AlHassan et al.

BMC Health Services Research (2023) 23:1065 BMC Health Services Research
https://doi.org/10.1186/s12913-023-10080-y

RESEARCH Open Access

Sexual workplace violence in the health

sector in Saudi Arabia: a cross sectional study
Aseel Khaled AlHassan1*, Reem Tarik AlSaqat2 and Fahad Saleh Al Sweleh3

Abstract
Background Sexual workplace violence occurs worldwide with increasing prevalence, causing psychological
and physical injuries. However, only few reports from the Kingdom of Saudi Arabia have investigated the most
involved health specialty and its association with other factors, such as working and sociodemographic conditions.
The aim of this study was to determine the prevalence of workplace sexual violence over 12 months, from May 2018
to May 2019, circumstances related to the event, and consequences for the perpetrator and survivor and to identify
associated factors among all healthcare workers (HCWs) in Saudi Arabia.
Methods This cross-sectional study included all HCWs registered with the Saudi Commission for Health Specialties
who worked for > 1 year in the health sector (government or private) in Saudi Arabia until May 2019. A non-probability
convenient sampling technique was used. A modified self-administered questionnaire sent via email was utilized
to assess workplace violence. Descriptive statistics were used to report percentages and frequencies, while advanced
statistics, such as bivariate analysis, were used to determine associations. Multivariate logistic binary regression analy-
sis was used to assess the combined and individual associations between relevant predictors of exposure of HCWs
to recent sexual violence at the workplace.
Results In total, 7,398 (male, 51.3%; female, 48.7%) HCWs were electively enrolled in the study (mean age
40 ± 8.62 years). Most were non-Saudi (60%). Overall, 3.9% were sexual violence survivors. Approximately 60.7%, 51.4%,
48.3%, and 65.9% of female workers, nurses, Saudi natives, and night shift workers (18:00 to 07:00), respectively, were
significantly exposed to sexual violence. Furthermore, approximately 54.8% of those with direct physical contact
with patients had a higher rate of exposure to sexual harassment (p = 0.001).
Conclusions The prevalence of sexual violence is low but remains a risk to HCWs, especially those working night
shifts and having direct physical contact with patients. Thus, more support, specific strategies, and policies are needed
to reduce the rate of occurrence, protect HCWs, and prevent such events. The underreporting of cases may be skew-
ing the magnitude of the problem; thus, more education and additional research in Saudi Arabia are needed regard-
ing sexual violence experienced by HCWs.
Keywords Sexual violence, Survivors, Healthcare workers, Saudi Arabia, Abuse, Violence, Sexual harassment

*Correspondence: Background
Aseel Khaled AlHassan The World Health Organization (WHO) defines vio-
[email protected]
1
King Khalid Hospital in AlKharj, Ministry of Health, P.O. BOX: 52166, lence as "the intentional use of physical force or power,
Riyadh, Kingdom of Saudi Arabia threatened or actual, against oneself, another person,
2
Princess Nourah bint Abdulrahman University, Riyadh, Kingdom of Saudi or against a group or community, that either results
Arabia
3
Dental University Hospital, King Saud medical city, King Saud University, in or has a high likelihood of resulting in injury, death,
Riyadh, Kingdom of Saudi Arabia psychological harm, maldevelopment, or depriva-
tion" [1]. Workplace violence (WPV) could be physical

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AlHassan et al. BMC Health Services Research (2023) 23:1065 Page 2 of 12

or psychological, including verbal violence, bullying/ Therefore, this study aimed to determine the preva-
mobbing, racial harassment, and sexual violence [1]. lence of sexual WPV over a period of 12 months, cir-
Although the prevalence of sexual violence is lower cumstances related to events, consequences for attackers
than that of other types of violence [2–4], it should and survivors, target populations at all healthcare pro-
not be overlooked, as it impacts the health and qual- vider facilities in Saudi Arabia, and the most susceptible
ity of life of the harassed persons (hereafter survivors) group of healthcare providers. We also identified the fac-
negatively [5, 6]. According to the WHO, sexual vio- tors associated with WPV in healthcare facilities in Saudi
lence is “any unwanted, unreciprocated, and unwel- Arabia.
come behavior of a sexual nature that is offensive to the
person involved, and causes that person to feel threat- Methods
ened, humiliated, or embarrassed” [7]. In a systemic Data collection
review and meta-analysis, Worke et al. [8] reported a An analytical cross-sectional study was conducted
prevalence of workplace sexual violence in all Ethiopian between November 4, 2018, and July 1, 2019, among all
workplaces of 22%. In another review of patient vio- healthcare providers registered in the Saudi Commission
lence against healthcare workers (HCWs) in psychiatric for Health Specialty (SCFHS) and who had been working
inpatient wards, the rate of sexual WPV was 9.5–37.2% for more than 1 year in the health sector (government or
[9]. Other reviews have reported varying rates of 0.3% private) in Saudi Arabia as of May 2019. A non-probabil-
in Taiwan [3], 12% in Ghana [10], and 73% in Turkey ity convenient sampling technique was used; the desired
[5]. Another systematic review and meta-analysis of sample size was determined based on a maximum vari-
sexual WPV inflicted by patients and visitors reported a ance assumption of 50% that the healthcare workers
rate of 14.2% [2]. These variations may be due to differ- would report a positive experience of the types of abuse
ent understandings of the meaning of sexual violence in studied. The desired sample size required to detect the
different cultures and the availability of staff per popu- true proportion of individuals who had experienced any
lation, noting that the lower the ratio, the heavier the type of abuse studied with 95% confidence and a mar-
workload, and the less time available for proper com- gin of error equal to 5% was deemed to be 384. All eli-
munication with the patients [2]. In Saudi Arabia, a gible participants (i.e., physicians, pharmacists, nurses,
conservative Arabic community, sexual harassment is midwives, health specialists, healthcare technicians, and
a very sensitive issue. Reported rates of work violence ambulance personnel) were invited to participate in the
in specific localities around Saudi Arabia ranged from study. A total of 304,002 healthcare providers met the
3% to 76.5% [4, 11–13]. None of these studies focused eligibility criteria. Students, interns, employees of the
on sexual WPV and were conducted in certain cities administrative department, healthcare providers not reg-
in Saudi Arabia, in hospitals in the same city and same istered in the SCFHS, or providers with less than 1 year
departments, such as the nursing or emergency depart- of work experience were excluded.
ment. The reluctance of victims to report incidents may Data were collected using a modified self-administered
be due to the fear of potential repercussions, such as questionnaire developed by the Joint Program on Work-
damage to their professional or personal reputation, or place Violence in the Health Sectors of the WHO, Inter-
the possibility of retaliation from the perpetrator [14]. national Labour Organization, International Council of
Sexual attack can result in fear, safety concerns, injury, Nurses, and Public Services International [17]. One of the
work leave [15], and diminished work quality [16]. authors (AH) translated the questionnaire into Arabic for
Other effects include psychological disorders, such as staff who were not fluent in English. The questionnaire
anxiety, depression, posttraumatic stress, and/or eating was then revised by the other two authors (FS and RS)
disorders [6]. This low reporting rate can lead to under- who are both bilingual. Questions that did not apply to
estimation of the problem and therefore imposes the Saudi Arabia were omitted.
need for stricter regulations and mechanisms to pre- A pilot test was conducted for reliability and validity
vent the attacks and deal with their side effects. by distributing the questionnaire to five physicians, five
Previous studies have focused on sexual WPV in high- dentists, five nurses, and five pharmacists, who were both
risk environments and specialties in some cities in Saudi Arabic and English speakers and had clinical experience
Arabia. To our knowledge, none of these studies covered in validating the Arabic translation to avoid misunder-
the whole of Saudi Arabia and all specialties. In addi- standings; these practitioners were excluded from the
tion, few studies have focused on the association between main study.
WPV and independent risk factors, such as sociodemo- The questionnaire included questions related to
graphic factors, working conditions, and factors from demographic data of the respondents, workplace char-
hospital violence reports. acteristics, violent events in the previous 12 months,
AlHassan et al. BMC Health Services Research (2023) 23:1065 Page 3 of 12

risk factors for WPV, personal opinions, perceptions, Results

attitudes, experiences, and WPV-related recommen- Demographic characteristics
dations. The questionnaire had a total of 88 questions A total of 304,002 HCWs were identified from the
divided into five sections: personal and workplace data, SCFHS database; only 7,398 (male, 51.3%; female,
physical workplace violence, verbal abuse, bullying/ 48.7%) responded to the questionnaire. The partici-
mobbing, and sexual harassment. pants’ mean age was 40 ± 8.62 years, and 60% were of
The questionnaires were e-mailed to the study popu- non-Saudi origin. Of the participants, nurses, mid-
lation by the researchers. To increase the response rate, wives, and healthcare specialists accounted for 38.1%,
the researchers sent reminder emails to the participants physicians for 30.91%, healthcare technicians and
after 2 weeks. ambulance technicians for 25.54%, and pharmacists
for 5.43%. Most of the participants were employed
full-time (89.86%) in the public/government sector
Data analysis (72.47%). Their work settings were as follows in ascend-
Data were entered into SPSS IBM (Version 22). ing order: ambulatory, specialized units, general medi-
Descriptive statistics (frequency and table) were used cine, emergency, intensive care, technical services,
to describe the basic features of the data. Continuous management, operating room, general surgery, psychi-
variables are expressed as mean and standard devia- atric, and support services (Table 1).
tion (SD), whereas categorical variables are expressed
as frequencies and percentages. Multiple response Experience of sexual workplace violence
dichotomy analysis was used to describe the items Only 3.9% of HCWs had experienced a sexual violence
measured with dichotomies (“tick all that apply to you” incident at their workplace in the last 12 months, with
questions). The Kolmogorov–Smirnov test of normal- most of the sexual harassments coming from patients
ity and histograms were used to assess the statistical (29.5%) or a staff member (27.6%). Most of the survi-
normality assumption of metric variables. Levene’s vors pretended that it had never happened (43.3%)
test of homogeneity of variance was used to assess the immediately after the act, while 36.2% asked the
statistical homogeneity of variance assumption. The offender to stop, and 28.4% had taken no action against
chi-square test of independence was used to explore the offender (Table 2).
the associations between the categorical variables,
while an adjusted likelihood ratio-chi-squared test was Consequences of sexual violence
used when the expected count assumption of the chi- As shown in Table 3, participants reported a moderate
squared test was violated. An independent samples level of disturbance due to their distressing memories,
t-test was used to assess the mean differences of contin- with a self-rated score of 3.4 out of 5 bothering points.
uous variables across the levels of categorically binary Additionally, the participants reported a relatively high
measured variables. level of hyper-alertness related to their experiences of
A multivariate binary logistic regression analysis was sexual harassment, with a score of 3.93 out of 5 bother-
conducted to assess the combined and individual asso- ing points. In Table 4, 11.2% of the survivors believed
ciations between relevant predictors of exposure of the an action was taken to investigate the event further by
HCWs to recent physical violence at the workplace. Asso- mainly the managers (86.7%). However, 60% of those
ciations between the measured predictor variables and whose events were investigated reported that a verbal
their outcomes are expressed as odds ratios (ORs) with warning was issued to the offenders. The overall sat-
95% confidence intervals (CIs). A p-value below 0.05 was isfaction with the corrective and investigative actions
considered statistically significant. taken to handle the sexual harassment event were
between dissatisfied to slightly satisfied (mean satis-
faction = 2.16 out of 5). The primary reasons for not
Ethical approval reporting the sexual harassment were fear of the nega-
This study was conducted according to the guidelines tive consequences, thought of reporting being pointless
of the Declaration of Helsinki. Approval was obtained or useless, and shame.
from the institutional review board of King Saud Univer-
sity College of Medicine (approval number: E-18–3391) Experience of sexual attacks and their sociodemographic
before the study was started. Written informed consent and professional factors
for participation, publication, and confidentiality was Female HCWs had a higher rate of harassment than
obtained from the study participants at the beginning of male HCWs. The age of the HCWs was significantly
the survey.
AlHassan et al. BMC Health Services Research (2023) 23:1065 Page 4 of 12

Table 1 Descriptive analysis of healthcare workers’ Table 2 Descriptive analysis of healthcare workers’ perceptions
sociodemographic and professional characteristics. N = 7398 and experience of sexual workplace violence
Characteristics n (%) Variable Total n (%)

Sex Occurrence of sexual violence in the last 12 months, n = 7398

Male 3792 (51.3) No 7108 (96.1)
Female 3606 (48.7) Yes 290 (3.9)
Age Typical incident of violence in your workplace, n = 268
20–29 years 402 (5.4) Yes 205 (76.5)
30–39 years 3752 (50.7) No 63 (23.5)
40–49 years 2143 (29) The attacked person, n = 268
50–59 years 882 (11.9) Patient/client/ 79 (29.5)
  ≥ 60 years 219 (3) Staff member 74 (27.6)
Nationality Relatives of patient/client 49 (18.3)
Saudi 2957 (40) Management staff member/supervisor 24 (9)
Non-Saudi 4441 (60) Other persons 17 (6.3)
Clinical role External colleague/worker 15 (5.6)
Physicians 2287 (40) General public 10 (3.7)
Pharmacists 402 (5.4) Place of incident, n = 268
Nurses, midwives, and healthcare specialist 2819 (38.1) Inside health institution or facility 245 (91.4)
Healthcare technicians and ambulance personnel 1890 (25.5) Other place 13 (4.9)
Rank/ seniority Outside (on way to work/health visit/home) 8 (3)
Junior 4605 (62.2) At patient’s/client’s home 2 (0.7)
Senior 1876 (25.4) Response to the incident, n = 268
Consultant 917 (12.4) Tried to pretend it never happened 116 (43.3)
Experience years Told the offending person to stop 97 (36.2)
1–5 years 851 (11.5) Took no action 76 (28.4)
6–10 years 2334 (31.5) Reported it to a senior staff member 53 (19.8)
11–15 years 1905 (25.8) Told a colleague 48 (17.9)
16–20 years 1025 (13.9) Told my friends/family members 26 (9.7)
  ≥ 21 years 1283 (17.3) Transferred to another position elsewhere 16 (6)
Working sector Completed an Incident/accident report form 14 (5.2)
Semi-governmental organization 380 (5.1) Took another action 8 (3)
Private sector 1656 (22.4) Sought counselling 8 (3)
Public/ governmental sector 5362 (72.5) Sought help from the medical association 4 (1.5)
Employment type Completed a compensation claim 1 (0.4)
Full-time 7256 (98) Sought help from the Saudi commission for healthcare 1 (0.4)
Part-time 78 (1.1) workers
Temporary/ casual 64 (0.9) Preventability of incident, n = 268
Yes 174 (64.9)
No 94 (35.1)

associated with exposure to sexual harassment at the

workplace in the last 12 months (p < 0.001), as a higher proportion of survivors in the working sector did not
proportion of the survivors were in the 30–39 and correlate significantly with exposure to sexual violence,
20–29 years age groups than in the > 40 years age group. indicating that the HCWs in different sectors may have
Non-Saudi HCWs were less sexually harassed in the a nearly equal rate (Table 5).
last 12 months than Saudi HCWs (p = 0.003). In addi-
tion, physicians comprised the least proportion of the Experience of sexual attacks and their working conditions
survivors (p < 0.001), while nurses comprised the great- HCWs who worked in shifts, especially those working
est proportion. Furthermore, the consultant HCWs had the night shift (18:00 to 07:00), were significantly more
a lower rate of sexual violence in the last year compared exposed to sexual violence at the workplace (p < 0.050)
to the seniors and juniors (p < 0.001). In addition, the (Table 6). In addition, direct physical contact with the
AlHassan et al. BMC Health Services Research (2023) 23:1065 Page 5 of 12

Table 3 Bothered about sexual violence

Variable Point/5

Bothering about attack

a- Repeated, disturbing memories, thoughts, or images of the attack, mean (standard deviation, SD) Likert rating 3.40 (1.41)
b- Avoiding thinking about or talking about the attack or avoiding having feelings related to it-mean (SD) Likert rating 3.50 (1.36)
c- Being "super-alert" or watchful and on guard -mean (SD) Likert rating 3.93 (1.33)
d- Feeling like everything you did was an effort -mean (SD) Likert rating 3.54 (1.35)

patients was a significant predictor of sexual violence

among the HCWs (p = 0.001). Moreover, the sex of the
patients with whom the HCWs had been working was
not a significant predictor of sexual violence (p = 0.155).
Table 4 Consequences of sexual violence
Variable Total n (%) Experience of sexual attacks and characteristics
from hospital violence reporting guidelines
Investigation of the causes of the incident, n = 268
Violence-related worry was more common in survivors
No 209 (78)
(mean score, 3.5/5 points using a Likert scale, SD = 1.21)
Yes 30 (11.2)
than in non-survivors (mean score, 2.82; SD = 1.33)
Don’t know 29 (10.8)
(p < 0.001). Furthermore, HCWs working in institutions
The perpetrator, n = 30
with policies and guidelines for dealing with work-related
Management staff member/employer 26 (86.7)
violence had a lower rate of WPV than those in institu-
Community 2 (6.7)
tions with no such policies and guidelines (p = 0.006)
Other 3 (10)
(Table 7). Encouragement from work to report WPV of
Police 3 (10)
any type was a significant predictor of lower rates of sex-
Medical association 1 (3.3)
ual WPV in the last year (p < 0.001); HCWs in violence-
Consequences for the perpetrator, n = 30
intolerant work environments had a significantly lower
Verbal warning issued 18 (60)
exposure to WPV than those in workplaces without vio-
Don’t know 4 (13.3)
lence intolerance policies. Furthermore, encouragement
None 4 (13.3)
from managers and employers was a significant predictor
Other 2 (6.7)
of lower exposure to sexual violence among the HCWs
Reported to police 1 (3.3)
(p < 0.001).
Aggressor prosecuted 1 (3.3)
The offer of employer or supervisor, n = 117
Relationship between healthcare workers’ experience (in
Opportunity to speak about/report it 58 (92.1)
years) and exposure to sexual violence
Other support 32 (50.8)
Female HCWs had more significant exposure to sex-
Counselling 27 (42.9)
ual violence than male HCWs (Fig. 1). HCWs with
Incident handling satisfaction, n = 260
Mean (SD) Likert rating, 1 = V dissatisfied, 5 = V. satisfied,
6–10 years of experience were the most susceptible group
Very dissatisfied 130 (50)
in both sexes. However, a decrease in exposure to sexual
Dissatisfied 34 (13.1)
violence was observed with an increase in the HCWs’
Neutral 48 (18.5)
experience (in years), regardless of sex.
Satisfied 21 (8.1)
Multivariate logistic binary regression analysis results
Very satisfied 27 (10.4)
Female HCWs had a more significant exposure to
Reason for not reporting the incident, n = 260
sexual violence in the past year than male HCWs
I was afraid of negative consequences 120 (46.2)
(p = 0.002). There was no association between age
I thought it was useless 104 (40)
of HCWs and sexual violence exposure (p = 0.227).
I felt ashamed 77 (29.6)
However, non-Saudi HCWs had a significantly lower
I did not know who to report to the incident 38 (14.6)
(33.3% times less) predicted rate of sexual violence
It was not important 37 (14.2)
than Saudi HCWs (p = 0.005). In addition, nurses
Other 15 (5.8)
had the greatest likelihood of being exposed to sex-
I felt guilty 12 (4.6)
ual WPV (52.8% times higher, p = 0.002). There was a
AlHassan et al. BMC Health Services Research (2023) 23:1065 Page 6 of 12

Table 5 Bivariate analysis of the association between healthcare workers’ experience of sexual workplace violence and
sociodemographic/professional factors
Sexually attacked in your workplace n (%)
No = 7108 Yes = 290 test statistic p-value

Sex
Male 3678 (51.7) 114 (39.3) χ2 (1) = 17.24 < 0.001
Female 3430 (48.3) 176 (60.7)
Age
20–29 years 378 (5.3) 24 (8.3) χ2 (4) = 72.76 < 0.001
30–39 years 3544 (49.9) 208 (71.7)
40–49 years 2096 (29.5) 47 (16.2)
50–59 years 874 (12.3) 8 (2.8)
  ≥ 60 years 216 (3) 3 (1)
Nationality
Saudi 2817 (39.6) 140 (48.3) χ2 (1) = 8.68 0.003
Non-Saudi 4291 (60.4) 150 (51.7)
Clinical Role
Physicians 2226 (31.3) 61 (21) χ2 (3) = 24.6 < 0.001
Pharmacists 388 (5.5) 14 (4.8)
Nurses, Midwives, and Health specialists 2670 (37.6) 149 (51.4)
Healthcare Technicians and Ambulance staff 1824 (25.7) 66 (22.8)
Rank/seniority
Junior 4413 (62.1) 192 (66.2) χ2 (2) = 11.94 0.003
Senior 1795 (25.3) 81 (27.9)
Consultant 900 (12.7) 17 (5.9)
Experience years
1–5 years 814 (11.5) 37 (12.8) χ2 (4) = 71.70 < 0.001
6–10 years 2190 (30.8) 144 (49.7)
11–15 years 1829 (25.7) 76 (26.2)
16–20 years 1004 (14.1) 21 (7.2)
  > 20 years 1271 (17.9) 12 (4.1)
Working sector
Public/ governmental sector 5154 (72.5) 208 (71.7) χ2 (3) = 1.024 0.599
Private- for profit sector 1586 (22.3) 70 (24.1)
Other semi-governmental/private organization 368 (5.2) 12 (4.1)
Employment type
Full-time 6977 (98.2) 279 (96.2) χ2 (2) = 4.88 0.087
Part-time 73 (1) 5 (1.7)
Temporary/casual 58 (0.8) 6 (2.1)

significant negative association between HCW’s experi- was not significantly associated with exposure to sexual
ence and risk of sexual exposure in the last year. HCWs violence (p = 0.649), but encouragement by institution
with 6–10 years of experience were 3.696 times more leaders and administrators to report all cases of sexual
(269.6% times more) exposed to sexual violence com- violence was a significant predictor of a reduced risk of
pared to those with ≥ 21 years of experience (p < 0.001). WPV (38.4% times less) (p = 0.001). Moreover, HCWs
People working in the private sector had a greater risk caring for elderly patients during most of their work
(1.47 times more) of sexual violence than those work- time were 2.51 times (151% times more) more exposed
ing in other sectors (p = 0.016). The presence of a dedi- to sexual WPV than those caring for mainly non-elderly
cated guideline/procedure for reporting/handling WPV patients (p < 0.001) (Table 8).
AlHassan et al. BMC Health Services Research (2023) 23:1065 Page 7 of 12

Table 6 Bivariate analysis of the association between healthcare case, possibly because the study was conducted in a
workers’ experience of sexual attack at the workplace with their small conservative city with a population quite familiar
working condition factors with each other, which has the potential of a negative
Variable Sexually attacked in social impact. The low reporting rates in the study by
your workplace (%), El-Gilany et al. [19] was due to sex separation in pri-
n = 7398 mary healthcare centers. Alharbi et al. [13] reported
No = 7108 Yes = 290 test statistic p-value that almost 75% of their participants experienced sex-
ual violence; this may be due to the different definition
Work in shifts
of sexual violence used in their study. In addition, most
No 3082 (43.3) 99 (34.1) χ2 (1) = 9.67 0.002
of their participants were female. In a cross-sectional
Yes 4026 (56.6) 191 (65.9)
study [11] conducted in Riyadh city among nurses,
Working time between 18:00 (6 PM) and 07:00 (7 AM)
low sexual violence rates were observed. However, this
No 2636 (37.1) 85 (29.3) χ2 (1) = 7.24 0.007
study was conducted exclusively in Riyadh, and this
Yes 4472 (62.9) 205 (70.7)
finding cannot be extrapolated to the entire Saudi pop-
Interacting with patients/clients
ulation. Moreover, most of the participants were female
No 726 (10.2) 21 (7.2) χ2 (1) = 2.71 0.100
nurses (78.6%).
Yes 6382 (89.8) 269 (92.8)
Most countries have a high prevalence of sexual vio-
Routine direct physical contact (washing, turning, lifting) with patients/
clients
lence [3, 20–22]. A cross-sectional study conducted in
No 3275 (46.1) 110 (37.9) χ2 (2) = 14.15 0.001
Iran and involving HCWs reported a sexual violence
Yes 3110 (43.8) 159 (54.8)
rate of 4.7% [23], which was consistent with our findings.
Not Applicable 723 (10.2) 21 (7.2)
Like Saudi Arabia, Iran is a conservative community.
Patients/clients you most frequently work with are (tick all appropriate)
This could explain the low reporting rate due to the sen-
Newborns 1312 (18.5) 58 (20) χ2 (1) = 0.44 0.508
sitivity of the subject and the lower focus on investigat-
Infants 1544 (21.7) 69 (23.8) χ2 (1) = 0.70 0.402
ing the prevalence and causes. A systematic review was
Children 2628 (37) 123 (42.4) χ2 (1) = 3.53 0.060
conducted to estimate the prevalence of sexual violence
Adolescents 3385 (47.6) 162 (55.9) χ2 (1) = 7.58 0.006
among native HCWs in high-income countries between
2001 and 2019. The prevalence of sexual violence (both
Adults 5594 (78.7) 245 (84.5) χ2 (1) = 5.60 0.018
harassment and abuse) among HCWs was 6% [24]. How-
Elderly 4030 (56.7) 196 (67.6) χ2 (1) = 13.50 < 0.001
ever, those countries are less conservative than second-
Sex of the patients you most frequently work with
world countries and have better reporting access and
Unspecified/not 723 (10.2) 21 (7.2) χ2 (3) = 5.25 0.155
applicable rules to prevent and deal with such events. In contrast,
Female 557 (7.8) 16 (5.5) a quantitative review was conducted to estimate the rate
Male 623 (8.8) 27 (9.3) of different violence types among nurses worldwide [20].
Male and female 5205 (73.2) 226 (77.9) They had seven-fold higher rates of sexual violence than
those in our findings (25%). This might be due to under-
reporting of sexual harassment in Saudi Arabia, which
means more efforts should be directed toward sexual
Discussion
violence in our region. Another cross-sectional study
To the best of our knowledge, this is the first study in
conducted in Ethiopia reported a higher rate [9]; the
Saudi Arabia to estimate the prevalence of sexual WPV
authors explained this by the unavailability of a sufficient
in the healthcare sector. A low rate of sexual violence
and well-defined system of identification and control of
was observed in the present study, as only 3.9% of the
such incidents, as well as a lack of concern about HCWs’
participants were exposed. This study showed a signifi-
exposure to sexual violence. We observed that most of
cant association between exposure to sexual violence
the perpetrators were patients/clients and not staff mem-
and being a female HCW (p = 0.002). The odds of being
bers, which is consistent with other findings [3, 13, 25].
exposed to sexual violence were 1.5 higher (p = 0.002)
In a study conducted in Macau by Cheung et al. [26], all
among nurses. Sexual violence is a significant but not
but four of the survivors were harassed by patients and
well-documented problem, as no study measured it
their relatives; the relatively small number of HCWs in
in all cities in Saudi Arabia according to the authors’
Macau can explain this observation. Contrastingly, Celik
knowledge, which this study discussed.
et al. [27] found that most perpetrators were staff mem-
Most of the studies conducted nationally have
bers. However, they involved only nurses, who answer to
mainly focused on a particular city, hospital, or spe-
physicians, and could have placed them in a vulnerable
cialty. Al Anazi et al. [18] reported no sexual violence
position due to the power differences. Khoshknab et al.
AlHassan et al. BMC Health Services Research (2023) 23:1065 Page 8 of 12

Table 7 Bivariate analysis of the association between healthcare workers’ experience of sexual workplace violence and hospital
violence reporting guidelines
Variable Sexually attacked in your workplace (%),
n = 7398
No = 7108 Yes = 290 test statistic p-value

Worried about violence in the current workplace, Mean 2.82 (1.33) 3.49 (1.21) t (7396) = 8.44 < 0.001
(standard deviation)
Presence of procedures for reporting of violence
No 1993 (28) 103 (35.5) χ2 (1) = 7.67 0.006
Yes 5155 (72) 187 (64.5)
Knowing how to use report
No 751 (14.7) 32 (17.1) χ2 (1) = 0.85 0.358
Yes 4364 (85.3) 155 (82.9)
Encouragement to report workplace violence
No 2588 (36.4) 151 (52.1) χ2 (1) = 29.30 < 0.001
Yes 4520 (63.6) 139 (47.9)
Person who encourages reporting
Management staff/employer 3824 (53.8) 108 (37.2) χ2 (1) = 30.68 < 0.001
Colleagues 1432 (20.1) 52 (17.9) χ2 (1) = 0.85 0.356
Saudi commission for health specialist 555 (7.8) 15 (5.2) χ2 (1) = 2.72 0.099
Medical association 174 (2.4) 7 (2.4) χ2 (1) = 0.001 0.971
My own family/friends 357 (5) 19 (6.6) χ2 (1) = 1.351 0.245
Other persons 287 (4) 20 (6.9) χ2 (1) = 5.73 0.017

Fig. 1 Association between healthcare workers’ experience with risk of sexual workplace violence by sex

[23] reported that most perpetrators were relatives of the relatives a bigger chance for violence. The physical,
patients/clients, followed by patients. Their study was psychological, and economical pressures on patients and
conducted in teaching hospitals in which patients are their family members can account for the several sexual
usually surrounded by students and supervisors, giving violence cases [28].
AlHassan et al. BMC Health Services Research (2023) 23:1065 Page 9 of 12

Table 8 Multivariate logistic binary regression analysis of the predictors of exposure to recent sexual workplace violence
Multivariate adjusted Odds 95% C.I. for OR p-value
Ratio (OR)
Lower Upper

Experience, 6–10 years 3.696 1.836 7.442 < 0.001

Experience, 11–15 years 2.668 1.347 5.283 0.005
Encouragement to report from significant others 2.514 1.524 4.147 < 0.001
Experience, 1–5 years 2.413 1.101 5.258 0.028
Experience, 16–20 years 1.797 0.858 3.763 0.120
Sex, Female 1.546 1.180 2.026 0.002
Job, Nurse 1.528 1.171 1.995 0.002
Working sector, Private 1.467 1.073 2.004 0.016
Working with elderly patients 1.390 1.065 1.814 0.016
Worry level from violence at work, mean score 1.340 1.214 1.478 < 0.001
Working shifts, Yes 1.225 0.932 1.610 0.145
Has direct physical contact with clients 1.119 0.904 1.385 0.303
Seniority Level 1.028 0.842 1.254 0.786
Presence of Violence reporting guidelines at workplace 0.936 0.704 1.245 0.649
Age group 0.862 0.678 1.096 0.227
Nationality, Non-Saudi 0.667 0.502 0.885 0.005
Encouragement from institution administration to report 0.616 0.461 0.824 0.001
Constant 0.008 < 0.001
Abbreviations: CI Confidence interval
N = 7398

Most of the survivors in this study tried to pretend that would rather not report sexual harassment, which may
the incident never happened and some of them told the be due to their low knowledge of their rights or because
attacker to stop his/her behavior or took no action. In they have a lower working position. Song et al. [32] found
another study [23], most did nothing or told the person to lack of knowledge of how and what incidents to report,
stop. This implies a very serious outcome—the incident lesser attention to the healthcare providers compared to
can be repeated. Over three-quarter of the participants the patients, and previous experience of no action taken
said that no investigations were conducted to explore by the authorities after reporting as the main reasons for
the causes of the incident, which is more than the rates not reporting. Most survivors were harassed during their
reported by Chen et al. [3] and Khoshknab et al. [23]. night shifts between 18:00 to 07:00, which contrasts the
Apprehension of possible outcomes and feeling of no findings of Khoshknab et al. [23] who reported that most
ensuing action were reasons for not reporting. A study in incidents happen during morning shifts. The difference
India involving women [29] revealed that not reporting in work hours can explain the discrepancy.
may have been due to community standards and beliefs, In this study, female workers were more exposed to
as responsibility would entirely be shifted to the women’s sexual WPV, which is consistent with some findings [22,
behavior or attitude or the act would be considered nor- 33–35] and not consistent with others [30, 36]. El-Gilany
mal. Ignorance about one’s rights may also explain under- et al. [19] and Wang et al. [25] found no sex differences
reporting, as many are afraid to lose their jobs, especially between survivors, while Alharbi et al. [13] observed a
those in the private sector or with temporary jobs. A non-significant difference. In contrast to female work-
study in China [30] reported that when the perpetrator ers, male workers may normalize sexual violence in the
was a co-worker, the survivor was unlikely to report the workplace because they perceive some situations as
incident. This could be because the survivor does not more sexually oriented than their female counterparts
want to be stigmatized in the workplace or is afraid of the [37]; this may account for the low reporting rates among
potential outcomes, especially if the attacker has a higher male survivors. Torre et al. [38] also found no sex dif-
position. Repeated exposure to sexual violence can make ferences. However, most of the participants were young
the HCW tolerate the act and consider it normal in their (20–24 years), indicating less experience on how to act
daily work [31]; this can also explain non-reporting. Con- in such an event. Consistent with our findings, most of
versely, nurses in Turkey [27] with a low educational level the survivors in the study by Fujita et al. [22] were nurses,
AlHassan et al. BMC Health Services Research (2023) 23:1065 Page 10 of 12

explained by the high need for direct physical contact the attackers should be implemented. More importantly,
and interaction. Yenealem et al. [34] reported that almost new regulations (e.g., more staff members, shorter wait-
all survivors had little work experience (1–5 years) and ing times, and more support, such as prevention pro-
that 75% of them had procedures for reporting violence grams) are necessary.
in their workplaces. This study found that juniors and
HCWs with 6–10 years of experience are more vulner-
Limitations
able to sexual violence, implying that little experience
The main limitation of this study is its use of a retro-
could translate to lack of skills to manage such incidents
spective self-report questionnaire, which might cause
[34]. In another study conducted in Addis Ababa, most
recall bias. In addition, the subject’s sensitive nature may
of the nurses who were survivors were single and young,
have prevented some workers from participating, result-
implying their lack of experience in handling such situa-
ing in low reporting rates and reporting bias. In addi-
tions and their reverence for higher healthcare providers
tion, although this study had a sufficiently large number
in their society [39].
of participants, the results cannot be generalized to the
The consequences of sexual violence include psycho-
entire population.
logical stress, shame, depression, sleep disturbances,
The strength of this study is that the participants were
impaired practice, and unhealthy and uneasy relation-
all HCWs from government or private institutions in
ships with patients [28, 36, 40]. Moreover, the survivor
Saudi Arabia, unlike previous studies that focused mainly
may refer several patients to other colleagues and ask
on the emergency departments and nurses in specific
for unnecessary investigations to get rid of the aggres-
cities.
sor, which may subsequently lead to a greater cost [27].
Another study conducted in Iran [41] found that some
survivors lost their jobs because of absenteeism follow- Conclusion
ing violence-related trauma. Some survivors even quit The prevalence of sexual violence is low; however, it
their jobs or prevented their children from working in remains a risk faced by HCWs, especially those work-
their field or having a relationship with someone of the ing night shifts and having direct physical contact with
same profession. Moreover, some survivors’ relationship patients. The prevalence was highest among nurses, mid-
with their spouse was negatively affected, as their spouse wives, and healthcare specialists and lowest among phy-
would blame them for what happened or starting being sicians. To explore the causes of sexual violence and to
more suspicious. This may contribute to under-reporting implement solutions accordingly, further studies, espe-
in future and family divisions. Zeighami et al. [42] con- cially longitudinal, are needed. Educational programs for
ducted a qualitative study and proposed some strategies HCWs, patients, and their relatives are required. Further-
to prevent sexual violence by interviewing nurses with more, increasing awareness using the media is important.
a prior experience. They found that portraying a strict The underreporting of cases may skew the magnitude of
attitude with the perpetrator such as being inactive or the problem; thus, a more encouraging environment to
behaving ignorantly of the bad behavior, having a profes- report every violence incident with strict consequences
sional relationship and not talking or making jokes on for the perpetrators should be implemented. More
private matters, and wearing an unattractive uniform so importantly, new regulations (e.g., more staff members,
not to tempt others would stop him/her from continuing. shorter waiting time, and more support such as preven-
In addition, having the healthcare provider care for the tion programs) are necessary.
same sex or having a staff member with more experience
in the same shift, providing more protective measures Abbreviations
for HCWs on night shifts, and changing the workplace CI Confidence interval
for HCWs with a prior experience, are good preventive HCW Healthcare worker
OR Odds ratio
measures. Nonetheless, education and training on sexual SCFHS Saudi Commission for Health Specialty
violence should be provided early in schools, colleges, SD Standard deviation
and workplaces. Further, having a zero-tolerance policy WHO World Health Organization
WPV Workplace violence
by taking immediate legal actions should be promoted.
Longitudinal studies are needed to explore the reasons Acknowledgements
for sexual violence and implement solutions accordingly. A special thanks to the Saudi Commission for Health Specialties who helped
us reach the healthcare providers registered at their institution.
More awareness through educational programs and the
media for HCWs, patients, and their relatives is impor- Authors’ contributions
tant. In addition, a more encouraging environment to FS designed the study; AH, FS, and RS drafted the manuscript; AH and RS col-
lected data and performed quality control; AH, FS, and RS conducted the data
report every violent incident with strict consequences for analyses. All authors read and approved the final manuscript.
AlHassan et al. BMC Health Services Research (2023) 23:1065 Page 11 of 12

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