Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yjoh20 Download by: [University of Ottawa] Date: 17 April 2016, At: 03:57 International Journal of Occupational and Environmental Health ISSN: 1077-3525 (Print) 2049-3967 (Online) Journal homepage: http://www.tandfonline.com/loi/yjoh20 Exposure to Workplace Violence and Quality of Life among Drivers and Conductors in Maputo City, Mozambique Maria Tereza Couto, Stephen Lawoko & Leif Svanström To cite this article: Maria Tereza Couto, Stephen Lawoko & Leif Svanström (2009) Exposure to Workplace Violence and Quality of Life among Drivers and Conductors in Maputo City, Mozambique, International Journal of Occupational and Environmental Health, 15:3, 299-304, DOI: 10.1179/oeh.2009.15.3.299 To link to this article: http://dx.doi.org/10.1179/oeh.2009.15.3.299 Published online: 19 Jul 2013. Submit your article to this journal Article views: 14 View related articles Citing articles: 3 View citing articles http://www.tandfonline.com/action/journalInformation?journalCode=yjoh20 http://www.tandfonline.com/loi/yjoh20 http://www.tandfonline.com/action/showCitFormats?doi=10.1179/oeh.2009.15.3.299 http://dx.doi.org/10.1179/oeh.2009.15.3.299 http://www.tandfonline.com/action/authorSubmission?journalCode=yjoh20&page=instructions http://www.tandfonline.com/action/authorSubmission?journalCode=yjoh20&page=instructions http://www.tandfonline.com/doi/mlt/10.1179/oeh.2009.15.3.299 http://www.tandfonline.com/doi/mlt/10.1179/oeh.2009.15.3.299 http://www.tandfonline.com/doi/citedby/10.1179/oeh.2009.15.3.299#tabModule http://www.tandfonline.com/doi/citedby/10.1179/oeh.2009.15.3.299#tabModule 299 This cross-sectional study examined exposure to work- place violence and its consequences on quality of life (QOL) among workers in the road passenger transport sector in Maputo city, Mozambique. A random sample of 504 drivers and conductors were interviewed using structured questionnaires. Many participants reported experiencing psychological or physical violence at work. Sequelae of violence included sick leave follow- ing abuse (20%), physical injuries (32%), financial loss (28%), and various emotional reactions (28–56%). Exposure to workplace violence was a significant pre- dictor of QOL even after adjusting for confounding. Mechanisms to detect and deal with both immediate and long term consequences of work-related violence on QOL are recommended. Key words: Workplace vio- lence; drivers;conductors; quality of life; Africa INT J OCCUP ENVIRON HEALTH 2009;15:299–304 Over the past few decades, exposure to violence at work has received significant attention. Pub- lished research has reported yearly prevalence ranges of physical and/or psychological abuse of 8–73% in the healthcare sector,1–5 5–68% in the educa- tion sector,6,7 3–69% in public services,6,8 and 60–74% in the transport sector.9–11 Some research has been undertaken to understand consequences of workplace violence at both the indi- vidual and organizational levels.12–16 At the organiza- tional level, workplace violence may lead to increased absenteeism, financial loss, and increased costs (e.g. counseling costs) for both employer and employee.17–20 Employees are likely to experiences emotional reac- tions such as anger, fear, helplessness, sadness, and frustration as a result of workplace violence, eventually resulting in poor performance and diminished job sat- isfaction.12,21–23 In addition to organizational factors, work-related violence may disrupt family bonding as abused workers may find it difficult to distance them- selves from the abuse even while at home.23 Workplace violence has significant health conse- quences, including physical injuries, disabilities, psy- chosomatic complaints, emotional exhaustion, sleep- lessness, anxiety, stress, depression, post-traumatic stress syndrome, and mortality.15,16,24–30 Workplace violence can have grave consequences for workers’ quality of life (QOL). As we use it, QOL is a broad concept encompassing individuals’ physical health, psychological state, level of independence, social relationships, and relationships to features of their environment.31 Though there has been substan- tial research on the effects of workplace violence on some aspects of workers’ QOL, to the best of our knowledge, no study of the effects of workplace vio- lence incorporating a broad definition of QOL has been undertaken in sub-saharan Africa. Moreover, few studies in Africa have been undertaken on the preva- lence of workplace violence. In Mozambique, the only survey on workplace violence, which was conducted in the health sector in Maputo city, indicated a prevalence of verbal or physical abuse of 40%.32 Workplace vio- lence in other sectors of the Mozambique economy and its consequences on QOL remain unexplored. The current study focuses on the relationship between exposure to workplace violence and QOL of workers in the road passenger transport sector. More specifically, we asked the following research questions: a) What are the extent and immediate consequences (e.g. injury, sick-leave, emotional reactions) of work- place violence in the passenger transport sector in Maputo city, Mozambique? b) How does QOL differ between workers who have experienced workplace vio- lence and their peers who have not? c) Does workplace violence impact significantly as a predictor of QOL when possible confounding from other predictors (e.g. sociodemographic variables) is adjusted for? METHODS Settings and Participants The capital city of Mozambique, Maputo, has a popula- tion of 1,099,102 in an area of 300 km2.33 The main mode of transport of citizens and goods is by road. Pas- senger transport is provided by buses, minibuses, and taxis. Owned mainly by government and private trans- port associations, this sector caters mostly to the poor Exposure to Workplace Violence and Quality of Life among Drivers and Conductors in Maputo City, Mozambique MARIA TEREZA COUTO, STEPHEN LAWOKO, LEIF SVANSTRÖM Received from: Department of Public Health Sciences, Karolin- ska Institute, Stockholm, Sweden (MTC, SL, LS) and Faculty of Med- icine, Eduardo Mondlane University, Maputo, Mozambique (MTC). Send correspondence to Maria Tereza Couto, Karolinska Institutet, Department of Public Health Services, Norrbacka plan 2, 171 76 Stockholm, Sweden; email: . Disclosures:: The authors declare no conflicts of interest. D ow nl oa de d by [ U ni ve rs ity o f O tta w a] a t 0 3: 57 1 7 A pr il 20 16 and middle class strata of the population, although a few members of upper class members do use taxis. Each bus and minibus employes a driver and a conductor, while each taxi employs a driver only. All drivers and conductors are registered at the National Traffic Insti- tute (NTI), a government institution responsible for traffic control and regulation. Registered drivers and conductors are predominantly male. The total popula- tion of registered drivers and conductors at the NTI in Maputo city is 2,618, with the following distribution: 405 bus drivers, 377 bus conductors, 743 mini-bus drivers, 743 minibus conductors, and 350 taxi drivers. Partici- pants were sampled from this registry. A pilot study with 50 participants showed a preva- lence of workplace violence of 74%. Based on the pilot, a sample of 504 was found adequate for this study. Five hundred and four participants were randomly selected from the NTI database. We sampled from each stratum of employment category to assure a representa- tive sample, with the following distribution: 144 minibus drivers, 144 minibus conductors, 72 bus drivers, 72 bus conductors, and 72 taxi drivers. All drivers and conduc- tors were interviewed (response rate 100%). Design and Procedure The study design was cross-sectional and participants were interviewed using structured questionnaires. The questionnaires in English were translated to Por- tuguese, the official language in the country, using back translation. Questionnaires covered socio-demograph- ics characteristics, media access, literacy level, occupa- tional experience, organizational changes (e.g., down- sizing, schedule changes, closures, staff reassignment), work environment, work conditions, health conditions, QOL, lifestyle factors, consequences of workplace vio- lence, and burnout. For the current paper, questions concerning workplace violence, its immediate conse- quences, QOL, sociodemographic characteristics, and media access were of primary interest. Data was collected during eight consecutive weeks by three trained interviewers. The interviewer training package included education on the study aims, ques- tionnaire content, and ethical issues in data collection. Participants’ addresses and telephone numbers were obtained from records of each transportation com- pany, including government-owned and private enter- prises. Participants were contacted at work or at home. In some cases, appointments were made by phone. Most interviews were conducted at Maputo city’s main bus/minibus stop, although a few took place at loca- tions most convenient for the participant (e.g. other bus or taxi stop). When contacted, participants were offered an incentive package promising referral to a government hospital should they present with psycho- logical and/or physical symptoms resulting from vio- lence or any other cause. Ethics The National Committee of Bioethics for Health in Mozambique approved the study methods and proce- dures. Informed consent was obtained from all partici- pants, voluntary participation emphasized, and privacy respected while performing the interviews. Participants were assured confidentiality and anonymity, and were informed that results would be reported in group format so that no individual data could be identified. They were also informed that once data had been recorded, the questionnaires would be stored in secure lockers and ultimately destroyed. Measures Outcome Variables. QOL was assessed using a short ver- sion of The Gothenburg QOL Scale.34 The scale con- tains 15 items aggregated in 3 sub-scales: Social QOL, assessed using 4 questions probing satisfaction with work, economy, home and family, and housing situa- tion; Physical QOL assessed with 6 questions probing level of fitness, hearing, vision, health (well being), sleep, and energy; and Psychological QOL assessed using 5 questions probing level of self confidence, memory, mood, appetite, and patience. The items were scored on a scale of 1–7 (from “very bad” through “excellent, could not be better”). Total scores were calculated for the whole scale (i.e. total QOL with a range of 15–105) and for each sub-scale (i.e. social QOL with a range of 4–28; physical QOL with a range of 6–42; and psychologi- cal QOL with a range of 5–35). High scores correspond to high QOL on both total and subscales. The immediate consequences of workplace violence studied included: physical injury, financial loss, sick leave, anger, fear, disappointment, increased caution, and impaired job satisfaction. Participants were asked to indicate whether or not they had faced such conse- quences as a result of exposure to violence; response alternatives were “yes” or “no.” These questions have been previously validated in the developed countries.35 Independent Variables. Workplace violence was assessed by questions probing whether participants had ever or during the past 12 months experienced a verbal threat/aggression, been bitten, slapped, hit, pushed, spat at, scratched, pinched, punched, kicked, or faced any unpleasant experience at work (as perceived by the respondent). The responses alternatives were “yes” or “no.” An affirmative response to at least one of these experiences was operationalized as being exposed to violence. These questions have previously been vali- dated in the developed countries.21 Socio-demographic characteristics were in this study used to adjust for confounding effects. These variables included age, marital status, highest educational level, occupation, literacy level, and media access. As demo- 300 • Couto et al. www.ijoeh.com • INT J OCCUP ENVIRON HEALTH D ow nl oa de d by [ U ni ve rs ity o f O tta w a] a t 0 3: 57 1 7 A pr il 20 16 graphic variables are associated with both the outcome of interest (i.e. QOL)36,37 and with the predictor of interest (i.e. exposure to violence),38 they may to some degree confound the relationship between exposure to violence and QOL, warranting an adjustment for confounding. Statistical Analysis The SPSS for Windows version 16.0 software package was used for all analysis. The chi-square test was used to assess associations between categorical variables (i.e. study associations between categorical demographic vari- ables and exposure to violence as well as immediate con- sequences of workplace violence). T-tests were used to assess associations between a dichotomous variable (i.e. exposure to violence) and the continuous outcomes (i.e. QOL measures). Multiple linear regression was used to examine the independent association between exposure to workplace violence and QOL, while controlling for demographic and occupational characteristics. Statisti- cal significance was set at p < 0.05. RESULTS Characteristics of Participants As shown in Table 1, the greatest proportions of partic- ipants were aged 20–29 years (37.9%), married/ cohab- itant (57.9%), with a primary school or equivalent edu- cation (46.8%), and literate (75%). Minibus drivers/ conductors comprised 28.6% of the sample. A signifi- cant percentage had experienced abuse in various forms, with the majority having been verbally abused. Immediate Consequences of Workplace Violence in Exposed Participants in the Past 12 Months As shown in the Table 2, significant proportions among participants exposed to violence reported increased cautiousness and emotional reactions such as anger, dis- appointment, fear, and sadness. Other significant con- sequences included sick leave, financial loss, mild and severe physical injuries, and impaired job satisfaction. Association between Exposure to Workplace Violence and QOL in General A significant association was found between exposure to workplace violence and QOL (Table 3). Participants exposed to workplace violence during their life time reported on average a lower overall wellbeing index VOL 15/NO 3, JUL/SEP 2009 • www.ijoeh.com Workplace Violence among Drivers in Mozambique • 301 TABLE 1 Characteristics of Participants Number within Category (%) Age < 20 yrs 97 19.2 20-29 yrs 191 37.9 30-39 yrs 121 24.0 40-49 yrs 51 10.1 50-59 yrs 33 6.5 > 60 yrs 11 2.2 Marital Status Single 147 29.2 Married/cohabitant 292 57.9 Divorced/separated 44 8.7 Widower 21 4.2 Education Less than primary school 116 23.0 Primary school/similar 236 46.8 Upper secondary school/ university 152 30.2 Occupation Bus driver 72 14.3 Bus conductor 72 14.3 Minibus driver 144 28.6 Minibus conductor 144 28.6 Taxi driver 72 14.3 Literacy Level Can read 378 75.0 Cannot read 126 25.0 Access to media Have TV Yes 374 74.2 No 130 25.8 Have Radio Yes 456 90.5 No 48 9.5 Type of violence experienced a Verbal threat/aggression 237 47.0 Unpleasant experience 105 20.8 Pushed 103 20.4 Slapped/hit 77 15.3 Scratched/pinched 41 8.1 Kicked 32 6.3 Punched 31 6.2 Bitten 26 5.2 Spat at 15 3.0 Restrained 11 2.2 Others 28 5.6 aAs participants may have experienced several forms of vio- lence, proportions need not add up to 100%. TABLE 2 Immediate Consequences of Workplace Violence in Exposed Participants (Past 12 months) (N=234) Consequences N (%) Physical injury Mild 74 (22.8%) Severe 29 (9.0%) Financial loss 90 (27.8%) Sick leave 65 (20.1%) Anger 178 (54.9%) Fear 89 (27.5%) Sadness 93 (28.7%) Disappointment 116 (35.8%) Increased caution 180 (55.6%) Decreased job satisfaction 30 (9.3%) D ow nl oa de d by [ U ni ve rs ity o f O tta w a] a t 0 3: 57 1 7 A pr il 20 16 302 • Couto et al. www.ijoeh.com • INT J OCCUP ENVIRON HEALTH manifested in total QOL and on sub-scales of social wellbeing, physical wellbeing and psychological wellbe- ing than peers not exposed to violence. A similar trend was observed regarding exposure to violence in the past 12 month for total QOL, physical wellbeing, and psychological wellbeing (Table 3). Exposure to Violence as Predictor of QOL: Controlling for Demographics, Occupational Characteristics and Literacy Level As shown Table 4, exposure to violence during the past 12 months was significantly associated with all QOL dimensions, i.e. participants exposed to workplace vio- lence exhibited a lower QOL (total and subscales) than non-exposed peers even when demographic variables were adjusted for in a linear regression model. Other variables significantly predicting QOL dimensions in the models included age, education, and occupation. As age increased, total, physical, and psychological QOL diminished. Increasing educational attainment was associated with increased total, social, and physical wellbeing. Bus drivers exhibited higher social wellbe- ing, but lower physical and psychological wellbeing when contrasted with conductors and minibus drivers together. Bus conductors, on the other hand, exhibited higher social wellbeing but lower total QOL and lower physical and psychological wellbeing than the other employment categories when viewed together. A simi- lar trend was observed among minibus drivers/con- ductors. Literacy level did not predict QOL after adjust- ment for other possible predictors. DISCUSSION The results indicated that workplace violence in the pas- senger transport sector in Mozambique is common, with figures comparable to those observed in the transport sector in developed countries where prevalence ranging between (60–74%) has been reported.9–11 These find- ings are an indication that workplace violence in this sector is an occupational hazard likely to lead to grave public health consequences. Workplace violence impacted significantly on victim’s general wellbeing as manifested in QOL. The measure of QOL in this study incorporated constructs of physical, psychological and social wellbeing. Victims of violence were more likely to score low on these con- structs than their non-victimized peers even after possi- ble confounding from sociodemographic measures were controlled for in the analysis, suggesting that vio- lence at work may affect individuals’ QOL independent of other factors contributing to QOL such as age, edu- cation, and literacy. The physical, psychological and TABLE 3 Association between Exposure to Workplace Violence and QOL Mean score (±SD) Significancea Exposure to violence, life time Total QOL (score 15–105) Exposed 77.764 (±8.589) p < 0.01 Non exposed 80.587 (±7.551) Social wellbeing (score 4–28) Exposed 17.905 (±3.168) p < 0.01 Non-exposed 18.833 (±2.657) Physical wellbeing (score 6–42) Exposed 32.043 (±4.028) p < 0.05 Non-exposed 33.043 (±3.848) Psychological wellbeing (score 5–35) Exposed 27.815 (±3.686) p < 0.05 Non-exposed 28.710 (±3.076) Exposure to violence past 12 months Total QOL (score 15–28) Exposed 77.438 (±8.651) p < 0.01 Non-exposed 80.138(±7.778) Social wellbeing (score 4–28) Exposed 17.941 (±3.163) Non-exposed 18.427 (±2.914) Physical wellbeing (score 6–42) Exposed 32.043 (±4.028) p < 0.01 Non exposed 33.043 (±3.849) Psychological wellbeing (score 5–35) Exposed 27.815 (±3.686) p < 0.01 Non exposed 28.710 (±3.076) aDetermined by T-test. D ow nl oa de d by [ U ni ve rs ity o f O tta w a] a t 0 3: 57 1 7 A pr il 20 16 VOL 15/NO 3, JUL/SEP 2009 • www.ijoeh.com Workplace Violence among Drivers in Mozambique • 303 social trauma that victims face, relative to non-victims, may be a reflection of the long term consequences of abuse and suggest that violence at work is likely to affect victims’ wellbeing far and beyond the work place. This view is in line with the notion of intergenerational repercussions of workplace violence transcending to affect other areas of life, e.g. family life.23 As one of a very small number of studies in the field in Africa, this study provides initial data from the trans- port sector supporting the hypothesis that independ- ently, workplace violence is likely to affect the QOL of individuals within and beyond their work environment. Our response rate of 100%, though ideal, is unusual and warrants discussion. A number of factors acting together may have accounted for this total response. First, it is plausible that participants may have found the topic highly relevant. The high prevalence of violence in this study as well as its consequences on individual health seems to support this view. Another explanation for the total response could stem from the project organization. Information dissemination regarding the study and its objectives, training of data collection per- sonnel, emphasis on ethical considerations such as pri- vacy and confidentiality may have contributed to the total response rate. The incentive package offered to participants is another factor that may constitute a major contributor to the total response rate (i.e. all par- ticipants needing psychological support or medical care due to hearing, vision and sleep problems were referred to government hospitals, where treatment is free of charge). Moreover, in populations where access to healthcare is limited, as in Maputo, such an incentive package may have functioned as coercive, prompting the 100% participation. The possibility of participants being other-wise coerced to participate in the study cannot be entirely ruled out. It is plausible that their employers may have signaled participation as an obliga- tion when informing participants of the study. On the other hand, large household surveys such as the Demographic and Health Surveys (DHS) carried out in many countries in the Sub-Saharan Africa, have had high response rates. The Mozambique 2003 DHS, for example, achieved a response rate of about 95%.40 Simi- larly high response rates (97–99%)have been reported in Zambia and Tanzania.41,42 Our 100% response rate could therefore simply reflect a cultural characteristic. Another problem in relation to offering a referral incentive is the possibility of a bias towards over-report- ing of psychological and physical problems as resulting from abuse. Such health problems could stem from other sources (e.g. poverty) rather than the experience of violence. Another word of caution concerns the broad definition of violence adopted in this study. Undergoing an “unpleasant experience” is a subjective phenomenon that may not be a reflection of violence per se, though its impact on quality of life may be profound. How partici- pants understood this question therefore should be sub- ject to deeper qualitative research in the future. Finally, the cross-sectional design of this study does not allow for causal interpretation of our findings. CONCLUSIONS AND IMPLICATIONS Workplace violence in the road passenger transport sector is common and its consequences on health both in the short and long term are an indication that employment in the sector may constitute an occupa- tional and health hazard. These findings have impor- tant implications for secondary prevention. Policy makers and employers must develop mechanisms to detect and address both immediate and long term con- sequences of QOL. Employees should be encouraged to report incidents as they occur and should promptly be referred for counseling and other relevant treat- ment if the consequences of work place violence are to be managed at an early stage. TABLE 4 Exposure to Violence as Predictor of QOL, Controlling for Demographics, Occupational Characteristics and Literacy Level Standardized Coefficients Beta_______________________________________________________________ Social Physical Psychological Independent Variables Total QOL Wellbeing Wellbeing Wellbeing Age –0.283a –0.020 –0.383a –0.223a Education 0.144b 0.114b 0.131b 0.119 Bus driver 0.097 0.608a –0.146b –0.130b Bus conductor –0.318a 0.344a –0.525a –0.459a Minibus driver –0.032 0.418a –0.346a –0.278a Minibus conductor –0.022 0.684a –0.280c –0.219b Literacy level –0.039 –0.068 –0.017 –0.015 Exposure to violence past 12 month –0.116b –0.110b –0.043b –0.088b Note: Standardized betas provide a description of the direction and strength of association between the dependent variable and respective independent variables, when other variables in the model have been controlled for. 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