Quality of life of Family Health Strategy professionals: a systematic review

ABSTRACT BACKGROUND: Individuals’ quality of working life and motivation are directly related to their satisfaction and wellbeing. Although studies on the quality of life of family health workers have been conducted, there are none correlating these professionals’ wellbeing with this work model. OBJECTIVE: To review the scientific literature in order to identify the levels of quality of life, in their dimensions, of Family Health Strategy workers. DESIGN AND SETTING: Systematic review of observational studies developed through a partnership between two postgraduate schools (Piracicaba and Uberlândia). METHODS: The review followed the PRISMA recommendations and was registered in the PROSPERO database. Ten databases were used, including the “grey literature”. Two evaluators selected the eligible studies, collected the data and assessed the risk of biases, independently. The JBI tool was used to assess the risk of bias. A complementary statistical analysis was conducted on the means and standard deviations of the results from the WHOQOL-100 and WHOQOL-bref questionnaires. RESULTS: The initial search presented 1,744 results, from which eight were included in the qualitative analysis. The studies were published between 2007 and 2018. The total sample included 1,358 answered questionnaires. All the studies presented low risk of bias. The complementary analysis showed that the environmental factor (mean score 56.12 ± 2.33) had the most influence on the quality of life of community health workers, while physical health (mean score 14.29 ± 0.21) had the most influence on graduate professionals. CONCLUSION: Professionals working within the Family Health Strategy had dimensions of quality of life that varied according to their professional category.


INTRODUCTION
Over the last decades, Brazil has faced the challenge of changing the public healthcare model, i.e. to migrate from the Flexnerian model focused on procedures and specialized care to a comprehensive care model based on understanding the social determinants of health. 1,2 One of the crucial points in this change is to strengthen primary healthcare, for which the main operational strategy is the family health model. [3][4][5] This strategy makes it possible to expand access to healthcare services and implement actions towards comprehensive healthcare. 6,7 Expansion of this model has been associated with a 45% reduction in hospitalizations for conditions that are sensitive to resolution within primary healthcare, over a 15-year period. 5 Data from the Ministry of Health indicated that in 2019 there were 43,754 family health teams operating throughout the country. These teams were responsible for providing primary healthcare to 64.47% of the Brazilian population. 8 Family health work demands different skills for developing innovative community care practices, which makes the work complex and challenging. 9 Primary healthcare professionals present high prevalence (52.9%) of chronic stress associated with their work. 10 Analysis on this prevalence according to professional category shows that even higher prevalence can be observed: 54% among nurses and 67% among doctors. 11,12 However, studies conducted among Brazilian professionals in family health teams have shown lower prevalence of burnout syndrome, varying according to the region of Brazil. In one municipality in the northeastern region, the prevalence of professionals with medium and high levels of burnout was observed to be 37.9%. 13 In a municipality in southeastern Brazil, the prevalence of this syndrome reached 41 Access Theses and Dissertations) databases were used to partially capture the "grey literature". The MeSH (Medical Subject Headings),

DeCS (Health Sciences Descriptors) and Emtree (Embase Subject
Headings) resources were used to select adequate search descriptors.
The Boolean operators "AND" and "OR" were used to enhance the research strategy through several combinations, as shown in Table 1.
The search was performed in January 2020. The results obtained were exported to the EndNote Web™ software (Thomson Reuters, Toronto, Canada), in which duplicates were removed.

Study selection
The studies were selected in three stages. A calibration exercise was performed before the selection of studies, in which the reviewers discussed the eligibility criteria and applied them to a sample of 20% of the results retrieved to determine inter-examiner agreement. After an adequate level of agreement (kappa ≥ 0.81) had been reached, the first stage was started. In this, two reviewers (ACCPB and WAV) analyzed all the titles of the studies, independently. Any divergences between these examiners were discussed with a third reviewer (AMH) to reach a consensus. Studies that were not excluded in this phase continued to the next one. In the second phase, the same reviewers (ACCPB and WAV) read the abstracts, independently. The abstracts that did not meet the eligibility criteria were eliminated. Articles in which the titles met the objectives of the study but for which the abstract was unavailable were fully analyzed in the next phase. In the third phase, the preliminarily eligible studies were fully read to verify whether they met the eligibility criteria. In cases of disagreement between the two reviewers, a third one (AMH) was consulted to make a final decision. The studies rejected were registered separately, with explanations of the reasons for exclusion.

Data collection
To ensure consistency between the reviewers in the data collection process, a calibration exercise was performed, in which the reviewers (ACCPB and AMH) extracted information from an eligible study together. After the selection, the studies were analyzed and the two reviewers (ACCPB and AMH) extracted the following information from each of them: study identification (author, year and location), sex, number of questionnaires answered, occupation, types of questionnaires used, mean results regarding quality of life obtained from the questionnaires, application of additional questionnaires and collection of socioeconomic data from the sample.

Risk of individual bias of the studies
The risk of bias and individual quality of each study included were assessed using the JBI critical appraisal tools for use in systematic reviews on cross-sectional observational studies. 22 Two authors In this regard, it is important to understand that the way in which work is organized affects both the workers' quality of life and the service provided. These are therefore important objects of investigation. 15,16 It can thus be seen that adequate provision of services requires maintenance of the quality of life of family health professionals. 17 Individuals' quality of working life and motivation are directly related to their satisfaction and wellbeing. Dissatisfaction in a team harms the evolution and productivity of the institution. 18 Although studies on the quality of life of family health workers have been conducted, there are no studies correlating the wellbeing of these professionals with this work model, 19 or proposing actions directed to the quality of life of these workers.

OBJECTIVE
The aim of the present systematic review was to identify the levels of quality of life, in each of their dimensions, of Family Health Strategy workers.

Protocol registration
This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 20

and the Joanna Briggs Institute Manual for
Evidence Synthesis. 21 The systematic review protocol was registered in the PROSPERO database under # CRD42019123243.

Study design and eligibility criteria
This systematic review aimed to answer the following research question: "What are the levels of quality of life of professionals working in the Family Health Strategy?" This question was based on the "Population, Variable and Outcome" strategy, in which the population included in the study was primary healthcare professionals, the variable was the work in the Family Health Strategy and the outcome was quality of life, considering its different dimensions.
The inclusion criteria defined for selection of studies were that these should only be cross-sectional observational studies developed in Brazil, with quality-of-life questionnaires applied to professionals working in the Family Health Strategy. There were no restrictions on year or language. The following types of study were excluded: 1) experimental or non-cross-sectional studies; 2) studies that did not answer the research question; 3) studies on instrument validation; and 4) qualitative studies.

Sources of information and search strategies
The primary study sources used were the PubMed (including  20 The risk of bias was categorized as high when the study reached a "yes" score of up to 49%, moderate when the study reached a "yes" score of 50% to 69% and low when the study reached a "yes" score of more than 70%. The question assessing the inclusion criteria for the study participants (Q1) was considered to have been answered "yes" (criteria verified) when the studies included the universe of family health professionals. The question referring to exposure factors (Q3) was considered "not applicable" because this systematic review aimed to identify factors that influence the quality of life, but only the dimensions most affected. Similarly, the questions about identification (Q5) and treatment (Q6) of the confounding factors were considered "not applicable" because they would identify the validity of the exposure studied.

Study selection
In the initial phase of study identification, after exploring the ten electronic databases, 1,744 results were found. Next, duplicate articles were excluded, which left 1,373 studies for the analysis on titles and abstracts. From these, 12 remained for full-text reading.
After reading the full texts, a further four articles were excluded ( ("Quality of Life" OR "Life Quality") AND ("Family Health" OR "Family Health Strategy" OR "Primary Health Care") AND ("Health Occupation" OR "Health Worker" OR "Health Profession" OR "Health Personnel" OR "Occupational Health") ("Quality of Life" OR "Health Related Quality Of Life" OR "Health-Related Quality Of Life" OR "Life Quality" OR "HRQOL") AND ("Family Health" OR "Family Health Strategy") AND ("Health Worker" OR "Health Profession" OR "Health Personnel") LILACS http://lilacs.bvsalud.org/ ("Quality of Life") AND ("Family Health") AND ("Health Personnel") ("Qualidade de Vida") AND ("Saúde da Família") AND ("Saúde do Trabalhador") ("Quality of Life") AND ("Family Health") AND ("Health Workers") SciELO http://www.scielo.org/ ("Quality of Life") AND ("Family Health") AND ("Health Personnel") ("Quality of Life") AND ("Family Health") AND ("Occupational Health") ("quality of life") AND ("Family Health") AND ("health workers") Web of Science http://apps.webofknowledge. com/ (("Quality of Life" OR "Health Related Quality Of Life" OR "Health-Related Quality Of Life" OR "Life Quality" OR "HRQOL") AND ("Family Health" OR "Family Health Strategy" OR "Primary Health Care") AND ("Health Occupation" OR "Health Worker" OR "Health Profession" OR "Health Personnel" OR "Occupational Health")) ScienceDirect https://www.sciencedirect. com/ ("Quality of Life" OR "Life Quality" OR "HRQOL") AND ("Family Health" OR "Family Health Strategy" OR "Primary Health Care") AND ("Health Occupation" OR "Health Worker" OR "Health Profession" OR "Health Personnel" OR "Occupational Health") Embase http://www.embase.com ('quality of life' OR 'health related quality of life' OR 'health-related quality of life' OR 'life quality' OR 'hrqol') AND ('family health' OR 'family health strategy' OR 'primary health care') AND ('health occupation' OR 'health worker' OR 'health profession' OR 'health personnel' OR 'occupational health') OpenGrey http://www.opengrey.eu/ ("Quality of Life") AND ("Family Health" OR "Primary Health Care") AND ("Health Worker" OR "Health Profession" OR "Health Personnel") ("Quality of Life") AND ("Family Health") AND ("Occupational Health") OpenThesis http://www.openthesis.org/ ("Quality of Life" OR "Health Related Quality Of Life" OR "Health-Related Quality Of Life" OR "Life Quality" OR "HRQOL") AND ("Family Health" OR "Family Health Strategy") AND ("Health Worker" OR "Health Profession" OR "Health Personnel") OATD https://oatd.org/ ("Quality of Life" OR "Health Related Quality Of Life" OR "Health-Related Quality Of Life" OR "Life Quality" OR "HRQOL") AND ("Family Health" OR "Family Health Strategy") AND ("Health Worker" OR "Health Profession" OR "Health Personnel") Thus, eight studies [26][27][28][29][30][31][32][33] were selected for the qualitative analysis, but only five of these were retained for the complementary analysis stage. One of the three studies that were not retained for this final stage 27 differed from the others regarding the instrument for measuring the quality of life. The other studies that were not retained 28,29 did not present the data on quality of life in full. Figure 1 shows the entire process of identification, selection and eligibility of the studies. Martin et al. 25 The instrument used in the study did not address quality of life Fernandes et al. 17 Instrument validation Mota et al. 23 Instrument validation Ejlertsson et al. 24 Duplicate publication

Characteristics of eligible studies
The eligible studies were published between 2007 and 2018. [26][27][28][29][30][31][32][33] The total sample included 1358 questionnaires answered by Family Health Strategy workers. Their average age ranged from 28 to 33 years (Table 3). 26,33 All eight studies had been approved by ethics committees and the workers had signed an informed consent statement. The category of workers with the highest number of participants was community health workers (n = 557), but nurses (n = 180) and physicians (n = 162) also answered the questionnaires. All of the studies were conducted using questionnaires. Five studies [28][29][30][31]33 used the WHOQOL-bref protocol, which is a reduced version of the WHOQOL-100 questionnaire, which was used in two studies. 26

Risk of individual bias of the studies
All eight studies presented low risk of bias. The studies by Kluthcovsky et al., 30 Ursine et al. 33 and Morais et al. 28 obtained positive evaluations in all the criteria analyzed. The studies by Vasconcelos and Costa-Val, 31 Figueiredo et al., 27 Miranzi et al., 32 Fernandes et al. 26 and Teles et al. 29 obtained positive evaluations for 80% of their questions. The question assessed as negative in these five studies 26,27,29,31,32 related to the description of study location and subjects (Q2) because the studies did not inform these data, especially concerning study subjects ( Table 4).

Result measurement and qualitative synthesis
The study by Figueiredo et al. 27 used Walton's QWL, which contains the following domains: adequate and fair compensation,   working conditions, work capacities, work opportunity, social integration, respect for workplace laws, working life space and social relevance. 34 These authors 27 observed that the mean overall QWL score was 6.72 points, and fair compensation and working conditions were the domains most affected. Although these instruments were used in the studies by Teles et al. 29 and Morais et al., 28 their data were not included in Table 5 because they were presented as percentages measured in the quality-of-life domains. The study by Teles et al. 29 focused on assessing the results among professionals with low quality of life, and an overall score of 6.72 was obtained. These authors indicated that community health workers had moderate quality of life. Morais et al. 28 observed that physicians presented unsatisfying quality of life in the physical, social and environmental domains and an overall score of 14.5 ± 2.2.

Complementary statistical analysis
Only five studies 26,[30][31][32][33] presented sufficient mean and standard deviation data for the complementary analysis. Three studies that were included in the descriptive synthesis [27][28][29] were not included in this stage for the following reasons: one study used a different instrument, 27 another study presented data on workers with low quality of life 29 and another study described its data in a manner that prevented grouping in the complementary analysis. 28 Figure 2A shows the quality-of-life scores reported in the eligible studies based on the WHOQOL-bref questionnaire. Through estimating weighted means according to sample sizes, it was found that the total quality-of-life score from the WHOQOL-bref questionnaire was 71.74 (SD = 3.27). The environmental domain was the most affected (mean = 56.12; SD = 2.   The worst results were found in the physical and environmental domains. The main complaints from the participants were lack of bonding, insecurity in the workplace, number of employment links and wages. when working with families because they were exposed to urban violence without any type of protection against this reality, which was present in several regions. There was also a feeling of insecurity and uncertainty regarding the job, which was observed by Souza and Freitas 36  and their monthly income may be considered to be close to 38  There is high prevalence of work burnout among graduate professionals. 40,42 Silva et al. 42 indicated that the prevalence of burnout was 64% and the prevalence of inability to work was 32% among nurses, physicians, dentists and social workers. Lima, Farah and Teixeira 40 studied physicians, nurses and dentists working in the Family Health Strategy in a large city in the state of Minas Gerais, Brazil, and found that more than half of the professionals presented burnout syndrome. Kluthcovsky et al. 30 Miranzi et al. 32 Fernandes et al. 26 Vasconcellos et al. 31 Ursine et al. 33 Physical health Social relantioships The studies included in this systematic review used different instruments to assess the quality of working life, from unspecific ones (WHOQOL-100 and WHOQOL-bref) to a specific instrument for the work environment (Walton's QWL). Regarding the unspecific instruments included in this systematic review, it is worth noting that both were developed by the same group of researchers: WHOQOL-bref is the short version of WHOQOL-100. 35 The authors of these instruments suggested that both are effective in assessing quality of life within the concept determined by the World Health Organization, but that the short version would be indicated for assessing work routines in epidemiological studies. 35 The existence of several instruments lies within the very essence of the concept of quality of life: polysemic, imperfect and dynamic. 43 The specific instrument used by Figueiredo et al. 27 (Walton's QWL) comes from the conception of work-related quality of life that has been observed within a context of labor movements towards more legal certainty in the workplace, better working conditions and adequate remuneration. 34 However, the creation of this concept, and consequently the instrument, was linked to a historical and cultural particularity of a region, with constant updates and new propositions for the concept of work-related quality of life. 44 Therefore, the systematic review and meta-synthesis by Pennisi et al. 45 indicated that assessing the quality of life of Family Health Strategy professionals should include the following factors: working conditions, work processes, interpersonal relationships, personal aspects, work context, work overload and autonomy.
This study is not free from limitations. The first of them related to the heterogeneity observed in the eligible studies, caused by the use of different questionnaires to assess the quality of life Another important factor is the influence of the region covered by the family health team on the quality of life of community health workers. There is an important paradox in considering this relationship and the promotion of quality of life for this professional category because the region is itself the workplace of community health workers, but is also the main factor responsible for interfering with their quality of life.