Getulio Vargas Foundation, São Paulo, Brazil.
Department of Politics, University of York, York, North Yorkshire, UK.
Glob Health Promot. 2022 Mar;29(1):14-22. doi: 10.1177/17579759211012375. Epub 2021 Jun 10.
Health promotion in Brazil relies on community health workers (CHWs), frontline providers linking the health system with vulnerable groups. Brazilian CHWs are overwhelmingly women from poor backgrounds, with precarious and sometimes hazardous working conditions, as well as fragmented and unsystematic training. This paper evaluates how the COVID-19 pandemic exacerbated pre-existing vulnerabilities of CHWs (pertaining to low salary, precarious and hazardous working conditions and inadequate training) and created new ones, with a profound impact on their ability to carry out health promotion activities. Drawing on testimonials of dozens of CHWs and online discussions promoted by their unions, the paper reveals that during the pandemic CHWs were asked to continue their work without adequate training and protective equipment, thus exposing themselves to the risk of infection. It further shows how the pandemic rendered dangerous the close interaction with patients that is at the heart of their health promotion role. Nonetheless, CHWs sought to adapt their work. In the absence of leadership and coordination on the part of the federal government, CHWs mobilized different forms of resistance at the national and individual levels. Despite this, COVID-19 contributed to a trajectory of erosion of health promotion in Brazil. Findings from this case signal the difficulties for health promotion in low- and middle-income countries relying on CHWs to bridge the health system and vulnerable users.
巴西的健康促进依赖于社区卫生工作者（CHWs），他们是将卫生系统与弱势群体联系起来的一线服务提供者。巴西的 CHWs 绝大多数是来自贫困背景的女性，工作条件不稳定，有时甚至很危险，并且培训也很零散、不系统。本文评估了 COVID-19 大流行如何加剧了 CHWs 先前存在的脆弱性（与低工资、不稳定和危险的工作条件以及培训不足有关），并创造了新的脆弱性，这对他们开展健康促进活动的能力产生了深远影响。本文通过数十名 CHWs 的证词和他们的工会在线讨论，揭示了在大流行期间，CHWs 被要求在没有足够培训和防护设备的情况下继续工作，从而使他们面临感染的风险。它进一步表明，大流行使他们与患者的密切互动变得危险，而这种互动是他们健康促进角色的核心。尽管如此，CHWs 还是试图适应他们的工作。在联邦政府缺乏领导力和协调的情况下，CHWs 在国家和个人层面上采取了不同形式的抵抗。尽管如此，COVID-19 还是导致了巴西健康促进的侵蚀轨迹。这一案例的研究结果表明，对于依赖 CHWs 来弥合卫生系统和弱势用户之间差距的中低收入国家来说，健康促进面临着困难。
