Violence against healthcare: reviewing the evidence base and identifying areas for future research

A hospital damaged in an attack on a U.S. military air base in Bagram, north of Kabul, Afghanistan, December 11, 2019, photo by Mohammad Ismail/Reuters

A hospital damaged in an attack on a U.S. military air base in Afghanistan

Mohammad Ismail/Reuters

RAND Europe explored the nature of violence against healthcare, the impact of this violence, and corresponding interventions on a global scale – the first time an evidence review of this scale has been undertaken in this area — to understand what additional research might be needed to inform policy and develop countermeasures.

The study highlighted the need for systematic reviews of research and evaluations of interventions in conflict areas, and increased data collection on low intensity, high frequency violence in conflict areas.

What is the issue?

Violence against healthcare professionals, workers, patients and infrastructure occurs not only in areas of conflict, such as Syria and Yemen, but also in non-conflict areas around the world across high, medium and low income countries. Research can increase understanding of the nature, causes and impact of violence against healthcare, as well as inform countermeasures in this area. More work is needed in this area, however, and RAND Europe’s study for the International Committee of the Red Cross (ICRC) and Elrha, a charity that seeks solutions to humanitarian problems through research and innovation, offers a global review of the existing evidence base.

How did we help?

RAND Europe researchers explored the current research on the nature of violence against healthcare, the impact of this violence, and corresponding interventions on a global scale – the first time an evidence review of this scale has been undertaken in this area.

Researchers identified 23 areas where there is insufficient evidence on violence against healthcare, highlighting where additional research is needed to improve understanding and to enhance the design of effective interventions. From this analysis of evidence gaps, the study team then sought to prioritise research areas, supporting a more systematic and informed approach for developing future research and, in turn, enabling policymakers and practitioners to provide healthcare services that are open, secure and free from violence.

What did we find?

Characteristics of the existing evidence base

  • Overview of evidence base. Our literature review identified 1,412 relevant sources, with the number of publications having increased over the last 10 years. Most sources focus on violence against healthcare in North America, Europe and East Asia, with a small proportion of research focusing on conflict or post-conflict settings.
  • Conceptualisation of violence. Most studies conceptualise violence as physical or psychological, with many of the papers reviewed focusing on violence carried out by patients towards healthcare workers in healthcare facilities.
  • Evidence on the nature of violence. Of the three themes under analysis – the nature of violence against healthcare, the impact of violence and corresponding interventions – the majority of studies focus on the first.
  • Evidence on the impact of violence. Around a quarter of publications examine the impact of violence against healthcare, with many studies in this category examining the personal impact of violence on healthcare workers.
  • Evidence on interventions. Similarly, around a quarter of publications focus on interventions with a focus on training, tools, policy and techniques for countering violence against healthcare.

23 research gaps were identified, which can be clustered into six groups

  1. The nature of violence against healthcare. Gaps in this area include a lack of understanding of why perpetrators commit violence and of the gender dynamics of violence, pointing to limitations in our knowledge of the underlying dynamics and causes of violence.
  2. The impact of violence. Existing research appears to focus on the personal impacts of violence and the immediate impact on healthcare delivery, while wider impacts such as the economic cost of violence or the prolongation of conflict are less understood.
  3. Interventions. More research is needed on the role of groups who are not involved in the immediate delivery of healthcare, such as the military, NGOs and police, particularly in conflict areas. To help develop more comprehensive interventions, we also need to better understand under-researched issues such as organisational culture.
  4. Specific contexts of violence. More insight is needed on the similarities and differences between violence against healthcare in conflict and non-conflict environments. There is also a lack of research on areas that are not considered to be conflict environments but still experience high levels of violence, such as areas with high levels of gang-related violence or organised crime.
  5. Limitations in data collection. While difficult to implement in a reliable manner, existing surveillance data – data collected on an ongoing basis – does not capture key information on perpetrators and specific locations of attacks. Data in conflict environments also appears to focus predominantly on high-impact attacks and to a lesser extent on frequent but lower-impact types of violence, such as looting, blockading and arrests.
  6. Specific research methods. The limited number of systematic reviews on conflict areas makes it difficult to understand the degree to which existing policies are supported by evidence and more challenging to identify further areas of research that address limitations in the existing evidence.

What are priority areas for further research?

To identify research priorities, the research gaps were scored by a RAND Europe Expert Group against three criteria: impact of the research; feasibility of carrying out the research; and relevance to policymakers, practitioners and researchers.

  • Undertaking systematic reviews of research in conflict areas received the highest overall combined score, indicating that research in this area may not only have a relatively large impact on our understanding of and ability to counter violence against healthcare, but also relatively low barriers to implementation.
  • Increasing data collection on low intensity, high frequency violence in conflict areas scored highest for impact, as did the need for more evaluations of interventions that safeguard healthcare workers in conflict areas. Also receiving the highest combined score, the highest feasibility score was assigned to systematic reviews of research in conflict areas.
  • Undertaking evaluations of interventions in conflict areas was considered to be the most relevant research area for practitioners, policymakers and researchers alike. Other research areas that were scored as most relevant for these groups include data on lower-intensity, higher-frequency violence in conflict areas; research on contextual drivers of violence; and surveillance data in conflict areas.