Gender-based violence (GBV) is one of the most pervasive and underreported public health challenges in Europe. Rooted in unequal power relations and structural inequalities, it manifests across all social contexts, at home, in public spaces, and, less visibly, in the very places designed to provide care and support. Healthcare settings, including hospitals, outpatient clinics, nursing homes, and residential care facilities, are not immune to violence. On the contrary, they represent environments where vulnerability, dependency, and professional obligation converge daily, creating conditions in which violence can occur, directed at those receiving care, but also at those providing it. This is one of the issues currently being explored within the BRAVE-WOW project, which examines occupational violence affecting health and social care workers across Europe.
The broader picture: GBV through the lens of emergency data
Emergency departments (EDs) offer a unique window into the visible spectrum of GBV. When women seek emergency care following violence, they leave a clinical and epidemiological trace that surveillance systems can capture and analyse. This is the premise behind a recently published study in The Lancet Public Health (Carannante et al, 2026), conducted by researchers from the Italian National Institute of Health (ISS) and European partners within the EU-IDB network.
The study analysed data from 16 European countries spanning 2008 to 2023, identifying over 10,000 GBV-related ED attendances among women and girls aged 15 years or older. The findings reveal a distinct and clinically coherent profile. Victims were predominantly women in their reproductive years, with a mean age of 38 years. Head and facial injuries accounted for nearly half of all cases, a rate more than three times higher than in other female injuries, reflecting the anatomical targeting characteristic of intentional violence. Contusions and bruises were the most frequent injury type, present in 48% of GBV cases. Hospital admission was required in over one in five cases, with a mean length of stay of 5.3 days. After adjustment for age, time period, and country, GBV was associated with significantly higher odds of severe outcomes compared with other forms of violence against women (OR 1.22, 95% CI 1.12–1.34). Intimate partners accounted for nearly half of all identified perpetrators, and the domestic setting was the predominant site of violence, with almost two-thirds of incidents occurring in or around the home. Consistently with this domestic nature, GBV cases peaked sharply during night-time hours when overall ED presentations decline, a temporal signature of violence occurring in private settings, away from potential witnesses.
These patterns describe only the visible spectrum of GBV. Most incidents go undisclosed, unrecognised, or untreated: EDs capture women who sought care, whose injuries were recognised as violence-related, and whose perpetrator was documented. The data are a lower bound, shaped as much by recognition and disclosure practices as by the underlying epidemiology.
Violence against healthcare workers: an occupational dimension
Within the BRAVE-WOW project, the ISS research team has been exploring a specific and often overlooked dimension of this phenomenon: intentional violence occurring within healthcare and social care environments during paid work. Using data from the European Injury Database Full Data Set (IDB-FDS), researchers identified intentional injury cases (coded as Assault or Other violence) recorded in medical service areas (hospitals, outpatient clinics, and emergency departments), homes for the elderly, and nursing homes, and occurring during paid working activity.
Applying these criteria to the available IDB-FDS dataset yields 514 cases, a small number reflecting the simultaneous application of three selective filters (healthcare setting, occupational context, and intentional violence). The figure is a conservative lower bound: much occupational violence goes uncaptured because the activity field is left blank or the event not coded as intentional. What these 514 cases offer is nonetheless a well-defined and internally consistent picture of a phenomenon that is real, clinically significant, and distinct from other forms of violence in the IDB.
The demographic profile of these cases is coherent with the composition of the health and social care workforce. Sixty percent of victims were female and 40% male, with a mean age of approximately 40 years. The gender distribution, less skewed than in domestic GBV, reflects the mixed but female-predominant workforce of healthcare settings, where men are more represented in certain roles (security, psychiatric care, emergency services) that carry specific exposure to patient-perpetrated violence.
The distribution by place of occurrence points toward institutional clinical environments: hospitals account for 32% of cases and other medical service areas for nearly half (49%). Homes for the elderly (11%) and nursing homes (3%) reflect the specific risk in residential care, where staff interact with cognitively impaired or behaviourally disturbed residents.
The temporal distribution of these cases contrasts sharply with the night-time pattern observed in domestic GBV. Excluding cases with unknown time of attendance, accesses are concentrated during daytime and early evening hours, with peaks between 09:00 and 18:00 and a secondary peak around 21:00, consistent with day and evening shift patterns. This is the temporal signature of occupational violence: it happens at work, during working hours, in the course of providing care.
The agent of violence is, in almost three quarters of cases (72%), another person, the individual being cared for, or someone accompanying them. This is not violence involving weapons or objects; it is direct physical confrontation between a worker and a patient, resident, or visitor. The remaining cases involve a variety of objects and instruments, but these are marginal in both frequency and narrative weight. The core finding is unambiguous: in healthcare workplaces, the source of intentional violence is overwhelmingly human, and overwhelmingly the person in front of the worker.
Clinically, the injury profile of these 514 cases resembles the GBV pattern described in the Lancet study more closely than it resembles a typical occupational injury distribution. Contusions and bruises account for 57% of cases (higher even than the 48% observed in domestic GBV) followed by open wounds (14%), distortions and sprains (7%), and fractures (4%). The orthopaedic component is modest, unlike what would be expected from accidental workplace injuries. Concussions are present in 3% of cases. This profile is consistent with direct physical aggression: blows, pushes, bites, and the defensive injuries sustained while attempting to restrain or withdraw from an agitated individual.
The clinical outcome picture reinforces the burden. Nearly 60% of cases were sent home after treatment, but almost one quarter were discharged without any treatment at all, possibly reflecting cases where the worker attended the ED for documentation purposes rather than medical necessity, or where injuries were considered minor. Approximately 9% were referred for further specialist treatment, and 4% were admitted directly to hospital. These proportions, applied to a conservative case count, suggest that the true occupational burden of violence in healthcare settings across Europe is substantially larger than any current surveillance system captures.
A surveillance system ready to be improved and a role for BRAVE-WOW
When an intentional injury is recorded in the IDB-FDS, a dedicated Violence Module is activated, collecting four additional variables specifically designed to characterise the circumstances of the assault: the sex and age group of the perpetrator, the relationship between victim and perpetrator, and the context in which the assault occurred. In principle, these variables would allow researchers and policymakers to answer the questions that matter most for prevention: who is attacking healthcare workers, in what relational context, and under what circumstances?
In practice, the picture that emerges from the 514 occupational violence cases identified in this analysis is one of systematic and striking incompleteness. The sex of the perpetrator is unknown in 75% of cases; the perpetrator’s age group is unknown in 80%; the context of the assault is unspecified in 73%; and the relationship between victim and perpetrator is unspecified or residually categorised in over 80% of cases. The Violence Module, in short, exists, but is largely not filled in.
The information that does emerge from the documented minority is nonetheless suggestive. Among perpetrators with known sex, men account for 78%. Among cases with a documented relationship, care givers unrelated to the victim and strangers each account for 40 cases, a finding consistent with the dual exposure of healthcare workers to both patient-perpetrated and visitor-perpetrated violence. The assault context, where recorded, is predominantly altercation (12%) or otherwise unspecified, with virtually no cases involving organised crime, drug-related incidents, or sexual assault, reinforcing the picture of situational, care-related violence rather than premeditated aggression.
But the dominant finding is the silence: three quarters of cases leave the perpetrator unidentified, the relationship undocumented, and the context uncharacterised. This is not a failure of the instrument; the Violence Module is well designed and, when completed, highly informative, as the Lancet study demonstrates. The failure is one of documentation practice: ED personnel do not systematically fill in the Violence Module fields, either because no institutional protocol mandates it or because the professional culture of emergency care does not yet treat colleague-directed violence with the same rigour as patient-directed injury.
This is precisely the knowledge gap that BRAVE-WOW is positioned to address, not by building new surveillance infrastructure, but by generating the contextual knowledge that routine ED data cannot provide. The project has already launched a dedicated survey across healthcare workers in Portugal, Italy, Spain, and Slovenia, designed to assess the prevalence, causes, and consequences of violence and harassment in the workplace, alongside individual experiences and perceptions of organisational climate. Where the IDB Violence Module records, when it records at all, the bare mechanics of an assault, the BRAVE-WOW survey reaches into the working environment itself: who is exposed, under what organisational conditions, with what perceived institutional support, and with what consequences for wellbeing and professional continuity. These are the dimensions that a passive surveillance system built around ED attendances cannot capture, and that are indispensable for designing prevention strategies that go beyond counting injuries.
Why this matters: the BRAVE-WOW response
The BRAVE-WOW project directly addresses gender-based violence in occupational settings, with particular attention to health and social care workers. Funded under the EU CERV Programme, the project brings together partners from Portugal, Italy, Slovenia, and Spain to tackle a problem that sits at the intersection of gender inequality, occupational health, and institutional responsibility. Its approach combines epidemiological analysis of occupational violence, as illustrated by the IDB-based work described in this news item, with a dedicated survey of healthcare workers already underway across the four partner countries, legal and organisational assessment of the conditions that enable or inhibit violence, and the development of practical tools for prevention and awareness-raising.
These findings illustrate both dimensions of this challenge: a measurable phenomenon (514 cases, predominantly female victims in their early forties, injured during working hours by the people they care for) and a structural knowledge gap, a surveillance system capable of characterising this violence in depth but deprived of the information it needs by inadequate documentation practices.
BRAVE-WOW works on both sides of this divide. By documenting the extent and characteristics of GBV in care workplaces, the project contributes to making a largely invisible occupational risk visible. By developing tools for prevention, early identification, and organisational response, it supports the institutional conditions under which documentation improves, violence is recognised rather than normalised, and data can finally begin to answer the questions that policy needs answered. The 514 cases identified here are the beginning of that process. They are a signal, not a census, of a problem that deserves far greater attention than it currently receives.
References
Carannante A, Pitidis A, Fondi G, Fian T, Alves T, Valkenberg H, Nijman S, Giustini M; IDB group. Gender-based violence against women and girls aged ≥15 years presenting to European emergency departments: a multinational, cross-sectional analysis. Lancet Public Health. 2026 Apr;11(4):e253-e263. doi: 10.1016/S2468-2667(26)00030-7. Available at: https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(26)00030-7/fulltext