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Home Health The vulnerabilities of the Brazilian health workforce during health emergencies: Analysing personal feelings, access to resources and work dynamics during the COVID‐19 pandemic – Lotta – – The International Journal of Health Planning and Management

The vulnerabilities of the Brazilian health workforce during health emergencies: Analysing personal feelings, access to resources and work dynamics during the COVID‐19 pandemic – Lotta – – The International Journal of Health Planning and Management

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2.1 Case selection and context

The results discussed in this paper are based on data collected from an online survey of 1630 public health professionals in Brazil between 15 June 2020 and 1 July 2020. Brazil was selected for three reasons. First, because it is one of the main epicentres of the pandemic.18,19 Second, because it has a public health system with a large health workforce that was heavily affected by the pandemic.20 Third, because it is a country with high levels of inequality, including within the health workforce,21 which enables us to understand the impact of the pandemic in such a context.

Regarding the first reason, on 11 March 2020, the World Health Organization officially declared COVID‐19 as a worldwide pandemic.22 On February 26th, Brazil confirmed its first case of COVID‐19, thus becoming the first Latin American country to do so. Although the country had several weeks to prepare, based on the earlier impacts in Europe and Asia, the Brazilian Government did not adopt effective preventive actions.16,21 Political instability added to the disorder in the Health Ministry, which spent three months without a Heath Minister. President Jair Bolsonaro’s constant denial of the pandemic and the consequent lack of investment in the health response further contributed to the high rates of cases and deaths in the country.21,23,24 By the end of June 2020 (when data for this paper were collected) Brazil had reached a total of 2 million people infected and more than 75,000 deaths.25 By mid‐November 2020, when this paper was written, these figures had risen to 5.8 million cases and 165,658 deaths.25

Regarding the second reason why we selected Brazil as our case study, two factors must be considered. On one hand, this critical and uncertain crisis scenario has been experienced on a daily basis by the health workforce, who are constantly exposed to the virus, and other challenges such as lack of basic resources and of health care infrastructure and low adherence to social distancing the population, among others.3,5,26,27 On the other hand, Brazil has a national public health system, the Sistema Único de Saúde (SUS), which is responsible for providing free health care to every citizen as a social right, guaranteed in the 1988 democratic Constitution.28 The system is complex and organized at three levels of care: primary health care (PHC), specialized care and hospital care. The system is also decentralized, which means that all 5557 municipalities, 27 states and the Federal Government share responsibilities but also each have their own specific constitutional duties for making sure the system operates effectively.29 SUS is the biggest public health system in the world, with more than 190 million users.30 Recent research has highlighted the reach of the SUS and its capacity to reduce indicators of health inequality in Brazil.29,31 However, budget cuts and neoliberal oriented policies since 2016 have systematically reduced federal investment in the system—a scenario that some authors have described as critical and severe.28,32 Therefore, while the SUS represents an achievement in the provision of universal public health, the system has been under attack in recent years.

The health workforce is constantly exposed to the COVID‐19 virus and therefore is more likely to be infected than the wider population.3 Up to October 2020, there had been 41,164 cases and 449 deaths among nurses.33 Some estimate that this represents about 30% of all deaths of nurses from COVID‐19 worldwide.34 Although the numbers are not yet precise or fully up‐to‐date, the rates of cases reported are very high, leading these authors to argue that the overloading of the system, under‐provision of PPE, and lack of training and investment are the key factors that have contributed to this current situations.5

In this critical context, in which various vulnerabilities and inequalities in and outside the Brazilian public health system tend to be reproduced, we decided to analyse different professions within the health workforce: physicians, nurses and CHWs. These three professional categories play essential and distinct roles in the health system and, at the same time, they expose the inequalities within it. Nurses and Physicians may work at different levels of the health system, providing services inside hospitals and health clinics. CHWs are part of PHC teams and have the responsible for providing health services through visits to patients’ homes. In observing these different professions, our analysis covers the health workforce from the PHC services to levels of high complexity in which nurses and doctors take the lead. This choice enables us to comprehend the health system as a whole. Past analyses have compared the distribution of these three professions, finding that inequalities within the Brazilian health workforce are linked to geographical dynamics and inequalities.35

Moreover, there is a historical dimension of the structural inequalities found in the Brazillian health system, which intersect with inequalities related to gender, race, social class and territory, among other factors35,36 The specialized literature calls attention to the ‘imbalances’ within the health workforce, in relation to dimensions such as: (i) profession/specialism, (ii) geography, (iii) institutional dynamics, and (iv) gender.36 Furthermore, the procedures and work routines of these professionals have also, to a greater or lesser degree, undergone changes under the pandemic context and depending on the proximity and centrality of their work in combatting the virus.26

2.2 Data collection

We collected data from an online survey in order to investigate the conditions under which frontline health workers were experiencing the pandemic in Brazil. This strategy enabled us to overcome some of the problems of collecting data during the COVID‐19 pandemic and the need for physical distancing. The online survey also has several advantages: (i) we were able to design mandatory questions, (ii) it is user‐friendly and easy to access, (iii) uploading and saving the information is straightforward, (iv) the data can be automatically converted into a database, and (v) respondent privacy is guaranteed.37,38

We formulated 47 questions based on previous research about frontline workers and health emergencies.8,39 Questions were organized into four sections: (1) Resources (access to PPE, training, testing), (2) Support (orientation, political support), (3) Changes in tasks and in interactions, and (4) Impact in Emotions and Mental Health (including mental health support and harassment). Each section contained various questions. Most of them were mandatory, closed and binary (Yes or No) or nominal/categorical. To capture qualitative perceptions we also included opened questions. The constructs and variables were based on the parameters proposed by Lietz,38 of simplicity, specificity, a guarantee of anonymity and adequacy of language used. All questions were checked by peers and tested with five volunteers (two physicians, two nurses and one CHW). We also developed tests of coherence, flow and content. Overall, 2138 public health workers responded to the survey. For this study, we used the data provided by 870 CHWs, 445 nurses and 315 physicians, producing a sample of 1630 health professionals.

The survey was disseminated on social media—via Whatsapp, Twitter and Facebook—, e‐mails and also through trade unions and workers’ associations. Data were collected anonymously between 15th June and 1st July 2020. The research was approved by the Ethical Committee. Due to pandemic restrictions, affecting accessibility, data coherence etc., we developed a convenience sample.37 This is a type of non‐probabilistic and non‐random sample that identifies members of a population that satisfy criteria such as accessibility, availability and willingness to participate in the research.40

During the period of data collection, we developed sample simulations and distributions in order to cover all Brazilian regions. Furthermore, we produced a proportional sample for each profession, while also taking gender and race into account. In both cases, we measured our tests to a 95% confidence interval, giving a margin of error of 5%, out of the population of each profession.41 This exercise is essential to understand how our sample differs from or resembles a randomly selected one40 and how it covers different types of inequality that exist within the health workforce.

This research is not probabilistic and the data cannot be generalized.37 Again, due to the conditions of the pandemic and the urgency of collecting data at its height in order to understand the impacts, the convenience sample is a reasonable option and has been used by other studies into health workers during the COVID‐19 pandemic8,9 or in previous health emergencies.39,42 Moreover, considering the limitations of the sample, we do not offer statistical analysis here. Quantitative analysis is offered only for exploratory and descriptive purposes.

2.3 Data analysis

Based on the literature on health workforce conditions, we seek to analyse the experience of public health workers in Brazil in facing the challenges of the COVID‐19 pandemic and the role of pre‐existing inequalities in shaping this experience. To this end, we separated the information collected in the online survey into three analytical sections:

  • (1)

    Working conditions: In this section we consider the variables linked to positive perceptions about access to personal protective equipment (PPE) and testing equipment, training, support from supervisors and guidance from management.

  • (2)

    Mental health and emotional consequences: In this section we consider the variables related to mental health, and emotional and psychological experiences during the pandemic, such as: feelings of fear, unpreparedness and stress/anxiety, as well as perceptions of impacts on mental health. Our prioritization of such emotions is based on a review of the existing literature on the psychological impacts of the pandemic on health workers.8,9,26,39,43

  • (3)

    Perceptions of changes to working procedures during the pandemic: These analyses were carried out using two strategies. In the first, we present indicators in a comparative panel divided according to profession (CHWs, nurses and physicians), based on descriptive statistics. The percentages correspond to the positive perceptions of these professionals to the different dimensions analysed. The questions that comprise these blocks are binary (Yes or No). To guarantee the consistency of the results, we performed chi‐square tests between the variables. The information presented in the first two sections of analysis are analysed in this way. The second strategy is qualitative analysis based on open questions about respondents’ perceptions of changes to working procedures during the pandemic. Analysis was conducted using content analysis.44,45 In light of the literature, we categorized responses in two distinct stages in order to identify certain patterns and trends: a first that allocated the responses into broad categories and a second that consolidated them into more specific ones.

We used SPSS and NVivo software to process and analyse our data. The results of these comparative analyses are discussed in detail in the next sections. We present both descriptive statistical analysis and qualitative results. Some excerpts of the open questions are also presented to provide further evidence for our arguments.

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