Effects of Urban Violence on Primary Healthcare: The Challenges of Community Health Workers in Performing House Calls in Dangerous Areas


Community health workers in developing countries usually perform house calls in degraded and violent territories. Thus, in this paper we study the effects of urban violence in the performance of CHWs in poorly developed territories, in order to understand the challenges of delivering care to dangerous communities in developing countries. We conducted telephone surveys for 5 months in 2017, within a systematic sample of 2.000 CHWs based on clinics distributed along the health regions of the city of Rio de Janeiro, Brazil. We completed 766 interviews, approximately 40% of the sample, 86% man and 14% women. Most participants are 30 to 39 years old (35%), followed by 27% of 40 to 49 years old participants. As CHWs work on the sharp end of the healthcare system, responsible for outreaching, community education, counseling, and social support, our study presents contributions to government and management levels on working conditions inside communities, constraints in assistance, and difficulties in implementing primary care policies.

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  1. 1.

    Rawaf, S., De Maeseneer, J., & Starfield, B. (2008). From Alma-Ata to Almaty: a new start for primary health care. The Lancet, 372, 1365–1367.

    Article  Google Scholar 

  2. 2.

    Declaration of Alma-Ata (1978). Alma-Ata, USSR: World Health Organization.

  3. 3.

    Payne, J., Razi, S., Emery, K., et al. (2017). Integrating community health workers (CHWs) into health care organizations. Journal of Community Health, 42, 983–990. https://doi.org/10.1007/s10900-017-0345-4.

    Article  PubMed  Google Scholar 

  4. 4.

    Rosenthal, E.L., Lacey, Y., Blondet, L., et al. (1998) A summary of the National Community health advisor study: Weaving the future—A policy research project of the University of Arizona. Tucson Univ Ariz Rural Health Office of the Mel Enid Zuckerman Ariz College Public Health, 14, 2005.

  5. 5.

    Standing, H., & Chowdhury, A. M. R. (2008). Producing effective knowledge agents in a pluralistic environment: What future for community health workers? Social Science and Medicine, 66, 2096–2107. https://doi.org/10.1016/j.socscimed.2008.01.046.

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    Singh, P., & Sullivan, S. (2011). One million community health workers: Technical task force report (pp. 304–310). New York: Earth Inst Columbia University.

    Google Scholar 

  7. 7.

    Perry, H. B., Zulliger, R., & Rogers, M. M. (2014). Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness. Annual Review of Public Health, 35, 399–421.

    Article  PubMed  Google Scholar 

  8. 8.

    Bibby, R. W. (1981). Crime and punishment: A national reading. Social Indicators Research, 9, 1–13. https://doi.org/10.1007/BF00668698.

    Article  Google Scholar 

  9. 9.

    Gaitán-Rossi, P., & Shen, C. (2018). Fear of crime in Mexico: The impacts of municipality characteristics. Social Indicators Research, 135, 373–399. https://doi.org/10.1007/s11205-016-1488-x.

    Article  Google Scholar 

  10. 10.

    Kitchen, P., & Williams, A. (2010). Quality of life and perceptions of crime in Saskatoon, Canada. Social Indicators Research, 95, 33–61. https://doi.org/10.1007/s11205-009-9449-2.

    Article  Google Scholar 

  11. 11.

    Abdalla, R. R., Massaro, L., de Queiroz Constantino Miguel, A., et al. (2018). Association between drug use and urban violence: Data from the II Brazilian National alcohol and drugs survey (BNADS). Addictive Behaviors Reports, 7, 8–13.

    Article  PubMed  Google Scholar 

  12. 12.

    Pavoni, A., & Tulumello, S. (2018) What is urban violence? Progress in Human Geography. https://doi.org/10.1177/0309132518810432.

    Article  Google Scholar 

  13. 13.

    Barahona, I. (2018). Poverty in Mexico: Its relationship to social and cultural indicators. Social Indicators Research, 135, 599–627. https://doi.org/10.1007/s11205-016-1510-3.

    Article  Google Scholar 

  14. 14.

    Jatobá, A., Bellas, H. C., Koster, I., et al. (2018). Patient visits in poorly developed territories: A case study with community health workers. Cognition, Technology & Work, 20, 125–152.

    Article  Google Scholar 

  15. 15.

    Lancman, S., Ghirardi, M. I. G., de Castro, E. D., et al. (2009). Repercussions of violence on the mental health of workers of the Family Health Program. Revista de Saude Publica, 43, 682–688.

    Article  PubMed  Google Scholar 

  16. 16.

    Glebbeek, M.-L., & Koonings, K. (2016). Between Morro and Asfalto. Violence, insecurity and socio-spatial segregation in Latin American cities. Habitat International, 54, 3–9. https://doi.org/10.1016/j.habitatint.2015.08.012.

    Article  Google Scholar 

  17. 17.

    Monteiro, J., & Rocha, R. (2017). Drug battles and school achievement: Evidence from Rio de Janeiro’s Favelas. Review of Economics and Statistics, 99, 213–228. https://doi.org/10.1162/REST_a_00628.

    Article  Google Scholar 

  18. 18.

    de Souza, E. R., & de Minayo, M. C. S. (2017). Public security in a violent country. Cad Saúde Pública. https://doi.org/10.1590/0102-311x00036217.

    Article  PubMed  Google Scholar 

  19. 19.

    Chaidez, V., Palmer-Wackerly, A. L., & Trout, K. E. (2018). Community health worker employer survey: Perspectives on CHW workforce development in the midwest. Journal of Community Health, 43, 1145–1154. https://doi.org/10.1007/s10900-018-0533-x.

    Article  PubMed  Google Scholar 

  20. 20.

    Morosini, M., & Fonseca, A. F. (2018). Configurações do trabalho dos Agentes Comunitários na Atenção Primária à Saúde entre normas e práticas. Atenção Primária à saúde no Brasil: conceitos, práticas e pesquisa (pp. 369–406). Fiocruz: Rio de Janeiro.

    Google Scholar 

  21. 21.

    Wennerstrom, A., & Rush, C. H. (2016). The terminology of community health workers. American Journal of Public Health, 106, e10. https://doi.org/10.2105/AJPH.2016.303248.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Torres, S., Balcázar, H., Rosenthal, L. E., et al. (2017). Community health workers in Canada and the US: working from the margins to address health equity. Critical Public Health, 27, 533–540.

    Article  Google Scholar 

  23. 23.

    Ospina, S.T. (2013) Uncovering the role of community health worker/lay health worker programs in addressing health equity for immigrant and refugee women in Canada: An instrumental and embedded qualitative case study

  24. 24.

    Lopes, D. M. Q., Beck, C. L. C., Prestes, F. C., et al. (2012). Community health agents and their experiences of pleasure and distress at work: A qualitative study. Revista da Escola de Enfermagem da U S P, 46, 633–640. https://doi.org/10.1590/S0080-62342012000300015.

    Article  PubMed  Google Scholar 

  25. 25.

    Scott, K., Beckham, S. W., Gross, M., et al. (2018). What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. Human Resource Health. https://doi.org/10.1186/s12960-018-0304-x.

    Article  Google Scholar 

  26. 26.

    Swartz, A., & Colvin, C. J. (2015). ‘It’s in our veins’: caring natures and material motivations of community health workers in contexts of economic marginalisation. Critical Public Health, 25, 139–152.

    Article  Google Scholar 

  27. 27.

    Balcazar, H., Lee Rosenthal, E., Nell Brownstein, J., et al. (2011). Community health workers can be a public health force for change in the United States: Three actions for a new paradigm. American Journal of Public Health, 101, 2199–2203.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Lemay, C. A., Ferguson, W. J., & Hargraves, J. L. (2012). Community health worker encounter forms: A tool to guide and document patient visits and worker performance. American Journal of Public Health, 102, e70–e75.

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Brazilian Ministry of Health (2006). Brazilian Primary Health Care National Policy. http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt0648_28_03_2006.html

  30. 30.

    do Alonso, C. M. C., Béguin, P. D., & Duarte, F. J. D. (2018). Work of community health agents in the family health strategy: Meta-synthesis. Revista Saúde Pública, 52, 14. https://doi.org/10.11606/s1518-8787.2018052000395.

    Article  Google Scholar 

  31. 31.

    Martines, W. R. V., & Chaves, E. C. (2007). Vulnerability and suffering in the work of a community health agent in the family Health program. Revista da Escola de Enfermagem da U S P, 41, 426–433. https://doi.org/10.1590/S0080-62342007000300012.

    Article  PubMed  Google Scholar 

  32. 32.

    de Coriolano, M. W. L., & de Lima, L. S. (2010). Focus groups with community health agents: Subsidies for understanding these social actors. Revista Enfermagem UERJ, 18, 92–96.

    Google Scholar 

  33. 33.

    Krug, E. G., Dahlberg, L. L., Mercy, J. A., et al. (2002). World report on health and violence. Geneva: World Health Organization.

    Google Scholar 

  34. 34.

    Evans, T. (2013). Organisational rules and discretion in adult social work. The British Journal of Social Work, 43, 739–758. https://doi.org/10.1093/bjsw/bcs008.

    Article  Google Scholar 

  35. 35.

    Tummers, L. L. G., Bekkers, V., Vink, E., et al. (2015). Coping during public service delivery: A conceptualization and systematic review of the literature. Journal of Public Administration Research and Theory, 25, 1099–1126. https://doi.org/10.1093/jopart/muu056.

    Article  Google Scholar 

  36. 36.

    Bergen, A., & While, A. (2005). “Implementation deficit” and “street-level bureaucracy”: Policy, practice and change in the development of community nursing issues. Health and Social Care in the Community, 13, 1–10. https://doi.org/10.1111/j.1365-2524.2005.00522.x.

    Article  PubMed  Google Scholar 

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Correspondence to Alessandro Jatobá.

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The authors declare that they have no conflicts of interest.

Research Involving Human Participants/Informed Consent

Regarding scientific research involving human beings, this study was conducted in accordance with the ethical principles of the Resolution No. 466/2012 of the Brazilian National Council of Health Care/Brazilian Ministry of Health and approved by ethics committees. Therefore, all participants had to express their agreement with to informed consent terms read by the telephone interviewer. In addition, participants had the option of receiving a copy of the informed consent terms by email. Moreover, participants’ confidentiality was ensured as their responses were not identified.

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Bellas, H.C., Jatobá, A., Bulhões, B. et al. Effects of Urban Violence on Primary Healthcare: The Challenges of Community Health Workers in Performing House Calls in Dangerous Areas. J Community Health 44, 569–576 (2019). https://doi.org/10.1007/s10900-019-00657-2

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  • Community health workers
  • Primary health care
  • House calls
  • Exposure to violence