Prevalence and Factors Associated with Violence among Primary and Secondary School Workers in Ouagadougou, Burkina Faso
Marthe Sandrine Sanon Lompo1, Issa Traoré2, Yannick Wilfried Boenzemwende Ninkéma1, Guiegui-Kouamé Chimène Pulcherie3, Constant Gouba1, Adama François Ouédraogo4, Souka Gaston Kaboré1, Arouna Ouédraogo1
1Unité de Formation et de Recherche en Sciences de la Santé, Département de Santé Publique, Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso.
2Institut Supérieur des Sciences de la Santé, Département de Santé Publique, Université Nazi Boni, Bobo Dioulasso, Burkina Faso.
3Unité de Formation et de Recherche Sciences médicales, Université Félix Houphouët Boigny, Abidjan, Côte d’Ivoire.
4Office de Santé des Travailleurs, Service de Pathologies Professionnelles, Ouagadougou, Burkina Faso.
DOI: 10.4236/odem.2024.123017   PDF    HTML   XML   29 Downloads   121 Views  

Abstract

Introduction: Violence is a major problem in today’s workplace. It affects workers in all sectors of activity. The aim of the study was to determine the prevalence and factors associated with violence among primary and secondary school staff in Ouagadougou. Materials and Methods: This was a cross-sectional, descriptive and analytical study that took place from April 22, 2020 to February 18, 2021 in primary and secondary schools in Ouagadougou. It focused on the educational staff of these establishments. Results: A total of 362 agents took part in the study. The average age of participants was 36.5 ± 6.89 years. The sex ratio was 1.62 men to one woman. The majority of workers were teachers, with 300 participants (82.87%). The average job tenure was 7 years ± 6.91 years. With regard to violence in the workplace, 87 workers were victims, representing a prevalence of 24.03%. Of these workers, 59 (67.81%) were men and 36 (41.38%) had less than six years’ experience. Acts of violence were predominantly pushing observed in 15 workers (50%), while shouting and aggressive tone dominated psychological violence and concerned 54 cases (36.24%). On univariate analysis, the factors associated with violence were age (p = 0.046) and type of establishment (p = 0.012). On multivariate analysis, only the nature of the establishment was the only factor associated with the occurrence of violence among teaching staff (OR = 2.3690, p = 0.0213). Conclusion: The prevalence of violence is high in these educational establishments. Age and type of establishment are factors associated with its occurrence. It is therefore necessary to develop an effective strategy for preventing this risk in the workplace.

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Lompo, M. , Traoré, I. , Ninkéma, Y. , Pulcherie, G. , Gouba, C. , Ouédraogo, A. , Kaboré, S. and Ouédraogo, A. (2024) Prevalence and Factors Associated with Violence among Primary and Secondary School Workers in Ouagadougou, Burkina Faso. Occupational Diseases and Environmental Medicine, 12, 225-241. doi: 10.4236/odem.2024.123017.

1. Introduction

A public health pathology, violence is now a real concern in the workplace, whatever the sector. Indeed, according to the Sumer survey, 22.4% of employees were victims of violence in the course of their professional activity in France in 2003. [1] Studies carried out in the healthcare sector show a high prevalence of violence in the workplace, as high as 69.8%. [2] [3] In Türkiye, 36.8% of education workers had experienced violence on the job in 2011. [4] Few data exist on the assessment of this risk in the education sector in Burkina Faso, where the problem remains a reality. [5] Whether at primary or secondary level, educational establishments are characterized by more or less frequent contact between pupils, teachers, parents and school life staff, which can give rise to violence between these different players. Several factors are at the root of violence among teaching staff, including school living conditions, excessive class size, poor student behavior, late or absent teachers, and inadequate communication within the school hierarchy. [6] The consequences of such violence are numerous, both for employees and for productivity. These include depression, sleep disorders, stress and even burnout. [7] Stress and violence suffered by workers are estimated to account for 30% of all illness- and accident-related expenditure, and represent between 0.5% and 3.5% of annual gross domestic product. [8] Few national data are available on the extent, characteristics and consequences of violence in the primary and secondary education sector, yet these establishments have been experiencing scenes of violence linked to growing incivism in recent years, all of which have consequences for the safety, health and well-being of staff. Hence the need for this study, which aims to determine the extent and factors associated with violence in primary and secondary schools in Burkina Faso.

2. Materials and Methods

This was a cross-sectional, descriptive and analytical study that took place from April 22, 2020 to February 18, 2021 in public and private primary and secondary schools in the city of Ouagadougou. It covered educational staff in the city of Ouagadougou.

Included in the study were public and private primary and secondary school teachers in the city of Ouagadougou with at least one year’s seniority in teaching.

Trainees and teachers with less than one year’s seniority or absent from their posts during the study period were not included in the study.

The sample size was calculated using the formula:

n: sample size

N: target population size 24778

P: expected proportion. In the absence of previous results on the prevalence of violence among education workers in Burkina Faso, we considered P = 50%

tp = 1.96 (Sampling confidence interval either 95%)

y: margin of sampling error 0.05

The sample size is: n = 378

Data were collected using an administered questionnaire. Analysis was performed using Epi Info software version 7.1.3. Qualitative variables were presented as raw frequencies and proportions, and compared using the Chi2 or Fisher exact test. Quantitative variables were presented as means (standard deviation). Factors associated with violence were investigated using logistic regression. The significance threshold was p < 0.05 for all statistical tests.

The dependent variable was violence, whether physical, psychological or sexual; the independent variables were the socio-professional characteristics of the victims of violence.

Ethical considerations

The agents included in the study gave their consent to participate. Furthermore, the anonymity of the respondents and the confidentiality of the results were taken into account throughout the study.

3. Results

3.1. Socio-Demographic and Occupational Characteristics of Workers

A total of 362 agents took part in the study. The mean age was 36.5 ± 6.89 years, with extremes ranging from 26 to 57 years. The sex ratio was 1.62 men to one woman. Married agents numbered 276 (76.24%). The teaching position was the most represented, involving 300 participants (82.87%). The average length of service was 7 years ± 6.91 years, with extremes ranging from one year to 33 years. The socio-professional characteristics of the agents are presented in Table 1.

Table 1. Socio-demographic and occupational characteristics of workers.

Number

Percentage

Gender

Male

224

61.88

Female

138

38.12

Marital status

Married

272

75.14

Single

78

21.55

Divorced

1

0.28

Widowed

7

1.03

Workstation

Teacher

300

82.87

Supervisor

27

7.46

Director

25

6.91

Principal

4

1.10

Censor

3

0.83

Bursar

3

0.83

3.2. Socio-Demographic and Professional Characteristics of Victims of Violence

A total of 87 agents were victims of violence in the course of their work, representing a prevalence rate of 24.03%. Fifty-nine victims (67.81%) were men. Workers aged between 26 and 36 accounted for 41 (47.13%). Of these victims, 36 (41.38%) had less than six years’ experience, and 49 (56.32%) were secondary school workers. Table 2 presents the socio-demographic and occupational characteristics of workers who were victims of workplace violence.

Table 2. Socio-demographic and professional characteristics of victims.

Number

Percentage

Gender

Male

59

67.81

Female

28

32.19

Age groups (years)

26 - 36

41

47.13

36 - 46

31

35.63

46 - 57

15

17.24

Workstation

Teacher

300

82.87

Supervisor

27

7.46

Director

25

6.91

Principal

4

1.10

Censor

3

0.83

Intendant

3

0.83

Length of service (years)

1 - 6

36

41.38

6 - 11

20

22.29

11 - 16

11

12.64

16 - 21

11

12.64

21 - 26

8

9.20

26 - 33

1

1.15

Level of education

Secondary

49

56.32

Primary

38

43.68

3.3. Characteristics of Violence

3.3.1. Typology of Violent Acts

Psychological violence was the most common type of violence recorded in the study, involving 99 cases (70.21%), followed by physical violence in 19 cases (13.48%). Seven cases of sexual violence (4.96%) were recorded. Among cases of physical violence, pushing was the most frequent act of violence, reported in 15 cases (50%). Shouting and aggressive tone dominated psychological violence, involving 54 cases (36.24%). Sexual harassment, reported by 7 workers (100%), was the most common form of sexual violence experienced by workers. It was characterized by touching and indecent proposals. The types of violence are shown in Table 3.

Table 3. Typologies of violent acts.

Frequency

Percentage

Typologies of violent n = 141

Physical abuse

19

13.48

Psychological abuse

99

70.21

Physical and psychological abuse

16

11.35

Sexual abuse

7

04.96

Origine of violent n = 97

Exogenous violence

65

67.01

Endogenous violence

32

32.99

Violent acts

Physical violence n = 30

Push

15

50

Punch

5

16.67

Object throw

5

16.67

Strangulation

4

13.33

Knife threat

1

3.33

Psychological violence n = 149

Shouting and aggressive tone

54

36.24

Insults

47

31.55

Threats of physical assault

18

12.08

Death threats

2

1.34

Rudeness

7

4.70

Insults

12

08.05

Threat of disciplinary action

6

04.03

Leering

3

02.01

Sexual violence n = 7

Sexual abuse

7

100

3.3.2. Perpetrators of the Attack

School parents were the main aggressors in 32 cases of violence (29.36%), followed by pupils in 17 cases (15.60%). Fourteen teachers (12.84%) were involved in the violence perpetrated on their colleagues. The perpetrators are shown in Table 4.

Table 4. Perpetrators of the attack.

Frequency

Percentage

School parents

32

29.36

One student

12

11.01

Several students

17

15.60

Outsiders

15

13.76

Teachers

14

12.84

Supervisor

13

11.93

Supervisor

6

05.50

Total

109

100

3.3.3. Professional Characteristics of Violence

The school yard was the scene of violence for 65 workers (74.71%), followed by the classroom, which recorded 12 cases of victims (13.79%). Indiscipline and revenge on the part of pupils and service users were the circumstances in which the violence occurred in 37 cases (36.28%); inadequate communication on the part of staff was noted in 25 cases (24.51%). Table 5 shows the professional characteristics of agent violence.

3.4. Factors Associated with Violence

3.4.1. Univariate Analysis of Factors Associated with Violence

On univariate analysis, the factors associated with violence were age (p = 0.046) and type of establishment (p = 0.012). The univariate analysis of factors associated with violence is presented in Table 6.

Table 5. Professional characteristics of violence.

Characteristics of violence

Frequency

Percentage

Location n = 87

Schoolyard

65

74.71

Classroom

12

13.79

Route

10

11.50

Circumstances of aggression n = 102

Student and user indiscipline and revenge

37

36.28

Lack of communication on the part of agents

25

24.51

Mental illness of the aggressor

3

02.94

Staff management problems

7

06.86

Social inequalities (age, gender, disability)

5

04.90

Conflicts with pupils

20

19.61

Students’ social background

5

04.90

Table 6. Univariate analysis of factors associated with violence.

Victim

OR

p

Yes

No

Gender

Male

59

165

1.40

0.191

Female

28

110

Age range

26 - 39

48

184

0.61

0.046

40 - 57

39

91

Length of service

1 - 14 years

63

209

0.49

0.49

15 - 34 years

24

66

Education level

Primary

38

115

0.92

0.76

Secondary

49

160

Type of school

Public

24

43

0.49

0.012

Private

63

232

3.4.2. Multivariate Analysis of Factors Associated with Violence

On multivariate analysis, only the nature of the school was a factor associated with the occurrence of violence among teaching staff. Thus, staff in public schools were around 2.36 times more exposed to violence than their colleagues in private schools (p = 0.0213; CI = 1.1373 - 4.9349). The results of the multivariate analysis are presented in Table 7.

Table 7. Multivariate analysis of factors associated with violence.

OR Adjusted

95% CIx

p

Length of service

1 - 14 years

0.9697

0.8860 - 1.0612

0.5034

15 - 34 years

Type of school

Public

2.3690

1.1373 - 4.9349

0.0213

Private

Gender

Male

1.3032

0.7639 - 2.2232

0.3312

Female

xConfidence Interval.

4. Discussion

4.1. Characteristics of Victims and Violence

A total of 87 agents were victims of violence in the course of their work, representing a prevalence rate of 24.03%. The majority of these victims were men, 59 (67.81%). The 26 to 36 age bracket was the most represented, involving 41 workers (47.13%). Of these victims, 36 (41.38%) had less than six years’ experience, and 49 (56.32%) were secondary school workers. Psychological violence was the most common type of violence observed in the study, involving 99 cases (70.21%), followed by physical violence in 19 cases (13.48%). Seven cases of sexual violence (4.96%) were also noted. Pupils’ parents were the main aggressors in 32 cases of violence (36.78%), followed by pupils in 17 cases of group aggression (15.60%). Fourteen teachers (12.84%) were implicated in scenes of violence perpetrated on their colleagues. Indiscipline and revenge on the part of pupils and school users were the most frequent circumstances in which violent incidents occurred, in 37 cases (42.52%).

Contrary to our findings, several authors have found higher prevalences of violence in the workplace [3] [9]-[11]. For example, in a study carried out in Bangladesh, 43% of healthcare workers were victims of violence [9]; a high prevalence of violence of 87.3% was found among security guards at a university in Egypt. [11] The low prevalence of violence perpetrated on the workers in our study could be explained by the fact that our sample was made up mainly of educators, whose behavior should show students good habits, in particular the avoidance of acts of violence. However, violence in the workplace remains a real concern in view of the risks to the health of staff who fall victim to it, such as sleep and psychological disorders [12]. Like our observations, other authors have noted the predominance of cases of psychological and physical violence compared with sexual violence [13] [14]. On the other hand, no cases of physical violence were observed in the study carried out by Bourbonnais et al. in Quebec. [15] Similarly, Opoku et al., in Ghana found only cases of verbal and sexual violence in their study of care staff. [16] The study by Boughima et al. corroborates our findings regarding the predominance of male victims of violence. [17] Contrary to these observations, a predominance of women was observed among victims of school violence in the study by Gilbert et al. [18]. However, our sample was composed mainly of men, which could explain their high representation among victims.

Workers with less professional experience were the most numerous among the victims in our observations. On the other hand, authors have noted higher proportions of victims of violence among workers who had lasted longer at their workstations. [9] [11] Lack of experience in the field of education can sometimes expose workers to scenes of violence, as they have not yet developed strategies for dealing with it, whether it be violence perpetrated between colleagues or that coming from pupils, parents or other school users. In most cases, the aggressors were people from outside the school, in particular a parent or a pupil. As staff are in constant contact with students, and to a lesser extent with parents, we need to establish good communication between these players, and encourage everyone to respect the school rules to ensure a calm working climate in our schools. This is more important given that indiscipline has been identified as one of the most frequent causes of violence. Sanctions should also be applied in the event of abuses, in accordance with the provisions of the internal regulations.

4.2. Factors Associated with Violence

In univariate analysis, the factors associated with violence were age (p = 0.046) and type of establishment (p = 0.012). However, gender, seniority in post and level of education were not factors associated with violence in the study.

In the multivariate analysis, only the nature of the establishment was a factor associated with the occurrence of violence. Staff in public schools were more exposed to violence than their colleagues in private schools. (p = 0.0213; CI = 1.1373 - 4.9349). Gilbert et al. also noted a statistical association between the occurrence of violence and the nature of the school, with public school teachers being more victimized than their colleagues in private schools. These authors also noted a predisposition of women to violence compared to men, but no significant association was found between age and the occurrence of violence. [18] In Bangladesh, healthcare workers in public facilities were around 3 times more exposed to violence than those in private facilities. [9] As for Sisawo et al. in Gambia, men were more exposed to violence than women in a population of caregivers. [3] Age was also a risk factor for workplace violence, according to data from Agbaje et al. among women working at a university in Nigeria. [14] According to these authors, workers aged 35 to 49 suffered 2.5 times more physical violence than those in other age groups. [14] Younger workers often lack the experience needed to deal with work-related situations that expose them to violence, and to adapt appropriate communication to prevent violence from occurring in the first place. As for public education structures, the number of staff and students is generally high, combined with working conditions that are often less than optimal, which could partly explain workers’ exposure to violence. Some authors have noted a statistical association between job seniority and the occurrence of violence. Thus, in the study by Sisawo et al., workers with 5 or more years’ experience were fewer victims of physical or moral violence in the course of their professional activity. [3] Conversely, Agbaje et al. found that workers with at least 10 years’ experience were more likely to suffer violence at work. [14] Beyond years of experience, other aspects should be taken into account in the genesis of workplace violence, in particular the ongoing training of agents in the prevention of violence in the workplace.

The prevalence of violence in these settings calls for the consideration of risk factors according to the interactive model of researchers at the Tavistock Institute. [19] According to this model, a distinction is made between risk factors related to the individual aggressor or victim, including age, which in our case was associated with the occurrence of violence, as well as gender, personality and mental health. On the other hand, there are factors associated with the workplace. Indeed, in our study, public institutions were more susceptible to violence because of the permeability to the external environment noted by researchers at the Tavistock Institute. Taking these factors into account will make it possible to establish prevention according to a primary level in which individuals and each person are characterized, allowing for specific action, the adoption of policies and regulatory texts, a secondary level that includes emergency actions in the face of aggressive behaviour and finally a tertiary level for the psychological care of victims.

Preventing violence in these establishments requires the implementation of a strategy involving all the players concerned. This will involve setting up frameworks for communication and listening within the school. In addition, including a module on violence in education and raising awareness among parents through the parents’ association is a good strategy for reducing violence. Lastly, promote relaxation and recreation settings that bring teachers and pupils together.

5. Limitations of the Study

We carried out a cross-sectional study which does not allow us to monitor changes in violence among workers over time. In addition, some workers did not take part in the study for personal reasons, even though they had been reassured of the confidentiality of the survey data.

6. Conclusion

Violence is a worrying risk among staff in public and private establishments in Ouagadougou. The factors associated with its occurrence were age and type of establishment. Action should be taken in these establishments to prevent acts of violence among staff, in view of both the somatic and psychological consequences of this risk.

Annexes

Questionnaire on the study of violence among education workers: the case of institutional workers.

Dear participants, please read these instructions carefully before answering the questionnaire:

The purpose of this study is to study the characteristics of violence among education workers in public and private primary and secondary schools.

This questionnaire consists of four parts:

1. The first part includes personal and epidemiological data.

2. The second part aims to characterize violence (type; causes, situations; circumstances, etc.).

3. The third part deals with the consequences, physical and mental impact of the violence on the personnel concerned.

4. The last part focuses on the availability of prevention procedures and regulations for acts of violence against education workers.

Please answer the questions by putting (√) in the right place (in the corresponding box □)

Thank you for your cooperation and understanding

Preliminary definitions (according to the WHO):

Workplace violence:

Incidents in which the person is the victim of abusive, threatened or physically assaulted behaviour in circumstances related to their work, including on the way to and from work, and involving an implicit or explicit challenge to their safety, well-being or health.

Part I: Epidemiological and occupational characteristics of the interviewees.

1. Establishment: ..................................................................................

2. a. Sex

marital status

□ Women

□ Men

3. Function:

□ Director

□ Principal

□ Censor

□ Supervisor

□ Teacher

□ Other: ................

□ Single

□ Married

□ Devourer (e)

□ Widow (ve)

3. Age:

4. Seniority:

Part Two: Data and Characteristics of Violence:

5. In the course of your work in schools and establishments, have you ever been a victim of an act of violence (of any kind)?

□ yes

□ no

NB: if not go to Part 4 to reply

6. Exogenous violence (a person who does not work in the institution)

1. Have you ever been the victim of an exogenous act of violence at the school level?

□ yes □ no

If so, what was the nature of it? If not, go to question 9

2. Physical abuse:

□ Surge □ Knife Threat

□ Shots (Strike) □ Throwing Equipment

□ Strangulation □ Others: ...............

3. Emotional abuse:

□ Insults

□ Shouts and aggressive tone

□ Threats of physical assault

□ Sexual harassment

□ Death threats

□ Others: ................

4. Location of the act of violence:

□ in the classroom

□ in the school yard

□ on the way (home-work)

□other: ......................

5. Time of the act of violence

□ 7 h - 16 h

□ 16 h - 18 h

□ 18 h - 7h
□ Imprecise

6. Frequency of acts of violence

□ Every day

□ Several times a month

□ Once a week □ Once a year

□ Once a month □ Other: ...................

7. The act of violence was committed by?

□ Parent of a pupil □ Several pupils □ One pupil □ A person from outside the school

□ Other …………….

8. Circumstances of the attack: In your opinion, what was the cause(s) of the attack? Tick the most probable

8.1 Factors linked to the pupils

□ Mental or psychiatric situation of the aggressor

□ Indiscipline/Vengeance

□ Your conduct

□ Conflict or dispute with a pupil

□ Social origin of the pupils 8.2 Factors linked to yourself as a teacher

□ Problem with management, supervision

□ Staff miscommunication

□ Because of my age, sex, nationality, disability

8.3 Factors linked to the school and level of education □ Primary □ Secondary □ Public □ Private Other....................................................

9. Endogenous violence (between staff)

9.1. Have you ever been the victim of an act of interpersonal violence in the establishment? □ yes □ no

9.2. If yes, the assailant was? □ Teacher □ Other □ Supervisor □ Line manager (specify)........................

9.3. If yes, which act of violence?

Physical: □ yes □ no

If yes, it was:

□ Pushing □ Blows

□ Strangulation

□ Equipment throwing

□ Other: ......................

Psychological: yes □ no □

If yes, it was:

□ Insults □ Death threats

□ Threats of assault

□ Shouting and aggressive tone □ Rudeness □ Leering

□ Touching □ Sexual harassment

□ Threats of disciplinary action □ Other: ............................

9.4. Circumstance of the attack □ Mental or psychiatric situation of the attacker □ Because of my age, sex, nationality, disability

□ Revenge, settling of scores □ Other .....................................

9.5. If yes, did you report the incident to the authorities or lodge a legal complaint? □ yes □ no

Part Three: Consequences, Physical and Mental Impact of Violence on the Education Officer: (answer if you were a victim of an act of violence)

10. After the act of violence, did you have a temporary interruption of work (ITT)

□ yes □ no

If so, how many days was it?

□ A few hours □ 1 day□ <5 days □ Between 5 and 10 days

□ Between 11 and 20 days□ >21 days

11. What was your reaction to the act

- Verbal self-defense □ yes □ no

- physical self-defense □ yes □ no

- No reaction □ yes □ no Other: ..........

12. If it was an act of physical violence, did you have any injuries?

□ yes □ no

□ abrasions □ hematoma

□ bruise □ wound

□ fracture □ other: ......

13. Did you report the incident?

□ yes □ no

If so, to whom?

Administration (Director, Principal, Censor, Supervisor): □ yes □ no

Authority (police): □ yes □ no □ justice □colleague

If not, why?

□ Unnecessary (no action will be taken)

□ Incident non important

□ I didn’t know the procedure for filing a complaint

□ Fear of negative consequences

□ I don’t have time to travel

□ other: ................

14. Following the declaration, do you know the spring?

□ No action has been taken by the administration

□ Settlement between the assaulted officer and the aggressor

□ Settlement between the administration and the aggressor

□ Legal proceedings and judgments

□ Others: ..................................................................

15. At what level, were you satisfied with the measures taken following the incident?

□ Very satisfied

□ Somewhat satisfied

□ Neither satisfied nor dissatisfied

□ Dissatisfied

□ Very dissatisfied

16. Impact on personal and professional life:

has. What are the negative effects or consequences of exposure to violence on you?

□ Fear and Anxiety (nightmares; insomnia) □ Avoid making decisions

□ Minimize communication or contact with students and others

□ Despair/Disappointment

□ Reduce communication or contact with students, staff, and other people

□ No impact on me

□ Others: .............................................................................................

b. Did you need psychological/psychiatric help after the act(s) of Violence?

□ yes□ no

c. Did you receive any medication after the incident(s)? □ yes □ no

If so, the name of the drug?……………………………………………..

d. After the incident(s) Did you have the thought of?

Stopping work□ yes □ no

Changing establishment□ yes □ no

Changing profession□ yes □ no

e. Has your attitude and enthusiasm towards work changed negatively following the incident? □ yes □ no

Part Four: Availability of prevention procedures, regulations for acts of violence against teaching staff:

16. Are there any

- Camera detection and protection of personnel □ yes □ no

- A security service □ yes □ no

- Alarme □ yes □ not

17. Does the institution have an anti-violence policy or program to address violence in the workplace?□ yes □ no□ I don’t know

18. Have you received training on preventing and combating violence in schools?

□ yes □ no

19. Is there a procedure to follow in your establishment in the event of an act of Violence?□ yes □ no □ I don’t know

20. If so, what is it? …………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………………………………………

21. Which of these measures can help prevent an act of violence from occurring in your work:

□ Conflict Management Training

□ Means of communication (posters, videos, etc.)

□ Presence of a security guard in institutions

□ Others to be proposed: ....................................................................................

22. Do you have any comments to add (real-life situations, proposals)?

□ yes □ no

If so, which one?........................................................................................................................

…………………………………………………………………………………………………………………..……………………………………………………………………………

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

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