Community health workers perspective on the COVID-19 impact on primary health care in Northeastern Brazil  <span class="so-article-trans-title" dir="auto"> Translated title: Perspectiva dos agentes comunitários de saúde sobre o impacto da COVID-19 na atenção primária à saúde no Nordeste do Brasil </span> <span class="so-article-trans-title" dir="auto"> Translated title: Perspectiva de los agentes comunitarios de la salud sobre el impacto de pandemia de COVID-19 en la atención primaria a la salud en el Nordeste de Brasil </span>

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Abstract:

This article evaluates the COVID-19 pandemic impacts on the Family Health Strategy (FHS) team’s work routines across a range of northeast Brazilian cities as perceived by community health workers (CHW). Data on COVID-19, CHW activities, and FHS teams were collected in 2021 by a structured questionnaire. A total of 1,935 CHWs from four state capitals (Fortaleza - Ceará State, João Pessoa - Paraíba State, Recife - Pernambuco State, Teresina - Piauí State) and four hinterland cities (Crato, Juazeiro do Norte, Barbalha, Sobral - Ceará State) participated in the study. Most CHWs were women (82.42%), with mean age 46.25±8.54 years. Many (39.92%) were infected with COVID-19, of which 70.78% believed they were infected in the workplace. A total of 77.82% defined their role as frontline in the fight against COVID-19, 16.07% reported receiving training for COVID-19, and 13.74% had access to sufficient protective equipment. Most (90.27%) believed their work routines were modified by the pandemic, either strengthening (41.46%) or weakening (44.41%) the team spirit. Home visits (60.55%), health promotion actions in schools (75.66%) and in specific community groups (93.96%), and other on-site community services (66.01%) showed a reduction in frequency. The sampled cities revealed a significant heterogeneity regarding responses to the COVID-19 pandemic, possibly associated with a lack of coordination by the Federal Government. Regardless of context, the pandemic led to a reconfiguration of local health systems, workflows, and primary care protocols for FHS teams. The importance of the Brazilian Unified National Health System (SUS) and its potential for reorganization during crisis should be acknowledged while preserving the headway made thus far.

Resumo:

Este artigo avalia as repercussões da pandemia da COVID-19 no cotidiano de trabalho da equipe da Estratégia Saúde da Família (ESF) em diversos municípios do Nordeste brasileiro, na perspectiva dos agentes comunitários de saúde (ACS). Um questionário estruturado foi utilizado para coletar informações sobre a COVID-19, atividades dos ACS e equipes da ESF em 2021. Participaram 1.935 ACS de quatro capitais (Fortaleza - Ceará, João Pessoa - Paraíba, Recife - Pernambuco e Teresina - Piauí) e quatro cidades do interior (Crato, Juazeiro do Norte, Barbalha e Sobral, Ceará). A idade média dos ACS era de 46,25±8,54 anos, sendo a maioria mulheres (82,42%). Muitos (39,92%) estavam infectados com COVID-19, dos quais 70,78% acreditavam ter sido infectados no ambiente de trabalho. Ao todo, 77,82% definiam seu papel como linha de frente no combate à COVID-19, 16,07% relataram receber treinamento para a COVID-19 e 13,74% tinham acesso a equipamentos de proteção suficientes contra a COVID-19. A maioria (90,27%) acredita que suas rotinas de trabalho foram modificadas pela pandemia, fortalecendo o espírito de equipe (41,46%) ou enfraquecendo-o (44,41%). Houve uma redução na promoção da saúde nas escolas (75,66%) e na frequência de visitas domiciliares (60,55%), de grupos específicos na comunidade (93,96%) e outros serviços comunitários locais (66,01%). Nos municípios avaliados, observou-se uma heterogeneidade significativa em relação à resposta à pandemia de COVID-19, possivelmente associada à falta de coordenação do Governo Federal. A pandemia levou a uma reconfiguração dos sistemas locais de saúde, fluxos de trabalho e protocolos de atenção primária para as equipes da ESF. A importância do Sistema Único de Saúde (SUS) e seu potencial de reorganização durante as crises devem ser reconhecidos, preservando-se os avanços alcançados até o momento.

Resumen:

Este artículo evalúa las repercusiones de la pandemia de COVID-19 en el trabajo cotidiano del equipo de la Estrategia Salud de la Familia (ESF) en diversos municipios del Nordeste brasileño, desde la perspectiva de los agentes comunitarios de salud (ACS). Se utilizó un cuestionario estructurado para recopilar información sobre COVID-19, actividades de los ACS y equipos de la ESF en el 2021. Participaron 1.935 ACS de cuatro capitales (Fortaleza - Ceará, João Pessoa - Paraíba, Recife - Pernambuco y Teresina - Piauí) y cuatro ciudades del interior (Crato, Juazeiro do Norte, Barbalha y Sobral - Ceará). La edad media de los ACS era de 46,25±8,54 años, y la mayoría eran mujeres (82,42%). Muchos (39,92%) estaban infectados con COVID-19, de los cuales el 70,78% creía haberse contagiado en el entorno laboral. En total, el 77,82% definió su papel como línea de frente en el combate a la COVID-19, el 16,07% informó haber recibido capacitación para la COVID-19 y el 13,74% tuvo acceso a equipos de protección suficiente contra la COVID-19. La mayoría (90,27%) cree que sus rutinas de trabajo se vieron modificadas por la pandemia, fortaleciendo el espíritu de equipo (41,46%) o debilitándolo (44,41%). Hubo una reducción en la promoción de la salud en las escuelas (75,66%) y en la frecuencia de las visitas domiciliarias (60,55%), de grupos específicos en la comunidad (93,96%) y otros servicios comunitarios locales (66,01%). En los municipios analizados, se observó una heterogeneidad significativa con relación a la respuesta a la pandemia de COVID-19, posiblemente asociada a la falta de coordinación del Gobierno Federal. La pandemia condujo a una reconfiguración de los sistemas locales de salud, los flujos de trabajo y los protocolos de atención primaria para los equipos de la ESF. Se debe reconocer la importancia del Sistema Único de Salud y (SUS) su capacidad de reorganización durante las crisis, preservando los avances logrados hasta el momento.

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The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

Erik von Elm, Douglas G. Altman, Matthias Egger … (2008)

Much of biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalizability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. Eighteen items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available on the web sites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.

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The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies

Erik von Elm, Douglas G. Altman, Matthias Egger … (2008)

Introduction Many questions in medical research are investigated in observational studies [1]. Much of the research into the cause of diseases relies on cohort, case-control, or cross-sectional studies. Observational studies also have a role in research into the benefits and harms of medical interventions [2]. Randomised trials cannot answer all important questions about a given intervention. For example, observational studies are more suitable to detect rare or late adverse effects of treatments, and are more likely to provide an indication of what is achieved in daily medical practice [3]. Research should be reported transparently so that readers can follow what was planned, what was done, what was found, and what conclusions were drawn. The credibility of research depends on a critical assessment by others of the strengths and weaknesses in study design, conduct, and analysis. Transparent reporting is also needed to judge whether and how results can be included in systematic reviews [4,5]. However, in published observational research important information is often missing or unclear. An analysis of epidemiological studies published in general medical and specialist journals found that the rationale behind the choice of potential confounding variables was often not reported [6]. Only few reports of case-control studies in psychiatry explained the methods used to identify cases and controls [7]. In a survey of longitudinal studies in stroke research, 17 of 49 articles (35%) did not specify the eligibility criteria [8]. Others have argued that without sufficient clarity of reporting, the benefits of research might be achieved more slowly [9], and that there is a need for guidance in reporting observational studies [10,11]. Recommendations on the reporting of research can improve reporting quality. The Consolidated Standards of Reporting Trials (CONSORT) Statement was developed in 1996 and revised 5 years later [12]. Many medical journals supported this initiative [13], which has helped to improve the quality of reports of randomised trials [14,15]. Similar initiatives have followed for other research areas—e.g., for the reporting of meta-analyses of randomised trials [16] or diagnostic studies [17]. We established a network of methodologists, researchers, and journal editors to develop recommendations for the reporting of observational research: the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. Aims and Use of the STROBE Statement The STROBE Statement is a checklist of items that should be addressed in articles reporting on the 3 main study designs of analytical epidemiology: cohort, case-control, and cross-sectional studies. The intention is solely to provide guidance on how to report observational research well: these recommendations are not prescriptions for designing or conducting studies. Also, while clarity of reporting is a prerequisite to evaluation, the checklist is not an instrument to evaluate the quality of observational research. Here we present the STROBE Statement and explain how it was developed. In a detailed companion paper, the Explanation and Elaboration article [18–20], we justify the inclusion of the different checklist items and give methodological background and published examples of what we consider transparent reporting. We strongly recommend using the STROBE checklist in conjunction with the explanatory article, which is available freely on the Web sites of PLoS Medicine (http://www.plosmedicine.org/), Annals of Internal Medicine (http://www.annals.org/), and Epidemiology (http://www.epidem.com/). Development of the STROBE Statement We established the STROBE Initiative in 2004, obtained funding for a workshop and set up a Web site (http://www.strobe-statement.org/). We searched textbooks, bibliographic databases, reference lists, and personal files for relevant material, including previous recommendations, empirical studies of reporting and articles describing relevant methodological research. Because observational research makes use of many different study designs, we felt that the scope of STROBE had to be clearly defined early on. We decided to focus on the 3 study designs that are used most widely in analytical observational research: cohort, case-control, and cross-sectional studies. We organised a 2-day workshop in Bristol, UK, in September 2004. 23 individuals attended this meeting, including editorial staff from Annals of Internal Medicine, BMJ, Bulletin of the World Health Organization, International Journal of Epidemiology, JAMA, Preventive Medicine, and The Lancet, as well as epidemiologists, methodologists, statisticians, and practitioners from Europe and North America. Written contributions were sought from 10 other individuals who declared an interest in contributing to STROBE, but could not attend. Three working groups identified items deemed to be important to include in checklists for each type of study. A provisional list of items prepared in advance (available from our Web site) was used to facilitate discussions. The 3 draft checklists were then discussed by all participants and, where possible, items were revised to make them applicable to all three study designs. In a final plenary session, the group decided on the strategy for finalizing and disseminating the STROBE Statement. After the workshop we drafted a combined checklist including all three designs and made it available on our Web site. We invited participants and additional scientists and editors to comment on this draft checklist. We subsequently published 3 revisions on the Web site, and 2 summaries of comments received and changes made. During this process the coordinating group (i.e., the authors of the present paper) met on eight occasions for 1 or 2 days and held several telephone conferences to revise the checklist and to prepare the present paper and the Explanation and Elaboration paper [18–20]. The coordinating group invited 3 additional co-authors with methodological and editorial expertise to help write the Explanation and Elaboration paper, and sought feedback from more than 30 people, who are listed at the end of this paper. We allowed several weeks for comments on subsequent drafts of the paper and reminded collaborators about deadlines by e-mail. STROBE Components The STROBE Statement is a checklist of 22 items that we consider essential for good reporting of observational studies (Table 1). These items relate to the article's title and abstract (item 1), the introduction (items 2 and 3), methods (items 4–12), results (items 13–17) and discussion sections (items 18–21), and other information (item 22 on funding). 18 items are common to all three designs, while four (items 6, 12, 14, and 15) are design-specific, with different versions for all or part of the item. For some items (indicated by asterisks), information should be given separately for cases and controls in case-control studies, or exposed and unexposed groups in cohort and cross-sectional studies. Although presented here as a single checklist, separate checklists are available for each of the 3 study designs on the STROBE Web site. Table 1 The STROBE Statement—Checklist of Items That Should Be Addressed in Reports of Observational Studies Implications and Limitations The STROBE Statement was developed to assist authors when writing up analytical observational studies, to support editors and reviewers when considering such articles for publication, and to help readers when critically appraising published articles. We developed the checklist through an open process, taking into account the experience gained with previous initiatives, in particular CONSORT. We reviewed the relevant empirical evidence as well as methodological work, and subjected consecutive drafts to an extensive iterative process of consultation. The checklist presented here is thus based on input from a large number of individuals with diverse backgrounds and perspectives. The comprehensive explanatory article [18–20], which is intended for use alongside the checklist, also benefited greatly from this consultation process. Observational studies serve a wide range of purposes, on a continuum from the discovery of new findings to the confirmation or refutation of previous findings [18–20]. Some studies are essentially exploratory and raise interesting hypotheses. Others pursue clearly defined hypotheses in available data. In yet another type of studies, the collection of new data is planned carefully on the basis of an existing hypothesis. We believe the present checklist can be useful for all these studies, since the readers always need to know what was planned (and what was not), what was done, what was found, and what the results mean. We acknowledge that STROBE is currently limited to three main observational study designs. We would welcome extensions that adapt the checklist to other designs—e.g., case-crossover studies or ecological studies—and also to specific topic areas. Four extensions are now available for the CONSORT statement [21–24]. A first extension to STROBE is underway for gene-disease association studies: the STROBE Extension to Genetic Association studies (STREGA) initiative [25]. We ask those who aim to develop extensions of the STROBE Statement to contact the coordinating group first to avoid duplication of effort. The STROBE Statement should not be interpreted as an attempt to prescribe the reporting of observational research in a rigid format. The checklist items should be addressed in sufficient detail and with clarity somewhere in an article, but the order and format for presenting information depends on author preferences, journal style, and the traditions of the research field. For instance, we discuss the reporting of results under a number of separate items, while recognizing that authors might address several items within a single section of text or in a table. Also, item 22, on the source of funding and the role of funders, could be addressed in an appendix or in the methods section of the article. We do not aim at standardising reporting. Authors of randomised clinical trials were asked by an editor of a specialist medical journal to “CONSORT” their manuscripts on submission [26]. We believe that manuscripts should not be “STROBEd”, in the sense of regulating style or terminology. We encourage authors to use narrative elements, including the description of illustrative cases, to complement the essential information about their study, and to make their articles an interesting read [27]. We emphasise that the STROBE Statement was not developed as a tool for assessing the quality of published observational research. Such instruments have been developed by other groups and were the subject of a recent systematic review [28]. In the Explanation and Elaboration paper, we used several examples of good reporting from studies whose results were not confirmed in further research – the important feature was the good reporting, not whether the research was of good quality. However, if STROBE is adopted by authors and journals, issues such as confounding, bias, and generalisability could become more transparent, which might help temper the over-enthusiastic reporting of new findings in the scientific community and popular media [29], and improve the methodology of studies in the long term. Better reporting may also help to have more informed decisions about when new studies are needed, and what they should address. We did not undertake a comprehensive systematic review for each of the checklist items and sub-items, or do our own research to fill gaps in the evidence base. Further, although no one was excluded from the process, the composition of the group of contributors was influenced by existing networks and was not representative in terms of geography (it was dominated by contributors from Europe and North America) and probably was not representative in terms of research interests and disciplines. We stress that STROBE and other recommendations on the reporting of research should be seen as evolving documents that require continual assessment, refinement, and, if necessary, change. We welcome suggestions for the further dissemination of STROBE—e.g., by re-publication of the present article in specialist journals and in journals published in other languages. Groups or individuals who intend to translate the checklist to other languages should consult the coordinating group beforehand. We will revise the checklist in the future, taking into account comments, criticism, new evidence, and experience from its use. We invite readers to submit their comments via the STROBE Web site (http://www.strobe-statement.org/).

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Brazil's unified health system: the first 30 years and prospects for the future

Marcia Castro, Adriano Massuda, Gisele Detomazi Almeida … (2019)

In 1988, the Brazilian Constitution defined health as a universal right and a state responsibility. Progress towards universal health coverage in Brazil has been achieved through a unified health system (Sistema Único de Saúde [SUS]), created in 1990. With successes and setbacks in the implementation of health programmes and the organisation of its health system, Brazil has achieved nearly universal access to health-care services for the population. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale universal health coverage in a highly unequal country with relatively low resources allocated to health-care services by the government compared with that in middle-income and high-income countries. Analysis of the past 30 years since the inception of the SUS shows that innovations extend beyond the development of new models of care and highlights the importance of establishing political, legal, organisational, and management-related structures, with clearly defined roles for both the federal and local governments in the governance, planning, financing, and provision of health-care services. The expansion of the SUS has allowed Brazil to rapidly address the changing health needs of the population, with dramatic upscaling of health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographical inequalities, insufficient funding, and suboptimal private sector-public sector collaboration. Fiscal policies implemented in 2016 ushered in austerity measures that, alongside the new environmental, educational, and health policies of the Brazilian government, could reverse the hard-earned achievements of the SUS and threaten its sustainability and ability to fulfil its constitutional mandate of providing health care for all.

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Author and article information

Contributors

Anya Pimentel Gomes Fernandes Vieira-Meyer:

ORCID: http://orcid.org/0000-0003-4237-8995

Role: contributed to the study designRole: definition of intellectual content, data collection and analysisRole: writing, editing and revising the manuscriptRole: approved the final version for publication

Franklin Delano Soares Forte:

ORCID: http://orcid.org/0000-0003-4237-0184

Role: contributed to the study designRole: definition of intellectual content, data collection and analysisRole: manuscript writing, editing, and revisionRole: approved the final version for publication

José Maria Ximenes Guimarães:

ORCID: http://orcid.org/0000-0002-5682-6106

Role: contribuited to the study designRole: definition of intellectual content, data collection and analysisRole: manuscript writing, editing, and revisionRole: approved the final version for publication

Sidney Feitoza Farias:

ORCID: http://orcid.org/0000-0002-3650-154X

André Luiz Sá de Oliveira:

ORCID: http://orcid.org/0000-0002-2483-550X

Maria Socorro de Araújo Dias:

ORCID: http://orcid.org/0000-0002-7813-547X

Claudete Ferreira de Souza Monteiro:

ORCID: http://orcid.org/0000-0003-0902-3340

Fernando José Guedes da Silva Júnior:

ORCID: http://orcid.org/0000-0001-5731-632X

Ana Patrícia Pereira Morais:

ORCID: http://orcid.org/0000-0001-6188-7897

Maria Rosilene Candido Moreira:

ORCID: http://orcid.org/0000-0002-9821-1935

Márcia C. Castro:

ORCID: http://orcid.org/0000-0003-4606-2795

Role: contributed to the data analysis, definition of intellectual content and manuscript revisionRole: approved the final version for publication

Aisha Khizar Yousafzai:

ORCID: http://orcid.org/0000-0002-1592-8923

Role: contributed to the data analysis, definition of intellectual content and manuscript revisionRole: approved the final version for publication

Journal

Journal ID (nlm-ta): Cad Saude Publica

Journal ID (iso-abbrev): Cad Saude Publica

Journal ID (publisher-id): csp

Title: Cadernos de Saúde Pública

Publisher: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz

ISSN (Print): 0102-311X

ISSN (Electronic): 1678-4464

Publication date (Electronic, pub): 11 August 2023

Publication date (Electronic, collection): 2023

Volume: 39

Issue: 7

Electronic Location Identifier: e00007223

Affiliations

[1 ] Fundação Oswaldo Cruz, Eusébio, Brasil.

[2 ] Universidade Federal da Paraíba, João Pessoa, Brasil.

[3 ] Universidade Estadual do Ceará, Fortaleza, Brasil.

[4 ] Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, Brasil.

[5 ] Universidade Estadual Vale do Acaraú, Sobral, Brasil.

[6 ]Universidade Federal do Piauí, Teresina, Brasil.

[7 ] Universidade Federal do Cariri, Crato, Brasil.

[8 ] Harvard TH Chan School of Public Health, Boston, U.S.A.

Author notes

[Correspondence ] A. P. G. F. Vieira-Meyer Fundação Oswaldo Cruz. Rua São José s/n, Eusébio, CE 61760-000, Brasil. anyavieira10@ 123456gmail.com

Additional information: ORCID: Anya Pimentel Gomes Fernandes Vieira-Meyer (0000-0003-4237-8995); Franklin Delano Soares Forte (0000-0003-4237-0184); José Maria Ximenes Guimarães (0000-0002-5682-6106); Sidney Feitoza Farias (0000-0002-3650-154X); André Luiz Sá de Oliveira (0000-0002-2483-550X); Maria Socorro de Araújo Dias (0000-0002-7813-547X); Claudete Ferreira de Souza Monteiro (0000-0003-0902-3340); Fernando José Guedes da Silva Júnior (0000-0001-5731-632X); Ana Patrícia Pereira Morais (0000-0001-6188-7897); Maria Rosilene Candido Moreira (0000-0002-9821-1935); Márcia C. Castro (0000-0003-4606-2795); Aisha Khizar Yousafzai (0000-0002-1592-8923).