Study on Home-Based Direct Care Workers' Coping Responses to Workplace Sexual Harassment and Their Satisfaction With Long-Term Care Preventive Strategies

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Introduction
The 2030 Agenda for Sustainable Development adopted by the United Nations emphasizes the importance of global sustainable development across environmental, economic, and social domains.In particular, Goal 3 "Ensure healthy lives and promote well-being for all at all ages" and Goal 5 "Achieve gender equality" are key goals for societies to progress towards sustainability (United Nations, 2015).As the global population grows older, promoting and implementing gender equality practices needs to be more proactive, especially in healthcare contexts.
However, discrimination, prejudice, and gender stereotypes place severe restrictions on those who work in the medical and health fields.Despite their best efforts, global gender advocates have not been able to completely eradicate gender discrimination in the field of global health (Heise et al., 2019), to the extent that workplace sexual harassment issues continue to emerge incessantly, threatening the physical and mental health of frontline staff (Hsieh & Huang, 2018).Not only are harassment events common in acute care settings, but also in home, community, and institutional long-term care contexts, consequently impacting service quality and staff safety, as well as professional development (Fineczko et al., 2023).In institutional type of long-term care facilities, sexual harassment of older residents should not be part of any job (Villar et al., 2019).A study of reactions of Spanish long-term care staff to sexual harassment experiences showed significant differences in attitudes and perceptions towards handling harassment across job positions (Villar et al., 2019).Notably, a recent meta-analysis of observational study in Chinese nurses indicated that when sexual harassment is a frequent occurrence, numerous negative consequences for professional development will arise (Zeng et al., 2019).Considering the major adverse impacts, administrators should devise effective preventive strategies and workplace policies, while also paying attention to post-event management tactics (Fineczko et al., 2023;Zeng et al., 2019).
Although countries internationally adopt legislation to protect staff rights when facing workplace sexual harassment, the actual implementation of formal reporting mechanisms and handling procedures after an incident occurs is often underestimated (Kirillova, 2020).A study exploring the extent of sexual harassment experienced by long-term care facility (LTCF) staff, their typical perceptions and ways of dealing with such situations, and how their job positions influence their reactions, strongly urged that LTCF employees should be respected and ensured of their right to work without harassment (Villar et al., 2019).Previous study on this issue is predominantly situated in 24-hour residential institutional long-term care settings, rarely focusing on home-based care service workers.Moreover, when workplace violence events occur, very few victims actually file formal reports (Grigorovich & Kontos, 2019).Based on previous studies, this results in limited knowledge regarding how home care providers respond when encountering sexual harassment hazards at work.One article explored how workplace harassment and discrimination may impede recruitment and retention of professionals in underserved areas (Ko & Dorri, 2019).More investigation on this issue is warranted to assess the adverse impacts of exacerbated occupational isolation due to such harassment and discrimination.When organizational leaders lack gender sensitivity or react passively, they may become perpetrators of institutional discrimination or harassment (Ko & Dorri, 2019;Von Gruenigen, & Karlan, 2018).In particular, ineffective management can also influence long-term care quality development (Fineczko et al., 2023).Therefore, in evaluating care quality in healthcare contexts, the structure-process-outcome quality assessment model proposed by Donabedian (1980) is an important model for health care quality evaluation and can serve as an analytical framework to ensure service quality (Kane & Kane, 1988).Its connotations are: structural factors refer to the environmental characteristics of a service, such as tangible conditions like facilities, equipment, and human resources; process factors indicate the actual processes and content of health care services, for example the interaction process between doctors and patients, including diagnostic accuracy, communication methods, care interaction experiences, etc.; finally, outcome factors refer to various consequence effects of care services on the health status of cases and staff, e.g.rehabilitation discharge rates, satisfaction levels, etc.This model also emphasizes the mutual influences among these three factorsgood structure facilitates process and thus enhances outcomes.It can also serve as the basis for workplace stress management (Whitney & Rose, 1990).Based on findings from the literature review, this study will adopt it as a framework to measure long-term care quality and analyze workplace sexual harassment prevention comprehensively (Fineczko et al., 2023;Kane & Kane, 1988).

Purposes
Citing relevant research, this study uses Donabedian's structure-process-outcome framework as a foundation (Figure 1) to explore home-based direct care workers' coping responses when encountering workplace sexual harassment and examine main factors influencing their satisfaction with WSH preventive strategies.

Research Design and Subjects
This was a correlational research design.Convenience sampling was used to recruit participants.Members of four home care institutions in Taiwan were surveyed using online questionnaire.The estimated sample size was based on a study on workplace violence assessment by Lin (2009).The sample size was estimated using G-power 3.0 for comparing two independent means.The parameters were set to a power of .9, a medium effect size (0.5), and an attrition rate of 2.5%.The estimated sample size was approximately 240.The inclusion criteria for participants were (1) having worked in the home care institution for at least one year, and (2) agreeing to complete the questionnaire.Excluded criteria were home-based workers currently unemployed.

Research Instruments
This study used a structured questionnaire divided into four parts, detailed as follows: 3.2.1 Basic Demographic Variables: Including Age, Gender.

Job
Attributes: including attributes of service agencies, years of work experience, categories of employees, and types of employment, daily working hours, overtime work conditions, and manpower load status.
3.2.3Questionnaire of coping response to WSH: Coping response after occurrence of WSH incidents, with 18 possible reactions, including taking no action or further action.Each item is scored by checkbox.

Perceived Norms About Policies of Workplace Sexual Harassment
This section has 2 questions on whether the workplace has established complaint (reporting) procedures and how familiar respondents are with workplace sexual harassment policies or procedures.The first question has a score range of yes (1 point), no (2 points), don't know (3 points).The second question has a score range from extremely unclear (1 point) to extremely clear (5 points).Excluding "don't know" (3 points) and reverse coding yes (2 points), no (1 point), the total score is 2 points and 5 points respectively.Higher scores indicate clearer perceived norms about policies of workplace sexual harassment., 2014).It surveys respondents' experiences over the past one year with stalking and sexual harassment incidents and perceptions at work, the harm (physical, mental and financial losses) from those incidents, and satisfaction with how the incidents were handled.There are 2 questions on whether it is common to encounter real or virtual sexual harassment.Each question has a score range from strongly disagree (1 point) to strongly agree (5 points).The total score is 10 points.Higher scores indicate that more common to encounter working sexual harassment.
(2) Overall harm score from sexual harassment incidents: This section contains 3 questions on physical harm, mental harm, and property losses.Each question is scored yes (1 point), no (2 points), and uncertain (3 points).Excluding non-responses (3 points) and reverse coding yes (2 points), no (1 point), the total score is 6 points.Higher scores indicate greater overall harm.

Scales of Personal Perceptions of WSH
(1) Satisfaction with the handling of real incidents of sexual harassment: This contains one question on satisfaction with related units' handling of encountered sexual harassment incidents.The score range is from extremely dissatisfied (1 point) to extremely satisfied (5 points).The total score is 5 points.Higher scores indicate greater satisfaction with handling of the incidents.
(2) Satisfaction with employer's implementation of prevention strategy for WSH: This contains one question on satisfaction with employer's implementation of prevention strategy for WSH.The score range is from extremely dissatisfied (1 point) to extremely satisfied (5 points).The total score is 5 points.Higher scores indicate greater satisfaction with employer's implementation of prevention strategy for WSH.
(3) Satisfaction with prevention strategy for WSH: including awareness of background and preventive strategies, strategies provided by devices, prevention strategies for improving the environment, and prevention strategies by education and training.Each item is scored from extremely poor (1 point) to extremely good (5 points).Higher scores indicate better personal perceptions of WSH in prevention strategy.

Data Collection and Analysis Methods
After obtaining approval from the ethics committee, the administrative departments of the recruitment sites were contacted to get support before commencing recruitment.SPSS Windows 20.0 statistical software was used for data analysis, including descriptive statistics (percentages, means, and standard deviations), independent samples t-tests, analysis of variance, Pearson's correlation coefficients, and hierarchical regression analysis.The regression analysis controls for the influence of explanatory variables on outcome variables, allowing for a more precise examination of factors influencing satisfaction with handling of sexual harassment incidents.

Analysis of Differences in Satisfaction With Employer's WSH Prevention Strategy Based on Personal and Job
Characteristics.
There is no significant difference in the satisfaction of different genders of research subjects with regard to employer's WSH prevention strategy (t=1.21,p=.30);However, there are significant differences in the attributes of different service organizations (t=2.93,p=.03).Those who serve in private service agencies have the lowest satisfaction; and there are significant differences in the satisfaction of employers' prevention and control strategy between different categories of Employees (t=3.62,p=.01), part-time workers have the lowest satisfaction score (Table 1).

Satisfaction and Responses to the Situation of WSH in Home-Based Direct Care Workers
The average satisfaction to with their employer's WSH in home-based direct care workers is 3.51 (SD=0.95).There were 16 coping methods used by study subjects when facing sexual harassment.Ordered by percentage from highest to lowest, the top three were: telling the harasser to stop this behavior (30.8%), reporting/complaining to a superior (28.6%), and taking no action (22.0%) (Table 2) Seeking assistance from religious organizations/authorities (e.g., seeking peace through temple visits, prayer, etc.) 1 1.10 Seeking assistance from civil organizations (e.g., helplines, women's organizations, women's rescue associations, etc.) 1 1.10

Correlation Analysis of Key Variables of Participants and Satisfaction With Employer's WSH Prevention Strategy
In the correlation analysis of satisfaction with the employer's WSH prevention strategy, the subjects of this study showed daily working hours (r=.12; p<.05), perceived norms about policies of WSH (r =.21; p <.01)., Satisfaction with prevention strategy for WSH (r =.40; p <.01), Awareness of background and preventive strategies for WSH (r =.32; p <.01), strategies provided by devices (r =.35; p p< .01),Prevention strategies for improving the environment (r =.30; p<.01), Prevention strategies by education and training (r =.18; p <.01), Satisfaction with the handling of real incidents of WSH (r = .54;p <.01), and has a statistically significant positive correlation with the employer's satisfaction with WSH prevention strategies, while the study subject's manpower load status (r =-.16; p<.01), Overall harm score from sexual harassment incidents (r =-.20;p<.01),there is a statistically significant negative correlation with satisfaction with employer WSH prevention strategies (Table 3).

Discussion
Home-based care is seen as a critical strategy for facilitating "aging in place", a key policy goal.Yet healthcare workers serving in clients' residences and communities often confront unpredictable occupational hazards, compromising personal safety and service quality.Despite anti-harassment legislation in many countries, a meta-analysis on Chinese nurses' and nursing students' experiences showed increasing prevalence of sexual harassment over time, highlighting the imperative of effective preventive and organizational interventions (Zeng et al., 2019).Likewise, our study found lower satisfaction with employers' anti-harassment measures among private relative to public LTC agencies, and among part-time workers.As postulated by the care quality framework, structural attributes of care settings influence anti-harassment infrastructure.
Sexual harassment should never be an expected part of caring for older adults in institutionalized.While recognizing clients' sexual needs, inappropriate behaviors must be acknowledged and addressed through organizational policies, guidelines and staff training for gender empowerment and incident response (Villar et al., 2019).Indeed, one fifth of participants took no action upon harassment, which is consistent with the recommendation made by Villar et al. (2019) that should call for action.
The varying reactions to sexual harassment among home-based workers align with findings in Spanish residential facilities (Villar et al., 2019).The complex emotions and cognitions underline the discrepancies between common responses and perceived best practices.Creating a supportive environment with adequate resources and education, while narrowing the distance between management and frontlines, can help align attitudes around response protocols (Villar et al., 2019) and prevent compromised quality from deficient leadership (Fineczko et al., 2023).
Based on the study findings, key factors influencing long-term care staff's satisfaction with anti-harassment strategies comprise: Inadequate staffing increases harassment risks and undermines confidence and fulfillment with preventive approaches.Managers should ensure personnel safety through appropriate allocation (Heise, et al., 2019;Gupta & Garg, 2020).Additionally, heightened perceptions of workplace hazards dampen satisfaction.Routine safety education could mitigate such threat cognitions and empower preventative skills (Irshad, Majeed, & Khattak, 2021).
Moreover, post-harassment investigation processes and outcomes may adversely impact victims' psychological and occupational well-being.Units should exercise sensitivity to avoid secondary victimization.Finally, robust anti-harassment infrastructure conveys organizational support, facilitating buy-in and contentment (Kirillova, 2020).Home care administrators should continuously optimize relevant protocols to uphold human rights values (Gupta & Garg, 2020).
In summary, consolidating structural, procedural and outcome facets could systematically elevate workplace security and affirmative climate towards realizing zero-tolerance harassment goals.

Conclusion
This is the first study based on Donabedian's structure-process-outcome framework to examine home-based caregivers' coping responses when encountering workplace sexual harassment and explore factors influencing their satisfaction with preventive strategies.Given the paucity of research attention to sexual harassment issues in home-based care settings, this study contributes to addressing gaps in the literature.In addition, by elucidating caregivers' actual coping tactics and evaluating the adequacy of organizational measures, the findings can inform the development of effectual response guidelines for frontline workers and the refinement of policies to construct safer, more respectful and professional home care environments.

Figure 1 .
Figure 1.The framework for workplace sexual harassment (WSH) based on the structure-process-outcome model 3.2.5 Scales of Personal Experiences of WSH (1) Perceived workplace hazards: This questionnaire referenced indicators for measuring gender-based violence prevention established in 2003 by the International Labor Office (ILO), International Council of Nurses (ICN), World Health Organization (WHO) and Public Services International (PSI) as well as Taiwan's Ministry of Health and Welfare (2013)( ILOSH Ministry of Labor

Table 1 .
Analysis of differences in satisfaction with employer sexual harassment prevention strategy based on personal and job characteristics (n=217)

Table 2 .
Satisfaction and responses to the situation of WSH in home-based direct care workers (n=90)

Table 3 .
Correlation analysis between key variables of study participants and employer's sexual harassment prevention measures satisfaction (n=217)

Table 4 .
Predictive factors influencing Satisfaction with employer's implementation of prevention strategy for WSH