Takemi Program in International Health
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A longitudinal study of the effects of urban violence on the mental health and work performance of Community Health Workers in northeastern Brazil
Anya P G F Vieira-Meyer,1 Aisha K Yousafzai 2
¹ Takemi Program in International Health, Harvard T.H. Chan School of Public Health, Boston, MA; Senior Researcher – Fundação Oswaldo Cruz Ceará (Fiocruz CE); Professor – Unichristus
² Professor of Child Development and Health – Harvard T.H. Chan School of Public Health, Boston, MA
Introduction
Violence is a complex and multifaceted phenomenon, fostered by a combination of risk factors such as poverty, inequality, the absence of the state, lack of employment opportunities, and crises of governance. Nevertheless, this complex phenomena is neither a static experience nor uniform among different settings.1 Organized crime has grown and diversified its endeavors in all parts of the Americas.2 Special attention needs to be given to Urban Violence (UV), which became widespread and disruptive of the community. Of the 50 most violent cities in the world, 17 are in Brazil,3 and 10 on its NE region.
In Brazil, the Family Health Strategy (FHS) underpins Primary Health Care (PHC) system, the backbone of the Brazilian Unified Health System (SUS). Each team comprises a physician, a nurse, a dentist, technicians, and community health workers (CHWs). CHW, more prevalent in vulnerable areas, live and work in the territory and act as intermediaries between the community and health facilities. Thus, they understand what happens in the community (suffering the effects of UV) and in the health system. In December 2020, there were 257,000 CHWs in Brazil, covering 61% of the Brazilian population.
Objective
The objective of this study was to evaluate the effects of urban violence on CHW’s mental health and work process in Brazil’s northeastern region.
Methods
- This multisite study was conducted in four Brazil NE State Capitals: Fortaleza (Ceará), João Pessoa (Paraíba), Recife (Pernambuco) and Teresina (Piauí), and four inner cities within Ceará State: Crato, Juazeiro do Norte, Barbalha, and Sobral. The NE region is among the poorest in Brazil, with high levels of UV and FHS coverage.
- Questionnaires included socio-demographic information; occupational information; mental health (SRQ-20) [4]; and indicator of violence. Violence indicator had two components: 1) CHW’s knowledge (saw/heard) about violence in their territory, and 2) personal/family experience of violence (suffered). Their sum resulted in the general violence indicator.
- Structural Equation Modeling (SEM) was utilized, confirming the theoretical model of how violence interferes with PHC. To understand the changes that occurred between 2021 and 2023, considering differences between capitals and inner cities, longitudinal analyses (MANOVA) and Cochran’s Q were also performed. For these, matched databased generated by Propensity Score Matching (PSM) was utilized.
Results
A total of 1,944 CHWs participated in the research in 2021 and 1,915 in 2023. In 2021, CHWs’ mean age was 46.2 years and length of time living in the neighborhood was 29.9 years.
Main descriptive findings – 2021 vs 2023
Violence is a reality on CHW live/work. More than 75% of CHW perceived/felt violence in their territory at both time points (2021 and 2023), with a higher frequency in capitals than in inner cities. Violence affects their mental and physical health, as well as their ability to assist families in the territory.
Structural Equation Modeling (SEM)-Confirming theoretical model (2023 data)
- Violence in the territory (saw/heard and (suffered/occurred) affects CHW perception of violence and interferes with their ability to care for families in the community.
- CHW mental health relates to CHW violence perception and is influenced by the violence suffered by CHW.
Longitudinal analysis of violence indicators – CHW 2021 and 2023 paired sample (N=705)
- Violence knowledge (saw/heard) increase with time for both capital and inner cities.
- Violence suffered (suffered/occurred) by the CHWs increased in capitals with time while diminished in the inner cities (Local and Time interaction).
CHW socio-demographic information and Common Mental Health distress (SRQ-20) – descriptive and comparative data 2021 vs 2023
- The majority of CHW are female and non-white.
- The prevalence of mental distress is high (around 40%), and was higher during the covid-19 pandemic (2021).
CHWs’ perceptions of violence and indicators for Violence (Violence Index) – descriptive and comparative data 2021 vs 2023
- Violence is a reality on CHW live/work. More than 75% of CHW perceived/felt violence in their territory at both time points (2021 and 2023), with a higher frequency in capitals than in inner cities.
- Violence affects their mental and physical health, as well as their ability to assist families in the territory.
Final Considerations
- Urban violence remains a pervasive element of the work environment for Community Health Workers (CHWs), with approximately 75% reporting its presence, particularly in capital cities. Mental distress was also consistently high across both study periods, affecting nearly 40% of CHWs.
- CHWs identified community violence as a significant impediment to the performance of their professional duties. It adversely affected their mental and physical health and compromised their capacity to deliver adequate care to families. Perceptions of violence were shaped not only by direct victimization but also by indirect exposure and were significantly associated with psychological distress.
- The findings highlight the challenging and often precarious conditions under which CHWs operate and emphasize the intersecting vulnerabilities faced by both health professionals and the populations they serve.
References
1. Moser CON. Urban Violence and Insecurity: An Introductory Roadmap. Environ Urban. 2004;16: 3–16.
2. Violence and organized crime, the great challenges for development in Latin America and the Caribbean. World Bank Blogs.
3. Most Violent Cities in the World 2024. World Population Review.
4. Barreto do Carmo MB, Santos LMD, Feitosa CA, Fiaccone RL, Silva NB da, Santos DND, et al. Screening for common mental disorders using the SRQ-20 in Brazil: what are the alternative strategies for analysis? Rev Bras Psiquiatr Sao Paulo Braz 1999. 2018;40: 115–122.
5. Vieira-Meyer APGF, Morais APP, Santos HPGD, Yousafzai AK, Campelo ILB, Guimarães JMX. Violence in the neighborhood and mental health of community health workers in a Brazilian metropolis. Cad Saude Publica. 2023;38: e00022122.
6. Vieira-Meyer APGF, Morais APP, Campelo ILB, Guimarães JMX. Violence and vulnerability of the Community Health Worker in the territory: implications for tackling COVID-19. Cienc Saude Coletiva. 2021;26: 657–668.
7. Bellas HC, Jatobá A, Bulhões B, Koster I, Arcuri R, Burns C, et al. Effects of Urban Violence on Primary Healthcare: The Challenges of Community Health Workers in Performing House Calls in Dangerous Areas. J Community Health. 2019;44: 569–576
Acknowledgements
Takemi Program in International Health