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Pérez JO, Mendes V. The intersectionality of health (in)security: Healthcare, disposable workers, and exposure within Brazil's pandemic politics. SECURITY DIALOGUE 2023; 54:155-172. [PMID: 38602940 PMCID: PMC10033498 DOI: 10.1177/09670106221148375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Brazil has suffered severe consequences from the Covid-19 pandemic, currently ranking second globally in terms of total fatalities, with more than 682,000 lives lost. This article critically outlines how a 'health security' framework overlooks processes of intersectionality and the varying impacts of the virus on different segments of society, or what we term health insecurity. We organize our analysis around three aspects of the pandemic that have become salient in Brazilian society, namely access to healthcare, disposable workers, and exposure to the virus, and delineate the intersectional impact of gendered inequality, neoliberal ideologies, and racial hierarchies within these three themes. Our methodology employs media and scholarly interpretations of Covid-19, and other secondary empirical and statistical data, to outline the virus's impacts on differently positioned bodies throughout Brazilian society. Our main findings reveal that during the pandemic, women's labor and health concerns have been undervalued, exploitative working conditions have been exacerbated, and Afro-Brazilians have been put in situations of higher exposure to the virus in both public and private spaces. This article underscores the need to better examine how public health, systems of oppression and exclusion, and (in)security overlap with each other.
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Lotta G, Nunes J, Fernandez M, Garcia Correa M. The impact of the COVID-19 pandemic in the frontline health workforce: Perceptions of vulnerability of Brazil's community health workers. HEALTH POLICY OPEN 2022; 3:100065. [PMID: 35036911 PMCID: PMC8752101 DOI: 10.1016/j.hpopen.2021.100065] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 12/16/2021] [Accepted: 12/19/2021] [Indexed: 12/26/2022] Open
Abstract
The COVID-19 pandemic has resulted in calls for an increased integration of community health workers (CHWs) into the health system response. Historically, CHWs can play an important role in ensuring the sustainability of health policy implementation - by addressing social determinants of health and maintaining care for ongoing health problems. Their frontline work, with close contact to populations, places CHWs in a position of increased vulnerability to becoming infected and to being the target of abuse and violence. These vulnerabilities compound underlying problems faced by CHWs, who often come from poor backgrounds, are insufficiently paid and receive inadequate training. Speaking to a scarcity of studies on how CHWs are impacted by the pandemic, this paper conducts a systematic study of CHWs in Brazil. Based on quantitative and qualitative data collected during June and July 2020, it considers perceptions and experiences of CHWs, comparing them with other health professionals. We study the extent to which the pandemic added to existing vulnerabilities and created new problems and imbalances in the work of CHWs. We conclude that COVID-19 led to a deterioration of the working conditions of CHWs, of their relations with other health professionals, and of their ability to carry out their essential work in the public health system.
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Magri G, Fernandez M, Lotta G. Inequality in the middle of a crisis: an analysis of health workers during the COVID-19 pandemic from the profession, race, and gender perspectives. CIENCIA & SAUDE COLETIVA 2022. [DOI: 10.1590/1413-812320222711.01992022en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Studies show that people in vulnerable conditions and some social groups such as women and black people have suffered more intensely from the COVID-19 pandemic impacts. This expression of inequality also manifests itself among healthcare workers, with greater exposure of some specific groups. This paper analyzes the effect of COVID-19 on health care workers and the working conditions in the Brazilian public health system, analyzed from professional, gender, and race perspectives. Data were collected from an online survey of 1,829 health workers conducted in March 2021. Indeed, we identified inequalities in health workers’ experiences during the health crisis generated by COVID-19, which are marked by the profession of each worker and are traversed by their gender and race traits.
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Magri G, Fernandez M, Lotta G. Desigualdade em meio à crise: uma análise dos profissionais de saúde que atuam na pandemia de COVID-19 a partir das perspectivas de profissão, raça e gênero. CIENCIA & SAUDE COLETIVA 2022; 27:4131-4144. [DOI: 10.1590/1413-812320222711.01992022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/08/2022] [Indexed: 11/21/2022] Open
Abstract
Resumo Estudos mostram que pessoas em condições de vulnerabilidade têm sofrido de forma mais intensa os impactos da pandemia de COVID-19, assim como alguns grupos sociais, como mulheres e negros. Essa expressão de desigualdade também se manifesta entre os trabalhadores da saúde, com maior exposição de alguns grupos específicos. Este artigo analisa a incidência da COVID-19 sobre os trabalhadores da saúde a partir das perspectivas de profissão, gênero e raça. Os dados foram coletados por uma survey online com 1.829 trabalhadores da saúde, realizada no mês de março de 2021. Encontramos que, efetivamente, há desigualdades nas experiências dos trabalhadores da saúde durante a crise sanitária gerada pela COVID-19. Essas desigualdades estão marcadas pela profissão de cada trabalhador e são atravessadas por suas características de gênero e raça.
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Nunes J, Lotta G. Are community health programmes always benign? Community health worker perceptions and the social construction of users in Brazil’s primary healthcare policy. Glob Public Health 2022; 18:2043923. [PMID: 35220924 DOI: 10.1080/17441692.2022.2043923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We examine how community health workers (CHWs), while working as links between doctors, nurses and vulnerable groups, participate in the social construction of citizens in the implementation of Brazil's primary healthcare policy. Drawing on interviews and a vignette experiment with CHWs in the city of São Paulo, we show that perceptions of CHWs about the vulnerability and agency of health system users impact upon their referrals to other levels of service. Judgments about the socioeconomic, cultural and moral conditions of families determine different referrals - on the one hand, to practices based on persuasion and respect for individual choices; on the other, to 'top-down' or forcible interventions. While implementing the same healthcare policy, CHWs construct users as (responsible) agents or (helpless) targets, thus determining different pathways in the health system and shaping the relationship between citizens and the state. Brazil's primary health policy, while seeking to tackle vulnerability, is also a site where social representations are reproduced that contribute to the denial of the agency of citizens deemed more vulnerable and to the definition of their bodies as sites for state intervention.
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Affiliation(s)
- João Nunes
- Department of Politics, University of York, York, UK
| | - Gabriela Lotta
- Public Administration, Getúlio Vargas Foundation, Sao Paulo, Brazil
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Hove J, D’Ambruoso L, Kahn K, Witter S, van der Merwe M, Mabetha D, Tembo K, Twine R. Lessons from community participation in primary health care and water resource governance in South Africa: a narrative review. Glob Health Action 2022; 15:2004730. [PMID: 34994680 PMCID: PMC8745361 DOI: 10.1080/16549716.2021.2004730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 11/05/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In South Africa, community participation has been embraced through the development of progressive policies to address past inequities. However, limited information is available to understand community involvement in priority setting, planning and decision-making in the development and implementation of public services. OBJECTIVE This narrative review aims to provide evidence on forms, extents, contexts and dynamics of community participation in primary health care (PHC) and water governance in South Africa and draw cross-cutting lessons. This paper focuses on health and water governance structures, such as health committees, Catchment Management Agencies (CMA), Water User Associations (WUAs), Irrigation Boards (IBs) and Community Management Forums (CMFs). METHODS Articles were sourced from Medline (Ovid), EMBASE, Google Scholar, Web of Science, WHO Global Health Library, Global Health and Science Citation Index between 1994 and 2020 reporting on community participation in health and water governance in South Africa. Databases were searched using key terms to identify relevant research articles and grey literature. Twenty-one articles were included and analysed thematically. RESULTS There is limited evidence on how health committees are functioning in all provinces in South Africa. Existing evidence shows that health committees are not functioning effectively due to lack of clarity on roles, autonomy, power, support, and capacity. There was slow progress in establishment of water governance structures, although these are autonomous and have mechanisms for democratic control, unlike health committees. Participation in CMAs/WUAs/IBs/CMFs is also not effective due to manipulation of spaces by elites, lack of capacity of previously disadvantaged individuals, inadequate incentives, and low commitment to the process by stakeholders. CONCLUSION Power and authority in decision-making, resources and accountability are key for effective community participation of marginalized people. Practical guidance is urgently required on how mandated participatory governance structures can be sustained and linked to wider governance systems to improve service delivery.
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Affiliation(s)
- Jennifer Hove
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
| | - Lucia D’Ambruoso
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- Public Health/Health Protection, National Health Service (NHS) Grampian, Scotland, UK
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- International Network for the Demographic Evaluation of Populations and Their Health (Indepth), Accra, Ghana
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Maria van der Merwe
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
- Independent Consultant, White river, South Africa
| | - Denny Mabetha
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science (Achds) Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, UK
| | | | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Cimini CCR, Maia JX, Pires MC, Ribeiro LB, Pinto VSDOEA, Batchelor J, Ribeiro ALP, Marcolino MS. Pandemic-related impairment in the monitoring of patients with hypertension and diabetes and the development of a digital solution for the community health worker: quasi-experimental and implementation study (Preprint). JMIR Med Inform 2021; 10:e35216. [PMID: 35191842 PMCID: PMC8966891 DOI: 10.2196/35216] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/23/2022] [Accepted: 02/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background The restrictions imposed by the COVID-19 pandemic reduced health service access by patients with chronic diseases. The discontinuity of care is a cause of great concern, mainly in vulnerable regions. Objective This study aimed to assess the impact of the COVID-19 pandemic on people with hypertension and diabetes mellitus (DM) regarding the frequency of consultations and whether their disease was kept under control. The study also aimed to develop and implement a digital solution to improve monitoring at home. Methods This is a multimethodological study. A quasiexperimental evaluation assessed the impact of the pandemic on the frequency of consultations and control of patients with hypertension and DM in 34 primary health care centers in 10 municipalities. Then, an implementation study developed an app with a decision support system (DSS) for community health workers (CHWs) to identify and address at-risk patients with uncontrolled hypertension or DM. An expert panel assessment evaluated feasibility, usability, and utility of the software. Results Of 5070 patients, 4810 (94.87%) had hypertension, 1371 (27.04%) had DM, and 1111 (21.91%) had both diseases. There was a significant reduction in the weekly number of consultations (107, IQR 60.0-153.0 before vs 20.0, IQR 7.0-29.0 after social restriction; P<.001). Only 15.23% (772/5070) of all patients returned for a consultation during the pandemic. Individuals with hypertension had lower systolic (120.0, IQR 120.0-140.0 mm Hg) and diastolic (80.0, IQR 80.0-80.0 mm Hg) blood pressure than those who did not return (130.0, IQR 120.0-140.0 mm Hg and 80.0, IQR 80.0-90.0 mm Hg, respectively; P<.001). Also, those who returned had a higher proportion of controlled hypertension (64.3% vs 52.8%). For DM, there were no differences in glycohemoglobin levels. Concerning the DSS, the experts agreed that the CHWs can easily incorporate it into their routines and the app can identify patients at risk and improve treatment. Conclusions The COVID-19 pandemic caused a significant drop in the number of consultations for patients with hypertension and DM in primary care. A DSS for CHW has proved to be feasible, useful, and easily incorporated into their routines.
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Affiliation(s)
| | - Junia Xavier Maia
- Telehealth Center, Hospital das Clínicas, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Magda Carvalho Pires
- Department of Statistics, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Leonardo Bonisson Ribeiro
- Telehealth Center, Hospital das Clínicas, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - James Batchelor
- Clinical Informatics Research Unit, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Antonio Luiz Pinho Ribeiro
- Telehealth Center and Cardiology Service, Hospital das Clínicas, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Milena Soriano Marcolino
- Telehealth Center, Hospital das Clínicas, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Ashraf N, Bandiera O, Davenport E, Lee SS. Commentary on "Promising careers? A critical analysis of a randomised control trial in community health worker recruitment in Zambia," by James Wintrup. Soc Sci Med 2021; 292:114531. [PMID: 34893356 DOI: 10.1016/j.socscimed.2021.114531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/01/2021] [Indexed: 11/19/2022]
Abstract
"Promising careers? A critical analysis of a randomised control trial in community health worker recruitment in Zambia" (Wintrup, 2021) raises important questions about the uses of randomized controlled trials (RCTs) and uses our RCT embedded in Zambia's National Community Health Assistant (CHA) Program (Ashraf et al., 2020a) as a case study to illustrate the pitfalls of the RCT methodology and especially its potential to do harm. This commentary clarifies the misunderstandings at the heart of Wintrup (2021)'s critique.
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Affiliation(s)
- Nava Ashraf
- Department of Economics, LSE, Houghton Street, London, WC2A 2AE, UK.
| | - Oriana Bandiera
- Department of Economics and STICERD, LSE, Houghton Street, London, WC2A 2AE, UK.
| | - Edward Davenport
- Department of Economics, MIT, 50 Memorial Drive, Cambridge, MA, 02142, USA.
| | - Scott S Lee
- Department of Medicine and Institute for Global Health, Vanderbilt University, 2525 West End Avenue, Suite 450, Nashville, TN, 37203, USA.
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