Journal of Community Health (2019) 44:569–576 https://doi.org/10.1007/s10900-019-00657-2 ORIGINAL PAPER Efects of Urban Violence on Primary Healthcare: The Challenges of Community Health Workers in Performing House Calls in Dangerous Areas Hugo Cesar Bellas1 · Alessandro Jatobá1 · Bárbara Bulhões2 · Isabella Koster3 · Rodrigo Arcuri4 · Catherine Burns5 · Kelly Grindrod5 · Paulo Victor R. de Carvalho6 Published online: 4 April 2019 © Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Community health workers in developing countries usually perform house calls in degraded and violent territories. Thus, in this paper we study the efects of urban violence in the performance of CHWs in poorly developed territories, in order to understand the challenges of delivering care to dangerous communities in developing countries. We conducted telephone surveys for 5 months in 2017, within a systematic sample of 2.000 CHWs based on clinics distributed along the health regions of the city of Rio de Janeiro, Brazil. We completed 766 interviews, approximately 40% of the sample, 86% man and 14% women. Most participants are 30 to 39 years old (35%), followed by 27% of 40 to 49 years old participants. As CHWs work on the sharp end of the healthcare system, responsible for outreaching, community education, counseling, and social support, our study presents contributions to government and management levels on working conditions inside communities, constraints in assistance, and difculties in implementing primary care policies. Keywords Community health workers · Primary health care · House calls · Exposure to violence Introduction inequality, and community health [3–5]. As defned by this document, “primary health care” involves, in addition to the The Declaration of Alma-Ata [1, 2] is a milestone for health sector, all aspects of national and community devel- implementation and institutionalization of the role of the opment. This is a more expansive defnition than the term Community Health Worker (CHW) in most countries, pro- often encompasses. In fact, the Alma-Ata Declaration states posing to expand what it termed “primary health care” to that primary health care “relies, at local and referral levels, vulnerable communities and to balance the triad of poverty, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially * Alessandro Jatobá and technically to work as a health team and to respond to [email protected] the expressed health needs of the community [2].” 1 Centro de Estudos Estratégicos, Fundação Oswaldo Cruz – CHWs have been recognized as key agents in expanding FIOCRUZ, Rio de Janeiro, RJ, Brazil primary care throughout the world, particularly in economi- 2 Instituto de Medicina Social, Universidade do Estado do Rio cally disadvantaged nations [6]. Currently, there are more de Janeiro - UERJ, Rio de Janeiro, RJ, Brazil than 5 million CHWs active in more than 180 countries. 3 Escola Nacional de Saúde Pública Sergio Arouca - ENSP, Although their job descriptions vary, common characteris- Fundação Oswaldo Cruz - FIOCRUZ, Rio de Janeiro, RJ, tics of their work involve activities outside of health facili- Brazil ties, engaging directly with people in their homes, neigh- 4 Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, borhoods, communities, and other nonclinical spaces [7]. Brazil However, as noted by Singh and Sullivan [6], the deploy- 5 University of Waterloo, Waterloo, ON, Canada ment of CHWs must be “evidence-based, community 6 Instituto de Engenharia Nuclear - IEN, Comissão Nacional responsive, and context specifc”. de Energia Nuclear, CNEN, Rio de Janeiro, RJ, Brazil Vol.:(0123456789)1 3 570 Journal of Community Health (2019) 44:569–576 Of concern is the deployment of CHWs in settings where the workforce itself—thus hampering their ability to perform high crime rates afect quality of life [8–10]. Low-income their role within the health system [22]. Furthermore, there communities in “third-world” countries are quite often also is some uncertainty concerning their actual role within afected by urban violence, typically as a result of criminal that health system, given their low wages and limited train- activity such as drug trafcking, gunfre, robberies, etc. [11, ing [23]. A similar scenario exists in developing countries 12]. These communities commonly experience signifcant such as South Africa, India, and Brazil [24–26]. social marginalization. Thus, despite the good intentions With these issues in mind, the Declaration of Alma-Ata behind programs that extend social services into these neigh- defned the delivery of what was termed “primary health borhoods through home visits and other site-based services, care.” This declaration served as an early basis for the devel- doing so also exposes CHWs (and, secondarily, their vehi- opment, within the Western hemisphere (e.g., Brazil, Gua- cles, computers, etc.) to dangerous conditions [13–15]. temala, Nicaragua, Honduras, Peru, and other nations), of In this study, we explore the kinds of services provided large-scale CHW programs in the 1970s and 1980s. In Bra- by CHWs during house calls in poorly developed areas, in zil, the role of the CHW was created in June 1991 through order to better understand the efects of urban violence on implementation of the Community Health Workers’ Pro- their working conditions. We believe this study contributes gram by the Brazilian Ministry of Health. This initiative to the development of best practices, as can be informed by established that CHWs should be recruited from within the a better comprehension of contending with potential danger communities they would serve. In so doing, the aim was while delivering neighborhood-based social assistance. This to promote a positive impact on quality of life and health work can support policymakers and local administrations in education, with a focus on maternal and childhood health developing policies geared toward improving social services and acting as a link between people’s health care needs and in these regions. the improvement of living conditions in vulnerable and poor We conducted structured telephone surveys with 766 communities [27, 28]. CHWs, sampled representatively from those districts in Rio In 1994, the Community Health Workers Program was de Janeiro, Brazil, where urban violence and crime rate indi- reformulated and integrated into the Family Healthcare cators have consistently been quite high over the past few Programme. In 1996, this became the Brazilian Family decades. These are districts that have become increasingly Healthcare Strategy. In 2006, the Family Healthcare Strat- difcult for authorities to manage in terms of law enforce- egy served as the basis for the Brazilian Primary Health ment [16–18]. Care National Policy [29]. This policy adds new assignments This article is divided into six sections. Following this to CHWs’ function (e.g., following up on appointments for introduction, we provide some contextualization on the patients with chronic conditions such as diabetes and hyper- role of CHWs. In “Methods”, we present our methods. In tension; control of infectious diseases such as tuberculosis “Results and Discussion” we show our results and discuss and Hansen’s Disease; and actions for health education and them. Finally, in “Conclusion”, we present our conclusions. health promotion). It is important to note that, in Brazil, the profession of CHW was formally created only as of 2002. Minimum The Role of Community Health Workers requirements for entering the profession are: (a) an elemen- tary school education level; (b) residence established within Despite the difculties in formulating a common understand- the community served; and (c) completion of the basic quali- ing of CHWs’ role across quite diferent realities around fcation course for CHWs. The CHW’s weekly schedule, per the world, it is possible to identify common aspects of their regulations, should comprise a maximum of 40 h; as well, practices: (a) their status as members of the communi- recruitment should be undertaken directly by municipali- ties where they work and thus strong identity ties to those ties. In January 2018, a new policy was published increasing whom they assist; (b) conducting interventions in the areas the set of assignments as well as the minimum admission of health education, disease prevention, and data collection; requirements for CHWs. and (c) promoting existing health care services within vul- In Brazil, CHWs’ salaries are close to the Brazilian mini- nerable, low-income populations [3, 19–21]. mum wage. In addition, CHWs are entitled by law to a haz- In Canada and the US, CHWs are responsible for pro- ard exposure compensation equivalent to an additional 30% moting equity in access to healthcare, focusing on vulner- increase in salary. Still, their total wage remains below that able populations such as low-income, elderly, migrants, and commonly paid to CHWs in other developing countries. In indigenous communities. However, although their identity addition, CHWs in Brazil face signifcantly adverse working ties with their communities help understanding, connecting, conditions [14, 30, 31]. and committing to health promotion in contexts of socio- These various policy reformulations illustrate the atten- economic deprivation, this also entails marginalization of tion the Brazilian legislature has given in recent times to 1 3 Journal