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      Workplace violence and its aftermath in China’s health sector: implications from a cross-sectional survey across three tiers of the health system

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          To determine the prevalence of physical violence and threats against health workers and the aftermath in tertiary, secondary and primary care facilities in China.


          A cross-sectional questionnaire study.


          5 tertiary hospitals, 8 secondary hospitals and 32 primary care facilities located in both urban and rural areas of Zhejiang Province, China, were chosen as the study sites.


          A total of 4862 health workers who have contact with patients completed a survey from July 2016 to July 2017.

          Outcome measures

          The prevalence of physical violence, threats and Yi Nao, specific forms of physical violence and their aftermath were measured by a self-designed and verified questionnaire. Multivariable logistic regression models were used to examine the association between perceived organisational encouragement of reporting workplace violence (WPV) and physical violence, threats and Yi Nao after controlling for age, sex, level of facility, professional ranking and type of health worker.


          Among all respondents, 224 (4.6%) were physically attacked and 848 (17.4%) experienced threats in the past year. Respondents in secondary hospitals were more likely to experience physical violence (AOR=3.29, 95% CI 2.21 to 4.89), threats (AOR=1.61, 95% CI 1.32 to 1.98) and Yi Nao (AOR=2.47, 95% CI 2.10 to 2.91), compared with primary care providers. Lack of organisational policies to report WPV was associated with higher likelihood of physical violence (AOR=3.64, 95% CI 2.57 to 5.18) and threats (AOR=2.21, 95% CI 1.76 to 2.78). Among physical violence cases, only 29.1% reported the attack to police mainly because most felt it useless to do so (58.8%). Only 25.7% were investigated and 72.4% of attackers received no punishment. Of all those attacked or threatened, 59.4% wanted to quit current post and 76.0% were fearful of dealing with urgent or severe cases.


          Proper management of the aftermath of violence against health workers is inadequate. Formal guidelines for reporting and managing WPV are urgently needed.

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          Most cited references 47

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          Launch of the health-care reform plan in China.

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            China's human resources for health: quantity, quality, and distribution.

            In this paper, we analyse China's current health workforce in terms of quantity, quality, and distribution. Unlike most countries, China has more doctors than nurses-in 2005, there were 1.9 million licensed doctors and 1.4 million nurses. Doctor density in urban areas was more than twice that in rural areas, with nurse density showing more than a three-fold difference. Most of China's doctors (67.2%) and nurses (97.5%) have been educated up to only junior college or secondary school level. Since 1998 there has been a massive expansion of medical education, with an excess in the production of health workers over absorption into the health workforce. Inter-county inequality in the distribution of both doctors and nurses is very high, with most of this inequality accounted for by within-province inequalities (82% or more) rather than by between-province inequalities. Urban-rural disparities in doctor and nurse density account for about a third of overall inter-county inequality. These inequalities matter greatly with respect to health outcomes across counties, provinces, and strata in China; for instance, a cross-county multiple regression analysis using data from the 2000 census shows that the density of health workers is highly significant in explaining infant mortality.
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              Making profits and providing care: comparing nonprofit, for-profit, and government hospitals.

               Jill Horwitz (2020)
              Three types of entities-nonprofit, for-profit, and government-own hospitals. Yet we know neither whether hospital types specialize in different medical services nor how service profitability affects specialization. In this econometric analysis of American Hospital Association data for every U.S. urban, acute care hospital (1988-2000), more than thirty services were categorized as relatively profitable, unprofitable, or variable. For-profits are most likely to offer relatively profitable medical services; government hospitals are most likely to offer relatively unprofitable services; nonprofits often fall in the middle. For-profits are also more responsive to changes in service profitability than the other two types.

                Author and article information

                BMJ Open
                BMJ Open
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                20 September 2019
                : 9
                : 9
                [1 ] departmentInstitute for Social and Family Medicine, School of Medicine , Zhejiang University , Hangzhou, China
                [2 ] departmentFaculty of Infectious and Tropical Diseases , London School of Hygiene and Tropical Medicine , London, UK
                [3 ] departmentCenter for Global Health, School of Medicine , Zhejiang University , Hangzhou, China
                [4 ] departmentInstitute for Global Health , University College London , London, UK
                [5 ] departmentDepartment of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine , The University of Hong Kong , Hong Kong, China
                Author notes
                [Correspondence to ] Dr Xudong Zhou; zhouxudong@ ; Professor Lu Li; lilu@

                SZY and DW are joint first authors.

                © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

                Occupational and Environmental Medicine
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                workplace violence, health sector, impunity, china


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