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/lp/springer-journals/violence-at-work-determinants-prevalence-among-health-care-workers-QabJbJTTkN
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- Springer Journals
- Copyright
- Copyright © 2019 by The Author(s).
- Subject
- Medicine & Public Health; Public Health; Occupational Medicine/Industrial Medicine
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- 2052-4374
- DOI
- 10.1186/s40557-019-0288-6
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- See Article on Publisher Site
Abstract
Background: Workplace violence is the intentional use of power, threatened or actual, against another person or against a group, in work-related circumstances, that either results in or has a high degree of likelihood of resulting in injury, death, psychological harm, mal development, or deprivation. The aim of this study is to assess magnitude and predictors of workplace violence among healthcare workers in health facilities of Gondar city. Methods: Institutional based cross sectional study design was employed to conduct this study. The study conducted in Gondar town from February 21 to march 21, 2016. Five hundred fifty three health care workers selected from health facilities of Gondar City administration. A stratified sampling technique was used for selecting the study subjects through simple random sampling. Data was collected by structured self administered questionnaire which is adapted from ILO/ICN/WHO/PSI after it is pretested & prepared in Amharic. The data was coded and entered in to EPI info version 7 and exported to SPSS version 20 software for analysis. The degree of association for variables was assessed using odds ratios with 95% confidence interval and p-value ≤0.05. Results: The prevalence of workplace violence was found to be 58.2% with [95% confidence interval (CI): (53.7, 62.3)] in which verbal abuse 282(53.1%) followed by physical attack 117(22.0%) and 38(7.2%) sexual harassment. Working at emergency departments [AOR = 3.99,95% CI:(1.49,10.73)], working at shifts [AOR = 1.98,95%, CI: (1.28,3.03)],short experiences [AOR = 3.09,95% CI: (1.20,7.98)], being nurse or midwife [AOR = 4.06, 95% CI: (1.20,13.74)] were positively associated with workplace violence. The main sources of violence are visitors/patient relatives followed by colleagues and patients. Conclusion: workplace violence is major public health problem across health facilities and the Ministry of Health should incorporate interventions in its different health sector development & management safety initiative. Keywords: Health facilities, Health care workers, Workplace violence, Gondar Background worldwide and one of the largest public health problem Workplace violence is the intentional use of power, [2]. Even though workplace violence occurred on both threatened or actual, against another person or against a private & public HCWs South African study shows pub- group, in work-related circumstances, that either results lic HCWs are more exposed than their private counter- in or has a high degree of likelihood of resulting in parts [3]. The rate of assaults on health workers is injury, death, psychological harm, mal development, or higher than that of other occupations-eight assaults per deprivation [1]. It has become an alarming phenomenon 10,000 workers compared with two per 10,000 for the general workplace [4]. Workplace violence causes ill health [5]. A longitudinal * Correspondence: dawaitgetachew105@gmail.com study on nurses demonstrates those who exposed to work- Department of Environmental and Occupational Health and Safety, Institute place violence develops higher somatic & musculoskeletal of Public Health, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, Ethiopia disorder symptoms than the comparison groups [5]. A Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Yenealem et al. Annals of Occupational and Environmental Medicine (2019) 31:8 Page 2 of 7 global review of 150,000 nurses shows that third of have hospital, 13 specialty clinics, 15 medium clinics & 11 pri- been physically assaulted, bullied, or injured, while mary clinics according to Gondar city administration health around two-thirds have experienced nonphysical assault department. About 994 health care workers employed at all [4]. A retrospective database review among United States level of health facilities. Sample size was determined by nurses about cost of workplace violence find annual work- using single population proportion formula, taking 29.9% place violence charges for the 2.1%of nurses reporting in- [13] prevalence of workplace violence from previous study juries were $94,156 ($78,924 for treatment and $15,232 in Hawassa.95% confidence interval margin of error of 4%. for indemnity) [6]. The final sample size was 553. In Ethiopia Most of healthcare workers are women in Stratified sampling techniques were used for selecting which they are exposed for both domestic & workplace the study subjects. First of all healthcare workers were violence which is a double burden [7]. Even though stratified in to private & government then further classi- workplace violence studies mostly focuses on psychiatric fied according to their type or level. Proportional num- and emergency department settings it is significantly bers of health care workers were selected from each prevalent in general healthcare workers [2]. strata of health facility by simple random sampling Healthcare workers who exposed to workplace vio- technique. lence result to enormous consequences [8]. A systematic review of literature comes up with seven types of conse- Data collection tools and procedures quences namely: physical, psychological, emotional, work Data were collected by structured self administered ques- functioning, relationship with patients/quality of care, tionnaire which is adapted to fit with this research object- social/general, and financial. Psychological (e.g., post- ive from [ILO/ICN/WHO/PSI] [14] after it is pretested & traumatic stress, depression) and emotional (e.g., anger, prepared in Amharic. The questionnaire was divided in to fear) consequences and impact on work functioning four parts. The first part was socio-demographic & occupa- (e.g., sick leave, job satisfaction) [9]. The most frequent tional characteristics like gender, age, educational status, and important effects of workplace violence as Longitu- profession, type of facility, working hour, working section dinal study from Finland shows physical violence lead to and marital status. The second, third & fourth section con- increment on intention of physician to leave while job tains physical violence, verbal abuse & sexual harassment satisfaction is affected by both bulling & physical vio- respectively with relevant related questions. Four environ- lence [10]. In musculoskeletal studies WPV especially mental and occupational health professionals working in physical violence shows a significant role in predisposing the city was used to collect the data from. Two environ- to acute & chronic low back pain in study in Iran [11]. mental health professional from Gondar university student The consequences workplace violence extends beyond services were assigned to supervise the data collection economic burden to be matter of quality of life [12]. process. Both data collectors and supervisors was given a In Ethiopia Very little information is available one day training on aim of study procedures of collection about workplace violence among healthcare workers. & exercise it. The questionnaire was discussed thoroughly Considering large number of work force in health care question by question. The study participants were made to sector in which majority of them are women. Currently fill the questionnaire in their respective health facility. government concern & intervention is limited domestic violence. But violence is not limited to house hold level Data processing and analysis and tackling demands comprehensive knowledge & fo- All the questionnaires were checked manually, coded cusing its effect on healthcare delivery as well. This and entered in to EPI info version 7.1.5.2 and exported study will provided a comprehensive baseline of work- to SPSS version 20 software for analysis of potentially place violence in healthcare workers which helps con- explanatory variables. Descriptive analyses were per- cerned bodies to initiates & start to shape strategies. formed to describe variables using summery measure, frequencies, figures & tables. 12 month WPV was eval- Methods uated by running bivirate logistic regression. Then vari- Study design, sample size determination, sampling ables with the P-value ≤0.2 analyzed in multivariable technique regression. The degree of association between depend- Institutional based quantitative cross sectional study was ant & independent variables was assessed using odds conducted in Gondar city in march 2016. Gondar is one ratios within 95% confidence interval p-value ≤0.05. of tourist destination city in Ethiopia, which is 747 km workplace violence is ascertained when the study re- from Addis Abeba and 170 km from regional capital spondents experienced at least one type of workplace Bahir Dar. According to CSA 2014 projection Gondar violence (i.e. physical violence, verbal abuse or sexual has 323,875 populations reside in it. There are one uni- harassment) in circumstances related to their work in versity hospital 8 health centres. In addition 1 medium the past 12 months. Yenealem et al. Annals of Occupational and Environmental Medicine (2019) 31:8 Page 3 of 7 Results Prevalence of workplace violence Socio demographic characteristics of respondents More than half (58.2%) [95% CI: (53.7, 62.3)] of health The response rate was 96.02% (N = 531).Among respon- care workers experienced at least one of manifestation dents 361(68.0%) were from government & private hospi- of workplace violence (physical, verbal & sexual) in the tals and the rest were from private clinics and health past 12 months. Health care workers mostly encountered centres. In addition 255(48.0%) were males and 276(52.0%) verbal abuse 282(53.1%) followed by physical attack were females. The median age was 27, IQR = 7 years with 117(22.0%) and 38(7.2%) sexual harassment. Among all the range of 20 to 56. Majority 289(54.4%) of healthcare one third (33.0%) of health care workers were a victim workers are between the age group of 26–35 years. Among of two forms of workplace violence of the study while total participants majorities 415(78.2%) are belong to only 4.2% of participant reported they were experience government health facilities while the rest work at private all forms. Over one third (37.9%) had witnessed physical facilities116 (21.8%).In respect to educational status violence on colleagues on their working environment. 405(76.3%) of HCWs have degree & above qualifications Females are most exposed in all forms of workplace vio- in their professions (Table 1). lence: verbal abuse 161(57.1%), physical attack 69(59.0%) & sexual harassment 38(100%) than men. Table 1 Socio demographic characteristics of health care Workplace characteristics of healthcare workers workers working at health facility at Gondar city administration, Two third 363(68.4%) of respondents reveal that unavail- March 2016(n = 531) ability of workplace violence reporting procedures in Variables Frequency Percentage their health facility. Inpatient departments are places Sex where one third 168(31.6%) of the health care workers Male 255 48.0 spent their time in the health facility. More than half of Female 276 52.0 all health care workers have short experiences of less Age than six years (Table 2). ≤ 25 76 14.3 Associations between exposure to types of violence and 26–35 289 54.4 organizational and workplace characteristics ≥ 36 166 31.3 Higher risk of physical violence was related to working at Religion shift, in inpatient department, govermet facilities and hav- Orthodox 454 85.5 ing lower years of experience. A total of 54.7% of health Muslim 56 10.5 care workers with fewer than 5 years of experience reported Others 21 4.0 physical violence, which decrease & increase with increase in experience. Physical violence was mostly reported in gov- Educational status ernment workers (86.3%) compared with privately owned Diploma 126 23.7 facilities. There is no any association is observed between Degree 361 68.0 all forms of violence in relation to job position & availabil- Masters 31 5.8 ity of reporting procedure. Verbal abuse showed stronger Specialty 13 2.4 relationship similar to physical violence with stronger risk Marital status in facility ownership. Sexual harassment demonstrated lower relationship with organizational & workplace char- Married 245 46.1 acteristics, which is limited with working department & Divorced 10 1.9 ownership of the facility (Table 3). Single 276 52 Profession Factors associated with workplace violence Nurse/midwife 339 63.8 In univarate analysis profession, level of facility, experi- HO 34 6.4 ence, department, age, Employment status, health facility ownership, shifts work becomes significantly associated Pharmacy/laboratory 111 20.9 with workplace violence. In fitting these variables in to Other HCWs 24 4.5 multivariate analysis only, department, profession, shift GP 23 4.3 work and experience remain significant. Facility ownership Occupational setting of health care workers demon- Private 116 21.8 strated that the odds of violence against health care Government 415 78.2 workers were nearly about four times higher among emer- NB: Others: Protestant/catholic/Adventist gency department workers than those served in outpatient Yenealem et al. Annals of Occupational and Environmental Medicine (2019) 31:8 Page 4 of 7 Table 2 Organizational and workplace characteristics of The study finds out 58.2% of respondents encounter healthcare workers working at health facilities of Gondar city WPV. This is higher than what is reported by WHO. The administration, March 2016, (n = 531) overall 12 month prevalence of workplace violence among Variables Frequency Percentage healthcare workers is in line with study findings in South Facility type Africa (61.9) [3], Thailand (54.1) [15] and Turkey(57.5%) [16]. This may be due to the methodological similarities Hospital 361 68.0 employed in the studies. And it is lower than study in Health center 92 17.3 Nigeria (69.4) [17] and Oromiya, Ethiopia (88.0) [18]as it Private clinics 78 14.7 may be the fact that both studies doesn’t include private Violence Reporting procedure sectors which relatively have low prevalence than govern- Available 168 31.6 ment counterparts. Even the Ethiopian study is only on Unavailable 363 68.4 hospitals & nurses in which known for their higher preva- lence of workplace violence. Department Workings in emergency departments have positive as- Inpatient departments 188 35.4 sociation with workplace violence. Those who work in Pharmacy/laboratory 108 20.3 clinical setting of emergency are four times exposed to Emergency departments 46 8.7 workplace violence than OPD workers. An emergency Other departments 25 4.7 working setting is where peoples are come in panic, with OPD 164 30.9 serious injuries that make them to be aggressive at health care providers. This is a place where life threaten- Experiences(in years) ing health conditions and death make visitors & patient 1–5 308 58.1 relatives to be violent. All these fuelled by nervousness 6–10 151 28.4 of HCWs which attributed to high workload & stress. 11–15 15 2.8 This finding is similar with study conducted in Hawassa, 16–38 57 10.7 Ethiopia [13]. Similar emergency service delivery system, Job position violence handling & security condition may account for the similarity of results. In addition despite of target Staff/service provider 484 91.2 population difference those who work in emergency de- Ward/clinic head 40 7.5 partments mostly are nurses. A more higher risk re- Coordinator 7 1.3 ported from Italian [19] study on both physical violence Shift work & threats. This disagreement happens since healthcare Yes 336 63.3 workers from developed nation will report incidents No 195 36.7 more frankly & correctly as their system responds pro- actively for employees safety. department (AOR = 3.99, 95% CI: (1.49,10.73)). Working Shift work appears to be an exacerbating factor for the at shifts revealed that it exposed to violence two times encountering of workplace violence among health care compared to those who worked at day shifts (AOR = 1.98, workers. Those working at shifts are more likely to ex- 95% CI: (1.28,3.03)).Health care providers of 1–5years of perience workplace violence than their colleagues of day experiences are three times at risk of encountering vio- shift. This finding is supported study from China [2]. lence at work in contrast to 16+ year served colleagues Working in shift implies low level of security in the in- (AOR = 3.09, 95% CI: (1.20,7.98)). Working as nurse & stitution, fewer staff in the department and decreased midwife in the health care facilities is four times more work performance between staffs initiate conditions likely to experience violence than the general practitioners favourable for violence. Even limited or no presence of (AOR = 4.06, 95% CI: (1.20,13.74)) (Table 4). hospital administration also can be attributed. While a study from Turkey [20] shows lower association than our research. This might be due that higher workplace Discussion violence prevention interventions are provided in such To the best of our knowledge this research is the first developed country than this study setting. comprehensive research of workplace violence on health Year of experience in health facilities have positive as- care both in profession & type of health facilities covered sociation with the occurrence of workplace violence. in Ethiopia. Being nurse/midwife by profession, working Those who have less than 6 years of experience 3 fold in emergency department, shift work and having short more likely victimized by violence than their seniors experiences are significantly associated with workplace with more than 16 years of experience in the health care violence. facilities. This may be health care workers with short Yenealem et al. Annals of Occupational and Environmental Medicine (2019) 31:8 Page 5 of 7 Table 3 Organizational and workplace characteristics of healthcare workers working at health facilities of Gondar city administration with type of violence, March 2016, (n = 531) Variable Physical violence Verbal abuse Sexual harassment yes no yes no yes no n (%) n (%) n (%) n (%) n (%) n (%) Job position Staff/service provider 107(22.1) 377(77.9) 231(47.7) 253(52.3) 37(7.6) 447(92.4) Ward/clinic head 9(22.5) 31(77.5) 24(60.0) 16(40.0) 1(2.5) 39(97.5) Coordinator 1(14.3) 6(85.7) 5(71.4) 2(28.6) 0(0.0% 7(100.0) Shift work Yes 96(28.6)** 240(71.4) 209 (62.2)** 127 (37.8) 29 (8.6) 307 (91.4) No 21(10.8) 174(89.2) 73 (37.4) 122 (62.6) 9 (4.6) 186 (95.4) Experiences(in years) 1–5 225(54.3)* 83(70.9) 184(65.2)* 124(49.8) 37(97.4) 271(55.0) 6–10 130(31.4) 21(17.9) 67(23.8) 84(33.7) 0(0.0) 151(30.6) 11–15 14(3.4) 1(0.9) 6(2.1) 9(3.6) 0(0.0) 15(3.0) 16–38 45(10.9) 12(10.3) 25(8.9) 32(12.9) 1(2.6) 56(11.4) Department Inpatient departments 64(54.7)** 124(30.0) 119(42.2)** 69(27.7) 20(52.6)* 168(34.1) Pharmacy/laboratory 6(5.1) 102(24.6) 53(18.8) 55(22.1) 3(7.9) 105(21.3) Emergency departments 22(18.8) 24(5.8) 34(12.1) 12(4.8) 6(15.8) 40(8.1) Other departments 3(2.6) 22(5.3) 7(2.5) 18(7.2) 2(5.3) 23(4.7) OPD 22(18.8) 142(34.3) 69(24.5) 95(38.2) 7(18.4) 157(31.8) Ownership Private 16(13.7)* 100(24.2) 44(15.6) ** 72(28.9) 3(7.9) * 113(22.9) Government 101(86.3) 314(75.8) 238(84.4) 177(71.1) 35(92.1) 180(77.1) Violence Reporting procedure Available 37(31.6) 131(31.6) 44(15.6) 72(28.9) 10(26.3) 158(32.0) Unavailable 80(68.4) 283(68.4) 238(84.4) 137(71.1) 28(73.7) 335(68.0) NB: statically significant at * = p < 0.05, ** = p ≤ 0.0001 experience and mostly young are lacking the skills of in health facilities in which patients & patient’s relatives managing violent conditions which can be acquired spent more of their health facility times with them. through experiences. The result is less than a study in Lower risk is reported from Brazil [23] & Serbia [24]. Hawassa [13]. Thedifferencemaybeduethediffer- This observable difference may be the difference of ence in study subjects by profession. As Hawassa study healthcare system in which professionals exposed to pa- is only on the nurses, who are deemed the most vul- tients & other potential sources of violence. In addition nerable while our study comprises all health profes- the proportion of nurses or midwifes & physicians in- sionals. The Congolese [21]study come up with a volved in these studies are not as large as this study nearly no association results. The inconsistency can be involves which decrease the risk of exposure. bydifferenceinsamplesizeastheCongoleseone is a In this study Respondents rated long waiting time for nationwide study & it doesn’t includes violence arising the service and lack of security condition as the pri- from co-workers which leads to a normality across all mary causes that facilitate occurrence of workplace experience categories. violence. This claim of HCWs supported by researches Practicing a specific profession is a significant factor from theMiddleEastcountries [22, 25].when patient/ that exhibits visible association with workplace violence. client wait for long time to get service they become ir- Being a nurse or midwife had increased encountering ritated & dissatisfied which results to quarrelling with workplace 4 times than working as physician. This is HCWs and even assaulting verbally & physically. Ad- supported by research from Saudi [22]. This can be rea- dressing long waiting time is also matter of improving son out since nurses are the front liners in giving service the quality of service that ministry of health strives. Yenealem et al. Annals of Occupational and Environmental Medicine (2019) 31:8 Page 6 of 7 Table 4 Univariate & multivariate logistic regression of factors associated with workplace violence among health care workers working at health facilities in Gondar, March 2016(n = 531) Variables Workplace violence COR(95% CI) AOR(95% CI) Yes no Working department Emergency 40 6 7.71(3.10,19.20)*** 3.99(1.49,10.73)** Inpatient 131 57 2.66(1.71,4.11) 1.41(0.78,2.55) Other 8 17 0.54(0.22,1.33) 0.42(0.16,1.11) Pharmacy/laboratory 54 54 1.15(0.71,1.88) 0.91(0.24,3.47) OPD 76 88 1 1 Shift work Yes 227 109 2.87(1.99,4.13)*** 1.98(1.28,3.03)** No 82 113 1 1 Years of experiences 1–5 206 102 2.40(1.35,4.26)** 3.09(1.20,7.98)* 6–10 71 80 1.05(0.57,1.95) 1.38(0.55,3.51) 11–15 6 9 0.79(0.25,2.52) 1.47(0.36,6.01) 16+ 26 31 1 1 Occupation Nurse/ Midwife 221 118 6.74(2.44,18.62)*** 4.06(1.20,13.74)* HO 13 21 2.23(0.66,7.46) 2.49(0.61,10.06) Pharmacist/Laboratory 56 55 3.66(1.27,10.56) 3.63(0.60,21.88) Other 14 10 5.04(1.40,18.14) 4.06(0.91,18.11) GP 5 18 1 1 Ownership Private 49 67 1 1 Government 260 155 2.29(1.50,3.49)*** 1.22(0.56,2.66) Type of facility Hospitals 231 130 3.35(2.00,5.61)*** 1.20(0.48,3.03) Health center 51 41 2.35(1.26,4.37) 1.23(0.44,3.43) Private clinics 27 51 1 1 Age(in years) ≤ 25 36 40 0.55(0.32,0.95)* 1.69(0.69,4.14) 26–35 170 119 0.87(0.59,1.29) 1.38(0.86,2.25) ≥ 36 103 63 1 1 Employment Full timer 296 201 1 1 Contract 13 21 0.42(0.20,0.85)* 1.10(0.42,2.87) NB: statically significant at * = p < 0.05, ** = p ≤ 0.006, *** = p ≤ 0.0001 liaison, central supply, physiotherapy, anaesthesia, x-ray, card room, triage physiotherapist, anthesist, optometrists, psychiatrists, radiographers The study clearly shows that policy & working strat- The study will come with possible limitations like Recall egies should steer towards reducing factors aggravating bias which emanates as respondents expected to remember workplace violence: such as log waiting time. In addition the past 12 month exposure. Having wider study subject result related to absence of violence reporting procedure coverage by profession & Inclusion of both government significantly related to having effective prevention of and private facilities will be considered as strength since it workplace violence. will give a picture of all health care workers. Yenealem et al. Annals of Occupational and Environmental Medicine (2019) 31:8 Page 7 of 7 Conclusions Received: 19 October 2018 Accepted: 17 February 2019 Workplace violence appears to be major occupational haz- ard & public health problem despite it is neglected both References by victims and health facilities. Short experiences, working 1. Cooper, C. and N. Swanson, Workplace violence in the health sector-State of the Art. Geneva: ILO www.who.int/entity/violence_injury_prevention/injury/en/ in emergency department, shift work & being nurse/mid- WVstateart.pdf Accessed 20 may 2017. wife has positive association with workplace violence. 2. Liu H, et al. Extent, nature, and risk factors of workplace violence in public tertiary hospitals in China: a cross-sectional survey. Int J Environ Res Public Abbreviations Health. 2015;12(6):6801–17. ART: Anti retroviral therapy; EPI-info: Epidemiological Information; GP: General 3. Steinman, S., Workplace violence in the health sector country case study: Practitioner; HCW: Health Care Worker; ICN: International Council of Nurses; South Africa. http://www.who.int/violence_injury_prevention/violence/ ICU: Intensive care unit; ILO: International Labor Organization; IQR: Inter interpersonal/en/WVcountrystudysouthafrica.pdf Accessed 10 may 2017 . quartile range; MCH: Maternal and child health; OPD: Outpatient department; 4. Nelson R. 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THM Involved in writing reasearch instruments,survey questionnaire. www.who.int/violence_injury_ up of the research proposal, data analyses, and wrote up the draft of the prevention/violence/.../en/WVquestionnaire.pdf Accessed 20 may 2017.2002. manuscript. All authors read and approved the final manuscript. 15. Sripichyakan, K., P. Thungpunkum, and B. Supavititpatana, Workplace violence in the health sector. 2001. Ethics approval and consent to participate 16. Aytac S, Dursun S, Akalp G. Workplace violence and effects on turnover Ethical clearance was obtained from institutional review board (IRB) of intention and job commitment: a pilot study among healthcare workers in University of Gondar. Formal letter of cooperation was presented to Turkey. Eur Sci J, ESJ. 2016;12(10):458–65. respective governmental & private health facilities. Each respondent were 17. Abodunrin O, et al. Prevalence and forms of violence against health informed about the objective of the study, how the result will contribute for care professionals in a South-Western city, Nigeria. Sky J Med Med Sci. employers & government in shaping policies concerning workplace violence. 2014;2(8):67–72. Respondent were involved after they give informed consent. Confidentiality 18. Jira C. Assessment of the prevalence and predictors of workplace violence of the data was maintained and respected. They also informed that all data against nurses working in referral hospitals of Oromia regional state, collected kept confidentially just for only the purpose of study. Ethiopia. JIMS8M: J Indian Manag Strateg. 2015;20(1):61–4. 19. Magnavita N, Heponiemi T. Violence towards health care workers in a public health Care Facility in Italy: a repeated cross-sectional study. BMC Consent for publication Health Serv Res. 2012;12(1):1. Not applicable. 20. Pinar T, et al. 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Journal
Annals of Occupational and Environmental Medicine – Springer Journals
Published: Apr 3, 2019