Introduction

Community health workers (CHWs) are part of the teams of the Family Health Strategy of the Brazilian National Health System (SUS)¹ and work on the front line of Primary Health Care, forming a link between the community and the health service. Standing out among the attributions of CHWs are the care of families who live in a given geographical area, health surveillance and the carrying out of educational activities among the population.¹

Studies developed in the Southeast, South and Northeast regions of the country found that CHWs were mostly in the 24-45 age group, female, had complete high school education and monthly family income of two to four minimum wages.^2,3 In the state of Rio Grande do Sul, 21.9% of the 564 CHWs studied reported being diagnosed as having hypertension and 5.5% as having diabetes mellitus.⁴ These results are similar to those found for CHWs in a municipality in the state of Rio Grande do Norte.⁵ Both in Rio Grande do Sul⁴ and in the capital of the state of Paraíba, João Pessoa (163 CHWs),⁶ a high percentage of overweight CHWs was found, 69.7% and 37.5% respectively, whereby the difference in these percentages may possibly be related to the fact that one of these studies used self-reported information,⁴ while the other used direct measurement.⁶

Simultaneous occurrence of two or more chronic non-communicable diseases in an individual, i.e. multimorbidity, increases risk of death, demand for health care and consequently costs imposed on the sector.⁷ Data from the 2013 National Health Survey indicate that 24.2% of Brazilian adults had two or more morbities.⁸ The relevance of the topic recommends investigation of occurrence of multimorbidity among healthcare workers.

The daily activities of CHWs in the community probably increase their exposure to situations of vulnerability while working, such as the demands of the population under their care and insecurity resulting from working in peripheral neighborhoods, which can affect the quality of life and health conditions of these workers.⁹ In this sense, studies with CHWs have been conducted in Brazil, mainly to identify the work processes involved in their jobs, their socio-demographic and economic reality and the impact of these aspects on their quality of life and mental health.^2,10 Despite the limited number of these studies and their clearly restricted samples of CHWs, there is evidence that this is a group of workers with compromised physical and mental health, even though they live in the Primary Health Care context and undertake actions to promote health and prevent diseases and illnesses.^4-6,10

To date, no research has been identified that investigates the health conditions of CHWs based on objective health information, only those using self-reported data from a limited number of chronic non-communicable disease. Information about the presence of multimorbidity in these health workers is scarce, for all the Brazilian Federative Units. Given this scenario, the present study aimed to assess health conditions, care of own health and lifestyle habits of CHWs in Vitória, state of Espírito Santo, Brazil.

Methods

Results

Of the 375 CHWs eligible for the study, 263 (70.1%) showed up for the examinations and interviews, and had their data collected. After exclusion of one pregnant woman, data from 262 CHWs were included in the analysis. The sociodemographic characteristics of the participants, according to sex and age group, are shown in Table 1.

The sample was composed mostly of female participants (94.3%), of brown race/skin color (50.0%), with complete high school education (81.3%), belonging to socioeconomic class C (58.8%), married (66.4%) and whose mean age was 46.1±9.3 years (Table 1). Mean length of time working as a CHW was 16.2±4.8 years.

Significant differences were found for age and marital status in relation to the ‘sex’ variable (p-value=0.023 and p-value=0.015, respectively). All sociodemographic variables presented in Table 1 were statistically different in relation to age group, with the exception of socioeconomic class.

Taking the total sample, 60.9% were sedentary (Table 2). A higher percentage of current smokers was found among those aged ≥45 years (p-value<0.001). Male participants had a higher percentage of alcoholic beverage consumption and higher mean time spent sitting, when compared to females (p-value=0.050 and p-value=0.001, respectively). Younger individuals had higher mean screen time and time spent sitting (p=0.021 and 0.007, respectively), compared to those aged ≥45 years (Table 2).

Table 2 also shows the percentages of diabetes mellitus (17.2%), hypertension (37.0%), hypercholesterolemia (57.3%), hypertriglyceridemia (27.1%), obesity (39.8%), abdominal obesity (50.4%) and metabolic syndrome (30.2%). All of these, with the exception of obesity and abdominal obesity, were significantly higher among individuals aged ≥45 years. Sixty CHWs (22.9%) were identified as having prediabetes.

Figure 1 shows the most frequent percentages of multimorbidity. Of the CHWs studied, 40.8% had three or more morbidities, the most frequent being the combination of BMI ≥30kg/m², abdominal obesity and hypercholesterolemia (22.0%). No statistically significant differences were observed between multimorbidity frequency and sex (p-value=0.061); however, 66.4% of individuals with three or more morbidities were aged ≥45 years (p-value<0.001).

Figure 1 Most frequent percentages of two and three morbidities among community health workers, CACEA Study, Vitória, Espírito Santo, Brazil, 2018-2019 

Table 3 shows the biochemical and clinical parameters, according to sex and age group. Female CHWs had higher values for total cholesterol (p-value=0.049), HDL-cholesterol (p-value=0.004) and PBF (p-value<0.001). Comparing biochemical and clinical parameters by age groups, total cholesterol (p-value<0.001), Lower Density Lipoprotein (LDL) cholesterol (p-value<0.001), triglycerides (p-value=0.008), PBF (p-value=0.047) and waist circumference (p-value=0.040) were higher in subjects aged ≥45 years.

We classified 10 (22.2%) CHWs as having diabetes mellitus and 9 (9.3%) as having hypertension, but who reported that they had not been previously diagnosed as having these conditions and therefore did not use specific medication for them (Table 4). Of those who had prior diagnosis, 20% were not on medication for diabetes mellitus or hypertension. Moreover, about 23% had higher than normal blood glucose and 22.5% reported use of anxiolytic and/or antidepressant medication, with no significant difference between both age groups (p-value=0.206), although use of this medication was associated with poorer self-perceived health status (p-value<0.010).

Discussion

The CHWs we studied were mostly female, married, of brown skin color, with complete high school education and belonging to socioeconomic class C. They had high percentages of prediabetes, diabetes mellitus, hypertension, obesity, cholesterol, hypertriglyceridemia, metabolic syndrome and sedentarism. About 40% had three or more associated morbidities, and of those previously diagnosed with diabetes mellitus and/or hypertension, one-fifth were not taking medication for these conditions. Anxiolytic and/or antidepressant medication use was high, and was associated with poor self-perceived health status.

A study conducted in the Metropolitan Region of Vitória (which includes the municipalities of Cariacica, Vitória, Vila Velha and Serra), with 291 CHWs, found similar results regarding the sociodemographic characteristics and income of these professionals,² as did studies conducted in the Northern⁶ and Southern regions of Brazil,³ with the exception of mean age, which in our study was higher than that found in those studies.^2,3,6 Some 30% of the sample reported having worked as CHWs for a period ≥20 years (data not shown), which may explain their higher mean age in relation to peers from other locations in Brazil.

Younger individuals use screen devices more frequently and are more familiar with them;²² and mean time spent sitting is greater among those with higher levels of education.²³ Both factors corroborate our findings on CWH screen time and time spent sitting. Although there is no consensus about recommended screen time for adults, the mean among the CHWs we studied was above 2 hours per day, which can be considered high. Therefore, sedentary behavior is a reality in the group studied, considering the high averages of screen time and time spent sitting, in addition to almost 61% reporting doing physical activities less than 10 minutes per week.

The relationship between adverse health conditions and age is already well established in the literature,²⁴ which may justify our findings for older individuals. Moreover, in this study in Vitória, ES, we found a high percentage of chronic non-communicable diseases, higher than that found in a subsample of the 2013 National Health Survey from the same city.²⁵ It should be emphasized that, although objective measurements were used in both of these studies, some of the diagnostic criteria were different, such as classification of diabetes mellitus and hypertension. In our study, we chose to increase diagnosis specificity, by using a greater number of criterias.

We found a considerable percentage of individuals who had diabetes mellitus and/or hypertension, and 13.4% of them were only classified as such during the study, i.e., they did not know their health condition until then. Even when they had prior diagnosis, a relevant percentage of CHWs did not use medication. This data is of concern, since they are professionals whose job includes raising community awareness about the need to control and adequately treat these diseases. We realize that underdiagnosis of diabetes mellitus and hypertension, which a priori are asymptomatic diseases, is still considerable, and may be reflected in lack of clinical follow-up and adequate treatment. Late diagnosis and management of chronic non-communicable diseases generates more costs for the health system and has considerable impact on terms of increasing morbidity and mortality.²⁶

More participants in our study were classified as obese compared to CHWs assessed in other studies, such as those conducted in João Pessoa, PB,⁶ in the state of Rio Grande do Sul⁴ and in Vitória, ES.²⁵

Female CHWs had higher total cholesterol and HDL-cholesterol values than male CHWs. This finding that may be related to their higher mean age, given the well-established relationship between age and serum lipid levels.²⁷ Furthermore, there is evidence that sex hormones can influence HDL-cholesterol: endogenous estrogen production in premenopausal women is associated with higher levels of HDL-cholesterol.²⁸ PBF was also higher in female CHWs, in line with the difference in the pattern of body fat distribution between the sexes.¹⁶

Age is an independent risk factor for a deteriorating lipid profile and development of cardiovascular disease.²⁷ However, in our study, younger individuals also presented high biochemical and clinical parameters. Therefore, the sample studied, regardless of age group, presented unfavorable health conditions and multimorbidity, as well as a high percentage of anxiolytic and/or antidepressant medication use associated with poor self-perceived health status.

A study with CHWs from Pelotas, RS, Brazil, found high prevalence of stress and depression, which was measured by scales to identify symptoms and by saliva cortisol content.¹⁰ Among health professionals, these conditions are related to psychosocial and environmental risk factors to which they are exposed during their work routines.⁹ CHWs are members of the community in which they work and, therefore, are seen not just as neighbors, but also as facilitators of access to the local health service.⁹ This characteristic and other pressures inherent to the work of any health professional, are indicated as being factors that contribute to reduction in their quality of life and poorer mental health.^9,10

Despite the high prevalence of chronic non-communicable diseases among Primary Health Care professionals,²⁹ the situation of CHWs requires attention, since their socioeconomic status is generally low, which represents a risk factor for the occurrence of these diseases. The social determinants of health can hinder the incorporation of measures to prevent and control diseases and illnesses,³⁰ given that these same professionals are responsible for raising the awareness of the community they assist.

Because it is a sample from a specific municipality, it is not possible to extrapolate its results to other locations, which we understand to be a limitation. However, the high adherence of the CHWs to our study makes it possible to consider that the sample is representative of the CHW population in Vitória. Moreover, some aspects assessed by our study were self-reported and, therefore, subject to memory bias, although it is worth highlighting the pioneer nature of this study in proposing a broad diagnosis of CHW health, through measurement and assessment of biochemical and clinical parameters, performed by a qualified team under supervision throughout the study period.

CHWs work in Primary Health Care, undertaking health promotion and disease prevention actions. We believe that assessing the health conditions of these workers can contribute to their self-care and, consequently, impact the performance of Family Health teams.

All participants received their test results with medical reports within ten days at the most, and those who presented any alteration were advised to seek treatment in the healthcare network. It is possible that their having undergone biochemical, clinical and imaging tests has encouraged them to seek treatment and change habits and lifestyles.

We conclude that the health conditions and lifestyle habits of CHW in Vitória, capital of the state of Espírito Santo, deserve attention, given the high percentage of chronic non-communicable diseases, multimorbidity and sedentary lifestyles found, in addition to early disease, considering the average age of the group. These health professionals will probably remain active indefinitely, for several years, on the labor market, pointing to the need for specific actions to prevent and treat the health problems we found.