Artigos

Conteúdo (article):

Work process of community health workers: Analysis of the influence of urban violence and Covid-19

Anya Pimentel Gomes Ferreira Vieira-Meyer
Fundação Oswaldo Cruz - Ceará (Fiocruz-Ceará), Eusébio, CE, Brazil
E-mail: anyavieira10@fiocruz.br
Orcid: http://orcid.org/0000-0003-4237-8995

Grayce Alencar Albuquerque
Universidade Regional do Cariri (URCA), Crato, CE, Brazil
E-mail: grayce.alencar@urca.br
Orcid: http://orcid.org/0000-0002-8726-0619

José Maria Ximenes Guimarães
Universidade Estadual do Ceará (UECE), Fortaleza, CE, Brazil.
E-mail: jm_ximenes@hotmail.com
Orcid: http://orcid.org/0000-0002-5682-6106

Regina Glaucia Lucena Aguiar Ferreira
Universidade Federal do Ceará (UFC), Fortaleza, CE, Brazil.
E-mail: reginalucenaa@ufc.br
Orcid: https://orcid.org/0000-0003-4225-7958

Andrea Silvia Walter de Aguiar
Universidade Federal do Ceará (UFC), Fortaleza, CE, Brazil.
E-mail: andrea.aguiar@ufc.br
Orcid: https://orcid.org/0000-0002-4316-9020

Alice Maria Correia Pequeno
Escola de Saúde Pública do Ceará (ESP-CE), Fortaleza, CE, Brazil.
E-mail: alicepequeno@gmail.com
Orcid: https://orcid.org/0000-0002-4248-1610

Ana Patrícia Pereira Morais
Universidade Estadual do Ceará (UECE), Fortaleza, CE, Brazil.
E-mail: anapatricia.morais@uece.br
Orcid: http://orcid.org/0000-0001-6188-7897

Franklin Delano Soares Forte
Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brazil.
E-mail: franklinufpb@gmail.com
Orcid: http://orcid.org/0000-0003-4237-0184

Sidney Feitoza Farias
Instituto Aggeu Magalhães – Fundação Oswaldo Cruz (IAM-Fiocruz), Recife, PE, Brazil.
E-mail: sidneyffarias@gmail.com
Orcid: http://orcid.org/0000-0002-3650-154X

Neiva Francenely Cunha Vieira
Universidade Federal do Ceará (UFC), Fortaleza, CE, Brazil.
E-mail: neivafrancenely@hotmail.com
Orcid: https://orcid.org/0000-0002-9622-2462

Fernando José Guedes da Silva Júnior
Universidade Federal do Piauí (UFPI), Teresina, PI, Brazil.
E-mail: fernandoguedes@ufpi.edu.br
Orcid: http://orcid.org/0000-0001-5731-632X

Aisha Khizar Yousafzai
School of Public Health, Harvard University, Boston, U.S.A
E-mail: ayousafzai@hsph.harvard.edu
Orcid: http://orcid.org/0000-0002-1592-8923

Abstract
In this multicenter, cross-sectional and quantitative study we evaluated the influence of urban violence and Covid-19 on the work process and team rapport of community health workers (CHWs) in eight municipalities of Northeastern Brazil. The collected information covered sociodemographics, work routines, exposure to violence, self-efficacy and coronavirus anxiety. A logistic regression was performed using as outcome variable the answer to the question: “Do you think your team work process changed during the pandemic?” The sample included 1,944 CHWs, of whom 56.60% stated that violence interfered in their work, and almost 75% reported adaptations in their work process to cope with Covid-19. During the sanitary emergency, team rapport was positively associated with the absence of such adaptations (OR=1.60; 95%CI=1.22-2.10) and with occupational exposure to violence (OR=2.73; 95%CI=1.72-4.34). Our results confirmed that urban violence and Covid-19 affected the work process of the CHWs. A better understanding of this dynamic can help design interventions to make primary health care more resilient and better prepared for future stressors.
Key words: Community health worker. Primary health care. Exposure to violence. Covid-19.

Introduction
As a social phenomenon, public health care is permeated by societal demands and objectives in which the concepts of health, disease and care are naturally intertwined.1
Oriented according to the tenets of the Family Health Strategy (FHS), the Brazilian Primary Health Care (PHC) network is a crucial component of the Unified Health System (SUS), arguably the country’s most important public health policy. The FHS model is a reorganization designed to ensure the provision of a wide scope of individual, collective and family health care services.2 The latter include comprehensive practices in addition to health promotion, prevention, protection, diagnosis, treatment, rehabilitation, harm reduction, palliative care and health surveillance delivered by multidisciplinary teams (each featuring a doctor, a nurse, a dentist, nursing technicians or assistants, oral health technicians or assistants, and community health workers) within the territory under their responsibility.3 PHC is therefore the preferred entry point to the SUS, covering the first level of care and coordinating health services towards greater effectiveness and improved health indicators.4
The FHS work process is aligned with a theoretical-practical framework that supports professional exercise and allows to organize and provide multidisciplinary care, not just individually but collectively and collaboratively, with a view to strengthening the institutional infrastructure and meeting the health needs of the population through ever-developing models of health care compliant with the tenets of the SUS.5,1
The role of the community health workers (CHWs) within the FHS allows them to interact with users in their local environment and establish relationships and flows between different parties, making the CHWs a highly effective link between the community and public health care services. Their work consists primarily of home visits and individual and collective educational activities such as health prevention and promotion, in addition to expanding the community’s access to treatment in general.6,7
The CHWs’ interactions with individuals and families, especially for those who live and work in the same neighborhood, allow them to gain a broader understanding of the social reality, which in the study area is frequently afflicted by violence and socioeconomic vulnerability, compromising the health and quality of life of the population and of the CHWs themselves.6,8 Thus, in their daily work CHWs are faced with the challenge of coping with poverty, violence, lack of basic sanitation and high disease prevalence, among other socio-environmental determinants.5,9 These issues are naturally exacerbated in crisis scenarios, such as sanitary emergencies.
The presence of urban violence—a social phenomenon expressed in interpersonal relationships outside the domestic space between two or more people who may or may not know each other—shifts the perception of continuity of daily routines and personal safety.10 Several Brazilian and international studies have pointed to violence as a significant risk factor for health professionals, such as CHWs interacting directly with residents in the territory.6,10,11
The level of urban violence reportedly rose during the Covid-19 pandemic, especially in vulnerable communities in large cities,6 increasing the exposure of CHWs to episodes of violence, either as witnesses, victims or impromptu peacemakers, posing a severe risk to their physical safety.10 Moreover, health professionals are subject to burnout due to the scarcity of physical and human resources at their facility, work and health system overload,12 stressful incidents, and lack of adequate training.
It should be noted that many health systems, even well-structured ones, collapsed during the Covid-19 pandemic.13 Many national governments ordered the canceling of non-Covid-19-related health care services and implemented strict lockdown measures,14,15 leading to the interruption of essential health care services in at least 117 countries.16 In addition to the impact of the disease itself, the sanitary emergency had acute secondary adverse effects on health systems and populations.17
The present study is intended as a contribution to the discussion on the PHC work process in Northeast Brazilian territories stricken by urban violence during the recent sanitary emergency. It also points to how the pandemic may have modulated the impact of urban violence on the CHWs’ work process and quality of life.

Methods
Study design, sampling and participants
This was a multicenter, cross-sectional, quantitative study conducted with CHWs from eight municipalities in Northeastern Brazil, of which four were state capitals (Fortaleza/CE, Recife/PE, João Pessoa/PB, Teresina/PI) and four were major inland cities in Ceará (Sobral, Juazeiro do Norte, Barbalha, Crato). The state capitals were representative of a wide spectrum of population size, FHS and CHW coverage, morbidity and mortality indicators associated with Covid-19, and indicators of urban violence. The inland municipalities were selected based on the same criteria, in addition to the requirement of being far removed from the state capital. It is worth noting that Fortaleza, Recife and Teresina are among the 50 most violent capitals in the world.18 As for the inland municipalities, Crato, Juazeiro do Norte and Sobral are among the most violent in the state of Ceará.19
According to the e-Manager System, the total number of CHWs in the eight municipalities during the study period was 7,909 (2020). A simple random sample calculation was performed for each municipality, with a sample error margin of 5%, 95% confidence level, and homogeneous distribution (80/20) of the population, yielding a final sample of 1,944 CHWs on active duty. CHWs on leave or vacation were excluded.

Data sampling
To standardize the data collection across the municipalities, a team of collectors were trained for 12 hours by professionals with expertise in the area. The training covered theoretical aspects of the research, quantitative data collection, biosafety protocols (ANVISA directive #04/2020),20 ethical aspects of research involving human beings, data collection instruments, and the definition of roles (collector, field coordinator, supervisor), using a role play method. Finally, a data collection schedule was prepared.
Authorization was obtained from the municipal managers prior to the data collection, which covered the period from April to August 2021. This allowed the collectors to schedule the most convenient day and time for the administration of the questionnaire. The collectors explained the purpose of the study to the participating CHWs, after which the respondents gave their informed written consent and completed the questionnaire individually in a separate room at the facility, with the collector available on the premises in case questions arose.
The instrument covered sociodemographic and professional variables and questions on the extent to which the CHWs perceived violence in the territory and the lockdowns to have impacted their work process. In addition, general self-efficacy, coronavirus anxiety and the level exposure to violence were evaluated.

Scales, indicators and variables
General self-efficacy and coronavirus anxiety were quantified with the general self-efficacy scale (GSE)21 and the coronavirus anxiety scale (CAS),22 respectively, with higher scores indicating greater self-efficacy or anxiety. The scales have a high level of reliability and validity (90% sensitivity and 85% specificity), making them efficient and valid tools in research and clinical practice. Scores range from 0 to 1 (GSE) and from 1 to 4 (CAS).
Exposure to violence was measured using a synthetic indicator developed for this study. The indicator combined two components: direct victimization and awareness of episodes of violence in the territory. Eight types of violence were considered: physical aggression, hold-up, stabbing, non-fatal shooting, fatal shooting, rape, gang violence, and others. The CHWs’ responses fell into two categories: 1) Awareness (heard about or witnessed violence) and 2) Victimization (suffered violence personally), each related to the context of the violence committed. A score between 0 (did not hear about or did not suffer violence) and 1 (heard about or suffered violence) was assigned. For example, CHWs reporting to have witnessed all the forms of violence listed above would have a score of 1.0 on the awareness scale. CHWs (or a close family member) reporting to have personally suffered half the forms of violence listed above would have a score of 0.5 on the victimization scale.
As mentioned above, the instrument also collected sociodemographic and professional variables and information on violence in the territory and the work process adopted during the lockdowns (Tables 1 and 2).

Data analysis
The collected data were analyzed with the software R (r-project.org, v. 4.2.3). In order to describe the sample, we estimated the absolute and relative frequencies of the nominal variables and calculated means and standard deviations for the continuous variables. The outcome variable was the answer to the yes/no question: “Do you think your team work process changed during the pandemic?”. We then performed a logistic regression analysis using as criterion the answer: “Improved team rapport with regard to integrated actions”. The regression analysis disregarded missing answers, reducing the sample from 1,944 to 1,935 CHWs.

Ethical aspects
The study protocol was filed under #4.587.955 and approved by the Research Ethics Committee of the Ceará State University (UECE). All participating CHWs gave their informed written consent.

Results
The 1,944 respondents were aged 46.21 years (SD=8.57) on average, and 82.3% were women. Approximately 85.0% worked and resided in the same neighborhood. The average time of employment with the FHS was 16.25 years (SD=6.81), while the time of work at the current PHC facility was 13.8 years (SD=6.31) (Table 1).
The CHWs answered questions about violence and Covid-19 in their daily work and about how these factors influenced the work process. Table 2 shows the effect of urban violence and the pandemic on variables related to the CHWs’ work in the territory, indicating the negative percentage impact of violence on family care, community activities and sick leave. Most CHWs (76.6%) confirmed the presence of violence in the neighborhoods served, and 43.5% had themselves suffered violence on the job. Likewise, violence interfered in the CHWs’ work (56.6%), at times leading to the suspension of scheduled FHS tasks (24.4%), including home visits (28.7%).
Almost 75% of the CHWs reported that during this period the work process was adapted to care for persons diagnosed with Covid-19. More than 77% were frontline workers, with a 47.5% increase in working hours, although only 16.2% reported to receiving training for this new task. For almost 80%, the team work process changed in the period, with 40% stating that team rapport improved with regard to integrated actions. The GSE and CAS scores were high (Table 2).
Table 3 shows the results of the variables included in the logistic regression model. The following variables remained associated with better team rapport during the pandemic: Not having adapted the work process to serve persons diagnosed with Covid-19 (OR=1.60; 95%CI=1.22-2.10) and being exposed to violence (OR=2.73; 95%CI=1.72-4.34). In contrast, greater self-efficacy (OR=0.78; 95%CI=0.63-0.98), not having received Covid-19-related training (OR=0.50; 95%CI=0.36-0.69), and inland locations (OR=0.36; 95%CI=0.28-0.47) were associated with no improvement in team rapport.
Greater GSE scores increased the likelihood of answering in the negative (OR=0.78), suggesting the CHWs did not perceive an improvement in team rapport. High scores of violence exposure (OR=2.73) were also associated with the perception of not improvement on team rapport.



Discussion
The new guidelines and procedures introduced in response to the sanitary emergency affected the CHWs’ workload. Our study shows that the work process was impacted by both the pandemic and urban violence. We also found that having received Covid-19-related training increased the likelihood of CHWs perceiving the lack of improvement in team rapport with regard to integrated actions, suggesting that training contributed to a more critical or qualified perception of team dynamics and a more acute perception of existing shortcomings. A similar trend was observed in inland municipalities where serious extant weaknesses in the public health care system were clearly exacerbated by the sanitary emergency.23,24,6
High GSE scores were correlated with the lack of perceived improvement in team rapport with regard to integrated actions, but high CAS scores were not associated with changes in team work process. Working during the lockdowns exposed the CHWs to several stressors, including lack of knowledge about the disease, risk of contamination, and work overload, potentially leading to the development of high levels of anxiety.12,25 This anxiety may have influenced their perception of improvement in team dynamics, although this could not be confirmed.
Interestingly, exposure to violence resulted in the perception of improved team rapport with regard to integrated actions. It would appear that exposure to violence spurred a feeling of unity and solidarity among team members working in settings of great social vulnerability. On the other hand, violence had a negative impact on family monitoring, community-based activities, and sick leave frequency. Thus, even if the rapport is better, violence has an adverse effect on team performance in the territory.6,8
In addition to the sanitary emergency, urban violence has a direct effect on the provision of PHC, especially when health services are rendered in areas of rampant socioeconomic vulnerability and CHWs need to interact with users in settings posing a considerable risk to their physical safety.10,6
Violent criminal behavior, which has historically been more prevalent in settings of social vulnerability, likely intensified in the period of lockdown restrictions and unemployent, casting the CHWs in the role of potential victims in the territories.6,8 A study from a city in Ceará involving 364 CHWs revealed that CHWs are heavily exposed to violence in their daily community work (>80%), as either victims or witnesses, with impacts on the health care system which are fully understood. The prevalence of perceived urban/community violence (hold-up, non-fatal shooting, fatal shooting and gang violence) increased between 2019 and 2021,26 but Brazilian CHWs are not the only health care workers at risk of violence on the job. Reports on CHWs witnessing or suffering violence in the workplace have been published in several other countries,27 including Spain28 and Bosnia and Herzegovina.29
Despite the high rates of violence observed in our study, the respondents reported an improvement in PHC team rapport and work process, perhaps due to a greater engagement of the team in addressing the problem. Some CHWs proactively sought additional knowledge and training and encouraged intersectoral actions and dialogue across the network, all of which may have contributed to mitigating the impact of violence.30
The teams were arguably strengthened internally by their joint efforts to tackle the problem of urban violence. Meetings held with team members and/or community leaders to build strategies and share experiences and lessons based on different outlooks and backgrounds helped reduce stress and anguish induced by the threat of violence in the territory.31
The fact that higher GSE scores were negatively associated with improvement in team rapport suggests a more critical stance in relation to the work process of others, especially on part of the most self-efficacious CHWs. It is reasonable to assume that CHWs with a strong perception of self-efficacy experience less stress in situations that demand greater personal effort, and are more motivated and persistent when pursuing a goal. This is achieved by motivational mechanisms (reflected in effort and perseverance) or coping mechanisms, or both.25,32-34 However, highly self-efficacious individuals tend to establish more ambitious goals and to commit accordingly.35 Likewise, individuals with greater self-confidence tend to evaluate their own work output more positively and to see themselves as competent professionals.36
The workload of health care professionals increased during the Covid-19 pandemic,37 associated with changes in working conditions and procedures, such as prophylactic measures to prevent viral spread, protective clothing, decontamination procedures, isolation of private areas, care of persons diagnosed with Covid-19, and the provision of information and emotional support to patients and families.37,38 However, as revealed by the present study, at health care facilities that did not undergo adaptations to care for persons diagnosed with Covid-19, the CHWs perceived an improvement in team rapport with regard to integrated actions. This may seem counter-intuitive, but it is conceivable that the absence of major technical adaptations eased the burden, allowing the team to give more attention to human resources.
The existence of disparities in the health care workforce during the sanitary emergency is noteworthy.39,24 In Brazil, different categories of health professionals were affected in different ways by the pandemic. Professionals who were already overstretched, such as many CHWs, were the most affected during the crisis. In other words, during the lockdowns changes in PHC work process and procedures did much to upset the fragile balance between the health professions. It is also recognized that such disparities may be related to the lack of coordinated action on the part of the federal government, in addition to the denialism that existed in various forms in the Brazilian states.24 Heterogeneous effects of the pandemic on PHC work process and occupational health have been described from around the world.40,41 For example, in the US, public health professionals with primarily academic functions were prone to suffer from burnout syndrome,42 while a study conducted in Singapore with doctors, nurses, health assistants, administrative and support staff found burnout syndrome to be more prevalent in health professionals working in high-risk areas outside their usual workplace.43 According to the authors, all levels of the health care workforce were susceptible to burnout during the sanitary emergency. Modifiable factors in the workplace included adequate training, avoiding long shifts (8 hours or more), and promoting safe work environments.
Working directly—and in many cases living—in the communities served gives CHWs first-hand knowledge of the territories. CHWs witness and deal with situations of vulnerability on a daily basis, and some face challenges of deprivation and health risks, like other users of the health care system.8,24 Their proximity to the population lays constant social and work demands on them, not uncommonly outside working hours.2,10,44 This increases their workload and may compromise the effectiveness of their work and team dynamics, highlighting the need for monitoring and frequent training.
All health care professionals should be given biosafety training in how to prevent Covid-19 transmission, including in non-clinical settings. Institutions should always ensure that frontline health care workers have access to information, adequate training, personal protective equipment and resources, and emotional support.2,14,17,45
In a study conducted between June and October 2020 with health care professionals from 19 Latin American countries, 77% reported having received some form of institutional Covid-19-related training and tended to display higher levels of knowledge.46 It may be assumed that higher levels of knowledge favor health care performance, enabling professionals to critically identify obstacles to efficient health care provision and weaknesses in the workplace. Our findings support this notion since the CHWs who had received training had the most acute perception of flaws in work process and team rapport during the crisis. In fact, the better qualified the workers, the more likely they are to avoid mistakes and the more promptly they will be able to detect and mitigate deficiencies in institutional spaces.47
The quality of professional training can determine the perception of improvement in team work process. Institutional support, training and ongoing education for CHWs during the pandemic proved to be insufficient, resulting in their withdraw from the territories. Moreover, the lack of clear guidelines based on attributes inherent to the work of the CHWs made it impossible to organize and strengthen PHC to respond adequately to the needs arising from health crises.48,24 Ideally, the CHWs’ training should be informed by a less technical and more problematizing outlook, based on emancipatory, ethical, and political principles.49 Training has the potential to directly interfere in the FHS work process and team rapport. This may explain the association observed in the present study between training (not necessarily of high quality) and the perception of insufficient team rapport.
Our study has limitations inherent to cross-sectional research employing self-report instruments, including the possibility of interference of confounding factors. Nevertheless, we believe our results add significantly to current knowledge of the topic and provide relevant theoretical subsidies for PHC professionals, especially CHWs, looking to understand the dynamics of community-based health care. Providing safer work environments, adapting services to new stressors and providing adequate training to health professionals (especially CHWs) improves team work process and, consequently, the provision of care to the population.

Conclusion
During the recent pandemic, new measures and routines significantly affected the workload of PHC workers. Our study shows that the work process of CHWs was negatively impacted by the sanitary emergency and by urban violence. Having received Covid-19-related training, the adaptation of procedures and facilities to care for persons diagnosed with Covid-19, the location of the municipality (state capital vs. inland municipality), exposure to violence, and self-efficacy were found to influence the CHWs’ perception of improvement in team rapport with regard to integrated actions. An understanding of these relationships can help develop interventions making FHS teams more resilient and better prepared for future stressors.

References
1. Santos DS, Mishima SM, Merhy EE. Processo de trabalho na Estratégia de Saúde da Família: potencialidades da subjetividade do cuidado para reconfiguração do modelo de atenção. Cien Saúde Colet. 2018; 23(3): 861-870. https://doi.org/10.1590/1413-81232018233.03102016
2. Maciel FBM, Santos HLPC, Carneiro RAS, Souza EA, Prado NMBL, Teixeira CFS. Agente comunitário de saúde: reflexões sobre o processo de trabalho em saúde em tempos de pandemia de COVID-19. Cien Saúde Colet. 2020;25(suppl. 2): 4185-4195. https://doi.org/10.1590/1413-812320202510.2.28102020
3. Ministério da Saúde (BR). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set.
4. Lavras C. Atenção primária à saúde e a organização de redes regionais de atenção à saúde no Brasil. Saude soc. 2011; 20(4): 867-874. https://doi.org/10.1590/S0104-12902011000400005
5. Lima JR, Borges LM. Desafios do trabalho dos agentes comunitários frente à comunidade e às equipes de saúde. Psicologia em Ênfase. 2022; 3: 75-87.
6. Vieira-Meyer APGF, Morais APP, Campelo ILB, Guimarães JMX. Violência e vulnerabilidade no território do agente comunitário de saúde: implicações no enfrentamento da COVID-19. Cien Saude Colet. 2021;26(2):657-668. https://doi.org/10.1590/1413-81232021262.29922020
7. Morosini MV, Fonseca AF. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saúde Debate. 2018; 42(num especial): 261-274. https://doi.org/10.1590/0103-11042018S117
8. Vieira-Meyer APGF, Morais APP, Santos HPG, Yousafzai AK, Campelo ILB, Guimarães JMX. Violence in the neighborhood and mental health of community health workers in a Brazilian metropolis. Cad Saúde Pública. 2022; 38(12):e00022122. https://doi.org/10.1590/0102-311XEN022122
9. Lima CCM, Fernandes TF, Caldeira AP. Contexto de trabalho e custo humano no trabalho para agentes comunitários de saúde. Cien Saude colet. 2022;27(8):3181–92. https://doi.org/10.1590/1413-81232022278.19192021
10. Almeida JF, Peres MFT, Fonseca TL. O território e as implicações da violência urbana no processo de trabalho dos agentes comunitários de saúde em uma unidade básica. Saude soc. 2019;28(1):207–21. https://doi.org/10.1590/S0104-12902019170543
11. Almeida JF, Peres MFT, Lima TF. A violência no território e a construção de vínculos entre os agentes comunitários de saúde e os usuários em um serviço de atenção primária. Rev. Epos. 2016; 7(1):92-109 .
12. Gusso AK, Lourenço RG. Violência contra profissionais de saúde durante a pandemia do Coronavírus da Síndrome Respiratória Aguda Grave 2. Enferm Foco. 2022;13:e-202230. https://doi.org/10.21675/2357-707X.2022.v13.e-202230
13. Legido-Quigley H, Asgari N, Teo YY, Leung GM, Oshitani H, Fukuda K, et al. Are high-performing health systems resilient against the Covid-19 epidemic? The Lancet. 2020; 395(10227); 848-850. https://doi.org/10.1016/S0140-6736(20)30551-1
14. Aquino EML, Silveira IH, Pescarini Jm, Aquino R, Souza-Filho JA, Rocha AS, et al. Medidas de distanciamento social no controle da pandemia de COVID-19: potenciais impactos e desafios no Brasil. Cien Saude Colet. 2020; 25(1): 2423-2446. https://doi.org/10.1590/1413-81232020256.1.10502020
15. Arsenault C, Gage A, Kim MK, Kapoor NR, Akweongo P, Amponsah F, et al. COVID-19 and resilience of healthcare systems in ten countries. Nat Med, 2022; 28: 1314–1324. https://doi.org/10.1038/s41591-022-01750-1
16. World Health Organization. Third round of the global pulse survey on continuity of essential health services during the COVID-19 pandemic: November-December 2021. Interim Report. Geneva: WHO, 2022. 54 p.
17. Robertson LJ, Maposa I, Somaroo H, Johnson O. Mental health of healthcare workers during the COVID-19 outbreak: A rapid scoping review to inform provincial guidelines in South Africa. S Afr Med J. 2020;110(10):1010-1019. https://doi.org/10.7196/SAMJ.2020.v110i10.15022
18. Seguridad, Justicia y Paz. Las 50 ciudades más violentas del mundo 2018 [Internet]. México; 2021 [acessado 2023 Jul 10]. Disponível em: https://geoenlace.net/seguridadjusticiaypaz/webpage/archivos.php

19. Brasil. Instituto de Pesquisa Econômica Aplicada (IPEA). Atlas da violência: Retratos dos municípios brasileiros - 2019 [Internet]. Rio de Janeiro: IPEA; 2019 [acessado 2023 Jul 12]. Disponível em: https://repositorio.ipea.gov.br/bitstream/11058/9489/1/Atlas_da_violencia_2019_municipios.pdf
20. Agência Nacional de Vigilância Sanitária (BR). Nota técnica GVIMS/GGTES/ANVISA nº 04/2020. Orientações para serviços de saúde: medidas de prevenção e controle que devem ser adotadas durante a assistência aos casos suspeitos ou confirmados de infecção pelo novo coronavírus (SARS-CoV-2). https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/servicosdesaude/notas-tecnicas/nota-tecnica-gvims_ggtes_anvisa-04_2020-25-02-para-o-site.pdf (accessed on 12/Set/2023).
21. Balsan LAG, Carneiro LL, Bastos AVB, Costa VMF. Adaptação e validação da Nova Escala Geral de Autoeficácia. Aval. Psicol. 2020;19(4): 409-419. http://dx.doi.org/10.15689/ap.2020.1904.16654.07
22. Lee SA. Coronavirus Anxiety Scale: a brief mental health screener for COVID-19 related anxiety. Death Studies. 2020;44(7):393-401. https://doi.org/10.1080/07481187.2020.1748481
23. Silva JB, Muniz AMV. Pandemia do Coronavírus no Brasil: impactos no território cearense. Espaço e Economia. 2020; 17. https://doi.org/10.4000/espacoeconomia.10501
24. Vieira-Meyer APGF, Forte FDS, Guimarães JMX, Farias SF, Oliveira ALS, Dias MSA, et al. Community health workers perspective on the COVID-19 impact on primary health care in Northeastern Brazil. Cad Saúde Pública [Internet]. 2023;39(7):e00007223. https://doi.org/10.1590/0102-311XEN007223
25. Vieira-Meyer APGF, Farias SF, Forte FDS, Costa MS, Guimarães JMX, Morais APP, et al. Saúde mental de agentes comunitários de saúde no contexto da COVID-19. Cienc. Saúde Coletiva. 2023;28(8): 2363–2376. https://doi.org/10.1590/1413-81232023288.06462023
26. Vieira-Meyer APGF, Ferreira RGLA, Albuquerque GA, Guimarães JMX, Morais APP, Meyer CHC, et al. Gender and Violence in the Daily Routine of Community Health Workers in Fortaleza, Brazil. J Community Health. 2023; 48: 810–818. https://doi.org/10.1007/s10900-023-01221-9.
27. Closser S, Sultan M, Tikkanen R, Singh S, Majidulla A, Maes K, et al. Breaking the silence on gendered harassment and assault of community health workers: an analysis of ethnographic studies. BMJ Glob Health. 2023 May;8(5):e011749. https://doi.org/10.1136/bmjgh-2023-011749
28. Gascon S, Leiter MP, Andrés E, Santed MA, Pereira JP, Cunha MJ, et al. The role of aggressions suffered by healthcare workers as predictors of burnout. J Clin Nurs 2013; 22:3235. https://doi.10.1111/j.1365-2702.2012.04255.x
29. Jatic Z, Erkocevic H, Trifunovic N, Tatarevic E, Keco A, Sporisevic L, Hasanovic E. Frequency and Forms of Workplace Violence in Primary Health Care. Med Arch. 2019;73(1):6-10. https:// doi.10.5455/medarh.2019.73.6-10
30. Santos ASF, Pereira MCSA, Costa LNF, Castro EA, Ribeiro DAL, Rabelo AF, et al. Estratégias de manejo da violência por profissionais da atenção primária à saúde. REAS. 2023; 23(7): 1-9. https://doi.org/10.25248/REAS.e13144.2023
31. Araújo Neto DX, Silva AR, Dias ACS, Nunes JC, Sousa Júnior OR, Oliveira PC, et al. A violência como um problema de saúde e seu enfrentamento na Atenção Primária: uma revisão narrativa. REAC. 2021; 35:e7918. https://doi.org/10.25248/reac.e7918.2021
32. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychological Review. 1977; 84:191-215. https://doi.org/10.1037/0033-295X.84.2.191
33. Bandura A. Regulation of cognitive processes through perceived self-efficacy. Developmental Psychology. 1989; 25(5): 729-735. https://doi.org/10.1037/0012-1649.25.5.729
34. Blostein DL. The role of goal instability and career self-efficacy in the career exploration process. Journal of Vocational Behavior. 1989; 35(2):194-203. https://doi.org/10.1016/0001-8791(89)90040-7
35. Cherniss C. The role of professsional self-efficacy in the etiology and amelioration of burnout. In: Schaufeli WB, Maslach C, Marek T. editores. Professional burnout: recent developments in theory and research. 1. Ed. Washington: Taylor & Francis. 1993. p. 135-149.
36. Barreira DD, Nakamura AP. Resiliência e a auto-eficácia percebida: articulação entre conceitos. Aletheia. 2006; 23: 75-80.
37. Yiğit I, Özkan F. Anxiety and Work Overload Perception Levels of Primary Healthcare Professionals During the COVID-19 Pandemic. Work. 2023: 1-10. https://doi.org/10.3233/WOR-220495
37. Lucchini A, Elli S, De Felippis C, Greco C, Mulas A, Ricucci P, et al. The evaluation of nursing workload within an Italian ECMO Centre: a retrospective observational study. Intensive Crit. Care Nurs. 2019;55:102749. https://doi.org/10.1016/j.iccn.2019.07.008
38. Reper P, Bombart MA, Leonard I, Payen B, Darquennes O, Labrique S. Nursing activities score is increased in COVID-19 patients. Intensive Crit. Care Nurs. 2020; 60: 102891. https://doi.org/10.1016/j.iccn.2020.102891
39. Fernandez M, Lotta G, Corrêa M. Challenges for Primary Health Care in Brazil: an analysis on the labor of community health workers during a COVID-19 pandemic. Cien Saude Colet. 2021; 25(Supl.2):4099-4120. https://doi.org/10.1590/1981-7746-sol00321
40. Aulanko I, Sanmark E, Oksanen L, Oksanen S, Lahdentausta L, Kivimäki A, et al. Working conditions during the COVID-19 pandemic in primary and tertiary healthcare: a comparative cross-sectional study. Int J Occup Med Environ Health. 2023; 36(1):139-150. https://doi.10.13075/ijomeh.1896.01944
41. Skagerström J, Fernemark H, Nilsen P, Seing I, Hårdstedt M, Karlsson E, et al. Challenges of primary health care leadership during the COVID-19 pandemic in Sweden: a qualitative study of managers\' experiences. Leadersh Health Serv (Bradf Engl). 2023(ahead-of-print):389–401. https://doi.org/10.1108/LHS-08-2022-0089
42. Stone KW, Kintziger KW, Jagger MA, Horney JA. Public Health Workforce Burnout in the COVID-19 Response in the U.S. Int J Environ Res Public Health. 2021;18(8):4369. https://doi.org/10.3390/ijerph18084369
43. Tan BYQ, Kanneganti A, Lim LJH, Tan M, Chua YX, Tan L, et al. Burnout and Associated Factors Among Health Care Workers in Singapore During the COVID-19 Pandemic. J Am Med Dir Assoc. 2020;21(12):1751-1758.e5. https://doi.org/10.1016/j.jamda.2020.09.035
44. Martines WRV, Chaves EC. Vulnerabilidade e sofrimento no trabalho do agente comunitário de saúde no Programa de Saúde da Família. Rev. esc. enferm. USP. 2007; 41 (3): 426-433. https://doi.org/10.1590/S0080-62342007000300012
45. Zhang M, Zhou M, Tang F, Wang Y, Nie H, Zhang L, et al. Knowledge, attitude, and practice regarding COVID-19 among healthcare workers in Henan, China. J Hosp Infect. 2020;105(2):183-187. https://doi.org/10.1016/j.jhin.2020.04.012
46. Sousa MLA, Shimizu IS, Patino CM, Torres-Duque CA, Zabert I, Zabert GE, et al. COVID-19 knowledge, attitudes, and practices among health care workers in Latin America. J Bras Pneumol. 2022;48(5):e20220018 https://doi.org/10.36416/1806-3756/e20220018
47. Ministério do Desenvolvimento Social e Combate à Fome (BR). SUAS: Configurando os Eixos de Mudança. 1. ed. Brasília: MDS, 2008, vol. 1, 136 p.
48. França CJ, Nunes CA, Vilasbôas ALQ, Aleluia ÍRS, Aquino R, Nunes FGS et al. Características do trabalho do agente comunitário de saúde na pandemia de COVID-19 em municípios do Nordeste brasileiro. Cien Saude Colet. 2023; 28(5), 1399–1412. https://doi.org/10.1590/1413-81232023285.18422022
49. Melo MB, Quintão AF, Carmo RF. O Programa de Qualificação e Desenvolvimento do Agente Comunitário de Saúde na perspectiva dos diversos sujeitos envolvidos na atenção primária em saúde. Saude soc. 2015; 24 (1); 86-99. https://doi.org/10.1590/S0104-12902015000100007.