Violence against Healthcare Workers during the COVID-19 Pandemic: A Review of Incidents from a Lower-Middle-Income Country

Background: Healthcare workers (HCWs) across the globe have met tremendous challenges during the COVID-19 (coronavirus disease 2019) pandemic, such as shortages of personal protective equipment, extensive work hours, and constant fear of catching the virus or transmitting it to loved ones. Adding on to the already existing burnout, an increase in incidents of violence and aggression against HCWs was seen in Pakistan and globally. Objectives: Primarily to review cases of violence against HCWs in Pakistan, highlighting and comparing the instigating factors seen within the country and globally. Secondly, to enlist possible interventions to counter workplace violence in healthcare during a pandemic and in general. Methods: Incidents of violence towards HCWs in Pakistan during the COVID-19 pandemic occurring between April 7, 2020, and August 7, 2020, were included. The incidents reported from local newspapers were reviewed. Findings and Conclusion: A total of 29 incidents were identified, with perpetrators of violence most commonly being relatives of COVID-19 patients. Most frequent reasons included mistrust in HCWs, belief in conspiracy theories, hospitals’ refusal to admit COVID-19 patients due to limited space, COVID-19 hospital policies, and the death of the COVID-19 patients. Protests by doctors and other HCWs for provision of adequate PPE, better quarantine conditions for doctors with suspected COVID-19, and better compensation for doctors on COVID-19 patient duty resulted in police violence towards HCWs. To avoid such incidents in the future, institutions, healthcare policymakers, media organisations, and law enforcement agencies must work together for widespread public awareness to counter misconceptions and to exhibit responsible journalism. In hospitals, measures such as de-escalation training and increased security must be implemented. Furthermore, law enforcement agencies must be trained in non-violent methods of crowd dispersal and control to manage peaceful protests by HCWs over legitimate issues.


INTRODUCTION
With the COVID-19 (coronavirus disease 2019) pandemic having caused more than 58 million reported cases and 1 million reported deaths globally as of November 20, 2020, healthcare workers (HCWs) are facing unprecedented challenges while remaining on the frontlines [1]. These include exhaustive work hours, shortages of personal protective equipment (PPE), and a constant fear of contracting COVID-19 themselves or transmitting it to their loved ones. To add to these challenges, a worrying surge in violence against healthcare workers has been reported globally [2,3]. According to the World Health Organization (WHO), up to 38% of HCWs encounter physical violence at some point in their careers, which causes psychological distress and burnout and in turn affects healthcare delivery [4]. In Pakistan, one third of all HCWs have reported aggression directed towards them, with the most common being in verbal form [5]. As the number of confirmed COVID-19 cases in Pakistan crosses 374,000 [6], growing tensions amongst the population have led to an increase in incidents of violence and hostility all over the country. In this review, we describe the incidents of aggression and violence towards HCWs during the COVID-19 pandemic in Pakistan, as reported by local newspapers. In addition, factors motivating these incidents are discussed and related solutions are suggested to provide healthcare systems and the Government of Pakistan with evidence-based action plans to negate such events in the future.

SEARCH STRATEGY AND SELECTION CRITERIA
In the absence of any published literature, our search strategy consisted of reviewing reports of violence against healthcare workers by local news agencies in Pakistan, which uploaded their reports/articles to their websites from April 7, 2020, to August 7, 2020. News websites searched included The Express Tribune, Geo News, The Nation, Dawn News, Samaa News, The News International, News Intervention, Gandhara, National Public Radio (NPR), and CNN. The search was independently performed by two members of the research team (NA and HR), who compiled lists of relevant articles on MS Excel. Once the search was completed, a third member of the research team (OAB) reviewed and synthesized both lists. Duplicates (reports of the same incident in different news reports) were excluded. Discrepancies in lists were settled by referring to the news article in question and determining its suitability for inclusion.

DISCUSSION
More than 400 incidents of violence disrupting healthcare were reported worldwide with over 260 cases of aggression being responses to COVID-19 health measures. According to the International Committee of the Red Cross (ICRC), a total of 611 incidents of violence and harassment took place in the first six months of the pandemic [20]. However, these numbers could be understated, because most cases go unreported [21]. A majority of the targets are doctors and nurses directly dealing with COVID-19 patients, and perpetrators either include the family of COVID-19 patients, the general community, or law enforcement personnel [2].
According to our review of cases in Pakistan, the attacks on health care workers were mainly driven by grievances over the death of COVID-19 patients, a mistrust towards doctors borne of widespread conspiracy theories, and resistance towards protective COVID-19 measures set by the government. Cases of violence and harassment against HCWs with similar inciting factors occurred across the globe. In India, a quarantine facility was vandalised, and HCWs were assaulted over the death of a COVID-19 patient [21]. In Central America and Caribbean countries, doctors and nurses were attacked on multiple occasions due to frustration caused by lack of proper care, concerns regarding COVID-19 testing, and reluctance to adhere to rules regarding burial of COVID-19 patients [22]. In the United States, public health officials have been targets of physical threats, protests, and cyber harassment as a result of opposition to usage of masks and lockdown policies, coupled with criticism from political leaders and social media slander campaigns [23]. An additional factor contributing to violence is the fear of catching the virus from HCWs. Several nurses in Mexico were assaulted while travelling to work, a nurse was attacked with bleach in Philippines, and in India, HCWs were chased by mobs, threatened by neighbours and landlords to vacate their homes, and faced hostility during contact tracing [3,[24][25][26]  severely affected the COVID-19 response. In Afghanistan, a maternity ward was attacked by gunmen in May 2020 [22].
Workplace violence in healthcare has been extensively documented in literature. Several multicentre studies have been conducted in Pakistan, and worldwide, to document the magnitude, types, and various factors involved in violence against the medical profession. In a systematic review published in 2019, Liu and colleagues reported that 61.9% of HCWs experienced some form of violence in the past year, with verbal abuse being the most common, and 24.4% HCWs experienced physical violence [27]. The emergency department is the most common site, and most cases are unreported because HCWs consider these aggressions towards themselves as a norm. In Pakistan, incidents have ranged from bullying, harassment, vandalism, and showing of weapons, to threats of extortion and kidnapping [5]. Workplace violence is more prevalent in public hospitals, as compared to private hospitals, due to overcrowding, easy access to the facility by the public, and resource constraints. A similar trend can be observed during this pandemic as well, because almost no cases of violence have been reported from private hospitals [5]. Major contributing factors to these incidents are unexpected outcomes or death of a patient, unavailability of resources at the facility, long waiting times and delay in treatment, miscommunication with patients and their families, and a general lack of awareness in society. Mostly relatives of the patients instigate the violence, as seen in this pandemic too. In the past, misconceptions regarding polio vaccinations have triggered incidents of violence towards health workers, similar to how misinformation regarding COVID-19 has fuelled attacks recently. Another reason observed in the past is the relatives falsely blaming doctors for harming their patients, and a similar pattern can be noted in the incidents of violence that have taken place in the past months [28].
Violence against HCWs can lead to increased work-related stress, burn out, and post-traumatic stress disorder. It negatively affects job performance, in turn leading to poor quality of health care [5]. It is also an additional contributor to already existing psychological distress caused by COVID-19. HCWs are working extra hours, with inadequate PPE and a shortage of medical equipment like ventilators, all the while being at a higher risk of getting infected and spreading it to their families [3,26]. As of July 2020, over 5,000 healthcare workers had been infected with COVID-19 in Pakistan, and 58 lost their lives [29]. Having an increased risk of exposure to COVID-19, with an addition of violent incidents, HCWs developed increased anxiety and depression, and some were even compelled to quit their duties [30].
The impact and consequences of violence, especially during an ongoing pandemic, warrants a need to implement evidence-based solutions to counter such events in the future. We categorised our proposed solutions obtained from a review of existing literature into a pandemic-oriented approach and general interventions to counter workplace violence in healthcare.

PANDEMIC AND HEALTHCARE CRISIS ORIENTED SOLUTIONS
Widespread misinformation about the disease, coupled with already heightened fear and anxiety within the community, seems to be the most notable driving factor in violence towards HCWs worldwide. Therefore, in a global healthcare crisis it is imperative to effectively educate the public through awareness campaigns early on; provide easily accessible, credible sources of information; and ensure speeches made by political leaders and people of influence are verified with facts. Secondly, scientific basis of health policies, and disease experiences from the people themselves, should be communicated to the public to ensure compliance with protective health measures [2]. Some examples of actions taken to counter misconceptions during this pandemic include 'Stop the Spread' campaign by WHO in conjunction with the UK government and removal of unsubstantiated content from social media giants like Facebook and Twitter [31,32]. Even though the spread of the virus seems to be slowing down in our part of the world, the introduction of the COVID-19 vaccine may bring new challenges. In a cross-country study, 8.4% of HCWs reported misconceptions about vaccines being a cause of verbal violence [5]. To prevent future hostilities, our leaders and media will have to exhibit responsible journalism. In light of a pandemic, local governments need to invest in hospital security measures as part of their response budgets, while hospital administrations need to formulate a standard action plan to be followed during any conflict [3]. Additionally, it is important to extend support and to promote self-care practices for HCWs exposed to high levels of stress [33].
Furthermore, offenders must be held accountable for their actions and prosecuted adequately. Following recent incidents during this pandemic, governments have implemented new policies for protection of HCWs, for example, imprisoning perpetrators for up to seven years with a fine of up to five lakh in India [34], and introducing dedicated transport for HCWs in some cities of Mexico to ensure their safety [35]. Lastly, a comprehensive database of such incidents will help understand the scope of this problem and will help us learn lessons from the past, because violence against HCWs is a repeating trend during pandemics and epidemics [2].

GENERAL MEASURES TO COUNTER WORKPLACE VIOLENCE IN HEALTHCARE
Organisationally, establishing aggression management teams for de-escalating and controlling incidents of violence in earlier stages can significantly reduce consequences of workplace violence [36]. A strict zero-tolerance attitude towards threats or any forms of violence against staff members should be enforced, along with proper reporting platforms, counselling avenues for victims, and follow-ups on prosecution of offenders [36,37]. Patient education can decrease incidents of violence by 18.6%; therefore, patients and their families need to be well informed of management plans and possible outcomes. Furthermore, reduction in waiting times and strict one-attendant policies to avoid overcrowding can help decrease frustration amongst patients [23,38].
Training HCWs in de-escalation techniques, as advised by Occupational Safety and Health Administration guidelines [39], along with recognition of perpetrators and self-defence, can ensure their protection. Development of interpersonal skills can prove useful when instructing perpetrators to stop the violent act [40].