Reducing violence against health care in DRC and Iraq via citizen science and de-escalation trainings

Principal Investigators: Sonja Merten, Swiss Tropical and Public Health Institute; Ghislain Bisimwa, Université Catholique de Bukavu; Riyadh Lafta, Mustansiryah University.

What did the study set out to achieve?

Violence against healthcare workers (HCWs) and alarming levels of distrust towards the medical profession is a humanitarian issue with long-term consequences especially in fragile and conflict settings.

This research aimed to evaluate the effectiveness of a violence de-escalation training for HCWs in combination with an organisational level intervention that may further contribute to curb the violence. For this purpose, a community-developed set of rules was implemented in health facilities and hospitals via a displayed code of conduct. Citizen science and other participatory methods were used to facilitate community engagement and increase community trust in HCWs. The validation of the code of conduct by government and health authorities aimed to ensure the code of conduct was enforced effectively.

Using mixed methods this study explored the triggers and drivers of violence, and generated robust evidence on the effectiveness, cost, and consequences of the intervention to address violence against HCWs in two fragile contexts - the Democratic Republic of the Congo (DRC) and Iraq. The study tested the impact of the violence de-escalation training only (IT), code of conduct only (CC), and the combined intervention of both training and code of conduct (IT+CC).

The research builds on work of the ICRC Healthcare in Danger initiative.

What were the key findings?

• Violence was widespread at baseline. 96% of DRC HCWs and 65% of Iraqi doctors reported verbal abuse; ~11% reported physical violence in both settings. Reports of sexual violence and financial misconduct were present but less frequent.
• Perpetrators varied: in Iraq, violence came from patients and their relatives; in DRC, colleagues were also frequent perpetrators.
• Drivers of violence were at system and interpersonal levels. In Iraq, they included public mistrust, lack of institutional protection, poor communication, and absence of visitor rules. In DRC, drivers were hierarchical tensions, weak supervision, confidentiality breaches, and long wait times. These informed the CC in both settings.
• CC-only intervention had the most consistent and durable impact in Iraq, and significantly reduced verbal and physical abuse in DRC.
• IT-only showed short-term improvements in both countries, but effects weakened over time.
• Combining CC+IT did not enhance outcomes and may have diluted impact, especially in Iraq.
• Burnout and PTSD was high in both settings. Burnout decreased most with the Iraq CC-only intervention, but there was no impact on PTSD.

What does this mean for policymakers and practitioners?

The study demonstrates that addressing workplace violence is not only about protecting individuals, but also about strengthening health system structures - from workforce protection and facility governance to quality service delivery and community trust.

Participatory and contextualised interventions like facility-level codes of conduct and individual-level de-escalation training can serve as practical tools for integrating violence prevention into routine health system functions, especially in settings where health systems are already under pressure.

For humanitarian and health actors in fragile settings, these findings highlight the need to invest in health system resilience by institutionalising violence prevention strategies that respond to local drivers and reinforce accountability and trust.

Future research should explore how the effects of these interventions can be institutionalised and sustained.

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