&

Aggression, Micro-aggression, and

Abuse Against Health Care Providers
During the COVID-19 Pandemic. A
Latin American Survey
Sebastia
n García-Zamoraa, Laura Pulidob,
Andr
es Felipe Miranda-Arboledac,d,
Darío Eduardo Garcíae,f, Gonzalo P
erezg,
Mauricio Priottia, Diego X. Changoh, Melisa Antoniollii,
Ezequiel Jos
e Zaidelj, Ricardo Lopez-Santik,
Gustavo Vazquezl, Rodrigo Nun ~ez-Mendezm,


Luz Teresa Cabraln, Alvaro Sosa-Liprandij,
Kiera Libliko, and Adrian Baranchukc*
From the a Cardiology Department, Delta Clinic, Rosario, Santa Fe, Argentina, b Asociaci
on Argen-
tina de Medicina Respiratoria (AAMR), Buenos Aires, Argentina, c Division of Cardiology, Queen’s
University, Kingston, Ontario, Canada, d Cardiology Department, Pablo Tob
on Uribe Hospital,
Medell
ın, Colombia, e Hospital de Alta Complejidad en Red “El Cruce”, Buenos Aires, Argentina,
f
Federaci
on Latinoamericana de Medicina de Emergencias (FLAME), Buenos Aires, g Division of
Cardiology, Cl
ınica Olivos, Buenos Aires, Argentina, h Cardiology and Advanced Cardiac Imaging
Division, Hospital Universitario del R
ıo, Cuenca, Azuay, Ecuador, i Consejo Argentino de Residentes
de Cardiolog
ıa (CONAREC), Argentina, j Cardiology Department, Sanatorio G€ uemes, Ciudad
Aut
onoma de Buenos Aires, Argentina, k Division of Cardiology, Hospital Italiano de La Plata, Bue-
nos Aires, Argentina, l Department of Psychiatry, Queen’s University, Kingston, Ontario, Canada, m
Asociaci
on de Residentes y Fellows de Cardiolog
ıa de M
exico A. C. (ARCAME), M
exico, n Cardiol-
ogy Department, Hospital Nacional de Itagu
a, Paraguay and o Department of Medicine,
a, Itagu

Queen’s University, Kingston, Ontario, Canada.

Abstract: The COVID-19 pandemic has had tremen-

dous consequences globally. Notably, increasing com-
plaints of verbal and physical violence against health
care providers have been reported. A cross-sectional
electronic survey was conducted between January 11
and February 28, 2022 to delineate the violent

Funding: The present study has not received any grants or financial support.
Declaration of Competing Interest: The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence the work reported in this paper.
Curr Probl Cardiol 2022;47:101296
0146-2806/$
see front matter
https://doi.org/10.1016/j.cpcardiol.2022.101296

Curr Probl Cardiol, October 2022 1

 behavior against front-line health professionals in
Latin America. A total of 3544 participants from 19
countries were included. There were 58.5% women,
70.8% were physicians, 16% were nurses, and 13.2%
were other health team members. About 54.8%
reported acts of abuse: 95.6% verbal abuse, 11.1%
physical abuse, and 19.9% other types. Nearly half of
those who reported abuse experienced psychosomatic
symptoms after the event, 56.2% considered changing
their care tasks, and 33.6% considered quitting their
profession. In a logistic regression model, nurses (odds
ratio (OR) 1.90, P < 0.001), doctors (OR 2.11, P <
0.001), and administrative staff (OR 3.53, P = 0.005)
experienced more abuse than other health workers.
Women more frequently reported abuse (OR 1.56, P
< 0.001), as well as those who worked directly with
COVID-19 patients (OR 3.66, P < 0.001). A lower
probability of abuse was observed at older ages (OR
0.95, P < 0.001). There has been a high prevalence of
abuse against health personnel in Latin America dur-
ing the COVID-19 pandemic. Those caring for
COVID-19 patients, younger staff, and women were
found to be at elevated risk. It is imperative to develop
strategies to mitigate these acts and their repercussions
on the patient-provider relationship and outcomes.
(Curr Probl Cardiol 2022;47:101296.)

Introduction

&
W
orkplace violence (WPV) against Health Care Providers
(HCP) is not a novel issue. This problem has been recognized
for more than 3 decades.1-5 Despite hundreds of research
articles describing this issue, emerging literature shows that this situation
has been increasing with time.5-13 The World Health Organization
(WHO) published a Framework approach to it in 2002.14 In this docu-
ment, the WHO together partnered with the International Labour Office,
the International Council of Nurses, and Public Services International to
define WPV as “incidents where staff are abused, threatened or assaulted

2 Curr Probl Cardiol, October 2022

in circumstances related to their work [. . .] involving an explicit or
implicit challenge to their safety, well-being or health”.
The Coronavirus disease 2019 (COVID-19) pandemic has resulted in
consequences beyond the direct damage caused by the disease and its
impact on the health systems.15 Complaints of violence against HCP
have become frequent and are of great concern.16 The adaptation of medi-
cal services to follow the COVID-19 protocols recommended by the
WHO has led to prolonged triage in the emergency departments and
occasionally closing or restricting access to some services, causing
patients and caregivers frustration.
In light of these difficulties, the Inter-American Society of Cardiology
(SIAC) developed a survey to characterize the frequency and type of vio-
lent actions against front-line health professionals in Latin America.

Material and Methods

Study Design
This study was designed and implemented following the Consensus-
Based Checklist for Reporting of Survey Studies (CROSS) proposed by
the Enhancing the QUAlity and Transparency Of health Research
(EQUATOR) Network.16 A cross-sectional electronic survey was carried
out between January 11 and February 28, 2022. The survey was devel-
oped in Google Forms (Mountain View, CA) (see Supplementary Materi-
als), with 5 sections and 49 questions. Demographics, profession, work
environment, previous experiences of violence, and reactions after expo-
sure to violence were registered in the survey. The link with the question-
naire was publicly accessible and circulated via e-mail, medical society
communications, and social media platforms (Twitter, WhatsApp,
Instagram).
Violence definitions were based on the Framework guideline of the
WHO14 is provided in the supplementary material (see Table S1, Supple-
mentary Materials).

Study Population
Different HCP from Latin America who have been providing care
from March 2020 onwards, regardless of whether they interacted with
COVID-19 patients, were included. The opportunity to refuse to partici-
pate in the study was given to the respondents and their personal

Curr Probl Cardiol, October 2022 3

information was protected and anonymized. The SIAC Ethics Board
approved this protocol.

Statistical Analysis
A non-probabilistic snowball sampling was performed. Continuous
variables were expressed as mean and standard deviation or median and
interquartile range, according to their distribution. The normality of each
variable was evaluated using graphic tools (histograms and normal proba-
bility plots) and the Shapiro-Wilk test. The categorical variables were
expressed by numbers and percentages.
The Student’s t-test was used for comparisons between groups of the
continuous variables that were normally distributed. Comparisons
between proportions were made using the Chi-square test or Fisher’s
exact test depending on the frequency of expected values.
A multiple logistic regression model was constructed manually to
explore the variables associated with health personnel suffering violence.
All variables that achieved a value of P
0.2 in the univariate model
were evaluated in the multiple logistic regression model, as well as those
considered clinically relevant by the authors were selected to be included.
To develop the final model a 2-tail P-value < 0.05 was used. The predic-
tive capacity of the model was evaluated by constructing ROC (Receiver
Operating Characteristic) curves, and its goodness of fit using the
Hosmer-Lemeshow test, comparing the predicted values by deciles.
The analyzes were performed with STATA version 13.0.

Results
The survey was completed by 3544 participants from 19 countries
(Table S2, Supplementary Materials); 58.5% were women and the mean
age of the responders was 41.9 § 11 years. A total of 70.8% of the res-
ponders were physicians, 16.0% were nurses, 3.4% were physiothera-
pists, and the remaining 9.8% had other roles within the health team
(Table 1). Approximately 85.1% of physicians were specialists: 33.9%
were cardiologists, 14.4% were intensivists or emergency physicians,
10.9% were in a surgical specialty, 7.7% were pediatricians or in related
subspecialties, and the remaining 33.1% were from various other
specialties.
Over a third of the physicians had been practicing for over 15 years
(38.7%), followed by those who had completed their education
5-10 years ago (24.9%) (Table 1).

4 Curr Probl Cardiol, October 2022

TABLE 1. Baseline characteristics of the participants according to their gender

Characteristicy Women Men P

Age 40.5 § 9.9 43.9 §12.1 <0.001
Physicians (n = 2503) 51.9% 48.1% <0.001
Nurses (n = 563) 79.6% 20.4% <0.001
Secretaries and administrative (n = 100) 77.0% 23.0% <0.001
Kinesiologists (n = 119) 56.3% 43.7% 0.62
Technicians (n = 97) 56.7% 43.3% 0.71
Pharmacists (n = 35) 82.9% 17.1% 0.003
Biochemists (n = 27) 66.7% 33.3% 0.26
Others (n = 88) 84.1% 15.9% <0.001
Years of practice
* less than 5 60.1% 39.9%
* 5-10 64.4% 35.6%
* 11-15 y 61.3% 38.7% <0.001
* more than 15 y 52.2% 47.8%
* I prefer not to say 54.1% 45.9%
Work regularly with COVID-19 patients
* yes 58.6% 41.4% 0.14
* I’m not sure 65.7% 34.3%
y12 participants did not declare their gender.

The majority of participants worked in public practice (36.3%) with

28.8% working in private practice and the remaining working in both.
Direct and regular care to COVID-19 patients was provided by 74.7% of
all respondents. Table 1 summarizes the baseline characteristics of the
participants according to their gender.
Among all participants, 54.8% reported experiencing WPV during the
study period: 95.6% verbal violence, 11.1% physical violence, and
19.9% other types of violence. Overall, women more frequently experi-
enced any type of violence than men (65.2% Vs 50.7%, P < 0.0001). In
contrast, concerning physical violence, no differences were observed by
gender (11.4% in women Vs 10.5% in men, P = 0.52).
Regarding the frequency of violence episodes, 13.1% of participants
reported experiencing some form of violence daily, 26.4% of respondents
experienced it about once a week, whereas 38.8% reported a frequency of
a few times in a month or rarely (21.7%). The acts of violence most fre-
quently involved patients’ relatives (32%) or patients in conjunction with
their relatives (35.1%). Less frequently, the participants reported having
experienced violence exclusively from their patients (9.1%), or by not
related bystanders (23.9%). In over a quarter of cases there were no wit-
nesses to the violence (28.1%), whereas when there were witnesses,
almost half were indifferent to the situation (44.6%). Conversely, in
19.7% of reported cases, the witnesses intercepted in favor of the health

Curr Probl Cardiol, October 2022 5

personnel. Infrequently the witnesses joined in the aggression (7.6%). In
contrast, when the acts of violence occurred in the presence of another
member of the health team, in most cases they intercepted on behalf of
the victim (46.6%) or requested help from third parties (12.9%).
The victims rated the stress level of these events as an average of 8.2 §
1.8 points (on a scale from 1 to 10, where “1 was the less stressful situa-
tion and 10 the most stressful situation in their life”). On average, women
found these events more stressful than men (8.4 § 1.7 Vs7.8 § 2.1, P <
0.0001). Approximately half of the health personnel who experienced
WPV reported psychosomatic symptoms following the event (Fig 1),
(Fig 2). As a consequence, 12.4% of the victims engaged in psychological
care outside their workplace. Psychosomatic and cognitive symptoms
were more frequent among victims of physical violence (P < 0.01)
(Table 2). Among all participants who reported violence, 56.2% consid-
ered changing their care tasks and 33.6% consider quitting their profes-
sion. Notably, only 23.0% of the health personnel who experienced
violence stated that they pursued legal action based on an event.
A total of 71.8% of participants expressed having witnessed acts of
violence against other members of the health team during the studied
period.
A logistic regression model was developed to explore which socio-
demographic variables or characteristics were associated with
experiencing some type of violence (Table 3). According to this
model, the HCP most exposed to violence were nurses (odds ratio
[OR] 1.90 CI 95% 1.33-2.72; P < 0.001), doctors (OR 2.11, CI 95%
1.55-2.89; P < 0.001), and administrative staff (OR 3.53, CI 95%
1.46-8.53; P = 0.005) while the physiotherapists showed a non-signifi-
cant trend towards experiencing violence less frequently. Women
more frequently reported violence (OR 1.56, CI 95% 1.33-1.83; P <
0.001) as well as those who worked with patients with COVID-19
(OR 3.66, CI 95% 3.02-4.44; P < 0.001) and those members of the
health team who worked in the public care system (OR 1.86, CI 95%
1.52-2.28; P < 0.001). Conversely, a lower probability of violence
was observed at older ages (OR 0.95, CI 95% 0.94-0.96; P < 0.001).
We also reported differences in the frequency of acts of violence
among the participants according to their country of residence
(Table 3).
The developed model showed adequate goodness of fit in the Hosmer-
Lemeshow test (P = 0.81) and a good predictive capacity assessed with
a ROC curve (area under ROC curve = 0.74) (Table S3 and Figure S1,
Supplementary Material).

6 Curr Probl Cardiol, October 2022

Curr Probl Cardiol, October 2022

FIG 1. Symptoms experienced by the participants after suffering an act of violence. (Color version of figure is available online.)
7
8
Curr Probl Cardiol, October 2022

FIG 2. Central illustration, of violence, and aggression toward health care providers during the COVID-19 pandemic. (Color version of figure is available
online.)
TABLE 2. Psychosomatic symptoms after referred for the participants, according to the type of
violence suffered

Symptoms Physical violence Verbal and other P

(n = 233) violence (n = 1867)
Revival symptoms 64.0% 48.6% <0.0001
Evasion symptoms 64.8% 52.9% 0.001
Hypervigilance 71.7% 59.0% <0.0001
Cognitive symptoms 66.1% 53.5% <0.0001
Required psychological care 20.9% 12.5% 0.001

Discussion
The main findings of our study are as follows: (1) a high prevalence of
violence towards HCP is occurring in Latin America during the COVID-
19 pandemic, especially verbal abuse; (2) more than 1 in 10 participants
reported having suffered physical violence; (3) victims of physical vio-
lence experienced more cognitive and psychosomatic symptoms than
those who experienced verbal abuse; (4) the most vulnerable subjects to
experiencing WPV were young woman, especially who work as physi-
cians, nurses, or administrative staff, and (5) about half of the victims of
violence experienced psychosomatic symptoms, with a similar proportion

TABLE 3. Regression model to explore the characteristics associated with suffering some type of
violence

Variable OR CI 95% P
Female sex 1.56 1.33 - 1.83 <0.0001
Health team member* <0.0001
Doctor 2.11 1.55 - 2.89 <0.0001
Nurses 1.90 1.33 - 2.72 0.005
Administrative staff 3.53 1.46 - 8.53 0.077
Physiotherapists 0.64 0.39 - 1.05
Age 0.95 0.94 - 0.96 <0.0001
Workplacey
Public 1.86 1.52 - 2.28 <0.0001
Public & private practice 1.47 1.21 - 1.79 <0.0001
Work with COVID-19 patients 3.66 3.02 - 4.44 <0.0001
Country of residencez
Argentina 1.34 1.10 - 1.63 0.004
Ecuador 1.15 0.86 - 1.55 0.344
Mexico 0.55 0.40 - 0.77 <0.0001
Colombia 0.66 0.45 - 0.98 0.038
Less than 10 y from graduation 0.83 0.67 - 1.02 0.079
*compared with other member of the health system.
ycompared with health team members that works in private practice only.
zcompared with health team members.

Curr Probl Cardiol, October 2022 9

of subjects considering changing their care tasks, while a third of those
who suffered attacks considered abandoning their profession (Central
illustration).
In 2020, a meta-analysis including 65 studies with 61,800 health care
professionals found a prevalence of WPV of 19.3%. There was extremely
high heterogeneity in this analysis with a prevalence of violence in stud-
ies ranging from 3% to 88%.8 The authors found a higher frequency of
acts of violence against nursing staff than against physicians, but they did
not report differences by gender,8 contrary to what we found in our study.
Another systematic review of health personnel from Spain found that the
most frequent form of aggression was verbal with the main causes being
waiting times and delays, and this information is underreported.6 Interest-
ingly, despite these observations being made prior to the COVID-19 pan-
demic, their findings are very similar to our survey.
Although the exact epidemiology of the violent episodes against front-
line workers during COVID-19 pandemic has not been established, multi-
ple reports have exposed different types of violence17 and discrimination
against specific populations during this period.18 The violence against
medical personnel has increased during the past few years, and studies
from countries such as India suggest that approximately 75% of doctors
may experience violence at least once during their practice.19 The current
COVID-19 pandemic has magnified a problem that had been growing
progressively in different latitudes.20-23
Mu~ noz Del Carpio-Toia et al. performed a cross-sectional online sur-
vey of 200 physicians in Peru during the COVID-19 pandemic. Of the
respondents, 84.5% suffered some type of violence with the primary
aggressor typically being a family member or caregiver (43% of reported
cases). A multi-logistic regression showed that female doctors (OR
= 2.48, 95% confidence interval [CI] = 1.06-5.83) and those working in
COVID-19 wards (OR = 5.84, 95% CI = 1.60-21.28) were the most likely
to experience violence.22 These results are similar to our findings, how-
ever, the incidence of violence was significantly higher in the previously
mentioned study as compared to ours (84.5% Vs 54.8%). This may be
because only physicians working in COVID hospitals participated in their
survey while in our study the invitation was not restricted.
The relationship between the WPV and COVID-19 was recently
highlighted in a study from the Mayo Clinic which showed that during
the pandemic the rate of violent incidents in the emergency department
increased to 2.53 incidents per 1000 visits, compared to 1.13 incidents
per 1000 visits during the prior 3 months.21

10 Curr Probl Cardiol, October 2022

 In our study, older practitioners had a lower risk of violence and verbal
aggression was much more likely than physical violence. These findings
are consistent with the results of a study from Brazil which, after an
adjusted logistic regression model, demonstrated that less than 20 years
of experience was associated with a higher risk of violence.25 In the same
study, the nursing staff suffered more violence; this represents a signifi-
cant difference from our study where the administrative staff was at
higher risk (OR 3.20, P < 0.0001). The discrepancy can be explained as
in previous studies the non-medical staff was not considered in the
survey.24
Our survey revealed a major problem related to WPV. The negative
psychologic consequences of HCP after a violent episode are significant
and lead even to consideration of quitting practice in the third part of res-
ponders. This issue has been pointed out previously.25-27 Accordingly,
Gillespie et al. found that almost 60% of emergency department workers
experienced posttraumatic stress symptomatology after verbal or physical
aggression.25 On the other hand, Shi et al. evaluated Chinese healthcare
workers who suffered physical violence.27 In this study, nearly 1 in 3 par-
ticipants experienced post-traumatic stress disorder symptoms. A study
by Nam et al. evaluated 422 health care workers who experienced verbal
or physical violence in a training general hospital in South Korea.26 They
found that WPV was significantly associated with lower empathy with
patients. Additionally, authors reported higher post-traumatic stress
symptom severity among victims of verbal as compared to physical vio-
lence. A possible explanation for this observation is that victims of verbal
violence made less frequent complaints about it while receiving less insti-
tutional protection, similar to our findings. This highlights the importance
of not ignoring the deleterious consequences of any type of violence.
The COVID-19 pandemic is still ongoing. Explanations for the poten-
tial increase in violence to health care workers throughout include fear
and panic, misinformation about COVID-19, poor levels of health educa-
tion, diminished health care quality, difficulties in timely access due to
services, and increase workload, and emotional stress in health practi-
tioners.17,27-30 Potential strategies to mitigate the progression of this prob-
lem include protecting health workers through legislation, improved
communications with patients and families, critical analysis of informa-
tion on social media, facilitating patients’ access through telemedicine
strategies, and improving access to primary settings. All of these strate-
gies can help to alleviate the pressure on frontline health workers as well
as the stress related to acute care and subsequently violent episodes.17

Curr Probl Cardiol, October 2022 11

 Our survey has limitations that should be taken into account when
interpreting the results. First, due to the sampling used and given the large
number of countries involved, it was not feasible to calculate a total pos-
sible sample to evaluate the response rate. This could have generated a
response bias among those individuals who have suffered episodes of vio-
lence. However, almost half of the participants did not report experienc-
ing violence, which attenuates this potential bias. Second, although
health personnel from 19 countries participated in the survey, nearly 3-
quarters of the respondents were from 3 countries. Third, although differ-
ent members of the health system participated in the survey, most of the
respondents were physicians and nurses. This limits the generalizability
of our findings to other team members. Fourth, our survey was not pilot
tested to gauge the accuracy of responses. However, because the partici-
pants had an adequate level of education, there is no clear evidence to
suggest that the answers were biased in any direction. Finally, due to the
heterogeneity of the participants included and the different scenarios
where the respondents work, the results of the logistic regression model
must be interpreted with caution. Nevertheless, our findings are consistent
with previous literature, both in the context of the COVID-19 pandemic
and with previous studies.
To the best of our knowledge, our study is the largest health WPV sur-
vey performed during the COVID-19 pandemic, and the first international
study that took the information at a continental level from HCP with dif-
ferent roles on the front line working with COVID-19 patients.

Conclusion
Our survey detected a high prevalence of violence against health per-
sonnel in Latin America during the COVID-19 pandemic. Although most
of the victims experienced verbal violence, 1 in 10 participants reported
some type of physical aggression during this time. The staff who works
regularly with COVID-19 patients and their relatives, younger members
of the health, team, and women were found to be especially vulnerable to
verbal violence.
The frequency of psychosomatic symptoms after suffering WPV was
significant. Furthermore, some participants considered changing their
care tasks or changing their profession due to this reason.

Authorship Details
Conception and design of the project: S.G.Z., L.P., R.L.S., G.V., A.S.
L., and A.B. Data collection: L.P., A.F.M.A., D.E.G., G.P., M.P., D.X.C.

12 Curr Probl Cardiol, October 2022

A., E.J.Z., R.N.M., L.T.C., K.L. Data analysis, and interpretation: S.G.Z.,
L.P., D.E.G., G.P., M.P., D.X.C.A., M.A., A.F.M.A., A.B. Drafting the
article: S.G.Z., L.P., M.P., D.X.C.A., M.P., A.F.M.A., K.L. Drafting the
tables and figures: S.G.Z., D.E.G., G.P., M.P., D.X.C.A., M.P., M.A., E.J.
Z., R.N.M., L.T.C. Drafting central illustration: L.P., A.F.M.A., K.L., A.
B. Critical revision of the article: S.G.Z., A.F.M.A., E.J.Z., R.L.S., G.V.,
A.S.L., and A.B. Final approval of the version to be published: All
authors have read and agreed to the published version of the manuscript.

Acknowledgment
We want to express our deepest gratitude to all colleagues and health
personnel who have been working on the front line against COVID-19
for more than 2 years, despite all the adversities. We also thank the SIAC
Executive Board that allowed us to carry out this survey, and to all the
colleagues who selflessly participated in it.

Supplementary materials
Supplementary material associated with this article can be found in the
online version at doi:10.1016/j.cpcardiol.2022.101296.

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