Violência no território e saúde mental de agentes comunitários de saúde em uma metrópole brasileira

Vieira-Meyer, Anya Pimentel Gomes Fernandes; Morais, Ana Patrícia Pereira; Santos, Helena Paula Guerra dos; Yousafzai, Aisha Khizar; Campelo, Isabella Lima Barbosa; Guimarães, José Maria Ximenes

Anya Pimentel Gomes Fernandes Vieira-Meyer

contributed to the study conception and design, data collection, analysis and interpretation, writing, and revision of the manuscript; and approved the final version of the manuscript

Fiocruz Ceará, Eusébio, Brasil.

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

Ana Patrícia Pereira Morais

contributed to the study conception and design, data collection, analysis and interpretation, writing, and revision of the manuscript; and approved the final version of the manuscript

Universidade Estadual do Ceará, Fortaleza, Brasil.

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

Helena Paula Guerra dos Santos

contributed to data analysis and interpretation, writing, and review of the manuscript; and approved the final version of the manuscript

Secretaria Municipal de Saúde de Fortaleza, Fortaleza, Brasil.

http://orcid.org/0000-0002-9808-9546

Aisha Khizar Yousafzai

revised the manuscript; and approved the final version of the manuscript

School of Public Health, Harvard University, Boston, U.S.A.

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

Isabella Lima Barbosa Campelo

contributed to data analysis and interpretation, writing and review of the manuscript; and approved the final version of the manuscript

UniFanor, Fortaleza, Brasil.

http://orcid.org/0000-0003-1552-7350

José Maria Ximenes Guimarães

contributed to data analysis and interpretation, writing and review of the manuscript; and approved the final version of the manuscript

Universidade Estadual do Ceará, Fortaleza, Brasil.

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

Correspondence
A. P. G. F. Vieira-Meyer Fiocruz Ceará. Rua São José s/n, Eusébio, CE 61760-000, Brasil. anya.vieira@fiocruz.br

Contributors

A. P. G. F. Vieira-Meyer contributed to the study conception and design, data collection, analysis and interpretation, writing, and revision of the manuscript; and approved the final version of the manuscript. A. P. P. Morais contributed to the study conception and design, data collection, analysis and interpretation, writing, and revision of the manuscript; and approved the final version of the manuscript. H. P. G. Santos contributed to data analysis and interpretation, writing, and review of the manuscript; and approved the final version of the manuscript. A. K. Yousafzai revised the manuscript; and approved the final version of the manuscript. I. L. B. Campelo contributed to data analysis and interpretation, writing and review of the manuscript; and approved the final version of the manuscript. J. M. X. Guimarães contributed to data analysis and interpretation, writing and review of the manuscript; and approved the final version of the manuscript.

Additional information

ORCID: Anya Pimentel Gomes Fernandes Vieira-Meyer (0000-0003-4237-8995); Ana Patrícia Pereira Morais (0000-0001-6188-7897); Helena Paula Guerra dos Santos (0000-0002-9808-9546); Aisha Khizar Yousafzai (0000-0002-1592-8923); Isabella Lima Barbosa Campelo (0000-0003-1552-7350); José Maria Ximenes Guimarães (0000-0002-5682-6106).

Variables	n	%
Sociodemographic profile
Sex (n = 1,406)
Male	266	18.92
Female	1,140	81.08
Age (years) (n = 1,307)
< 40	355	27.16
40-59	845	64.65
≥ 60	107	8.19
Subprefecture (n = 1,423)
I	188	13.21
II	159	11.17
III	274	19.26
IV	129	9.07
V	388	27.27
VI	285	20.03
Marital/Partnership status (n = 1,417)
Does not live with spouse/partner	681	48.06
Lives with spouse/partner	736	51.94
Children (n = 1,432)
No	302	21.09
Yes	1,130	78.91
Religious identity (n = 1,427)
No	93	6.52
Yes	1,334	93.48
Time living in the neighborhood (years) (n = 1,232)
< 20	318	25.81
≥ 20	914	74.19
Race/Skin color (n = 1,433)
Not black	1,331	92.88
Black	102	7.12
Schooling level (n = 1,433)
High school not completed	91	6.35
High school completed	852	59.46
Higher education	490	34.19
Good relationship with neighbors (n = 1,417)
No	257	18.14
Yes	1,160	81.86
Work
Time with the FHS (years) (n = 1,394)
< 12	1,011	72.53
≥ 12	383	27.47
Time as CHW at current facility (years) (n = 1,345)
< 12	1,090	81.04
≥ 12	255	18.96
Income (minimum wages) (n = 1,351)
Up to 2	898	66.47
Over 2	453	33.53
Other jobs (n = 1,421)
No	1,284	90.36
Yes	137	9.64
Living and working in the same neighborhood (n = 1,421)
No	231	16.26
Yes	1,190	83.74
CHW activities
Home visits (n = 1,430)
No	73	5.10
Yes	1,357	94.90
Targeted health promotion activities (n = 1,429)
No	409	28.62
Yes	1,020	71.38
PSE activities (n = 1,430)
No	896	62.66
Yes	534	37.34
Community activities (n = 1,430)
No	751	52.52
Yes	679	47.48
Obstacles to the work
Large number of families in the area covered (n = 1,418)
No	822	57.97
Yes	596	42.03
Absence of bond with families (n = 1,418)
No	1,379	97.25
Yes	39	2.75
Limited access of families to the facility (n = 1,418)
No	1,005	70.87
Yes	413	29.13
Urban violence (n = 1,418)
No	719	50.71
Yes	699	49.29

Variables	n	%
Violence
Has suffered domestic violence (n = 1,325)
No	1,007	76.00
Yes	318	24.00
Considers neighborhood violent (n = 1,426)
No	239	16.76
Yes	1,187	83.24
Violence in the community served (n = 1,413)
No	231	16.35
Yes	1,182	83.65
Causes of violence
Poverty (n = 1,426)
No	800	56.10
Yes	626	43.90
Lack of education (n = 1,428)
No	882	61.76
Yes	546	38.24
Alcohol and drug abuse (n = 1,427)
No	278	19.48
Yes	1,149	80.52
Impunity (n = 1,426)
No	927	65.01
Yes	499	34.99
Drug trafficking (n = 1,427)
No	324	22.70
Yes	1,103	77.30
Criminal gangs (n = 1,428)
No	477	33.40
Yes	951	66.60
Types of violence in the community
Domestic (n = 1,424)
No	989	69.45
Yes	435	30.55
Urban (n = 1,424)
No	258	18.12
Yes	1,166	81.88
Institutional (n = 1,423)
No	997	70.06
Yes	426	29.94
Believes violence interferes with work (n = 1,411)
No	421	29.84
Yes	990	70.16
Has witnessed violence on the work environment (n = 1,412)
No	525	37.18
Yes	887	62.82
Has suffered violence on the work environment (n = 1,422)
No	830	58.37
Yes	592	41.63
Has been threatened with violence on the work environment (n = 1,420)
No	755	53.17
Yes	665	46.83
Has been deprived of contact with families, suspended unaccompanied home visits, or requested transfer to another area due to violence (n = 1,409)
No	1,000	70.97
Yes	409	29.03
Has taken leave from work due to violence (n = 1,421)
No	1,192	83.88
Yes	229	16.12
Has suspended FHS-related activities due to violence (n = 1,421)
No	902	63.48
Yes	519	36.52
Has considered moving due to violence (n = 1,421)
No	666	46.87
Yes	755	53.13
Has considered changing occupation due to violence (n = 1,412)
No	1,100	77.90
Yes	312	22.10
Believes physical health on the job is impacted by violence (n = 1,412)
No	743	52.62
Yes	669	47.38
Feels capable of coping with violence in the community (n = 1,401)
No	951	67.88
Yes	450	32.12
Mental health
Believes mental health on the job is impacted by violence (n = 1,415)
No	622	43.96
Yes	793	56.04
SRQ-20 (n = 1,368)
< 7	920	67.25
≥ 7	448	32.75
Uses medication for emotional dysregulation (n = 1,423)
No	1,128	79.27
Yes	295	20.73

Variables	SRQ-20				p-value	OR	95%CI
	< 7		≥ 7
	n	%	n	%
Sociodemographic profile
Sex (n = 1,341)
Male	693	64.17	387	32.51	< 0.001	2.416	1.728-3.376
Female	212	81.23	49	18.77		1.000	-
Age (years) (n = 1,253)
< 40	220	63.95	124	36.05	0.003	2.200	1.298-3.729
40-59	545	67.62	261	32.38	0.014	1.869	1.132-3.087
≥ 60	82	79.61	21	20.39		1.000	-
Subprefecture (n = 1,356)
I	121	69.54	53	30.46	0.024	1.879	1.085-3.255
II	99	65.13	53	34.87		2.297	1.318-4.004
III	173	67.05	85	32.95		2.108	1.260-3.527
IV	103	81.10	24	18.90		1.000	-
V	243	64.80	132	35.20		2.331	1.425-3.813
VI	175	64.81	95	35.19		2.329	1.395-3.878
Marital/Partnership status (n = 1,351)
Does not live with spouse/partner	422	65.53	222	34.47	0.276
Lives with spouse/partner	483	68.32	224	31.68
Children (n = 1,365)
No	191	67.49	92	32.51	0.924
Yes	727	67.19	355	32.81
Religious identity (n = 1,360)
No	45	48.39	48	51.61	< 0.001	2.320	1.519-3.544
Yes	868	68.51	399	31.49		1.000	-
Time living in the neighborhood (years) (n = 1,177)
< 20	181	59.74	122	40.26	0.004	1.491	1.138-19.55
≥ 20	602	68.88	272	31.12		1.000	-
Race/Skin color (n = 1,366)
Not black	861	68.01	405	31.99	0.034	1.000	-
Black	57	57.58	42	42.42		1.566	1.033-2.373
Schooling level (n = 1,433)
High school or less	622	69.03	279	30.97	0.054	1.000	-
Higher education	297	63.87	168	36.13		1.261	0.995-1.596
Good relationship with neighbors (n = 1,350)
No	151	67.26	98	32.74	0.014	1.428	1.074-1.898
Yes	757	68.76	344	31.24		1.000	-
Work
Time with the FHS (years) (n = 1,287)
< 12	626	64.80	340	35.20	0.008	1.433	1.099-1.869
≥ 12	264	72.53	100	27.47		1.000	-
Time as CHW at current facility (years) (n = 1,244)
< 12	685	65.61	359	34.39	0.006	1.563	1.136-2.151
≥ 12	179	74.90	60	25.10		1.000	-
Income (minimum wages) (n = 1,298)
Up to 2	574	66.67	287	33.33	0.580
Over 2	298	68.19	139	31.81
Other jobs (n = 1,355)
No	826	67.54	397	32.46	0.579
Yes	86	65.15	46	34.85
Living and working in the same neighborhood (n = 1,355)
No	145	65.61	76	34.39	0.575
Yes	766	67.23	268	32.77
CHW activities
Home visits (n = 1,363)
No	46	65.71	24	34.29	0.775
style="text-indent:12px"Yes	871	67.36	422	32.64
Targeted health promotion activities (n = 1,318)
No	257	66.07	132	33.93	0.555
Yes	659	67.73	314	32.27
PSE activities (n = 1,363)
No	577	68.04	271	31.96	0.440
Yes	340	66.02	175	33.98
Community activities (n = 1,363)
No	506	70.28	214	29.72	0.013	1.000	-
Yes	411	63.92	232	36.08		1.334	1.063-1.674
Obstacles to the work
Large number of families in the area covered (n = 1,352)
No	547	70.04	234	29.96	0.008	1.000	-
Yes	361	63.22	210	36.78		1.359	1.081-1.709
Absence of bond with families (n = 1,352)
No	890	67.68	425	32.32	0.018	1.000	-
Yes	18	48.65	19	51.35		2.210	1.148-4.255
Limited access of families to the facility (n = 1,352)
No	663	69.28	294	30.72	0.010	1.000	-
Yes	245	62.03	150	37.97		1.380	1.080-1.764
Urban violence (n = 1,352)
No	506	73.65	181	26.35	< 0.001	1.000	-
Yes	402	60.45	263	39.55		1.828	1.452-2.302

Variables	SRQ-20				p-value	OR	95%CI
	< 7		≥ 7
	n	%	n	%
Violence
Has suffered domestic violence (n = 1,272)
No	695	71.95	271	28.05	< 0.001	1.000	-
Yes	172	56.21	134	43.79		1.997	1.531-2.606
Considers neighborhood violent (n = 1,359)
No	182	80.18	45	19.82	< 0.001	1.000	-
Yes	732	64.66	400	35.34		2.176	1.530-3.094
Violence in the community served (n = 1,349)
No	177	80.09	44	19.91	< 0.001	1.000	-
Yes	732	64.89	396	35.11		1.776	1.413-2.233
Causes of violence
Poverty (n = 1,360)
No	554	72.80	207	27.20	< 0.001	1.000	-
Yes	360	60.10	239	39.90		1.728	1.372-2.176
Lack of education (n = 1,362)
No	601	71.98	234	28.02	< 0.001	1.000	-
Yes	315	59.77	212	40.23		1.535	1.134-2.077
Alcohol and drug abuse (n = 1,361)
No	198	74.44	68	25.56	0.005	1.000	-
Yes	717	65.48	378	34.52		1.481	1.084-2.023
Impunity (n = 1,316)
No	631	71.87	247	28.13	< 0.001	1.000	-
Yes	284	58.92	198	41.08		1.781	1.410-2.249
Drug trafficking (n = 1,361)
No	242	78.83	65	21.17	< 0.001	1.000	-
Yes	673	63.85	381	36.15		2.107	1.559-2.848
Criminal gangs (n = 1,362)
No	337	74.39	16	25.61	< 0.001	1.000	-
Yes	579	63.70	330	36.30		1.655	1.288-2.127
Types of violence in the community
Domestic (n = 1,314)
No	659	69.81	285	30.19	0.003	1.000	-
Yes	256	61.69	159	38.31		1.436	1.127-1.829
Urban (n = 1,359)
No	190	76.00	60	24.00	0.001	1.000	-
Yes	725	65.37	384	34.63		1.677	1.223-2.999
Institutional (n = 1,313)
No	676	71.01	276	28.99	< 0.001	1.000	-
Yes	238	58.62	168	41.38		1.728	1.357-2.202
Believes violence interferes with work (n = 1,347)
No	311	77.94	88	22.06	< 0.001	1.000	-
Yes	595	62.76	353	37.24		2.096	1.599-2.748
Has witnessed violence on the work environment (n = 1,348)
No	380	76.31	118	23.69	< 0.001	1.000	-
Yes	529	62.24	321	37.76		1.954	1.523-2.506
Has suffered violence on the work environment (n = 1,355)
No	593	75.16	196	24.84	< 0.001	1.000	-
Yes	323	57.07	243	42.93		2.276	1.805-2.870
Has been threatened with violence on the work environment (n = 1,355)
No	539	74.97	180	25.03	< 0.001	1.000	-
Yes	373	58.65	263	41.35		2.111	1.675-2.660
Has been deprived of contact with families, suspended unaccompanied home visits, or requested transfer to another area due to violence (n = 1,345)
No	695	73.00	230	27.00	< 0.001	1.000	-
Yes	211	53.69	166	46.31		2.332	1.826-2.978
Has taken leave from work due to violence (n = 1,356)
No	811	71.08	330	28.92	< 0.001	1.000	-
Yes	102	47.44	113	52.56		2.722	2.022-3.663
Has suspended FHS-related activities due to violence (n = 1,355)
No	621	71.96	242	28.04	< 0.001	1.000	-
Yes	291	59.15	201	40.85		1.772	1.403-2.237
Has considered moving due to violence (n = 1,354)
No	419	67.36	203	32.64	0.911
Yes	491	67.08	241	32.92
Has considered changing occupation due to violence (n = 1,344)
No	701	66.89	347	33.11	0.742
Yes	201	67.91	95	32.09
Believes physical health on the job is impacted by violence (n = 1,349)
No	551	78.16	154	21.84	< 0.001	1.000	-
Yes	360	55.90	284	44.10		2.822	2.227-3.577
Feels capable of coping with violence in the community (n = 1,339)
No	595	64.81	323	35.19	0.003	1.461	1.133-1.884
Yes	307	72.92	114	27.08		1.000	-
Mental health
Believes mental health on the job is impacted by violence (n = 1,350)
No	500	84.89	89	15.11	< 0.001	1.000	-
Yes	406	53.35	344	46.65		4.912	3.762-6.413
Uses medication for emotional dysregulation (n = 1,357)
No	827	77.15	245	22.85	< 0.001	1.000	-
Yes	90	31.58	195	68.42		7.313	5.485-9.750

Variables	OR	95%CI	p-value
Category 1 - Sociodemographic
Female sex	2.529	1.781-3.589	< 0.001
Age (years)
< 40 vs. > 60	2.490	1.428-4.342	0.001
40-59 vs. > 60	2.117	1.253-3.578	0.005
No religious identity	2.365	1.497-3.735	< 0.001
Category 2 - Work
Subprefecture
I vs. IV	1.568	0.555-2.875	0.146
II vs. IV	2.042	1.107-3.768	0.022
III vs. IV	1.722	0.977-3.034	0.060
V vs. IV	2.044	1.191-3.507	0.009
VI vs. IV	1.952	1.114-3.419	0.019
Time with the FHS < 12 years	1.367	1.009-1.851	0.043
Activities in the community	1.384	1.073-1.785	0.012
Work compromised by absence of bond with family	2.494	1.118-5.564	0.026
Category 3 - Violence
Mental health impacted by violence	2.456	1.700-3.550	< 0.001
Uses medication for emotional dysregulation	6.163	4.271-8.894	< 0.001
Considers neighborhood violent	1.632	1.025-2.597	0.039
Identifies impunity as a cause of violence	1.412	1.027-1.941	0.034
Has suffered domestic violence	1.629	1.149-2.308	0.006
Physical health is impacted by violence	1.432	1.022-2.005	0.037

[1] Correspondence
A. P. G. F. Vieira-Meyer Fiocruz Ceará. Rua São José s/n, Eusébio, CE 61760-000, Brasil. anya.vieira@fiocruz.br