Evaluation of overall quality of life of community health agents: the relative contribution of sociodemographic variables and domains of quality of life

Abstracts

OBJETIVO: Avaliar a contribuição relativa de cada domínio da qualidade de vida (físico, psicológico, relações sociais e meio ambiente) e das variáveis sociodemográficas para a qualidade de vida geral de agentes comunitários de saúde de um município do interior do Paraná, Brasil. MÉTODO: Estudo descritivo, de corte transversal e com abordagem quantitativa. O grupo de estudo foi composto por 169 agentes (86,2% do total), que responderam o World Health Organization Quality of Life Instrument Bref, instrumento genérico para avaliar qualidade de vida, proposto pela Organização Mundial da Saúde. Foram utilizados testes de correlação e regressão linear multivariada. O nível de significância adotado para as análises foi de 5%. RESULTADOS: Das variáveis sociodemográficas analisadas, nenhuma contribuiu de modo significativo para o domínio geral da qualidade de vida. Para os quatro domínios, o que mais contribuiu para a qualidade de vida geral foi o físico, seguido do psicológico e do meio ambiente, os três explicando 47,9% da variância. O domínio das relações sociais não contribuiu significativamente para a qualidade de vida geral. CONCLUSÃO: Observou-se que a variância da qualidade de vida geral não foi completamente explicada pelas variáveis sociodemográficas e pelos domínios da qualidade de vida. Assim, maior atenção deve ser dada pelos pesquisadores aos diferentes modos de entender qualidade de vida, em especial valorizando métodos de pesquisa e avaliação interdisciplinar.

Agente comunitário de saúde; qualidade de vida; Organização Mundial da Saúde

ORIGINAL ARTICLE

Evaluation of overall quality of life of community health agents: the relative contribution of sociodemographic variables and domains of quality of life

Ana Cláudia G. C. Kluthcovsky^I; Angela Maria Magosso Takayanagui^II; Claudia Benedita dos Santos^III; Fábio Aragão Kluthcovsky^IV

^IPhysician. MSc. in Public Health Nursing. Professor, Department of Nursing, Universidade Estadual do Centro-Oeste, Guarapuava, PR, Brazil.

^IINurse. Professor, PhD in Nursing. Associate professor, Department of Maternal and Child Nursing and Public Health, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil

^IIIPhD in Statistics. Professor, Department of Maternal and Child Nursing and Public Health, Escola de Enfermagem de Ribeirão Preto, USP

^IVPhysician. MSc. in Public Health Nursing. Professor, Department of Nursing, Universidade Estadual do Centro-Oeste e Faculdade Guairacá

^{Correspondence}

ABSTRACT

OBJECTIVE: This study aimed at evaluating the relative contribution of each life quality domain (physical, psychological, social relationships and environment) and of sociodemographic variables to overall quality of life of community health agents from a municipality located in the State of Paraná, Brazil.

METHODS: A descriptive and cross-sectional study was carried out using a quantitative approach. The sample was composed of 169 agents (86.2% of the total). The World Health Organization Quality of Life Instrument Bref was used as a generic instrument to evaluate quality of life. Correlation tests and multivariate linear regression were used, considering a significance level of 5%.

RESULTS: None of the sociodemographic variables significantly interfered with overall quality of life. Among the four domains, the physical domain contributed the most to overall quality of life, followed by the psychological and environment domains, all of them accounting for 47.9% of variance. The domain of social relationships did not show significant contribution to overall quality of life.

CONCLUSION: It was observed that variance of overall quality of life was not completely explained by sociodemographic variables neither by quality of life domains. Thus, more attention should be given by researchers to different forms of understanding quality of life, especially research methods and interdisciplinary evaluation.

Keywords: Community health agent, quality of life, World Health Organization.

Introduction

Expansion and qualification of basic care, structured through a strategy by the Family Health Program (FHP), is a priority policy so that the Brazilian Ministry of Health can consolidate the Brazilian Unified Health System. The main objective is to overcome the disease-centered model. Team work is a key element for a permanent search for communication and experience and knowledge exchange between team members and the population of established territories. Health professionals and health community agents (HCA) are responsible for their respective territories, in a clear strategy of bond formation.¹

HCA are the link between the professional team and the community.² They work with family enrolment, and may be linked to a basic health unit by the Program of Community Health Agents (PACS) or by the FHP as members of the multiprofessional team.¹ They develop activities for disease prevention and health promotion through individual and collective educational actions to the families for which they are responsible.²

Started in 1994, FHP has presented an expressive growth over the past years, representing an important demand for health workers in the work market. Data from March 2007 indicated 219,379 HCA in activity in our country, present in rural and urban communities. That number is even more significant if we consider that, at that same time, 109,588,882 Brazilians (59% of the estimated total population) were assisted by HCA, and 5,299 Brazilian municipalities (95.2% of the total) had HCA.³

Results of the work performed by such increased number of health teams and professionals can be observed in studies on the FHP^4,5 and on the work developed by HCA,^6-9 which reveal better results in indicators of maternal, child and adult health and user satisfaction.

Considering the importance of HCA as health workforce and the dimension of the respective impact on health indicators, it is important to understand the work dynamics of these professionals. The role of "translator" from the scientific into the popular universe, insertion in the family context and problems, frequent resistance of the population against a proposal of change in habits, conflicts and relationship difficulties with community members and within the health team are some examples of pressures to which HCA are continuously submitted. They also require attention to decide which information from the community, family and individuals should be shared with the team, so that benefits are generated to the community. This demands an ability to face the dynamism of sanitary reality problems.¹⁰

The Brazilian Ministry of Health emphasizes the need of qualifying the workforce through permanent education, as a form of contributing to consolidate the National Health Policy.¹ Besides factors related to their formation, the importance of knowing other aspects of the life of HCA stands out, taking into account the agent's person, dilemmas, difficulties and achievements, which are factors influenced by the peculiar nature of their work.

Such aspect of the professional, which is more subjective, is not taken into consideration systematically. Increased number of studies on HCA, especially after 2000, reveals a concern by researchers in characterizing agents and their respective functions, evaluating work process and results, among other issues. However, no studies were found in the literature on the evaluation of HCA satisfaction or quality of life.¹¹

Thus, it is relevant to investigate the quality of life of HCA, since this information can support implementation of new strategies to improve their conditions of life and work and subsidize public health policies, which can generate a positive impact on health, concerning both HCA and the population they assist.

Quality of life and standard of life were initially the objectives of study by social scientists, philosophers and politicians,¹² focusing on material aspects. The concept was gradually widened, comprehending the socioeconomic and human development (objective aspect) and individual perception (subjective aspect) of people about their lives, thus valuing the individual's opinion.¹³

Many terms are often used in the literature as synonyms of quality of life, such as well being, happiness, conditions of life and more commonly satisfaction with life.¹⁴

Quality of life is defined by the World Health Organization (WHO) as: "the individual's perception of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns." In that definition is implicit the idea that the concept of quality of life is subjective, multidimensional and includes positive and negative evaluation elements.^12,15

Overall quality of life (OQL) can be evaluated using generic scales, without specifying diseases, or specific scales, which generally point to situations related to the individuals' quality of life and to the experience of diseases, worsened status or medical interventions, referring to chronic diseases or chronic consequences of diseases or acute worsened status.¹⁶

A distinction has been made between overall quality of life, quality of life dimensions or domains and components that are part of each dimension.^17-19 In a model proposed by Spilker, quality of life can be seen in three levels: first, overall perception of quality of life; second, each quality of life domain; and third, specific components of each domain.¹⁹

Due to the consensus in the literature on the relationship between the first level (OQL) and the second level (different domains) of Spilker's quality of life model,^20,21 this study aimed at evaluating existence and extension of contributions of sociodemographic variables and quality of life domains, including physical, psychological, social relationships and environment in OQL of HCA.

Methods

This is a descriptive, cross-sectional, quantitative study, which included HCA from a municipality located in the state of Paraná, Southern Brazil. Its economy is based on industry, farming, cattle raising and services and has a population of approximately 160,000 inhabitants, most of them residents of the urban area.²²

The municipality was under Full Management of Increased Basic Care and, up to December 2004, it had 33 FHP teams and a total of 196 HCA, of whom 193 were part of the FHP, and three of the PACS. With daily working time of 8 hours, mean monthly income of HCA was R$ 367.78, which corresponded to 1.4 minimum wages at that time.

Data collection

The study was analyzed and approved by the Research Ethics Committee of Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo.

A pilot study was carried out including 11 HCA, all working in the same municipality where the present study was performed. These HCA were given explanations about the study, and the same instructions were given to the individuals under investigation when the definite data collection was performed. In the pilot study, there was no difficulty in understanding the questions in the questionnaire, and the data collected were included in the study.

Twenty HCA did not participate in the study because they were on leave or on vacation and seven refused to participate.

Therefore, out of 196 HCA, the study group was comprised of 169 HCA, i.e., 86.2% of the total agents in that municipality.

Before starting data collection, all study participants, including those in the pilot study, signed a consent form.²³ HCA working both for a FHP and PACS team were considered. Data were collected in previously arranged meetings by a group of research assistants, previously trained, from November 5 to 12, 2004.

Instrument for data collection

The instrument used for data collection was the generic questionnaire on quality of life developed by WHO, the World Health Organization Quality of Life Instrument Bref (WHOQOL-Bref).²⁴ The questionnaire was answered by HCA individually, in a single meeting, and were self-administered, using the answers of the past 2 weeks as reference.

WHOQOL-bref is the shortened version of WHOQOL-100, both developed in multi-centered studies by the Quality of Life Group in the Department of Mental Health of WHO. In Brazil, the Portuguese version of WHOQOL-bref was developed at the WHOQOL center for Brazil, and was performed according to the methodology recommended for versions of this document.²⁴

The first part of the questionnaire is the information file about the respondent, which characterizes the individuals. The second part is the questionnaire, comprised of 26 questions. The first two questions are called overall or OQL; when calculated together, they generate an independent score of domains. The first question (Q1) refers to quality of life in general, and the second (Q2) to satisfaction with one's own life. The other 24 questions are distributed into four domains: physical, psychological, social relationships and environment.^24,25 The answers for the WHOQOL-bref questions have Likert scales, with five levels each and a scoring system that can range from 1 to 5.

Both OQL and domains are measured in a positive direction, thus higher scores indicate better assessment of quality of life. The scores can be transformed into two types of scales, one from 4 to 20 and another from 0 to 100.²⁶

This questionnaire was chosen as an instrument for data collection in this study because WHOQOL-bref had been applied in its Portuguese version, showing satisfactory psychometric characteristics,²⁴ besides being comprehensive and of fast application. In addition, there is a lack of validated generic instruments to assess quality of life, especially regarding worker's health.

Statistical analysis

For the statistical analysis of sociodemographic variables concerning OQL and domains, Pearson's correlation coefficient and Student's t test and variance analysis were used. Pearson's correlation coefficient was calculated between the four domains (physical, environmental, social and psychological) and OQL.

Models of multiple linear regression analysis were developed to verify the contribution of sociodemographic variables in quality of life domains and OQL and the contribution of these domains in the OQL. Significance level was set at 5%.

Results

Of the 169 (100%) HCA studied, 18 (10.6%) were male and 151 (89.3%) were female. Mean age of HCA was 31.1 years, with standard deviation of 8.8, minimum age of 19.1 and maximum age of 60.1 years. As to schooling level, 61.5% had completed high school, followed by 18.3% who had incomplete high school. With regard to marital status, most HCA were married (42.6%), followed by single (35.5%) and by those living as a married couple (13%) (Table 1).

Clique here to enlarge

Statistical analysis showed that sociodemographic variables (age, gender, schooling level and marital status) did not present statistically significant differences in relation to OQL. As to the domains, there was only significant difference between genders (p = 0.022) for the physical domain, and the female gender had mean assessment value (75.0±13.0) higher than the male gender (67.5±13.1).

As to self-perception of health by HCA, 60.9% classified it as "good," followed by 19.5% of those who classified it as "very good." However, 15.4% assessed it at an intermediate level, and 3.6% unfavorably (weak or very bad). Despite those results, 74 (43.8%) HCA reported having some type of health problem when the data were collected. Of these 74 HCA, the most reported health problem was "high pressure" (21%), followed by "chronic foot problem" (8%) and "depression" (6%).

Table 2 shows that, among all domains, that regarding social relationships had the highest mean score, followed by physical and psychological domains. The environmental domain had the lowest mean score.

Clique here to enlarge

Pearson's correlation was used for the analysis of all four domains and OQL. Table 3 shows that all four domains were correlated positively and significantly with OQL, and all correlations had moderate magnitude.

To verify the contribution and to what extent each quality of life domain explained OQL (dependent variable), multiple linear regression analysis was performed. Since the sociodemographic variables were not significant for OQL, as previously observed, they were not included in this model.

Among the four domains, the physical was the domain that explained OQL the most, contributing with 35%, followed by the psychological (9.1%) and environmental (3.8%). The domain of social relationships contributed with 0.8%, but it was not significant. All four domains together (physical, psychological, environmental and social relationships) explained 48.7% of OQL. Domains with significant contribution represented 47.9%.

Discussion

Several studies consider the influence of sociodemographic variables in the assessment of quality of life, such as age and gender,²⁷ besides schooling level and marital status.^19,20,28

HCA in this study were predominantly comprised of women and young adults, mean age of 31.1 years, and most agents were married.

Other studies in HCA have demonstrated predominance of women in this profession.^29,30 There seems to be a certain resistance by the community against male community agents, especially due to an embarrassment experienced by families in revealing some particularities of the female universe to a male agent, as well as due to the difficulty in having access to residences.³⁰

The age group represented by young adults was the most frequent in a study on HCA.²⁹ It is believed that older agents tend to know the community better, have more bonds and friendships, but may have some enemies or conflicts with other local people. In addition, because they have their own concepts about the health/disease process, they may be more resistant to new concepts related to health promotion. On the contrary, younger agents do not know the community so well, and may be less involved; however, they may not have enemies and be more open to changes and new concepts.²⁹ Furthermore, the fact of being hired through open competition may favor the admission of young individuals used to evaluations due to exams in their school routine.

Most (61.5%) had completed high school, followed by 18.3% with incomplete high school, which are higher means when compared with the schooling level of HCA in the South Region and in Brazil. The lowest schooling level, incomplete elementary school, was reported by 4.1%, and 8.9% of the HCA were attending higher education, a percentage that is higher than the mean in the South Region and in Brazil.³¹ Higher schooling level can also be a characteristic introduced by the hiring method in the setting under investigation.

Since it is a cross-sectional study, and even without scores of the general population or of other HCA groups for comparisons, evaluations performed by the HCA in this study indicated good mean evaluations regarding mean OQL scores and for domains, when compared with respective minimum and maximum values.

Statistical analyses of sociodemographic variables age, gender, schooling level and marital status related to OQL domains showed that only the variable gender was significantly different for the physical domain, with female gender having mean evaluation value (75.0±13.0) higher than the male gender (67.5±13.1).

According to a study carried out by Pinheiro et al.,³² women used the same health service more regularly, besides having other favorable access indicators in relation to men, such as number of medical visits, use of dental care services and higher demand for health services to perform routine and prevention examinations.

It is also likely that female HCA, due to their work in health, have facilitated access to health services and information, thus avoiding occurrence or worsening of diseases.

Regarding self-perception of health status, it should be observed that most HCA (80.4%) considered their health status as good or very good; however, 43.8% of the total HCA reported having some health problem. Such apparent discrepancy between a significant number of HCA who reported health problems and higher proportion of positive self-evaluations of health status suggests that health problems might not have a major influence in their daily activities.

When analyzing the contribution of each domain for OQL, the physical was the domain that explained OQL the most, contributing with 35%, followed by the psychological (9.1%) and environmental (3.8%). The domain of social relationships was not significant.

Due to greatest influence of the physical domain on OQL of HCA, it is important to stress the ability to work as a factor that may interfere with quality of life, which can be related to the predominant age group of young adults in that reality.

Work, along with food, housing and education, is a basic human need that should be met to have a life with quality.³³ Therefore, someone who does not have a satisfactory work can have difficulties and will hardly have a life with quality or acceptable.

The second domain in terms of influence on OQL of HCA was the psychological. Both burnout³⁴ and professional stress¹⁰ have increasingly become serious threats for health professionals, and may affect their health, quality of life, work performance and efficiency, besides causing communication difficulties and dissatisfaction, with consequent repercussions in quality of care.

According to Camelo & Angerami,¹⁰ in a study on evaluation of stress in FHP professionals, self-esteem of an individual can be influenced by work satisfaction. Thus, someone who has occupational stress may take their difficulties to the family environment or bring them to their professional environment, which can be translated into feelings of insecurity.

The environmental domain had little contribution in OQL of HCA. Even so, it is worth stressing the issue of wages and work regime. In a study by Pedrosa & Teles,⁶ HCA considered their wages as insufficient in relation to the work they performed. In addition, we stress the importance of a wage incentive policy, as well as the guarantee of labor rights, since an employee who earns worthy wages feels valued, satisfied and consequently has increased productivity and better performance in their jobs.

The domain of social relationships did not show significant contribution to OQL of HCA. This domain is represented in the questionnaire by the lower number of questions (three), and this is a factor that makes it less stable from the psychometric perspective.²⁴

Despite the domain of social relationships not having significant contribution to OQL, it is known that HCA are differentiated professionals in the sense of social relationships, since they live in the community where they work, performing their job directly with the community. In this sense, relationship of HCA in the work environment has been particularly studied over the past years with regard to people in the community or to other members of the health team.^4,6,9

In summary, this study showed that quality of life domains were different as to their respective contributions to OQL. However, its limitations should be considered, such as the cross-sectional design, which does not consider, therefore, possible time variations in domains and in OQL and the subsequent effect of domains in OQL, as well as any other important factor that could be influencing OQL of HCA.

Paschoal¹³ emphasizes the importance of evaluating self-perceived quality of life, thus valuing the individual's opinion. Quality of life would have a different concept from person to person, with a tendency of changing throughout life. To Fayers & Machin,¹⁸ overall evaluation of quality of life allows the individual to define that concept in a more significant manner for themselves, besides being able to be responsive to individual differences. To do so, it requires that the individual considers all aspects of a phenomenon, ignores those that are not relevant in that situation and thinks about other aspects according to their respective values and objective, so that an evaluation measurement can be provided.

Another fact that demands attention was the limited contribution of domains in OQL.^20,21 This could be partially explained by use of a shortened evaluation instrument, with OQL comprised of two questions and the domains of social relationships comprised of three questions.

To measure and operationalize quality of life, it is usually accepted the need of rebuilding the concept of its measurable components within the several processes involved in the creation of quality of life and representing aggregated (or separate) measures of quality of life as an index. Developing an understanding of the quality of life concept through those mechanisms and analysis of respective components inevitably requires the use of evaluation presuppositions about the relationship of component parts between themselves and with quality of life as a whole.¹⁷

Arnold et al.²⁰ reported that losses in one or more quality of life domains do not necessarily result in OQL loss and that the choice of a certain evaluation measurement is dependent upon the type of information one is searching for, such as, for example, whether the focus is physical aspects or general well being of patients.

Despite conceptual differences, it seems clear that quality of life is eminently interdisciplinary, requiring the contribution of different knowledge areas for methodological and conceptual enhancement.³⁵

This study and other similar studies may provide a support implementation of new strategies to improve conditions of life and work of HCA, which can doubtlessly bring an impact on the actions performed by such professionals and consequently on Brazilian public health. In addition, it can serve as motivation for further research, using a combination of other instruments for data collection, as well as other methodological approaches.

References

Received June 3, 2007

Accepted July 18, 2007

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Publication Dates

• Publication in this collection
  13 Dec 2007
• Date of issue
  Aug 2007

History

• Received
  03 June 2007
• Accepted
  18 July 2007