili P, Ayhan Baser D, Doganer A, Saper SHK. Violence in healthcare at a glance: The example of the Turkish physician. Int J Health Plann Mgmt. 2020;35:1559–70. doi:10.1002/hpm.3056

Coskun SC. An analysis of the exposure to violence and burnout levels of ambulance staff. Turk J Emerg Med. 2019;19(1):21–5. doi:10.1016/j.tjem.2018.09.002

Darawad MW, Al-Hussami M, Saleh AM, Mustafa WM, Odeh H. Violence against nurses in emergency departments in Jordan: nurses’ perspective. Workplace Health Saf. 2022;63(1):9–17. doi:10.1177/2165079914565348

Demirci S, Ugurluoglu, O. An evaluation of verbal, physical, and sexual violence against healthcare workers in Ankara, Turkey. J Forensic Nurs. 2020;16(4):E33–E41. doi:10.1097/JFN.0000000000000286

Emam, GH, Alimohammadi H, Sadrabad AZ, Hatamabadi H. Workplace violence against residents in emergency department and reasons for not reporting them; a cross sectional study. Emerg (Tehran). 2018;6(1):e7. PMID:29503832

Erdur B, Ergin A, Yuksel A, Turkcuer I, Ayrık C, Boz B. Assessment of the relation of violence and burnout among physicians working in the emergency departments in Turkey. Ulus Travma Derg.2015;21(3):175–81. doi:10.5505/tjtes.2015.91298

Esmaeilpour M, Salsali M, Ahmadi F. Workplace violence against Iranian nurses working in emergency departments. Int Nurs Rev. 2011;58(1):130–7. doi:10.1111/j.1466-7657.2010.00834.x

Fallahi-Khoshknab M, Oskouie F, Najafi F, Ghazanfari N, Tamizi Z, Ahmadvand H. Psychological violence in the health care settings in Iran: a cross-sectional study. Nurs Midwifery Stud. 2015;4(1):1–6. doi:10.17795/nmsjournal24320

Fallahi-Khoshknab M, Oskouie F, Najafi F, Ghazanfari N, Tamizi Z, Afshani S. Physical violence against health care workers: a nationwide study from Iran. Iran J Nurs Midwifery Res. 2016;21(3):232–8. doi:10.4103/1735-9066.180387

Ghareeb NS, El-Shafei DA, Eladl AM. Workplace violence among healthcare workers during COVID-19 pandemic in a Jordanian governmental hospital: the tip of the iceberg. Environ Sci Pollut Res. 2021;28(43):61441–9. doi:10.1007/s11356-021-15112-w

Gunaydın N, Kutlu Y. Experience of workplace violence among nurses in health-care settings. J Psychiatr Nurs. 2012;3(1):1–5. doi:10.5505/phd.2012.32042

Hamdan M, Abu Hamra A. Workplace violence towards workers in the emergency departments of Palestinian hospitals: a cross-sectional study. Hum Resour Health. 2015;13(1):28. doi:10.1186/s12960-015-0018-2

Hamzaoglu N, Turk B. Prevalence of physical and verbal violence against health care workers in Turkey. Int J Soc Determinants of Health and Health Services. 2019;49(4):844–61. doi:10.1177/0020731419859828

Harthi M, Olayan M, Abugad H, Abdel Wahab M. Workplace violence among health-care workers in emergency departments of public hospitals in Dammam, Saudi Arabia. East Mediterr Health J. 2020;26(12):1473–81. doi:10.26719/emhj.20.069

Honarvar B, Ghazanfari N, Raeisi Shahraki H, Rostami S, Bagheri Lankarani K. Violence against nurses: A neglected and healththreatening epidemic in the university affiliated public hospitals in Shiraz, Iran. Int J Occup Environ Med. 2019;10(3):111–23. doi:10.15171/ijoem.2019.1556

Jafree SR. Workplace violence against women nurses working in two public sector hospitals of Lahore, Pakistan. Nurs Outlook. 2017;65(4):420–7. doi:10.1016/j.outlook.2017.01.008

Jaradat Y, Nielsen MB, Bast-Pettersen R. Psychosomatic symptoms among Palestinian nurses exposed to workplace aggression. Am J Ind Med. 2018;61(6):533–7. doi:10.1002/ajim.22851

Khademloo M, Moonesi FS, Gholizade H. Health care violence and abuse towards nurses in hospitals in North of Iran. Glob J Health Sci. 2013;5(4):211–6. doi:10.5539/gjhs.v5n4p211

Khan MN, Haq ZU, Khan M, Wali S, Baddia F, Rasul S et al. Prevalence and determinants of violence against health care in the metropolitan city of Peshawar: a cross sectional study. BMC Public Health. 2021;21(1):330. doi:10.1186/s12889-021-10243-8

Kisa S. Turkish nurses’ experiences of verbal abuse at work. Arch Psychiatr Nurs. 2008;22(4):200–7. doi:10.1016/j.apnu.2007.06.013

Kitaneh M, Hamdan M. Workplace violence against physicians and nurses in Palestinian public hospitals: a cross-sectional study. BMC Health Serv Res. 2012;12(1):469. doi:10.1186/1472-6963-12-469

Lafta RK, Falah N. Violence against health-care workers in a conflict affected city. Med Confl Surviv. 2019;35(1):65–79. doi:10.1080/13623699.2018.1540095

Mirza NM, Amjad AI, Bhatti ABH, Mirza F, Shaikh KS, Kiani J et al. Violence and abuse faced by junior physicians in the emergency department from patients and their caretakers: a nationwide study from Pakistan. J Emerg Med. 2012;42(6):727–33. doi:10.1016/j.jemermed.2011.01.029

Mohamad O, AlKhoury N, Abdul-Baki MN, Alsalkini M, Shaaban R. Workplace violence toward resident doctors in public hospitals of Syria: prevalence, psychological impact, and prevention strategies: a cross-sectional study. Hum Resour Health. 2021;19(1):8. doi:10.1186/s12960-020-00548-x

Oztok B, Icme F, Kavakli H, Gunaydin G, Sener A, Celi̇k G. Evaluation of violence against emergency physicians in Turkey. Eurasian J Emerg Med. 2018;17(4):182–6. doi:10.5152/eajem.2018.20982

Oztunç G. Examination of incidents of workplace verbal abuse against nurses. J Nurs Care Qual. 2006;21(4):360–5. doi:10.1097/00001786-200610000-00014

Pinar T, Acikel C, Pinar G, Karabulut E, Saygun M, Bariskin E et al. Workplace violence in the health sector in Turkey: a national study. J Interpers Violence. 2017;32(15):2345–65. doi:10.1177/0886260515591976.

Picakciefe M, Akca S, Elibol A, Deveci A, Yilmaz N, Yilmaz UE. The analysis of violence against the nurses who are in employee status in Mugla State Hospital, Turkey. HealthMED. 2012;6(11):3626–37.

Rafeea F, Al Ansari A, Abbas EM, Elmusharaf K, Abu Zeid MS. Violence toward health workers in Bahrain Defense Force Royal Medical Services’ Emergency Department. Open Access Emerg Med. 2017;8(9):113–21. doi:10.2147/OAEM.S147982.

Rahmani A, Hassankhani H, Mills J, Dadashzadeh A. Exposure of Iranian emergency medical technicians to workplace violence: a cross‐sectional analysis. Emerg Med Australasia (EMA). 2012;24(1):105–10. doi:10.1111/j.1742-6723.2011.01494.x.

Sadrabad AZ, Bidarizerehpoosh F, Farahmand Rad R, Kariman H, Hatamabadi H, Alimohammadi H. Residents’ experiences of abuse and harassment in emergency departments. J Interpers Violence. 2019;34(3):642–52. doi:10.1177/0886260516645575

Samir N, Mohamed R, Moustafa E, Abou Saif H. Nurses’ attitudes and reactions to workplace violence in obstetrics and gynaecology departments in Cairo hospitals. East Mediterr Health J. 2012;18(3):198–204. doi:10.26719/2012.18.3.198

Sani SG, Tabrizi FJ, Rahmani A, Sarbakhsh P, Zamanzadeh V, Dickens GL. Resilience and its relationship with exposure to violence in emergency nurses. Nurs Midwifery Stud. 2020;9(4):222–8. doi:10.4103/nms.nms_6_20

Shaikh S, Baig LA, Hashmi I, Khan M, Jamali S, Khan MN et al. The magnitude and determinants of violence against healthcare workers in Pakistan. BMJ Glob Health. 2020;5(4):e002112. doi:10.1136/ bmjgh-2019-002112

Shoghi M, Sanjari M, Shirazi F, Heidari S, Salemi S, Mirzabeigi G. Workplace violence and abuse against nurses in hospitals in Iran. Asian Nurs Res. 2008;2(3):184–93. doi:10.1016/S1976-1317(08)60042-0

Teymourzadeh E, Rashidian A, Arab M, Akbari-Sari A, Hakimzadeh SM. Nurses exposure to workplace violence in a large teaching hospital in Iran. Int J Health Policy Manag. 2014;3(6):301. doi:10.15171/ijhpm.2014.98

Towhari AA, Bugis BA. The awareness of violence reporting system among healthcare providers and the impact of new ministry of health violence penalties in Saudi Arabia. Risk Manag Healthc Policy. 2020;13:2057–65. doi:10.2147/RMHP.S258106

Turki N, Afify AA, AlAteeq M. Violence against health workers in family medicine centers. J Multidiscip Healthc. 2016;9:257–66. doi:10.2147/JMDH.S105407

Uzun O. Perceptions and experiences of nurses in Turkey about verbal abuse in clinical settings. J Nurs Scholarsh. 2003;35(1):81–5. doi:10.1111/j.1547-5069.2003.00081.x

Unsal Atan S, Baysan Arabaci L, Sirin A, Isler A, Donmez S, Unsal Guler M et al. Violence experienced by nurses at six university hospitals in Turkey. J Psychiatr Ment Health Nurs. 2013;20:882–9. doi:10.1111/jpm.12027

Zafar W, Khan R, Siddiqui SA, Jamali S, Razzak JA. Workplace violence and self-reported psychological health: coping with post-traumatic stress, mental distress, and burnout among physicians working in the emergency departments compared to other specialties in Pakistan. J Emerg Med. 2016;50(1):167–77. doi:10.1016/j.jemermed.2015.02.049

Database

Terms

PubMed

((dentist OR Oral healthcare workers OR dental professionals OR dental assistant OR dental hygienists) AND (“Aggression” OR “Violence” OR “Abuse*” OR “Sex Offense*” OR “Occupational Injur*” OR "Assault” OR “Bullying” OR “Harassment” OR “Threat*” OR “Attack” ) NOT (child Abuse)) Workplace (“Physician*” OR “Medical Staff” OR “Health* Personnel” OR “Health* worker*” OR “Health* employee*” OR "Health* worker” OR "Health* professional” OR "Health* provider” OR “Nurs*” OR “Health* staff” OR “Doctor” OR “Dent*” OR "Radiologist” OR “Radiographer” OR “Pharmacist*” OR "Assistant”) “Physician*” OR “Medical Staff” OR “Nurs*” OR "Doctor” OR "Dent*” OR “Radiologist” OR “Radiographer" OR “Pharmacist*” OR "Assistant" OR “General practitioner*” OR ((“Health*" AND (“Personnel” OR “Worker*” OR “Employee*” OR “Professional” OR “Provider” OR “Staff”)) “caregivers*” OR “care-giver*” OR “case managers” OR “case manager*” OR “GP” “home carer*” OR “social care worker*” OR “OR “social worker*” OR “community worker*” (“East* Mediterrenian” OR “Turk*" OR "Iraq*" OR "Syria*” OR “Iran*” OR “Afghan*” OR “Bahrain*” OR “Djibouti*” OR “Egypt*” OR “Jordan*” OR “Kuwait*” OR “Leban*” OR “Libya*” OR “Morocc*” OR “Oman*” OR “Palestin*” OR “Pakistan*” OR “Qatar*” OR “Saudi Arab*” OR “Somali*” OR “Sudan*” OR “Tunisia*” OR “United Arab Emirates” OR “Yemen*")

Cochrane Library

((dentist OR Oral healthcare workers OR dental professionals OR dental assistant OR dental hygienists) AND (violence OR bullying OR threats OR harassment))

Scopus

((dentist OR Oral healthcare workers OR dental professionals OR dental assistant OR dental hygienists) AND (violence OR bullying OR threats OR harassment))

Science Direct

(((dentist OR dental assistant OR dental hygienists) AND (violence OR bullying OR harassment)) AND (Cross-section OR Crosssectional) NOT (Child Abuse)))

Web of Science

((dentist OR Oral healthcare workers OR dental professionals OR dental assistant OR dental hygienists) AND (violence OR bullying OR threats OR harassment) NOT (child Abuse))

ProQuest

((dentist OR Oral healthcare workers OR dental professionals OR dental assistant OR dental hygienists) AND (violence OR bullying OR threats OR harassment))


Table 2. Loney criteria quality scores for 75 studies from the WHO Eastern Mediterranean Region and Türkiye conducted during 1999–2021

Study

Country

Loney criteriona

Total quality score

1

2

3

4

5

6

7

8

Abbas et al. 2010

Egypt

1

1

1

0

0

0

1

1

5

Abdellah et al. 2017

Egypt

0

0

0

0

0

1

1

1

3

Abou-ElWafa et al. 2015

Egypt

1

1

0

1

0

1

1

1

6

Abualrub et al. 2007

Iraq

0

0

0

1

0

1

0

1

4

Abualrub et al. 2014

Jordan

0

0

1

1

0

1

0

1

4

Acik et al. 2008

Türkiye

1

1

1

1

0

1

1

1

7

Adib et al. 2002

Kuwait

1

1

1

1

0

1

0

1

6

Ahmed, 2012

Jordan

1

0

1

1

1

1

0

0

5

Akbolat et al. 2021

Türkiye

1

1

0

1

1

1

0

1

6

Al Anazi et al. 2020

Saudi Arabia

1

1

0

0

1

1

1

1

6

Alameddine et al. 2011

Lebanon

1

1

0

1

1

1

1

1

7

Alameddine et al. 2015

Lebanon

1

0

1

0

1

0

0

1

4

AlBashtawy et al. 2013

Jordan

0

0

1

1

0

0

0

1

3

AlBashtawy, 2013

Jordan

0

1

0

1

0

0

1

1

4

Algwaiz et al. 2012

Saudi Arabia

1

1

1

1

0

0

1

1

6

Alhamad et al. 2021

Jordan

1

1

1

0

1

0

0

0

4

Alharbi et al. 2021

Saudi Arabia

0

1

1

1

0

1

0

1

5

Al-Omari et al. 2015

Jordan

1

1

1

1

1

1

0

0

6

Al-Omari et al. 2019

Jordan

0

0

0

1

1

0

0

0

2

Alqahtani et al. 2020

Saudi Arabia

0

0

0

1

1

1

1

1

5

Alsaleem et al. 2018

Saudi Arabia

1

0

1

1

1

1

1

1

7

Al-Shaban et al. 2021

Saudi Arabia

0

1

0

1

1

1

1

1

6

Alshahrani et al. 2021

Saudi Arabia

1

1

1

0

1

1

0

1

6

Alshamlan et al. 2017

Saudi Arabia

1

1

1

1

0

1

1

1

7

Alsmael et al. 2020

Saudi Arabia

1

1

1

0

1

0

1

1

6

Arafa et al. 2022

Egypt

0

0

0

1

0

0

1

1

3

Atawneh et al. 2003

Kuwait

1

1

0

1

0

1

1

0

5

Ayranci et al. 2005

Türkiye

0

0

0

1

1

1

1

1

5

Ayranci et al. 2006

Türkiye

1

1

1

1

0

1

1

1

7

Baig et al. 2018

Pakistan

0

0

1

1

0

1

1

1

5

Baykan et al. 2015

Türkiye

1

0

1

1

1

1

1

1

7

Bayram et al. 2017

Türkiye

1

1

1

1

1

1

1

1

8

Belayachi et al. 2010

Morocco

1

0

0

1

0

0

1

0

3

Boz et al. 2006

Türkiye

0

0

0

1

0

0

0

0

1

Cevik et al. 2020

Türkiye

0

0

1

0

0

1

0

0

2

Coskun, 2019

Türkiye

0

0

0

1

0

0

1

1

3

Darawad et al. 2015

Jordan

0

0

0

1

0

0

1

1

3

Demirci et al. 2020

Türkiye

1

1

1

1

0

1

1

1

7

Emam et al. 2018

Iran, IR

1

0

0

1

0

1

1

1

5

Erdur et al. 2015

Türkiye

1

1

0

0

0

1

1

1

5

Esmaeilpour et al. 2011

Iran, IR

0

0

0

1

1

1

0

0

3

Fallahi-Khoshknab et al. 2015

Iran, IR

1

1

1

1

0

1

1

1

7

Fallahi-Khoshknab et al. 2016

Iran, IR

1

0

1

0

1

1

1

1

6

Ghareeb et al. 2021

Jordan

1

1

1

1

0

1

0

1

6

Gunaydın et al. 2012

Türkiye

1

1

1

1

0

0

0

1

5

Hamdan et al. 2015

Palestine

1

1

1

1

1

1

1

1

8

Hamzaoglu et al. 2019

Türkiye

0

1

1

0

0

1

1

1

5

Harthi et al. 2020

Saudi Arabia

0

0

0

1

0

1

1

1

4

Honarvar et al. 2019

Iran, IR

1

1

1

1

0

1

1

1

7

Jafree, 2017

Pakistan

1

1

0

1

0

0

1

1

5

Jaradat et al. 2018

Palestine

0

0

0

0

0

1

1

1

3

Khademloo et al. 2013

Iran, IR

1

0

0

1

1

1

0

0

4

Khan et al. 2021

Pakistan

1

1

1

1

1

0

1

1

7

Kisa et al. 2008

Türkiye

1

1

0

1

0

1

0

1

5

Kitaneh et al. 2012

Palestine

1

1

0

1

1

1

1

1

7

Lafta et al. 2019

Iraq

1

1

1

1

1

1

1

1

8

Mirza et al. 2012

Pakistan

1

0

1

1

1

1

1

1

7

Mohamad et al. 2021

Syrian Arab Republic

0

0

1

1

0

1

1

1

5

Oztok et al. 2018

Türkiye

1

0

1

1

1

0

0

1

5

Oztunc, 2006

Türkiye

1

1

0

1

0

0

0

1

4

Pinar et al. 2017

Türkiye

1

1

1

1

0

1

1

1

7

Picakcıefe et al. 2012

Türkiye

1

1

0

1

0

1

1

1

6

Rafeea et al. 2017

Bahrain

0

1

0

0

1

1

1

1

5

Rahmani et al. 2012

Iran, IR

1

1

0

1

1

0

0

0

4

Sadrabad et al. 2019

Iran, IR

1

1

0

1

1

1

0

0

5

Samir et al. 2012

Egypt

1

1

1

1

1

1

0

0

6

Sani et al. 2020

Iran, IR

0

1

0

0

0

1

0

1

3

Shaikh et al. 2020

Pakistan

1

1

1

0

1

1

1

1

7

Shoghi et al. 2008

Iran, IR

0

1

1

0

1

1

1

1

6

Teymourzadeh et al. 2014

Iran, IR

1

1

0

1

0

1

1

1

6

Towhari et al. 2020

Saudi Arabia

0

1

0

0

1

1

0

1

4

Turki et al. 2016

Saudi Arabia

1

1

0

0

1

1

1

1

6

Uzun, 2003

Türkiye

0

1

1

0

1

0

0

0

3

Unsal Atan et al. 2013

Türkiye

1

1

1

1

1

0

0

0

5

Zafar et al. 2016

Pakistan

1

1

0

1

0

1

1

1

6

a1: Random sample or whole population; 2: Unbiased sampling frame; 3: Adequated sample size (≥ 355); 4: Measures were standard; 5: Outcomes measured by unbiased assessors; 6: Adequated response rate (≥ 70); 7: Confidence intervals, subgroup analysis; 8: Study subject defined.

Table 3. Characteristics of the 75 studies reviewed conducted in the WHO Eastern Mediterranean Region and Türkiye during 1999–2021, noting numbers of violent incidents

Study

Country

Year conducted

Sample size

Professional group

Setting

Response rate (%)

Sampling

Quality score

Time interval

No. violent incidents, verbal

No. violent incidents, physical

Abbas et al. 2010

Egypt

2010

970

N

PC, GH

55.0

Random

5

Last 1 year

187

25

Abdellah et al. 2017

Egypt

2016

134

P, N, O

ED

94.4

Convenience

3

Last 1 year

78

21

Abou-ElWafa et al. 2015

Egypt

2013

275

N

ED, GH

96.1

Convenience

7

Last 1 year

140

110

Abualrub et al. 2007

Iraq

2005

116

N

ED, GH

100.0

Purposive

4

Last 1 year

NR

49

Abualrub et al. 2014

Jordan

2008

422

N

GH

84.4

Convenience

4

Last 1 year

288

NR

Acik et al. 2008

Türkiye

2007

1712

P

GH

70.0

All

7

During career

1 142

272

Adib et al. 2002

Kuwait

1999

5876

N

ED, GH

84.0

All

6

Last 6 month

2 813

423

Ahmed, 2012

Jordan

2010

447

N

GH

89.4

Random

5

Last 6 months

166

82

Akbolat et al. 2021

Türkiye

2018

299

P, N, O

GH

80.3

All

6

Last 1 year

147

67

Al Anazi et al. 2020

Saudi Arabia

2018

352

P, N, O

GH

94.6

Random

6

Last 1 year

162

29

Alameddine et al. 2011

Lebanon

2010

256

P, N, O

ED

70.3

Random

7

Last 1 year

207

66

Alameddine et al. 2015

Lebanon

2012

593

N

NR

64.8

Stratified

4

Last 1 year

366

56

ALBashtawy et al. 2015

Jordan

2011

355

P, N, O

ED

60.8

Convenience

3

Last 1 year

216

40

ALBashtawy, 2013

Jordan

2011

227

N

ED

54.4

Convenience

4

Last 1 year

145

27

Algwaiz et al. 2012

Saudi Arabia

2011

383

P, N

GH

63.8

Stratified

6

Last 1 year

244

31

Alhamad et al. 2021

Jordan

2019

969

P

GH

51.4

Stratified

4

Last 1 year

545

54

Alharbi et al. 2021

Saudi Arabia

2019

404

P, N, O

GH

89.8

Convenience

5

During career

321

273

Al-Omari et al. 2015

Jordan

2013

468

N

ED, GH

93.6

Convenience

6

Last 1 year

317

247

Al-Omari et al. 2019

Jordan

2018

57

N

GH

NR

Convenience

2

Last 1 year

41

14

Alqahtani et al. 2020

Saudi Arabia

2018

164

P, N, O

ED

NR

All

5

Last 1 year

75

27

Alsaleem et al. 2018

Saudi Arabia

2017

738

P, N, O

PC, GH

92.2

Random

7

During career

377

284

Al-Shaban et al. 2021

Saudi Arabia

2018

213

P, N

GH

82.0

Convenience

6

Last 1 year

138

63

Alshahrani et al. 2021

Saudi Arabia

2018

492

P, N, O

ED

70.0

Random

6

During career

371

102

Alshamlan et al. 2017

Saudi Arabia

2015

391

N

GH

86.9

All

7

Last 1 year

120

NR

Alsmael et al. 2020

Saudi Arabia

2019

360

P, N, O

PC

64.0

Cluster

6

Last 1 year

152

5

Arafa et al. 2022

Egypt

2021

209

P, N

GH

69.7

All

3

last 6 months

89

20

Atawneh et al. 2003

Kuwait

2002

81

N

ED

94.0

All

5

Last 1 year

70

13

Ayrancı et al. 2005

Türkiye

2002

195

P, N, O

ED

80.6

Convenience

5

Last 1 year

98

12

Ayrancı et al. 2006

Türkiye

2001

1 209

P, N, O

ED, GH, PC

88.4

Stratified

7

Last 1 year

528

165

Baig et al. 2018

Pakistan

2017

822

P, N, O

ED, GH

95.5

Convenience

5

Last 1 year

251

120

Baykan et al. 2015

Türkiye

2012

597

P

ED, GH, PC

75.9

All

7

During career

486

134

Bayram et al. 2017

Türkiye

2015

713

P

ED

79.0

Random

8

Last 1 year

NR

222

Belayachi et al. 2010

Morocco

2009

60

P

ED

100.0

All

3

During career

NR

5

Boz et al. 2006

Türkiye

2003

79

P, N, O

ED

NR

Convenience

1

Last 1 year

70

39

Cevik et al. 2020

Türkiye

2017

948

P

ED, PC, GH

94.8

Convenience

2

During career

610

93

Coskun, 2019

Türkiye

2017

143

P, N, O

ED

NR

Convenience

3

During career

124

49

Darawad et al. 2015

Jordan

2013

174

N

ED

58.0

Random

3

During career

152

37

Demirci et al. 2020

Türkiye

2019

347

P, N, O

GH

100.0

Stratified

7

During career

310

32

Emam et al. 2018

Iran, IR

2015

280

P

ED

81.4

Random

5

During career

254

192

Erdur et al. 2015

Türkiye

2014

174

P

ED

85.0

Convenience

5

Last 2 month

75

9

Esmaeilpour et al. 2011

Iran, IR

2009

178

N

ED

90.8

Convenience

3

Last 1 year

163

35

Fallahi-Khoshknab et al. 2015

Iran, IR

2011

5 874

P, N, O

PC

90.3

Cluster

7

Last 1 year

4179

NR

Fallahi-Khoshknab et al. 2016

Iran, IR

2011

5 677

P, N, O

GH

90.3

Random

6

Last 1 year

 

1333

Ghareeb et al. 2021

Jordan

2021

382

P, N

GH

75.5

All

6

Last 6 month

210

120

Günaydın et al. 2012

Türkiye

2011

868

N

GH

66.7

Random

5

Last 1 year

524

225

Hamdan et al. 2015

Palestine

2013

444

P, N, O

ED

74.50

Random

8

Last 1 year

310

158

Hamzaoglu et al. 2019

Türkiye

2017

447

P, N, O

ED, PC, GH

100.0

Random

5

During career

397

164

Harthi et al. 2020

Saudi Arabia

2018

324

P, N, O

ED

85.0

All

4

Last 1 year

126

45

Honarvar et al. 2019

Iran, IR

2017

405

N

GH

96.4

Random

7

Last 1 year

340

87

Jafree, 2017

Pakistan

2013

309

N

GH

34.8

Random

5

Last 1 year

177

165

Jaradat et al. 2018

Palestine

2012

341

N

PC, GH

91.7

Convenience

3

Last 1 year

83

17

Khademloo et al. 2013

Iran, IR

2013

271

N

GH

76.5

All

4

Last 1 year

260

79

Khan et al. 2021

Pakistan

2017

842

P, N, O

PC, GH

65.6

Stratified

7

Last 1 year

192

3

Kisa et al. 2008

Türkiye

2006

339

N

GH

82.7

Convenience

5

Last 1 year

269

NR

Kitaneh et al. 2012

Palestine

2011

240

P, N

GH

87.7

Stratified

7

Last 1 year

139

50

Lafta et al. 2019

Iraq

2018

700

P, N, O

PC, GH

87.5

Random

8

During career

502

99

Mirza et al. 2012

Pakistan

2007

675

P

ED

93.0

Convenience

7

Last 2 month

439

80

Mohamad et al. 2021

Syrian Arab Republic

2020

1 127

P

GH

91.9

convenience

5

Last 1 year

955

215

Oztok et al. 2018

Türkiye

2013

502

P

ED

82.4

Random

5

During career

414

308

Oztunc, 2006

Türkiye

2004

290

N

GH

64.4

All

4

Last 1 year

233

NR

Pınar et al. 2017

Türkiye

2012

12 944

P, N, O

PC, GH

89.6

Random

7

Last 1 year

5595

875

Picakcıefe et al. 2012

Türkiye

2009

268

N

GH

86.5

All

6

During career

207

62

Rafeea et al. 2017

Bahrain

2017

100

P, N, O

ED

NR

Convenience

5

Last 1 year

78

11

Rahmani et al. 2012

Iran, IR

2009

138

O

ED

86.2

Convenience

4

Last 1 year

98

52

Sadrabad et al. 2019

Iran, IR

2011

215

P,N,O

ED

72.6

All

5

During career

144

22

Samir et al. 2012

Egypt

2008

416

N

GH

83.2

Random

6

Last 6 month

325

113

Sani et al. 2020

Iran, IR

2018

118

N

ED

NR

Convenience

3

Last 1 year

95

30

Shaikh et al. 2020

Pakistan

2018

8 579

P, N, O

GH

100.0

Random

7

Last 6 month

2909

567

Shoghi et al. 2008

Iran, IR

2008

1 317

N

GH

87.8

Convenience

6

Last 6 month

1122

363

Teymourzadeh et al. 2014

Iran, IR

2010

301

N

ED, GH

73.0

All

6

Last 1 year

193

37

Towhari et al. 2020

Saudi Arabia

2020

135

P, N, O

PC

98.0

Convenience

4

During career

62

3

Turki et al. 2016

Saudi Arabia

2014

270

P, N, O

PC

90.0

Convenience

6

Last 1 year

116

8

Uzun, 2003

Türkiye

2001

467

N

GH

69.0

Convenience

3

Last 1 year

405

NR

Ünsal Atan et al. 2013

Türkiye

2008

441

N

GH

61.2

All

5

During career

209

63

Zafar et al. 2016

Pakistan

2013

179

P

ED,GH

92.2

Convenience

6

Last 1 year

 

28

Table 4. Luis Furuya-Kanamori (LFK) index for the studies reviewed

Type of violence

No. of studies

LFK index value

No transformation

Double arcsin transformation

Logit transformation

Verbal violence (total)

71          

2.42 (major asymmetry)

3.63 (major asymmetry)

4.12 (major asymmetry)

Physical violence (total)

69          

  5.42 (major asymmetry)

3.53 (major asymmetry)

–0.94 (no asymmetry)

Verbal violence during career

17          

–1.19 (minor asymmetry)

2.41 (major asymmetry)

3.47 (major asymmetry)

Verbal violence in last 1 year

54          

2.63 (major asymmetry)

3.59 (major asymmetry)

3.88 (major asymmetry)

Physical violence during career

18          

2.81 (major asymmetry)

0.46 (no asymmetry)

–1.19 (minor asymmetry)

Physical violence in last 1 year

51          

5.81 (major asymmetry)

3.98 (major asymmetry)

–0.96 (no asymmetry)

 

Table 5. Subgroup analysis of physical and verbal violence reported in 75 studies from the WHO Eastern Mediterranean Region and Türkiye conducted during 1999–2021

Subgroup

During career

Last 1 year or less

Pooled prevalance

I2

No. of studies

χ2a

P

Pooled prevalence

I2

No. of studies

χ2a

P

%

95% CI

%

95% CI

 

Physical violence

Country

 

 

 

 

 

 

 

 

 

 

 

Türkiye

25.0

14.1–35.9

98.97

9

12.68

0.027

19.6

9.5–29.8

99.32

8

45.45

< 0.001

Iran, IR

39.5

0.1–97.3

99.65

2

24.1

19.2–29.1

93.98

8

Pakistan

 

 

20.9

1.3–43.1

99.91

6

Jordan

21.0

14.5–27.5

 

1

22.2

10.2–34.2

98.78

7

Saudi Arabia

32.2

4.8–59.6

99.58

4

11.2

4.3–18.1

97.72

7

Egypt

 

 

18.9

5.9–31.9

98.45

5

Lebanon

 

 

17.0

2.1–31.8

96.67

2

Kuwait

 

 

10.6

2.2–19.1

78.07

2

Palestine

 

 

20.4

3.0–37.8

98.33

3

Syrian Arab Republic

 

 

19.1

16.8–21.4

 

1

Bahrain

 

 

11.0

4.7–17.3

 

1

Iraq

14.0

11.5–16.5

 

1 study

42.2

33.3–51.1

 

1

Morocco

8.0

0.5–15.5

 

1 study

 

 

Year conducted

 

 

 

 

 

 

 

 

 

 

 

 

2010 and earlier

15.6

10.3–21.0

86.49

4

4.53

0.033

20.7

14.0–27.3

99.21

15

0.33

0.564

2011 and later

29.7

17.9–41.4

99.34

14

18.3

14.0–22.7

99.60

36

Sample size

 

 

 

 

 

 

 

 

 

 

 

 

< 355

21.9

7.0–36.9

98.78

8

0.6

0.419

20.8

15.7–25.9

97.11

27

1.01

0.314

≥ 355

30.0

17.4–42.7

99.42

10

17.1

12.0–22.2

99.77

24

Professional group

 

 

 

 

 

 

 

 

 

 

 

 

Physician

31.0

9.5–52.5

99.63

6

1.78

0.412

14.7

6.9–22.5

98.13

6

3.83

0.147

Nurse

19.0

13.2–24.8

76.05

3

23.4

17.0–29.9

99.21

20

All health care staff

25.8

12.4–39.3

99.18

9

16.5

11.8–21.2

99.61

25

Quality score

 

 

 

 

 

 

 

 

 

 

 

 

< 6

30.3

15.4–45.3

99.34

11

1.41

0.235

18.8

13.7–23.9

98.52

26

0.01

0.918

≥ 6

20.4

13.5–27.2

97.05

7

19.2

14.0–24.4

99.75

25

Response rate

 

 

 

 

 

 

 

 

 

 

 

 

< 70%

22.6

11.2–34.1

91.67

3

0.30

0.581

16.3

8.7–23.8

99.59

16

0.84

0.360

≥ 70%

27.2

15.8–38.5

99.42

15

20.3

16.3–24.2

99.43

35

Total

23.4

16.1–32.0

99.0

18

 

19.0

15.4–22.6

99.00

51

 

 

Verbal violence

Country

 

 

 

 

 

 

 

 

 

 

 

 

Türkiye

75.9

66.7–85.1

98.37

9

26.02

< 0.001

62.4

50.5–74.3

99.25

10

160.08

< 0.001

Iran, IR

79.1

55.6–99.0

97.82

2

80.7

73.0–88.4

98.49

8

Pakistan

 

 

45.0

30.7–59.4

99.22

6

Jordan

87.0

82.0–92.0

 

1

59.8

52.1–67.4

95.06

8

Saudi Arabia

63.0

46.7–79.2

98.31

4

46.9

38.7–55.1

94.59

8

Egypt

 

 

49.7

30.6–68.8

98.77

5

Lebanon

 

 

71.4

52.8–90.1

97.04

2

Kuwait

 

 

66.8

29.6–99.0

98.97

2

Palestine

 

 

50.7

23.6–77.7

98.97

3

Syrian Arab Republic

 

 

85.0

83.0–87.0

 

1

Bahrain

 

 

78.0

70.0–86.0

 

1

Iraq

72.0

68.5–75.5

 

1

 

 

Year conducted

 

 

 

 

 

 

 

 

 

 

 

 

2010 and earlier

63.7

46.5–80.9

98.27

3

1.63

0.201

67.9

58.3–77.4

99.38

18

4.43

0.035

2011 and later

75.8

68.5–83.2

98.06

14

55.9

50.1–61.7

99.28

36

Sample size

 

 

 

 

 

 

 

 

 

 

 

 

< 355

77.9

66.1–89.8

97.65

7

0.94

0.331

63.1

56.2–69.9

97.77

28

1.52

0.218

≥ 355

70.7

62.3–79.1

98.41

10

56.6

48.9–64.3

99.69

26

Professional group

 

 

 

 

 

 

 

 

 

 

 

 

Physicians only

77.0

67.1–86.8

97.9

5

0.45

0.799

62.2

48.7–75.7

99.47

5

4.63

0.099

Nurses only

70.3

46.7–93.9

98.60

3

65.5

56.9–74.1

99.10

24

All health care staff

72.9

62.7–83.1

98.28

9

54.0

47.5–60.5

99.15

25

Quality score

 

 

 

 

 

 

 

 

 

 

 

 

< 6

74.0

63.6–84.5

98.50

10

0.02

0.899

62.5

54.8–70.3

98.99

29

1.17

0.280

≥ 6

73.1

64.3–82.0

97.77

7

56.9

50.3–63.5

99.50

25

Response rate

 

 

 

 

 

 

 

 

 

 

 

 

< 70%

73.6

47.5–99.8

98.79

3

0.01

0.995

60.1

50.8–69.4

98.75

18

0.01

0.960

≥ 70%

73.7

66.8–80.7

98.11

14

59.8

53.5–66.1

99.53

36

Total

73.7

67.8–80.4

98.01

7

 

59.9

54.7–65.1

99.05

4