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1.  Violence toward physicians in emergency departments of Morocco: prevalence, predictive factors, and psychological impact 
Anyone working in the hospital may become a victim of violence. The effects of violence can range in intensity and include the following: minor physical injuries, serious physical injuries, temporary or permanent physical disability, psychological trauma, and death. The aim of this study was to determine the frequency of exposure, characteristics, and psychological impact of violence toward hospital-based emergency physicians in Morocco.
This was a survey including emergency physicians who ensured emergency service during the last fortnight. The variables studied were those related to the victim (age and gender), and those related to aggression: assaulter gender, number, time, reason (delay of consultation and/or care, acute drunkenness, neuropsychiatric disease), and type (verbal abuse, verbal threat and/or physical assault). After the questionnaire was completed, State-Trait Anxiety Inventory (STAI) of Spielberg was applied to all participants.
A total of 60 physicians have achieved permanence in emergency department during the 15 days preceding the questionnaire response. The mean age was 24 ± 1 year and 57% were male. A total of 42 (70%) had been exposed to violence. The violence occurred at night n = 16 (27%), afternoon n = 13 (22%), evening n = 7 (12%) and morning n = 6 (10%). Reasons for violence were: the delay of consultation or care in n = 31 (52%) cases, acute drunkenness in n = 10 (17%) cases and neuropsychiatric disease in n = 3 (5%) cases. Twenty eight (47%) participants stated that they experienced verbal abuse, n = 18 (30%) verbal threat and n = 5 (8.3%) physical assault. Exposure to some form of violence was related to a higher median [interquartile range, IQR] state anxiety point (SAP); (51 [46-59] vs 39 [34-46]; P < 0,001), and trait anxiety point (TAP) (48 [41-55] vs 40,5 [38-53]; P = 0,01).
This study revealed a high prevalence (70%) of violence toward doctors in Morocco emergency departments. The exposure of physicians to some form of violence is greater among doctors with anxiety trait and was related to significant degree of anxiety state.
PMCID: PMC2954930  PMID: 20920159
2.  Frequency and severity of aggressive incidents in acute psychiatric wards in Switzerland 
Aggression and violence and negative consequences thereof are a major concern in acute psychiatric inpatient care globally. Variations in study designs, settings, populations, and data collection methods render comparisons of the incidence of aggressive behaviour in high risk settings difficult.
To describe the frequency and severity of aggressive incidents in acute psychiatric wards in the German speaking part of Switzerland.
We conducted a prospective multicentre study on 24 acute admission wards in 12 psychiatric hospitals in the German speaking part of Switzerland. Aggressive incidents were recorded by the revised Staff Observation Aggression Scale (SOAS-R) and we checked the data collection for underreporting. Our sample comprised 2344 treatment episodes of 2017 patients and a total of 41'560 treatment days.
A total of 760 aggressive incidents were registered. We found incidence rates per 100 treatment days between 0.60 (95% CI 0.10–1.78) for physical attacks and 1.83 (1.70–1.97) for all aggressive incidents (including purely verbal aggression). The mean severity was 8.80 ± 4.88 points on the 22-point SOAS-R-severity measure; 46% of the purely verbally aggression was classified as severe (≥ 9 pts.). 53% of the aggressive incidents were followed by a coercive measure, mostly seclusion or seclusion accompanied by medication. In 13% of the patients, one ore more incidents were registered, and 6.9% of the patients were involved in one ore more physical attack. Involuntary admission (OR 2.2; 1.6–2.9), longer length of stay (OR 2.7; 2.0–3.8), and a diagnosis of schizophrenia (ICH-10 F2) (OR 2.1; 1.5–2.9) was associated with a higher risk for aggressive incidents, but no such association was found for age and gender. 38% of the incidents were registered within the first 7 days after admission.
Aggressive incidents in acute admission wards are a frequent and serious problem. Due to the study design we consider the incidence rates as robust and representative for acute wards in German speaking Switzerland, and thus useful as reference for comparative and interventional research. Implications for clinical practice include the recommendation to extend the systematic risk assessment beyond the first days after admission. The study confirms the necessity to differentiate between types of aggressive behaviour when reporting and comparing incidence-data.
PMCID: PMC2231349  PMID: 18053203
3.  Development of a Data Collection Instrument for Violent Patient Encounters against Healthcare Workers 
Healthcare and social workers have the highest incidence of workplace violence of any industry. Assaults toward healthcare workers account for nearly half of all nonfatal injuries from occupational violence. Our goal was to develop and evaluate an instrument for prospective collection of data relevant to emergency department (ED) violence against healthcare workers.
Participants at a high-volume tertiary care center were shown 11 vignettes portraying verbal and physical assaults and responded to a survey developed by the research team and piloted by ED personnel addressing the type and severity of violence portrayed. Demographic and employment groups were compared using the independent-samples Mann-Whitney U Test.
There were 193 participants (91 male). We found few statistical differences when comparing occupational and gender groups. Males assigned higher severity scores to acts of verbal violence versus females (mean M,F=3.08, 2.70; p<0.001). While not achieving statistical significance, subgroup analysis revealed that attending physicians rated acts of verbal violence higher than resident physicians, and nurses assigned higher severity scores to acts of sexual, verbal, and physical violence versus their physician counterparts.
This survey instrument is the first tool shown to be accurate and reliable in characterizing acts of violence in the ED across all demographic and employment groups using filmed vignettes of violent acts. Gender and occupation of ED workers does not appear to play a significant role in perception of severity workplace violence.
PMCID: PMC3556953  PMID: 23358263
4.  Risk factors for work related violence in a health care organization 
Injury Prevention  2004;10(5):296-302.
Objective: Identify the exposure effects of job family, patient contact, and supervisor support on physical and non-physical work related violence.
Design: Cross sectional study of employees in a Midwest health care organization, utilizing a specially designed mailed questionnaire and employer secondary data.
Subjects: Respondents included 1751 current and former employees (42% response rate).
Results: Physical and non-physical violence was experienced by 127 (7.2%) and 536 (30.6%) of the respondents, respectively. Multivariate analyses of physical violence identified increased odds for patient care assistants (odds ratio (OR) 2.5, 95% confidence interval (CI) 1. 1 to 6.1) and decreased odds for clerical workers (OR 0.1, 95% CI 0.03 to 0.5). Adjusted for job family, increased odds of physical violence were identified for moderate (OR 5.9, 95% CI 2.1 to 16.0) and high (OR 7.8, 95% CI 2.9 to 20.8) patient contact. Similar trends were identified for non-physical violence (OR 1.4, 95% CI 1.1 to 2.0 and OR 1.7, 95% CI 1.3 to 2.3). Increased supervisor support decreased the odds of both physical (OR 0.7, 95% CI 0.6 to 0.95) and non-physical violence (OR 0.5, 95% CI 0.4 to 0.6), adjusting for job family and demographic characteristics.
Conclusions: Increased odds of physical violence were identified for the job family of nurses, even when adjusted for patient contact. Increased patient contact resulted in increased physical and non-physical violence, independent of job family, while supervisor support resulted in decreased odds of physical and non-physical violence.
PMCID: PMC1730138  PMID: 15470011
5.  Workplace violence in a large correctional health service in New South Wales, Australia: a retrospective review of incident management records 
Little is known about workplace violence among correctional health professionals. This study aimed to describe the patterns, severity and outcomes of incidents of workplace violence among employees of a large correctional health service, and to explore the help-seeking behaviours of staff following an incident.
The study setting was Justice Health, a statutory health corporation established to provide health care to people who come into contact with the criminal justice system in New South Wales, Australia. We reviewed incident management records describing workplace violence among Justice Health staff. The three-year study period was 1/7/2007-30/6/2010.
During the period under review, 208 incidents of workplace violence were recorded. Verbal abuse (71%) was more common than physical abuse (29%). The most (44%) incidents of workplace violence (including both verbal and physical abuse) occurred in adult male prisons, although the most (50%) incidents of physical abuse occurred in a forensic hospital. Most (90%) of the victims were nurses and two-thirds were females. Younger employees and males were most likely to be a victim of physical abuse. Preparing or dispensing medication and attempting to calm and/or restrain an aggressive patient were identified as ‘high risk’ work duties for verbal abuse and physical abuse, respectively. Most (93%) of the incidents of workplace violence were initiated by a prisoner/patient. Almost all of the incidents received either a medium (46%) or low (52%) Severity Assessment Code. Few victims of workplace violence incurred a serious physical injury – there were no workplace deaths during the study period. However, mental stress was common, especially among the victims of verbal abuse (85%). Few (6%) victims of verbal abuse sought help from a health professional.
Among employees of a large correctional health service, verbal abuse in the workplace was substantially more common than physical abuse. The most incidents of workplace violence occurred in adult male prisons. Review of the types of adverse health outcomes experienced by the victims of workplace violence and the assessments of severity assigned to violent incidents suggests that, compared with health care settings in the community, correctional settings are fairly safe places in which to practice.
PMCID: PMC3496587  PMID: 22873176
Workplace violence; Correctional health professionals; Incident management
6.  Aggression and violence against health care workers in Germany - a cross sectional retrospective survey 
Although international scientific research on health issues has been dealing with the problem of aggression and violence towards those employed in health care, research activities in Germany are still at an early stage. In view of this, the aim of this study was to examine the frequency and consequences of aggressive behaviour towards nurses and health care workers in different health sectors in Germany and to assess the need for preventive measures.
We conducted a cross-sectional retrospective survey. Nurses and health care workers from two nursing homes, a psychiatric clinic and a workshop for people with disabilities were interviewed using a standardised questionnaire. The sample covered 123 individuals (response rate 38.8%). The survey assessed the frequency, the type and the consequences of aggressive behaviour, and social support in connection with coping with aggression in the workplace. Odds ratios (OR) and 95% confidence intervals (CI) for putative risk factors which may influence the stress induced by aggression at the workplace were calculated using conditional logistic regression.
During the previous twelve months 70.7% of the respondents experienced physical and 89.4% verbal aggression. Physical aggression more frequently occurred in nursing homes (83.9% of the employees) and verbal aggression was more common in the psychiatric clinic (96.7% of the employees). The proportion of the individuals affected in the workshop for people with disabilities was lower (41.9% and 77.4% respectively). The incidents impaired the physical (55%) and emotional well-being (77.2%) of the employees. The frequency of incidents (weekly: OR 2.7; 95% CI 1.1-6.4) combined with the lack of social support (OR 2.8; 95% CI 1.2-6.6) increased the probability of higher stress due to aggression.
This study corroborates previous reports of frequent physical and verbal aggression towards care workers in the various areas of health care. The present study highlights differences between various areas of health care in Germany and the aggravating effect of prevention neglect such as missing social support at the workplace. Therefore our data suggest the need for improved target group specific prevention of aggressive incidents towards care workers and the need for effective aftercare in Germany.
PMCID: PMC2837654  PMID: 20184718
7.  Witnessing Violence Toward Siblings: An Understudied but Potent Form of Early Adversity 
PLoS ONE  2011;6(12):e28852.
Research on the consequences of witnessing domestic violence has focused on inter-adult violence and most specifically on violence toward mothers. The potential consequences of witnessing violence to siblings have been almost entirely overlooked. Based on clinical experience we sought to test the hypothesis that witnessing violence toward siblings would be as consequential as witnessing violence toward mothers. The community sample consisted of unmedicated, right-handed, young adults who had siblings (n = 1,412; 62.7% female; 21.8±2.1 years of age). History of witnessing threats or assaults to mothers, fathers and siblings, exposure to parental and sibling verbal abuse and physical abuse, sexual abuse and sociodemographic factors were assessed by self-report. Symptoms of depression, anxiety, somatization, anger-hostility, dissociation and ‘limbic irritability’ were assessed by rating scales. Data were analyzed by multiple regression, with techniques to gauge relative importance; logistic regression to assess adjusted odds ratios for clinically-significant ratings; and random forest regression using conditional trees. Subjects reported witnessing violence to siblings slightly more often than witnessing violence to mothers (22% vs 21%), which overlapped by 51–54%. Witnessing violence toward siblings was associated with significant effects on all ratings. Witnessing violence toward mother was not associated with significant effects on any scale in these models. Measures of the relative importance of witnessing violence to siblings were many fold greater than measures of importance for witnessing violence towards mothers or fathers. Mediation and structural equation models showed that effects of witnessing violence toward mothers or fathers were predominantly indirect and mediated by changes in maternal behavior. The effects of witnessing violence toward siblings were more direct. These findings suggest that greater attention be given to the effects of witnessing aggression toward siblings in studies of domestic violence, abuse and early adversity.
PMCID: PMC3244412  PMID: 22216127
8.  The relationship between sexual violence and human immunodeficiency virus (HIV) infection among women using voluntary counseling and testing services in South Wollo Zone, Ethiopia 
BMC Research Notes  2013;6:271.
Gender based violence affects the health and wellbeing of women across the world on an epidemic scale. While women remain more vulnerable to both sexual violence and risk of HIV infection, they are less able to access health and other welfare services than men. These vulnerabilities are further compounded by social factors, including the low status of women in many communities and their lack of decision-making power, both within the household and in wider society. The objective of this study was to assess the relationship between sexual violence and HIV infection among clients of voluntary counseling and testing (VCT) services in South Wollo Zone, Ethiopia.
A facility based cross sectional study was conducted using quantitative methods on a sample of 647 people living in seven selected districts of South Wollo Zone, Amhara Regional State.
The study revealed that sexual violence is significantly associated with the risk of HIV infection. The prevalence of lifetime sexual violence, lifetime partner violence, and last 12 months partner violence were 34.6%, 32.3% and 10.5% respectively. Both partner violence and lifetime sexual violence by another perpetrator were associated with HIV. The overall prevalence of HIV among VCT users was 21.5%. Both before (crude analysis) and after the results were adjusted for selected variables, women who experienced sexual violence in the last 12 months by their intimate partner or by another perpetrator is significantly associated with their HIV status. The chances of having HIV was 1.97 times higher among women victims who have a history of lifetime partner violence when compared with women who are not victims; crude odds ratio (COR) = 1.97, 95% Confidence Interval (CI), (1.34 - 2.90).
The study revealed that sexual violence is significantly associated with the risk of HIV infection. Empowerment of women can be used as an important tool to reduce both sexual violence and HIV. More importantly policy issues must be set by all actors to take action on the mediating variables that interacted with violence to aggravate the transmission of HIV.
PMCID: PMC3751471  PMID: 23856072
9.  Workplace violence against physicians and nurses in Palestinian public hospitals: a cross-sectional study 
Violence against healthcare workers in Palestinian hospitals is common. However, this issue is under researched and little evidence exists. The aim of this study was to assess the incidence, magnitude, consequences and possible risk factors for workplace violence against nurses and physicians working in public Palestinian hospitals.
A cross-sectional approach was employed. A self-administered questionnaire was used to collect data on different aspects of workplace violence against physicians and nurses in five public hospitals between June and July 2011. The questionnaires were distributed to a stratified proportional random sample of 271 physicians and nurses, of which 240 (88.7%) were adequately completed. Pearson’s chi-square analysis was used to test the differences in exposure to physical and non-physical violence according to respondents’ characteristics. Odds ratios and 95% confidence intervals were used to assess potential associations between exposure to violence (yes/no) and the respondents’ characteristics using logistic regression model.
The majority of respondents (80.4%) reported exposure to violence in the previous 12 months; 20.8% physical and 59.6% non-physical. No statistical difference in exposure to violence between physicians and nurses was observed. Males’ significantly experienced higher exposure to physical violence in comparison with females. Logistic regression analysis indicated that less experienced (OR: 8.03; 95% CI 3.91-16.47), and a lower level of education (OR: 3; 95% CI 1.29-6.67) among respondents meant they were more likely to be victims of workplace violence than their counterparts. The assailants were mostly the patients' relatives or visitors, followed by the patients themselves, and co-workers. Consequences of both physical and non-physical violence were considerable. Only half of victims received any type of treatment. Non-reporting of violence was a concern, main reasons were lack of incident reporting policy/procedure and management support, previous experience of no action taken, and fear of the consequences.
Healthcare workers are at comparably high risk of violent incidents in Palestinian public hospitals. Decision makers need to be aware of the causes and potential consequences of such events. There is a need for intervention to protect health workers and provide safer hospital workplaces environment. The results can inform developing proper policy and safety measures.
PMCID: PMC3541970  PMID: 23256893
Workplace violence; Hospitals; Health care workers; Nurses and physicians; Palestine
10.  Violence towards health care workers in a Public Health Care Facility in Italy: a repeated cross-sectional study 
Violence at work is one of the major concerns in health care activities. The aim of this study was to identify the prevalence of physical and non-physical violence in a general health care facility in Italy and to assess the relationship between violence and psychosocial factors, thereby providing a basis for appropriate intervention.
All health care workers from a public health care facility were invited to complete a questionnaire containing questions on workplace violence. Three questionnaire-based cross-sectional surveys were conducted. The response rate was 75 % in 2005, 71 % in 2007, and 94 % in 2009. The 2009 questionnaire contained the VIF (Violent Incident Form) for reporting violent incidents, the DCS (demand/control/support) model for job strain, the Colquitt 20 item questionnaire for perceived organizational justice, and the GHQ-12 General Health Questionnaire for the assessment of mental health.
One out of ten workers reported physical assault, and one out of three exposure to non-physical violence in the workplace in the previous year. Nurses and physicians were the most exposed occupational categories, whereas the psychiatric and emergency departments were the services at greatest risk of violence. Workers exposed to non-physical violence were subject to high job strain, low support, low perceived organizational justice, and high psychological distress.
Our study shows that health care workers in an Italian local health care facility are exposed to violence. Workplace violence was associated with high demand and psychological disorders, while job control, social support and organizational justice were protective factors.
PMCID: PMC3464150  PMID: 22551645
Aggression; Violence at the workplace; Health care workers; Post-traumatic stress; Organizational justice; Work stress; Social support; Job control; Demand; Psychological disorders.
11.  Resident-to-Resident Aggression in Long-Term Care Facilities: An Understudied Problem 
Resident-to-resident aggression (RRA) between long-term care residents includes negative and aggressive physical, sexual, or verbal interactions that in a community setting would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient. Although this problem potentially has high incidence and prevalence and serious consequences for aggressors and victims, it has received little direct attention from researchers to date. This article reviews the limited available literature on this topic as well as relevant research from related areas including: resident violence toward nursing home staff, aggressive behaviors by elderly persons, and community elder abuse. We present hypothesized risk factors for aggressor, victim, and nursing home environment, including issues surrounding cognitive impairment. We discuss methodological challenges to studying RRA and offer suggestions for future research. Finally, we describe the importance of designing effective interventions, despite the lack currently available, and suggest potential areas of future research.
PMCID: PMC2741635  PMID: 19750126
aggressive behavior; nursing homes; dementia; epidemiology
12.  Post-traumatic stress disorder following patient assaults among staff members of mental health hospitals: a prospective longitudinal study 
BMC Psychiatry  2006;6:15.
Violence by patients against staff members in mental health institutions has become an important challenge. Violent attacks may not only cause bodily injuries but can also have posttraumatic consequences with high rates of stress for mental health staff. This study prospectively assessed posttraumatic stress disorder (PTSD) in employees who were severely assaulted by patients in nine German state mental health institutions.
During the study period of six months 46 assaulted staff members were reported. Each staff member was interviewed three times after the violent incident, using the Impact of Event Scale-Revised (IES-R), a widely used PTSD research tool, as well as the Posttraumatic Stress Disorder Checklist – Civilian (PCL-C).
In the baseline assessment following an assault by a patient, eight subjects (17%) met the criteria for PTSD. After two and six months, three and four subjects respectively still met diagnosis criteria.
A small minority of assaulted employees suffer from PTSD for several months after a patient assault.
PMCID: PMC1458323  PMID: 16606454
13.  Prevalence and Correlates of Perpetration of Violence Among Young People: A Population-Based Survey From Goa, India 
The aim of this study was to describe the prevalence and factors associated with perpetration of violence in young people in India. It was a cross-sectional survey of 3663 individuals (16-24 years old). Data on sociodemographics, sexual/physical violence, common mental disorders, and substance abuse were collected by face-to-face structured interviews. Logistic regression was used to estimate odds ratios for association of violence with various factors. Prevalence of physical violence in the past year was 10.2%. In both genders, younger age, urbanicity, being a victim of sexual abuse, common mental disorders, and tobacco use were associated with increased risk of physical violence. Being a victim of forced sexual intercourse and alcohol use was associated with violence in males; and not living with parents was associated with violence in females. Future research should be designed to tease out the pathways that underlie the associations, identified in the study, to derive potential preventive strategies.
PMCID: PMC3855449  PMID: 21852419
young people; physical violence; victimization; common mental disorder; substance abuse; India
14.  Neighborhood Violence and its Association with Mothers’ Health: Assessing the Relative Importance of Perceived Safety and Exposure to Violence 
This paper presents a cross-sectional study examining the influence of neighborhood violence on multiple aspects of mothers’ health. While the influence of neighborhood violence on health is important to understand for all populations, mothers are especially important as they play a key role in protecting their children from the consequences of violence. Three hundred and ninety-two Baltimore City mothers of children 5 years and younger completed a self-administered survey that included questions about perceptions of their safety as well as their personal experiences with neighborhood violence. Separate models were run to compare the relationship between each measurement of neighborhood violence and five diverse health-related determinants and outcomes: self-reported health status, smoking, exercise, average hours of sleep a night, and sleep interruption. Controlling for mother’s age, child’s age, maternal education, and marital status, mothers with high exposure to neighborhood violence were twice as likely to report poorer health, smoking, never exercising, and poor sleep habits. Maternal perception of neighborhood safety was not related to any of the assessed health-related determinants and outcomes. This study emphasizes the importance of measuring exposure to neighborhood violence rather than solely assessing perceived safety. Neighborhood violence was a common experience for mothers in this urban sample, and should be considered by health professionals in trying to understand and intervene to improve the health of mothers and their children.
PMCID: PMC2704268  PMID: 19343500
Neighborhood violence; Women’s health; Measurement
15.  The Exploding Spark: Workplace Violence in an Infectious Disease Hospital—A Longitudinal Study 
BioMed Research International  2013;2013:316358.
Objectives. Workplace violence (WV) is an important occupational hazard for healthcare workers (HCWs). Methods. A longitudinal study was carried out on HCWs from an infectious disease hospital. Work-related stress, anxiety, and depression were measured at baseline in 2003, and they were reassessed in 2005, along with the assaults that occurred in the previous year. Results. One-year prevalences of 6.2% and 13.9% were reported for physical and verbal aggressions, respectively. Perpetrators were mainly patients. The professional groups most frequently attacked were physicians, followed by nurses. Workers with job strain at baseline had a significant risk of being subject to aggression (OR 7.7; CI 95%, 3.3–17.9) in the following year. The relationship between job strain and subsequent WV remained significant even after correction for anxiety, depression, and other confounders. Conversely, experiencing WV was associated with a high risk of job strain and effort-reward imbalance in the following year. The final levels of anxiety and depression were predicted using regression models that included physical aggression among predictive variables. Conclusions. WV is the spark that sets off a problematic work situation. Effective prevention of WV can only be achieved within the framework of an overall improvement in the quality of work.
PMCID: PMC3708405  PMID: 23936789
16.  Violence towards personnel in out-of-hours primary care: A cross-sectional study 
To investigate (1) the prevalence of occupational violence in out-of-hours (OOH) primary care, (2) the perceived cause of violence, and (3) the associations between occupation, gender, age, years of work, and occupational violence.
A cross-sectional study using a self-administered postal questionnaire.
Twenty Norwegian OOH primary care centres.
Physicians, nurses, and others with patient contact at OOH primary care centres, 536 responders (75% response rate).
Main outcome measures
Verbal abuse, threats, physical abuse, sexual harassment.
In total, 78% had been verbally abused, 44% had been exposed to threats, 13% physically abused, and 9% sexually harassed during the last 12 months. Significantly more nurses were associated with verbal abuse (OR 3.85, 95% confidence interval 2.17–6.67) after adjusting for gender, age, and years in OOH primary care. Males had a higher risk for physical abuse (OR 2.36, CI 1.11–5.05) and higher age was associated with lower risk for sexual harassment (OR 0.28, CI 0.14–0.59), when adjusted for background variables. Drug influence and mental illness were the most frequently perceived causes for the last occurring episode of physical abuse, threats, and verbal abuse.
This first study on occupational violence in Norwegian OOH primary care found that a substantial number of health care workers experience occupational violence from patients or visitors. The employer should take action to prevent occupational violence in OOH primary care.
PMCID: PMC3337531  PMID: 22348514
Cross-sectional studies; general practice; nurses; out-of-hours; physicians; prevalence; violence
17.  Magnitude, Types and Sex Differentials of Aggressive Behaviour Among School Children in a Rural Area of West Bengal 
Aggression affects academic learning and emotional development, can damage school climate and if not controlled early and may precipitate extreme violence in the future.
(1) To determine the magnitude and types of aggressive behavior in school children. (2) To identify the influence of age and sex on aggressive behavior.
Materials and Methods:
A cross-sectional study was conducted in Anandanagar High School, Singur village, West Bengal. Participants were 161 boys and 177 girls of classes VII to IX. The students were asked to complete a self-administered questionnaire indicating the types of aggressive behavior by them in the previous month and to assess themselves with reference to statements indicating verbal/physical aggression.
Overall, 66.5% of the children were physically aggressive in the previous month: Boys 75.8%, girls 58.2% (P = 0.001); 56.8% were verbally aggressive: Boys 55.2%, girls 61% (P = 0.97). Verbal indirect passive aggression was more common among girls (55.3%) than among boys (22.3%) (P = 0.000 [1.17E-09]). Boys were more liable to physical aggression, viz. 60.2% of the boys would hit on provocation compared with only 9% of the girls (P = 0.000 [6.6E-23]). Regarding attributes indicating verbal aggression, girls were more argumentative (63.8%) than boys (55.2%) (P = 0.134) and disagreeing (41.8%) compared with boys (33.5%) (P = 0.145). With increasing age/class, physical direct active aggression decreased while physical indirect passive and verbal indirect passive aggression increased. No classes had been taken on anger control/management by school the authorities.
Aggressive behavior was common both among boys and girls. Life skills education/counseling/classroom management strategies are recommended.
PMCID: PMC3714938  PMID: 23878425
Aggression; active; children; passive; physical; verbal
18.  Clinical violence in nursing students 
One of the significant issues in health studies is violence. Although violence against nurses has been recognized as a major occupational problem, its magnitude and extent is not clearly defined. The aim of this study was to determine the extent and types of violence during clinical training of nursing students.
In this descriptive and cross-sectional study, 180 sophomores, juniors and seniors of Shahid Beheshti, Tehran and Iran Medical Universities were selected by quota sampling method. A questionnaire was used for collecting data regarding violence over the past year. Content and test-retest methods were used for evaluating its validity and reliability, respectively.
Findings showed that 6.7%, 8.3% and 39.4% of the students experienced physical assault, physical menace and insult, respectively, over the past year. Most cases of the assaults (66.7%) were done by patients, most menaces by staff as well as patients’ attendants (18.1%) and most insults by staff (33.7%) and patients (31%). No significant relation was found between the sex as well as the educational year of the students and the experience of insult. 41.6% of the assaults were due to the effects of disease in assailants. However, no specific reason was found for physical menace and insult in most cases. 66.65%, 26.6% and 39.4% of the students reported physical assault, menace and insult to their tutors, respectively.
Nursing students are subject to more violence because of young age and inadequate experience. Therefore, devising educational programs regarding occupational violence as well as its prevention and providing necessary support and consultation following violence are essential.
PMCID: PMC3583097  PMID: 23449964
Violence; training; nursing students
19.  Intimate partner violence in urban Pakistan: prevalence, frequency, and risk factors 
Intimate partner violence (IPV) is an important public health issue with severe adverse consequences. Population-based data on IPV from Muslim societies are scarce, and Pakistan is no exception. This study was conducted among women residing in urban Karachi, to estimate the prevalence and frequency of different forms of IPV and their associations with sociodemographic factors.
This cross-sectional community-based study was conducted using a structured questionnaire developed by the World Health Organisation for research on violence. Community midwives conducted face-to-face interviews with 759 married women aged 25–60 years.
Self-reported past-year and lifetime prevalence of physical violence was 56.3 and 57.6%, respectively; the corresponding figures for sexual violence were 53.4% and 54.5%, and for psychological abuse were 81.8% and 83.6%. Violent incidents were mostly reported to have occurred on more than three occasions during the lifetime. Risk factors for physical violence related mainly to the husband, his low educational attainment, unskilled worker status, and five or more family members living in one household. For sexual violence, the risk factors were the respondent’s low educational attainment, low socioeconomic status of the family, and five or more family members in one household. For psychological violence, the risk factors were the husband being an unskilled worker and low socioeconomic status of the family.
Repeated violence perpetrated by a husband towards his wife is an extremely common phenomenon in Karachi, Pakistan. Indifference to this type of violence against women stems from the attitude that IPV is a private matter, usually considered a justifiable response to misbehavior on the part of the wife. These findings point to serious violations of women’s rights and require the immediate attention of health professionals and policymakers.
PMCID: PMC3089428  PMID: 21573146
intimate partner violence; domestic violence; Pakistan; gender inequality; prevalence; frequency; risk factors
To determine the extent of work-related violence against nurses in hospitals in Riyadh.
Materials and methods:
Through a cross sectional approach, a self administered questionnaire was offered to 500 active-duty nurses selected randomly. In addition to the demographic characteristics, the questionnaire inquired about exposure to workplace violence, hospital and department of employment at the time of exposure, characteristics of the assailant and nurses’ perception of the causes of violence.
Out of 434 respondents, 93 (21.4%) were males, and 341 (78.6%) females. The mean age was 36.1 ± 7.97 years. Workplace violence was experienced by 235 (54.3%) nurses. Of these 93.2% were exposed to harsh insulting language, 32.8% to verbal threat, 28.1% to attempts of physical assault, 17.4% to sexual harassment and 16.2% to actual physical assault. Nurses working in psychiatry and emergency units had the highest rate of exposure to violence (84.3% & 62.1% respectively) Nurses perceived shortage in security personnel (82%), shortage in nursing staff (63%), language barrier (36.3%) and unrestricted movement of patients in hospitals (21.5%) as causes of their exposure to violence.
improve security in hospitals by increasing the number of security officers on duty and increase the community's awareness of the problem.
PMCID: PMC3430167  PMID: 23008680
Workplace violence; occupational risk; nursing hazards
21.  Prevalence of physical and verbal aggressive behaviours and associated factors among older adults in long-term care facilities 
BMC Geriatrics  2005;5:13.
Verbal and physical aggressive behaviours are among the most disturbing and distressing behaviours displayed by older patients in long-term care facilities. Aggressive behaviour (AB) is often the reason for using physical or chemical restraints with nursing home residents and is a major concern for caregivers. AB is associated with increased health care costs due to staff turnover and absenteeism.
The goals of this secondary analysis of a cross-sectional study are to determine the prevalence of verbal and physical aggressive behaviours and to identify associated factors among older adults in long-term care facilities in the Quebec City area (n = 2 332).
The same percentage of older adults displayed physical aggressive behaviour (21.2%) or verbal aggressive behaviour (21.5%), whereas 11.2% displayed both types of aggressive behaviour. Factors associated with aggressive behaviour (both verbal and physical) were male gender, neuroleptic drug use, mild and severe cognitive impairment, insomnia, psychological distress, and physical restraints. Factors associated with physical aggressive behaviour were older age, male gender, neuroleptic drug use, mild or severe cognitive impairment, insomnia and psychological distress. Finally, factors associated with verbal aggressive behaviour were benzodiazepine and neuroleptic drug use, functional dependency, mild or severe cognitive impairment and insomnia.
Cognitive impairment severity is the most significant predisposing factor for aggressive behaviour among older adults in long-term care facilities in the Quebec City area. Physical and chemical restraints were also significantly associated with AB. Based on these results, we suggest that caregivers should provide care to older adults with AB using approaches such as the progressively lowered stress threshold model and reactance theory which stress the importance of paying attention to the severity of cognitive impairment and avoiding the use of chemical or physical restraints.
PMCID: PMC1310539  PMID: 16280091
22.  Predicting inpatient violence using an extended version of the Brøset-Violence-Checklist: instrument development and clinical application 
BMC Psychiatry  2006;6:17.
Patient aggression is a common problem in acute psychiatric wards and calls for preventive measures. The timely use of preventive measures presupposes a preceded risk assessment. The Norwegian Brøset-Violence-Checklist (BVC) is one of the few instruments suited for short-time prediction of violence of psychiatric inpatients in routine care. Aims of our study were to improve the accuracy of the short-term prediction of violence in acute inpatient settings by combining the Brøset-Violence-Checklist (BVC) with an overall subjective clinical risk-assessment and to test the application of the combined measure in daily practice.
We conducted a prospective cohort study with two samples of newly admitted psychiatric patients for instrument development (219 patients) and clinical application (300 patients). Risk of physical attacks was assessed by combining the 6-item BVC and a 6-point score derived from a Visual Analog Scale. Incidents were registered with the Staff Observation of Aggression Scale-Revised SOAS-R. Test accuracy was described as the area under the receiver operating characteristic curve (AUCROC).
The AUCROC of the new VAS-complemented BVC-version (BVC-VAS) was 0.95 in and 0.89 in the derivation and validation study respectively.
The BVC-VAS is an easy to use and accurate instrument for systematic short-term prediction of violent attacks in acute psychiatric wards. The inclusion of the VAS-derived data did not change the accuracy of the original BVC.
PMCID: PMC1459151  PMID: 16638122
23.  Examining the Determinants of Sexual Violence Among Young, Married Women in Southern India 
Journal of interpersonal violence  2012;27(12):2465-2483.
The prevalence of sexual violence is increasingly being studied in India. Yet the determinants of sexual violence, irrespective of physical violence, remain largely unexplored. Here the authors identify the determinants of sexual violence, and additionally, explore how the presence of physical violence modifies these determinants. A cross-sectional analysis is conducted using baseline data from a longitudinal study involving young married women attending reproductive health clinics in Southern India. A multivariable logistic regression analysis is conducted to first identify determinants of sexual violence and then repeated after stratifying elements based on presence or absence of physical violence identified from participants’ reports. 36% and 50% of the participants report experiencing sexual and physical violence, respectively. After adjusting for other covariates, women’s partners’ characteristics are found most significantly associated with their odds of experiencing sexual violence. These characteristics include husbands’ primary education, employment as drivers, alcohol consumption, and having multiple sex partners. Women’s contribution to household income also increases their odds of experiencing sexual violence by almost twofold; however, if they are solely responsible for “all” household income, the relationship is found to be protective. Physical violence modifies the determinants of sexual violence, and among women not experiencing physical violence, husbands’ primary education and employment as drivers increase women’s odds of experiencing sexual violence nearly threefold, and women who contribute “all” the household income (n = 62) do not experience sexual violence. These relationships are not significant among women experiencing physical violence. Study findings improve the understanding of the determinants of sexual violence. Future research is needed to examine the risk factors for different types of GBV independently and to tease apart the differences in risk factors depending on women’s experiences. The significance of male partners’ characteristics warrants in-depth research, and in order to promote gender-equitable norms, future interventions need to focus on male behaviors and men’s day-to-day survival challenges, all of which likely influence conflicts in marital relationships.
PMCID: PMC3617404  PMID: 22279129
gender-based violence; sexual violence; physical violence; India
24.  Treatment, Services and Follow-up for Victims of Family Violence in Health Clinics in Maputo, Mozambique 
Family violence (FV) is a global health problem that not only impacts the victim, but the family unit, local community and society at large.
To quantitatively and qualitatively evaluate the treatment and follow up provided to victims of violence amongst immediate and extended family units who presented to three health centers in Mozambique for care following violence.
We conducted a verbally-administered survey to self-disclosed victims of FV who presented to one of three health units, each at a different level of service, in Mozambique for treatment of their injuries. Data were entered into SPSS (SPSS, version 13.0) and analyzed for frequencies. Qualitative short answer data were transcribed during the interview, coded and analyzed prior to translation by the principal investigator.
One thousand two hundred and six assault victims presented for care during the eight-week study period, of which 216 disclosed the relationship of the assailant, including 92 who were victims of FV. Almost all patients (90%) waited less than one hour to be seen, with most patients (67%) waiting less than 30 minutes. Most patients did not require laboratory or radiographic diagnostics at the primary (70%) and secondary (93%) health facilities, while 44% of patients received a radiograph at the tertiary care center. Among all three hospitals, only 10% were transferred to a higher level of care, 14% were not given any form of follow up or referral information, while 13% required a specialist evaluation. No victims were referred for psychological follow-up or support. Qualitative data revealed that some patients did not disclose violence as the etiology, because they believed the physician was unable to address or treat the violence-related issues and/or had limited time to discuss.
Healthcare services for treating the physical injuries of victims of FV were timely and rarely required advanced levels of medical care, but there were no psychological services or follow-up referrals for violence victims. The healthcare environment at all three surveyed health centers in Mozambique does not encourage disclosure or self-report of FV. Policies and strategies need to be implemented to encourage patient disclosure of FV and provide more health system-initiated victim resources.
PMCID: PMC3117612  PMID: 21731793
25.  Prescription Drugs Associated with Reports of Violence Towards Others 
PLoS ONE  2010;5(12):e15337.
Violence towards others is a seldom-studied adverse drug event and an atypical one because the risk of injury extends to others.
To identify the primary suspects in adverse drug event reports describing thoughts or acts of violence towards others, and assess the strength of the association.
From the Food and Drug Administration (FDA) Adverse Event Reporting System (AERS) data, we extracted all serious adverse event reports for drugs with 200 or more cases received from 2004 through September 2009. We identified any case report indicating homicide, homicidal ideation, physical assault, physical abuse or violence related symptoms.
Main Outcome Measures
Disproportionality in reporting was defined as a) 5 or more violence case reports, b) at least twice the number of reports expected given the volume of overall reports for that drug, c) a χ2 statistic indicating the violence cases were unlikely to have occurred by chance (p<0.01).
We identified 1527 cases of violence disproportionally reported for 31 drugs. Primary suspect drugs included varenicline (an aid to smoking cessation), 11 antidepressants, 6 sedative/hypnotics and 3 drugs for attention deficit hyperactivity disorder. The evidence of an association was weaker and mixed for antipsychotic drugs and absent for all but 1 anticonvulsant/mood stabilizer. Two or fewer violence cases were reported for 435/484 (84.7%) of all evaluable drugs suggesting that an association with this adverse event is unlikely for these drugs.
Acts of violence towards others are a genuine and serious adverse drug event associated with a relatively small group of drugs. Varenicline, which increases the availability of dopamine, and antidepressants with serotonergic effects were the most strongly and consistently implicated drugs. Prospective studies to evaluate systematically this side effect are needed to establish the incidence, confirm differences among drugs and identify additional common features.
PMCID: PMC3002271  PMID: 21179515

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