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Original research
Prevalence and predictors of workplace sexual harassment of nurses in the Central Region of Ghana: a cross-sectional online survey
  1. Aliu Mohammed,
  2. Edward Wilson Ansah,
  3. Daniel Apaak
  1. Department of Health, Physical Education and Recreation, University of Cape Coast, Cape Coast, Ghana
  1. Correspondence to Dr Aliu Mohammed; aliu.mohammed{at}stu.ucc.edu.gh

Abstract

Objective We investigated the prevalence and predictors of workplace sexual harassment against nurses in the Central Region of Ghana.

Design A cross-sectional online survey.

Setting Central Region of Ghana.

Participants A total of 1494 male and female nurses from various healthcare facilities in the Central Region participated in this survey from August to September 2021.

Main outcome measures The prevalence of sexual harassment was determined using the Sexual Experiences Questionnaires and the Workplace Violence in the Health Sector Questionnaires. We used descriptive statistics to analyse participants’ characteristics and the occurrence of sexual harassment. Binary logistic regression was used to determine the predictors of sexual harassment. The survey instrument yielded a reliability value of 0.82.

Results The prevalence of sexual harassment was 43.6% when behaviour-based questions were applied and 22.6% when a direct question was used. The main perpetrators of sexual harassment were male physicians (20.2%), male nurses (15.4%), male relatives of patients (15.1%) and male patients (11.6%). Unfortunately, only a few victims lodged complaints of harassment. Compared with males, female nurses were more likely to be sexually harassed (adjusted OR, aOR 1.59, 95% CI 1.23 to 2.07). Moreover, nurses with higher work experience (aOR 0.86, 95% CI 0.80 to 0.93), those married (aOR 0.54, 95% CI 0.41 to 0.72) and those working in private or mission/Christian Health Association of Ghana health facilities (aOR 0.49, 95% CI 0.36 to 0.68) were less likely to be sexually harassed.

Conclusions The prevalence of workplace sexual harassment against nurses in the Central Region of Ghana is high and may compromise quality healthcare delivery in the region. Therefore, managers of healthcare facilities and the Ghana Health Service need to institute antisexual harassment interventions, including education, training and policy, with a focus on females in general, but especially those who are not married, less experienced and those working in public health facilities.

  • occupational & industrial medicine
  • health & safety
  • nurses

Data availability statement

Data are available on reasonable request.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • The online survey approach ensured easy participation of male and female nurses (1494) from various backgrounds and healthcare facilities.

  • This study investigated the prevalence and demographic factors associated with workplace sexual harassment against male and female nurses.

  • The online approach limited participation to only nurses who had the means of accessing the online survey, which could make the results biased.

  • The response rate was relatively low (16.5%).

  • Our findings are subject to recall bias since the incidence of sexual harassment and its associated factors were self-reported.

Introduction

Workplace sexual harassment remains a critical occupational hazard in the nursing profession.1 Despite being hugely under-reported,2 recent estimates suggest that 4 out of 10 female nurses globally have encountered sexual harassment at least once in their professional careers.1 Sexual harassment in the nursing profession affects not only the physical and psychological health of the nurse but also contributes to poor healthcare delivery, increases errors and compromises patients’ safety, leading to poor health outcomes.3 4 Although the problem of sexual harassment against nurses is acknowledged globally, the phenomenon is rarely studied in many countries,5 especially in low-income and middle-income countries (LMICs) such as Ghana.

Workplace sexual harassment is defined as any unwanted sexually suggestive behaviour that creates an intimidating, hostile and offensive work environment.6 Various forms of physical, verbal and non-verbal behaviours can be classified as sexual harassment. These behaviours range from mild forms, such as sexist jokes, to extreme forms, such as sexual assault.7 Although workers from all fields are exposed to sexual harassment,8 nurses remain one of the professional groupings with increased vulnerability to work-related sexual harassment.9

Estimates of sexual harassment against nurses have been reported, which vary by geographical location, demographics and methods of estimation.1 9 10 For example, a quantitative review of sexual harassment against nurses revealed that 25% of nurses worldwide experienced sexual harassment at work, with higher prevalence recorded in Anglo and European regions relative to Asia and the Middle East regions.9 In LMICs, a systemic review and meta-analysis reported a prevalence range of 0.6%–26.1% for studies that used the direct question method of sexual harassment estimation and 14.5%–98.8% for those that used behaviour-based methods.10 In Tanzania, 9.6% of nurses surveyed reported experiencing sexual harassment at work,11 while in Ethiopia12 and Ghana,13 the rates were 46.6% and 12.2%, respectively. Evidence suggests that most sexual harassment studies involving nurses in LMICs such as Ghana used either the behaviour-based approach or the direct question approach to estimate the prevalence.10 Thus, there are limited data on the use of both approaches in the same study to estimate the prevalence of sexual harassment.

Workplace sexual harassment is influenced by various individual and organisational factors.14 At the individual level, age, gender, marital status and work experience are associated with the occurrence of sexual harassment against nurses.3 15 16 However, aside from gender, the influence of other demographic factors on the occurrence of sexual harassment remains inconclusive.16 Meanwhile, organisational factors like job-gender ratios have also been linked to the occurrence of sexual harassment at workplaces,17 18 with the minority gender being predominantly exposed to the phenomenon.16 Interestingly, despite being the predominant workers in healthcare settings, female nurses remain the main targets for sexual harassment in healthcare facilities. This has been attributed to several other factors, including the sexualisation of the nurses’ role,18 the huge under-reporting of sexual harassment against male nurses2 and the dominant power of physicians.19

Sexual harassment negatively affects the physical and mental health of victims, and it may result in job withdrawal, team conflict and increased employee turnover, thereby compromising organisational productivity,20 in this case, quality healthcare delivery. For instance, nurses who continuously experience sexual harassment at work suffer physical and psychological health problems.3 21 Evidence suggests that such nurses report poor health and safety conditions, which in turn affect the delivery of appropriate care to patients.4 In addition, some victims of sexual harassment lose the opportunity to advance their careers when they quit their jobs due to persistent harassment or are fired in retaliation for reporting perpetrators.17 In addition, healthcare organisations may incur costs either directly, through payment of legal fees and claims, or indirectly due to reduced productivity, absenteeism, presenteeism or job turnover.8

Despite the negative impact of sexual harassment on the health and safety of nurses as well as healthcare delivery,4 the phenomenon is barely studied in many LMICs,5 especially in sub-Saharan Africa.11 In Ghana, there are very limited studies on work-related sexual harassment involving nurses,13 a situation that impedes the appreciation of the problem and limits the implementation of evidence-based interventions to address it. Meanwhile, studies on sexual harassment in some sectors in Ghana revealed high prevalence in institutions such as education,22 sports,23 faith-based organisations24 and healthcare.25 For instance, Boafo et al 13 reported that about 12.2% of the nurses surveyed in Ghana experienced work-related sexual harassment. However, Boafo et al’s13 study was limited to only nurses working in hospitals and did not include other nurses working at lower-level healthcare facilities such as polyclinics and health centres. In addition, the study did not include nurses working in the Central Region of Ghana, which limits our understanding of the phenomenon in the region. The Central Region is one of the poorest administrative regions in Ghana but has many large healthcare facilities and higher educational institutions which attract younger nurses to the region to work or to further their education.26

Furthermore, most of the research studies reported the prevalence of sexual harassment in Ghana using the direct question method of estimation.13 22 23 Thus, we used both the direct questions and behaviour-based estimation methods in the present study, and we provided further information on the prevalence of sexual harassment against nurses in the Central Region of Ghana. Moreover, although the sexual harassment policy has been recognised as one of the valuable tools in addressing the phenomenon in the nursing profession,1 5 there is currently no specific workplace sexual harassment policy for the healthcare sector in Ghana. Our findings may highlight the issue of sexual harassment against nurses in the region and contribute towards the development and implementation of interventions such as policies to address the problem.

Specific objectives

  1. To determine the prevalence of workplace sexual harassment against nurses.

  2. To identify the main perpetrators of sexual harassment against the nurses.

  3. To determine nurses’ responses to incidents of sexual harassment.

  4. To determine the influence of nurses’ demographic factors on the occurrence of sexual harassment against the nurses.

Methods

The study design and setting

This research forms part of a large ongoing study of sexual harassment in the healthcare sector in the Central Region of Ghana. In this study, we used an online cross-sectional survey to quantitatively examine the occurrence and factors associated with the occurrence of workplace sexual harassment against nurses in the region. Respondents were male and female nurses (nurse assistants, registered nurses and midwives) working at the various healthcare facilities in the region.

The Central Region is 1 of the 16 administrative regions in Ghana located in the southern part of the country. The region has 22 administrative districts, and Cape Coast is the regional capital. The region provides healthcare at all levels (primary, secondary and tertiary) due to the presence of diverse categories of healthcare facilities, including a teaching and a psychiatric hospitals. Approximately, 9075 nurses work at the various healthcare facilities in the region.27

Despite being home to various cadres of nurses at all levels of healthcare delivery, a previous study that estimated the prevalence of sexual harassment among nurses in Ghana did not include nurses from the Central Region.13 Although the current study targeted all nurses (census approach) working in the Central Region for data collection (online), only 1494 nurses, representing 16.5%, participated in this study. Because an ‘open’ online data collection approach was used, participation was conducted using a convenient sampling method. The data collection was done via the WhatsApp group platforms of the Ghana Registered Nurses and Midwives Association (GRNMA) and the Union of Professional Nurses and Midwives, Ghana (UPNMG), the two major associations for nurses in Ghana. These associations have WhatsApp group platforms for members in each of the 22 administrative districts in the region. Thus, to ensure representativeness and minimise participant selection bias, data were collected from nurses in all 22 administrative districts.

An online data collection approach was preferred because of the raging COVID-19 pandemic in the country at the time of data collection (24 August 2021–19 September 2021). The leadership of GRNMA and UPNMG in the region was initially contacted via phone call and was informed about the study. The study’s protocol, including the informed consent and the study questionnaire, was later forwarded to these leaders. On their approval, the leaders were tasked to share the informed consent form with the nurses in all 22 districts of the region via their WhatsApp group platforms. This was followed by sharing the survey link a week later via the same WhatsApp platforms. A series of follow-up reminders were done to ensure that nurses in each district received the survey link and responded to the instrument. To participate in this study, a nurse must have worked at least 12 months in any healthcare facility in the Central Region prior to data collection and must agree to complete the research questionnaire online.

Sexual harassment measures

The questionnaire was adapted from the Sexual Experiences Questionnaire, the Department of Defence short version (SEQ-DoD-s)28 and the Workplace Violence in Health Sector Questionnaire.29 We obtained permission from the publishers to use the SEQ-DOD-s, but the Workplace Violence in Health Sector Questionnaire is a publicly available instrument. The SEQ-DOD-s comprised 18 items of sexual harassment which has an alpha reliability of 0.92.28 The SEQ-DOD-s uses a 5-point response scale where 0=never, 1=once or twice, 2=sometimes, 3=often and 4=very often. To use the SEQ-DOD-s in determining the prevalence of sexual harassment, responses from the 18 items were collapsed into a dichotomous scale of ‘yes’ and ‘no’ where a total sexual harassment score of ‘0’ is categorised as ‘no’ (ie, respondents have not experienced sexual harassment) and a score greater than ‘0’ indicates ‘yes’ (ie, respondents have been sexually harassed).28 30 Frequencies and percentages were then computed for the ‘yes’ and ‘no’ categories to determine the prevalence of sexual harassment from a behaviour-based perspective.28 30

The Workplace Violence in Health Sector Questionnaire measures different forms of work-related violence, including sexual harassment.29 Three out of 12 items of the sexual harassment measure were included in the current survey because these items determine the prevalence, main perpetrators and victims’ response to sexual harassment. The Workplace Violence in Health Sector Questionnaire has been used in several studies,13 31 32 with a high level of reported test-retest reliability (1.00) for sexual harassment among nurses in Ghana.13 Our questionnaire was pretested among 62 nurses in the Greater Accra Region. The overall Cronbach’s alpha reliability of the instrument was 0.82.

Data analysis

The data were extracted using a Microsoft Excel file and assessed for eligibility based on respondents’ demographic characteristics. Data from all respondents who did not meet the eligibility criteria (68) were deleted before analysis. Data management was done using SPSS V.24. Descriptive statistics were used in presenting participants’ demographic characteristics, prevalence of sexual harassment, perpetrators and victims’ responses to sexual harassment acts. In addition, binary logistic regression was used to determine the extent to which the nurses’ demographic characteristics predict the occurrence of sexual harassment. The predictor variables (age, gender, work experience, marital status and ownership of health facility) were not determined a priori but based on parsimony and their theoretical relevance to the occurrence of sexual harassment in the nursing profession.3 15 31 32

Patient and public involvement

Patients or the public were not involved in this study.

Results

Demographic characteristics of respondents

A total of 1494 nurses across the region provided data for this study. Table 1 shows that the majority (75.3%) of the respondents were females and more than half (55.3%) were single. Respondents’ ages ranged from 22 to 55 years, and the mean age was 31.26 years (SD=4.62). The majority (80.8%) of the respondents work in public healthcare facilities (Ghana Health Service (GHS) and Ministry of Health (MoH) facilities). Moreover, participants reported working experience ranging from 1.0 to 27.0 years (M=5.32; SD=3.97).

Table 1

Demographic characteristics of respondents

Prevalence of sexual harassment

The prevalence of workplace sexual harassment was 43.6% when the behaviour-based method was applied and 22.6% when the direct question method was used (table 2).

Table 2

Prevalence of sexual harassment

Perpetrators of and nurses’ responses to workplace sexual harassment

As shown in table 3, based on responses from the direct question method, respondents were predominantly harassed by male physicians (20.2%). Unfortunately, the majority (62.6%) of the respondents only asked the perpetrator to stop the sexually harassing act, while only 2 (0.5%) of the nurses completed an incidence reporting form to report the harassers officially.

Table 3

Perpetrators of and nurses’ response to workplace sexual harassment

Demographic predictors of sexual harassment

Table 4 presents the demographic variables as predictors of sexual harassment in healthcare settings. The finding reveals that the demographic variables in the model are statistically significant predictors of sexual harassment occurring against the nurses, except age (B=−0.002, p=0.953). Except for gender, which is positive (B=0.47, p<0.001), work experience, marital status and type of health facility (by ownership) were negative predictors. The results show that female nurses were more likely to be sexually harassed at work compared with male nurses (adjusted OR, aOR 1.59, 95% CI 1.23 to 2.07). Again, nurses with higher work experience (aOR 0.86, 95% CI 0.80 to 0.93), those who were married (aOR 0.54, 95% CI 0.41 to 0.72), and those who worked in the Christian Health Association of Ghana (CHAG) and mission healthcare facilities (aOR 0.49, 95% CI 0.36 to 0.68) were less likely to be sexually harassed at work.

Table 4

Demographic variables predictors of workplace sexual harassment of nurses

Discussion

The prevalence of sexual harassment in the Central Region was 43.6% when behaviour-based questions were used and 22.6% when a direct question was used. The main perpetrators of workplace sexual harassment against these nurses were male physicians, male nurses, male relatives of patients and male patients. We also found that only a few victims lodged formal complaints of their ordeals. Gender, work experience, the type of healthcare facility respondents worked (by ownership) and marital status of the respondents significantly predicted the likelihood of sexual harassment against the nurses.

As reported in several meta-analyses,10 33 34 the prevalence of sexual harassment based on behaviour-based methods is high. It is also high when compared with the previous studies in India (40.3%)35 and Australia (45%).36 However, it is lower than that reported in Greece (70%)37 but higher than that in Taiwan (8.4%).38 Meanwhile, the current prevalence of sexual harassment, based on the direct question method, is higher than the global average among nurses (12.6%)2 and that previously found among nurses in Ghana (12.2%).13 The discrepancies in prevalence by methods of measurement of sexual harassment also suggest some lack of understanding of what constitutes an act of sexual harassment to these nurses. Perhaps, nurses need sexual harassment education. Although comparing the prevalence of sexual harassment among different studies and countries could be misleading due to various contextual factors,32 39 our findings suggest that the prevalence of workplace sexual harassment against nurses in the Central Region is unacceptably high. This calls for further and comprehensive studies on the phenomenon and the implementation of antisexual harassment policies in the healthcare sector to help reduce the occurrence of sexual harassment against nurses in the region.

In concordance with previous studies in Japan15 and Turkey,3 we found that physicians were the most common perpetrators of workplace sexual harassment against nurses. Notwithstanding, other key harassers included male nurses, male relatives of patients and male patients. The increased propensity of physicians to harass nurses has been attributed to the power differentials between physicians and nurses.10 36 For instance, in many healthcare settings, physicians are perceived to be higher in position or status, which they use to harass nurses sexually.3 We believe that serious consideration is urgently needed in the healthcare environment, with much attention given to male physicians. Other perpetrators such as male nurses, male relatives of patients, male patients, female nursing staff and female patients are equally important in sexual harassment issues. Therefore, the GHS needs to ensure that all healthcare facilities issue a position statement that promotes zero tolerance of sexual harassment. The service needs to educate all staff and clients on acts that constitute sexual harassment and the means to report such acts in case they occur. Perhaps that may contribute to minimising the occurrence of workplace sexual harassment and the negative impacts it has on healthcare delivery in the region.

Furthermore, we found that female nurses were more likely to be sexually harassed at work. Similar findings were reported in several studies.8 18 36 The attribution is made to the highly patriarchal nature of most cultures, which allows men to use their dominant positions in society and workplaces to harass women.19 This relative power imbalance and the male dominance in superior positions in healthcare in the country are likely to be fuelling such sexual harassment against nurses. Thus, measures to address issues of sexual harassment against nurses could be targeted at empowering female nurses (through antisexual harassment education, training and policy implementation) to deal with the phenomenon effectively.

We also found that nurses with more work experience were less likely to be sexually harassed at work. A previous study reported that workers with less work experience tend to be more susceptible to sexual harassment.40 Because more experienced nurses have an increased ability to withstand harassers and may even be part of leadership within the healthcare setup, they are less of a target to harassers.40 Therefore, implementing orientation programmes and training for newly recruited nurses on how to deal with issues of sexual harassment at the workplace could minimise their vulnerability.

Our findings further revealed that nurses who were married were less likely to be sexually harassed compared with those who were single. This finding agrees with a previous study, which suggested that unmarried nurses are the most frequent targets of sexual harassment in healthcare facilities in Ghana.13 Married women tend to be more intolerant of sexual harassment, which makes them less of a victim of workplace sexual harassment.14 On the contrary, unmarried women are often seen as soft targets for sexual harassment because they are mostly younger and naïve in dealing with issues of sexual harassment.14 Thus, in healthcare settings where sexual harassment policies and pragmatic antisexual harassment programmes and procedures are not available, unmarried and less experienced younger nurses suffer. Such a hostile healthcare environment not only negates the health and well-being of the nurse but also compromises organisations’ image and quality healthcare delivery, and lowers patient health outcomes.

We also found that nurses who worked in Mission/CHAG healthcare facilities and those in private facilities were less likely to be sexually harassed compared with those who worked in public healthcare facilities. The variations in settings and organisational culture contributed to the observed differences. We speculate that the mission and private healthcare facilities would want to maintain some high level of organisational integrity to attract clients for profit making. In contrast to our findings, a previous study in Pakistan reported that workers in private institutions were more likely to experience sexual harassment than those in public institutions.41 This calls for future studies to investigate the influence of organisational culture and leadership on the occurrences and outcomes of sexual harassment against nurses in Ghana.

Meanwhile, consistent with the findings from previous studies,42–44 only a few victims reported incidents of sexual harassment. Lack of reporting has been identified as a major hindrance to the fight against sexual harassment in the nursing profession.45 This non-reporting of cases does not only cast doubt on the lack of or the inability of management to deal with issues of workplace sexual harassment proactively, but it also questions the trust such victims have in management to resolve cases of sexual harassment. Unfortunately, on-the-job sexual harassment could have a serious impact on the well-being of victims, which in turn results in poor healthcare delivery with its associated errors and poor patient outcomes. Thus, when designing antisexual harassment policies for the healthcare sector, policy-makers, such as the MoH and GHS, need to include mandatory reporting of sexual harassment cases and provide multiple reporting options that allow victims to bypass harassing supervisors when filling for complaint.46 These measures could improve reporting of sexual harassment incidents and promote the resolution of cases and, thus, minimise the negative impacts of sexual harassment on the nurse victim, healthcare delivery, organisational image and patient outcomes.

Strengths and limitations

The strength of this study is the use of an online survey approach, which ensured easy participation of nurses from various backgrounds and healthcare facilities in the region. Moreover, the use of the two methods (behavioural-based and direct question methods) provided a comprehensive and robust estimates of workplace sexual harassment against nurses in the Central Region. Despite these strengths, we acknowledge some limitations in this study. First, despite our attempts to enhance participation and ensure representativeness by sharing the survey link on WhatsApp group platforms of nurses across all the 22 administrative districts in the region, we obtained a low response rate (16.5%), which is partly due to the heightened fear of embarrassment and victimisation associated with sexual harassment in Ghana. Second, respondents were recruited online via WhatsApp group platforms for nurses; thus, no statistical sampling technique was used. Moreover, we may have excluded nurses who did not have electronic devices and those who could not purchase data for online activities. This may lead to participant selection bias, which either overestimates or underestimates the phenomenon. Third, because this is a cross-sectional survey, we could not infer causality; we only reported associations between the variables. Also, this study is subject to recall bias since the incidence of sexual harassment and its associated factors were self-reported.

Conclusion

This study highlights the prevalence of sexual harassment within the healthcare sector in the Central Region of Ghana. Our findings revealed a high prevalence of sexual harassment against nurses in the region, with female nurses, those unmarried, those with less work experience and those who work in public healthcare facilities being the main victims. Therefore, managers of the healthcare facilities and the GHS in the region need to institute interventions such as education, training and policy on sexual harassment to help address the phenomenon. Reducing the incidence of sexual harassment within healthcare settings would improve the health and safety of the nurses, healthcare delivery and patient outcomes.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

The protocols were approved by the Institutional Review Board of the University of Cape Coast (UCCIRB/CES/2021/55), Ghana Health Service Ethics Review (GHS-ERC019/05/21) and further approval from the Central Regional Directorate of Health Services (CR/G-263/332). Permission was obtained from the heads of the nursing associations (GRNMA and UPNMG) before the instrument was circulated via their WhatsApp group platforms. We also circulated an informed consent form that contained information about the background and purpose of the study, eligibility criteria, anonymity, voluntary participation, confidentiality of participants’ information and the need to complete the questionnaire only once. Consent was indicated when a participant clicked the 'I agree' box and proceeded to complete the survey. Respondents were prompted to complete all items on the survey. We ensured that no personal information of the participants was linked to the survey data. Also, the dataset was kept completely anonymous and stored on the first researchers’ password-protected computer.

Acknowledgments

We acknowledge all the directors and heads of nursing associations that gave us access to their WhatsApp platforms for data collection. We are equally grateful to all nurses in the Central Region of Ghana for providing us with data for this research.

References

Footnotes

  • Contributors AM, EWA and DA conceived and designed the study. AM and EWA prepared and submitted the study protocol for ethical approval and collected the data. AM, EWA and DA analysed the data and wrote and reviewed the initial manuscript. AM is responsible for the overall content as guarantor. All authors substantially reviewed the manuscript and approved the final version for submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.