Abstract

This study aimed to analyze the factors related to the mental health of Community Health Workers (ACS) in the COVID-19 context. A total of 1,935 ACS from four Northeastern capitals and four cities in the inland region of Ceará participated. The following data were collected: sociodemographic; professional; SRQ-20; WHOQOL-Bref, exposure to violence, General Self-Efficacy Scale (EAEG), Multidimensional Scale of Perceived Social Support (MSPSS), COVID-19-related information, and the coronavirus anxiety scale (EAC). Approximately 40.5% had SRQ > 7, signaling high levels of Common Mental Disorders (CMD)/mental health issues. We adopted the Multiple linear (backward) regression. We observed that the increased risk of CMD was influenced by exposure to violence, EAC, not knowing they had COVID-19, not knowing the variables that reduced the risk, the physical and psychological domains of the WHOQOL-Bref, not having increased working hours, and not having had COVID-19. The data reveal the multidimensional dynamics of mental health and help understand the relationship between community violence, COVID-19, quality of life, age, and ESF working time with the mental health of ACS.

Key words:
Community health workers; COVID-19; Mental health; Violence; Primary health care

Introduction

The COVID-19 pandemic caused different repercussions in the context of people’s lives. Millions of individuals have been affected by the new Coronavirus worldwide. Others died or were at risk of being contaminated by different predispositions. A significant increase in psychological distress and symptoms and mental disorders of various people are estimated due to the setting experienced¹1 Word Health Organization (WHO). Mental health and COVID-19: early evidence of the pandemic's impact: scientific brief, 2 March 2022 [Internet]. 2022. [cited 2022 jun 10]. Available from: https://apps.who.int/iris/handle/10665/352189
https://apps.who.int/iris/handle/10665/3... . The World Health Organization (WHO) estimates that the global prevalence of anxiety and depression increased by 25%²2 United Nations (UN). Policy brief: COVID-19 and the need for actions on mental health [Internet]. 2020. [cited 2022 jun 10]. Available from: https://www.un.org/sites/un2.un.org/files/un_policy_brief-covid_and_mental_health_final.pdf
https://www.un.org/sites/un2.un.org/file... with the COVID-19 pandemic. Fear, concern, and stress are normal and understandable reactions to threats, uncertainties, or the unknown, but these behaviors were exacerbated in this context³3 Noal DS, Passos MFD, Freitas CM, organizadores. Recomendações e orientações em saúde mental e atenção psicossocial na COVID-19. Brasília: Fundação Oswaldo Cruz; 2020..

The world has been experiencing enormous, sudden transformations in the last two years since everyone’s daily life has changed, and it was necessary to adapt quickly to the new way of living. Besides controlling the fear of getting sick, the trauma of losing loved ones with the new Coronavirus, and the uncertainty about the short and long-term consequences, people suffered now from unemployment, poverty, and food insecurity, triggering mental health implications⁴4 Tausch A, E Souza RO, Viciana CM, Cayetano C, Barbosa J, Hennis AJ. Strengthening mental health responses to COVID-19 in the Americas: A health policy analysis and recommendations. Lancet Reg Health Am 2022; 5:100118.^,55 Neves JA, Machado ML, Oliveira LDA, Moreno YMF, Medeiros MAT, Vasconcelos FAG. Unemployment, poverty, and hunger in Brazil in COVID-19 pandemic times. Rev Nutr 2021; 34:e200170.. The main measures adopted by health authorities to reduce new cases, such as distancing and social isolation, caused significant changes in people’s home and work routines. They also escalated social inequalities and facilitated the emergence or the complications from other diseases due to care discontinuity⁶6 Carmo RM, Tavares T, Cândido AF, organizadores. Um olhar sociológico sobre a crise COVID-19 em livro. Lisboa: Observatório das Desigualdades; 2020..

Currently, the global COVID-19 epidemiological situation is losing strength. Although the Brazilian government declared the end of the Public Health Emergency of National Importance (ESPIN)⁷7 Brasil. Ministério da Saúde (MS). Portaria GM/MS nº 913, de 22 de abril de 2022. Declara o encerramento da Emergência em Saúde Pública de Importância Nacional (ESPIN) em decorrência da infecção humana pelo novo coronavírus (2019-nCoV) e revoga a Portaria GM/MS nº 188, de 3 de fevereiro de 2020. Diário Oficial da União 2022; 22 abr., the WHO maintained the international health emergency related to the coronavirus due to the very heterogeneous vaccination coverage between countries and the unpredictable behavior of the virus in the global pandemic context⁶6 Carmo RM, Tavares T, Cândido AF, organizadores. Um olhar sociológico sobre a crise COVID-19 em livro. Lisboa: Observatório das Desigualdades; 2020.. The reflection of this setting persists, and all the damage caused by COVID-19 is still unclear. However, the increased burden of mental health problems can be considered one of the most important long-term effects of the pandemic⁸8 Word Health Organization (WHO). Statement on the eleventh meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic [Internet]. 2022. [cited 2022 jun 10]. Available from: https://www.who.int/news/item/13-04-2022-statement-on-the-eleventh-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(COVID-19)-pandemic
https://www.who.int/news/item/13-04-2022... .

Evidence shows that the implications for mental health may last longer and be more prevalent than the pandemic itself and that the psychosocial and economic repercussions may be unpredictable, considering their amplitude in different contexts⁴4 Tausch A, E Souza RO, Viciana CM, Cayetano C, Barbosa J, Hennis AJ. Strengthening mental health responses to COVID-19 in the Americas: A health policy analysis and recommendations. Lancet Reg Health Am 2022; 5:100118.^,99 Reardon S. Ebola's mental-health wounds lingerin Africa. Nature 2015; 519(7541):13-14.. Thus, we observe a possible increase in the prevalence of suspected common mental disorders (CMD) among health professionals, particularly community health workers.

In occupational health, frontline health professionals dramatically impacted their routines. Regardless of the personal risk, they were directly involved in coping with the pandemic, forced to make hard decisions and work under unprecedented pressure. COVID-19-related concerns and fears contributed to more significant psychological distress, affecting symptoms of stress, increasing anxiety and depression, and increasing the likelihood of developing mental health disorders¹⁰10 Rosales Vaca KM, Cruz Barrientos OI, Girón López S, Noriega S, More Árias A, Guariente SMM, Zazula R. Mental health of healthcare workers of Latin American countries: a review of studies published during the first year of COVID-19 pandemic. Psychiatry Res 2022; 311:114501.^,1111 Dal'Bosco EB, Floriano LSM, Skupien SV, Arcaro G, Martins AR, Anselmo ACC. Mental health of nursing in coping with COVID-19 at a regional university hospital. Rev Bras Enferm 2020; 73(Suppl. 2):e20200434.. From this perspective, primary health care (PHC) professionals, operationalized by the Family Health Strategy (ESF), such as community health workers (ACS), were impacted differently¹²12 Vieira-Meyer APGF, Morais APP, Campelo ILB, Guimarães JMX. Violência e vulnerabilidade no território do agente comunitário de saúde: implicações no enfrentamento da COVID-19. Cien Saude Colet 2021; 26(2):657-668.^,1313 Maciel FBM, Santos HLPCD, Carneiro RADS, Souza EA, Prado NMBL, Teixeira CFS. Agente comunitário de saúde: reflexões sobre o processo de trabalho em saúde em tempos de pandemia de COVID-19. Cien Saude Colet 2020; 25(Supl. 2):4185-4195..

The ACS play a relevant role in healthcare, favoring access to health services, mediating in the construction of bonds between families and the ESF/PHC teams, conducting home visits, and providing guidance and support in resolving demands with health team members. The ACS performance improves health outcomes in various conditions and contexts¹⁴14 Valle TMRN, Resnicow K, Nery M, Brentani A, Kaselitz E, Agrawal P, Mand S, Heisler M. A pilot study of a community health agent-led type 2 diabetes self-management program using motivational Interviewing-based approaches in a public primary care center in São Paulo, Brazil. BMC Health Serv Res 2017; 17(1):32., which denotes the relevance of these professionals in coping with COVID-19¹³13 Maciel FBM, Santos HLPCD, Carneiro RADS, Souza EA, Prado NMBL, Teixeira CFS. Agente comunitário de saúde: reflexões sobre o processo de trabalho em saúde em tempos de pandemia de COVID-19. Cien Saude Colet 2020; 25(Supl. 2):4185-4195.. Mental health is essential for fully developing health promotion and care actions. However, these professionals are subject to territorial challenges, and their characteristics before and during the pandemic, such as violence, can influence their community work process and mental health¹²12 Vieira-Meyer APGF, Morais APP, Campelo ILB, Guimarães JMX. Violência e vulnerabilidade no território do agente comunitário de saúde: implicações no enfrentamento da COVID-19. Cien Saude Colet 2021; 26(2):657-668.^,1515 Cremonese GR, Motta RF, Traesel ES. Implicações do trabalho na saúde mental dos Agentes Comunitários de Saúde. Cad Psicol Social Trab 2013; 16(2):279-293..

The structural and social conditions of the territories of large urban centers are today settings of enormous social vulnerability. The provision of services and health actions must be available among PHC Units (UBS) and the different community arrangements. In these settings, this premise exposes the ACS to constant violence, food insecurity, and unemployment, among other conditions of extreme inequality experienced by the communities assisted by the Unified Health System (SUS). Thus, this whole situation of social vulnerability in the territory can adversely affect their mental health and quality of life, which may have been aggravated in the COVID-19 pandemic context¹²12 Vieira-Meyer APGF, Morais APP, Campelo ILB, Guimarães JMX. Violência e vulnerabilidade no território do agente comunitário de saúde: implicações no enfrentamento da COVID-19. Cien Saude Colet 2021; 26(2):657-668.^,1616 Souza LJR, Freitas MSC. O agente comunitário de saúde: violência e sofrimento no trabalho a céu aberto. Rev Baiana Saude Publica 2011; 35(1):96-109..

Thus, it is strategic to investigate the repercussions of continued exposure to these factors to measure their perceptions and ability to balance and manage their emotions to support the implementation of public policies to improve health and the qualification of the ACS work process. With this prerogative, this study aimed to analyze the factors related to the mental health of ACS in the COVID-19 context in different settings.

Methods

This multicenter, cross-sectional study was conducted in four northeastern Brazilian capitals, namely, Fortaleza-Ceará, João Pessoa-Paraíba, Recife-Pernambuco, and Teresina-Piauí, and four cities in the inland region of Ceará, Crato, Juazeiro, Barbalha, and Sobral. The study population involved PHC workers working with community health workers (ACS). According to data from the e-manager system of the Ministry of Health, referring to 2020, 7,909 ACS were working in the municipalities¹⁷17 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária à Saúde. e-SUS Atenção Primária [Internet]. [acessado 2022 set 14]. Disponível em: https://aps.saude.gov.br/ape/esus
https://aps.saude.gov.br/ape/esus... .

The simple random sample calculation was performed for each municipality based on a sampling error of 5%, a confidence level of 95%, and homogeneous distribution (80/20) of the studied population, totaling a sample of 1,935 ACS. These professionals were drawn and invited to participate in the research, considering the following inclusion criteria: ACS active in the work process; and as exclusion criteria: ACS on vacation or sick leave. For the present study, we decided to analyze the data by capitals and inland region cities, understanding that this design helps to understand the mental health-related dynamics (measured by the Self-Reporting Questionnaire - SRQ20) in these two realities.

Data collection

A single training of the collection team was conducted to ensure standardized data collection in all cities. Initially, theoretical aspects of the research project, quantitative data collection, biosafety protocol, human research ethical aspects, data collection instrument, and finally, the definition of roles in the collection process were discussed: collector, field coordinator, and supervisor, based on the simulation technique (role play). This step was completed with the data collection planning. The process was conducted by professionals with expertise in the area, totaling 12 hours.

Previous authorization for data collection was agreed upon with the municipal managers to conduct the research. Thus, scheduling the most convenient day and time for applying the questionnaire at the family health units was facilitated. Data were collected in a private room, and the study objectives and informed consent forms were initially presented, from April to August 2021 and strictly followed all the biosafety standards determined by Technical Note GVIM/GGTES/ANVISA N° 04/202018. Then, the instrument was applied with the presence of the collector to resolve doubts.

The instrument used contained sociodemographic data; professional; SRQ-20 - Self-Reporting Questionnaire-20 (mental health); WHOQOL-Bref - World Health Organization Quality of Life Questionnaire (Quality of life), exposure to violence (saw/knew or experienced violence), Overall Self-Efficacy Score (Balsan et al. 2020), the Multidimensional Scale of Perceived Social Support-MSPSS, and COVID-19-related information, including the Coronavirus Anxiety Scale.

The WHO developed the SRQ-20 for questions related to psycho-emotional symptoms. It has been used to measure the level of suspected common mental disorders (CMD) in Brazilian studies, especially in groups of workers. It is an important screening tool for mental health, adopting a cutoff > 7¹⁹19 Carmo MBB, Santos LM, Feitosa CA, Fiaccone RL, Silva NB, Santos DN, Barreto ML, Amorim LD. Screening for common mental disorders using the SRQ-20 in Brazil: what are the alternative strategies for analysis? Rev Bras Psiquiatria 2018; 40(2):115-122..

The WHOQOL-Bref is an instrument used to assess the quality of life (QoL), divided into four domains: physical, psychological, social relationships, and environment²⁰20 World Health Organization (WHO). Division of mental health and prevention of substance abuse. WHOQOL: measuring quality of life [Internet]. [cited 2022 set 14]. Available from: https://apps.who.int/iris/handle/10665/63482
https://apps.who.int/iris/handle/10665/6... ^,2121 Almeida-Brasil CC, Silveira MR, Silva KR, Lima MG, Faria CDCM, Cardoso CL, Menzel HK, Ceccato MDGB. Qualidade de vida e características associadas: aplicação do WHOQOL-BREF no contexto da Atenção Primária à Saúde. Cien Saude Colet 2017; 22(5):1705-1716.. The Coronavirus Anxiety Scale is a short scale to screen COVID-19-related anxiety²²22 Lee SA. Coronavirus Anxiety Scale: a brief mental health screener for COVID-19 related anxiety. Death Studies 2020 44(7):393-401., where higher scores refer to more significant anxiety.

The general self-efficacy scale²³23 Balsan LAG, Carneiro LL, Bastos AVB, Costa VMF. Adaptação e validação da Nova Escala Geral de Autoeficácia. Aval Psicol 2020; 19(4):409-419. was adopted to measure the ACS’ self-efficacy. Individuals with a higher perception of self-efficacy knowingly have a greater ability to control stressful events and determination when resolving these situations, regardless of the type of problem. Furthermore, we also employed the Multidimensional Scale of Perceived Social Support (MSPSS), developed by Zimet et al.²⁴24 Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Soc Psychol 1988; 52(1):30-41.. Support or social support can be understood as the social resources that people perceive as available or actually provided, which are related to the health outcomes of individuals.

Data analysis

Data were analyzed using the R software. The absolute and relative frequencies of nominal variables, quantitative variables’ mean and standard deviation, and 95% confidence intervals were estimated to describe the sample characteristics. Statistical tests were applied, considering a significance level of 5%. With the SRQ-20 score as the outcome, multiple linear regression analyses were performed using the backward variable selection method, via the Akaike Information Criterion (AIC), as the model’s exploratory character. We decided to perform three different analyses: the first considering the ACS of all cities; the second only for the capitals; and the last with the inland region municipalities of Ceará.

Ethical aspects

The Ethics Committee of the State University of Ceará approved this research under Opinion n° 4.587.955. The ACS who agreed to participate in the research signed the consent form before answering the questionnaire.

Results

A total of 1,935 Community Health Workers (ACS) answered the questionnaire in the eight cities surveyed: Fortaleza-CE (N = 364), João Pessoa-PB (N = 303), Recife-PE (N = 320), Teresina-PI (N = 309), Sobral-CE (N = 203), Juazeiro do Norte-CE (N = 215), Crato-CE (N = 127), and Barbalha-CE (N = 93).

In Table 1, we can observe the frequency analysis result for the sociodemographic variables of the participants and those related to the work performed by the ACS. In general terms, most participants are female (82.76%), with a mean age of 46 years, without a partner (58.2%), with children (81.0%), Catholic (65.8%), brown (71.8%), with high school education (47.3%), and income of up to two minimum wages. In general, participants perform an average of four different types of activities and around four types of home visits. Most worked on the frontlines during the pandemic (77.9%), despite not receiving training (84.0%). Just over half of the respondents indicated that the supply of PPE was not assured (54.6%), and they believed that the work biosafety standards needed to be revised (66.7%). In contrast, most believed they could be infected with Coronavirus at work (97.0%).

According to the participants, the service was adapted to care for patients with COVID-19 (74.94%) and working hours increased (48.41%). Furthermore, most considered themselves to be a transmission vehicle for the Coronavirus (94.5%), while 74.0% had a family member with COVID-19, and 40.4% reported having had COVID-19. A total of 78.7% of participants indicated changes in the teams’ work process during the pandemic. Table 2 presents the descriptive analysis of the instruments used to assess aspects related to the perception of violence; anxiety arising from the Coronavirus; elements related to mental health, social support, and quality of life.

The final model is statistically significant [F (24, 1,319) = 82.89; p < 0.001; R² = 0.60; R² adj. = 0.59] compared to the model with all participants. It comprises 20 predictors, which can be observed in Table 3. When observing the predictors, we can observe variables without statistical significance but retained by the model because the presence of these variables in the model does not imply a worsening of the fit, although it is not significant²⁵25 Hair Jr. JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Análise multivariada de dados. Porto Alegre: Bookman; 2009.. When data from all municipalities were analyzed together, the predictors increasing the risk of CMD were exposure to violence and not knowing if they had COVID-19. In contrast, those that reduced the risk were the physical and psychological domains of the WHOQOL, not considering themselves COVID-19 transmitters, not having had their working hours increased by the pandemic, and not having contracted COVID-19.

In turn, regarding the analysis considering only the capitals, we identified a statistically significant model after seven steps [F (28, 805) = 53.16; p < 0.001; R² = 0.65; R² adj. = 0.64], comprised of 24 predictors, as shown in Table 4. Finally, concerning the inland region municipalities, we identified a statistically significant model after 19 steps [F (17, 513) = 36.44; p < 0.001; R² = 0.55; R² adj. = 0.54]. Table 5 shows the 12 predictors retained in the model.

Discussion

This is one of the first studies to assess mental health and related factors in ACS in Northeast Brazil during the COVID-19 pandemic. We identified a significant portion of ACS with a relatively high prevalence of mental distress (about 40%, higher for ACS in the capitals). Previous studies²⁶26 Li Z, Ge J, Yang M, Feng J, Qiao M, Jiang R, Bi J, Zhan G, Xu X, Wang L, Zhou Q, Zhou C, Pan Y, Liu S, Zhang H, Yang J, Zhu B, Hu Y, Hashimoto K, Jia Y, Wang H, Wang R, Liu C, Yang C. Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control. Brain Behav Immun 2020; 88:916-919.

27 Wang C, Pan R, Wan X, Tan Y, Xu L, McIntyre RS, Choo FN, Tran B, Ho R, Sharma VK, Ho C. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. Brain Behav Immun 2020; 87:40-48.

28 Zhang J, Lu H, Zeng H, Zhang S, Du Q, Jiang T, Du B. The differential psychological distress of populations affected by the COVID-19 pandemic. Brain Behav Immun 2020; 87:49-50.^-2929 Varghese A, George G, Kondaguli SV, Naser AY, Khakha DC, Chatterji R. Decline in the mental health of nurses across the globe during COVID-19: a systematic review and meta-analysis. J Glob Health 2021; 11:05009. also observed this demand for mental health in the COVID-19 context among health professionals. The characteristics and contexts of the ACS in the capitals and inland region cities showed differences in some variables, confirming the relevance of studies involving different realities. In general, the capitals are more extensive, have a higher violence level, lower ESF coverage, and were initially more affected by COVID-19. Capitals Fortaleza and Recife, for example, which have a larger population and international air hubs, were more affected (cases and deaths) than other municipalities at the onset of the pandemic.

Our study showed an association of the following variables in the regression model for all cities: violence (seen or knew) in the territories; rising coronavirus anxiety index; increase in the working time in the family health strategy, and receiving more than four minimum wages with an increase in the SRQ-20 (worst mental health indicator). Worse quality of life in the physical and psychological dimensions and increasing age were also associated with increased SRQ-20. Despite some differences between the regression model when the ACS from all municipalities are analyzed together against the models when the ACS is divided into municipalities in the inland region and capital, these findings show mental health’s multidimensional dynamics. As a result, they help uncover the relationship between community violence, COVID-19, quality of life, age, and time working in the ESF with the ACS mental health. It is interesting to observe that, while age seems to be a protective factor, time as an ACS is positively related to common mental disorders, indicating that the ACS practice is a risk indicator for mental health. The intense daily work in primary care during COVID-19, the change in the work routine, precarious work, and life changes such as social distancing can be risk factors for mental health³⁰30 Dal'Bosco EB, Floriano LSM, Skupien SV, Arcaro G, Martins AR, Anselmo ACC. Mental health of nursing in coping with COVID-19 at a regional university hospital. Rev Bras Enferm 2020; 73(Suppl. 2):e20200434.. These findings are significant and deserve to be considered in developing public policies.

COVID-19 has generally affected the population. In Brazil, a study by Barros et al.³²32 Barros MBA, Lima MG, Malta DC, Szwarcwald CL, Azevedo RCS, Romero D, Souza Júnior PRB, Azevedo LO, Machado ÍE, Damacena GN, Gomes CS, Werneck AO, Silva DRPD, Pina MF, Gracie R. Relato de tristeza/depressão, nervosismo/ansiedade e problemas de sono na população adulta brasileira durante a pandemia de COVID-19. Epidemiol Serv Saude 2020; 29(4):e2020427. noted that 40.4% of participants often felt sad or depressed, and 52.6% frequently anxious or nervous. Health workers who were facing COVID-19 were also affected²⁹29 Varghese A, George G, Kondaguli SV, Naser AY, Khakha DC, Chatterji R. Decline in the mental health of nurses across the globe during COVID-19: a systematic review and meta-analysis. J Glob Health 2021; 11:05009.^,3333 Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, Yao L, Bai H, Cai Z, Xiang Yang B, Hu S, Zhang K, Wang G, Ma C, Liu Z. Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 Novel Coronavirus Disease Outbreak: a cross-sectional study. Brain Behav Immun 2020; 87:11-17.

34 Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations. Gen Psychiatry 2020; 33(2):e100213.

35 Holmes EA, O'Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, Ballard C, Christensen H, Cohen Silver R, Everall I, Ford T, John A, Kabir T, King K, Madan I, Michie S, Przybylski AK, Shafran R, Sweeney A, Worthman CM, Yardley L, Cowan K, Cope C, Hotopf M, Bullmore E. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry 2020; 7(6):547-560.^-3636 Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun 2020; 88:901-907..

Common mental disorders (CMD) measured by SRQ-20 may be related to the work context, manifesting by a set of symptoms, including fatigue, irritability, insomnia, difficult concentration, forgetfulness, and somatic complaints. However, they do not fully meet the diagnostic criteria of anxiety or depression but cause intense psychic distress, which may result in significant functional loss and psychosocial harm³⁷37 Santos AMVS, Lima CA, Messias RB, Costa FM, Brito MFSF. Transtornos mentais comuns: prevalência e fatores associados entre agentes comunitários de saúde. Cad Saude Colet 2017; 25(2):160-168.^,3838 Gonçalves DM, Stein AT, Kapczinski F. Avaliação de desempenho do Self-Reporting Questionnaire como instrumento de rastreamento psiquiátrico: um estudo comparativo com o Structured Clinical Interview for DSM-IV-TR. Cad Saude Publica 2008; 24(2):380-390..

Thus, it is not surprising to find reports of an increasing number of health professionals with anxiety symptoms, which may precede depression and, in turn, can reverberate (or relate to) the quality of life²⁹29 Varghese A, George G, Kondaguli SV, Naser AY, Khakha DC, Chatterji R. Decline in the mental health of nurses across the globe during COVID-19: a systematic review and meta-analysis. J Glob Health 2021; 11:05009.^,3939 Teles MA, Barbosa MR, Vargas AM, Gomes VE, Ferreira EF, Martins AM, Ferreira RC. Psychosocial work conditions and quality of life among primary health care employees: a cross sectional study. Health Qual Life Outcomes 2014; 12:72.

40 Leonelli LB, Andreoni S, Martins P, Kozasa EH, Salvo VL, Sopezki D, Montero-Marin J, Garcia-Campayo J, Demarzo MMP. Estresse percebido em profissionais da Estratégia Saúde da Família. Rev Bras Epidemiol 2017; 20(02):286-298.^-4141 Assunção AA, Pimenta AM. Satisfação no trabalho do pessoal de enfermagem na rede pública de saúde em uma capital brasileira. Cien Saude Colet 2020; 25(1):169-180.. Among possible stressors in the studied group, we can cite the lack of ACS training; the lack of PPE; the biosafety rules established are perceived as insufficient; and the work process change.

Furthermore, most ACS believe they are a COVID-19 transmitting vehicle, and many have had COVID-19 cases in the family, which can also be considered stressors. One study noted that the risk and fear of virus infection, along with social distancing (some feelings of loneliness), family life, and economic and uncertainty issues with the future, cause physical and mental fatigue³³33 Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, Yao L, Bai H, Cai Z, Xiang Yang B, Hu S, Zhang K, Wang G, Ma C, Liu Z. Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 Novel Coronavirus Disease Outbreak: a cross-sectional study. Brain Behav Immun 2020; 87:11-17..

This research also indicated a negative association between self-efficacy and greater SRQ in the ACS. In the COVID-19 context, having greater self-efficacy is essential, as it would mean having a greater ability to cope with the consequences of this disease in the living condition and lead to more coherent problem-solving and decision-making⁴²42 Heo YM, Lee M, Jang SJ. Intentions of frontline nurses regarding COVID-19 patient care: a cross-sectional study in Korea. J Nurs Manag 2021; 29(6):1880-1888.^,4343 Shahrour G, Dardas LA. Acute stress disorder, coping self-efficacy and subsequent psychological distress among nurses amid COVID-19. J Nurs Manag 2020; 28(7):1686-1695..

A study by Xiong et al.⁴⁴44 Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L, Chen-Li D, Iacobucci M, Ho R, Majeed A, McIntyre RS. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord 2020; 277:55-64. observed the association between lower self-efficacy and anxiety in nurses during the COVID-19 pandemic. Thus, self-efficacy can support mental health toward the well-being of health professionals during the pandemic⁴²42 Heo YM, Lee M, Jang SJ. Intentions of frontline nurses regarding COVID-19 patient care: a cross-sectional study in Korea. J Nurs Manag 2021; 29(6):1880-1888.^,4646 Lee J, Kang SJ. Factors influencing nurses' intention to care for patients with emerging infectious diseases: application of the theory of planned behavior. Nurs Health Sci 2020; 22(1):82-90., as it is related to motivation and accomplishment. Subjects with high self-efficacy do not easily give up. On the contrary, they increase the effort to overcome challenges⁴⁷47 Salanova M, Lorente L, Chambel M, Martínez I. Linking transformational leadership to nurse's extra-role performance: the mediating role of self-efficacy and work engagement. J Adv Nurs 2011; 67(10):2256-2266.. Compromised mental health, quality of life, and self-efficacy reduce work performance (delays and errors) and are a risk factor for accidents at work, conflicts between team members, and a higher likelihood of engaging in drug abuse⁴⁸48 Brandford AA, Reed DB. Depression in registered nurses: a state of the science. Workplace Health Saf 2016; 64(10):488-511.^,4949 Junqueira MAB, Santos MA, Araújo LB, Ferreira MCM, Giuliani CD, Pillon SC. Sintomas depressivos e o uso de drogas entre os profissionais da equipe de enfermagem. Esc Anna Nery 2018; 22(4):e20180129..

The present study also revealed the importance of early identification of mental health problems, which can affect other areas of life, including work. Knowledge about individual and contextual factors associated with ACS mental health is essential. It can contribute to this population’s most effective mental and occupational policies, especially those in high social vulnerability and violent areas. Thus, establishing a caregiver care policy can support the ACS in exercising their craft, improving their work process, and offering decent working conditions to improve their quality of life and effectiveness, thus qualifying healthcare provided to the population.

This study did not occur without limitations, and its cross-sectional design is one of them as it prevents establishing a cause and effect between the analyzed variables. However, analysis was performed at various levels and assessed contextual factors related to the mental health of ACS.

We can conclude that, although the ACS operated in northeastern cities with different peculiarities, about 40% of them had SRQ above 7, signaling high levels of CMD/mental health problems during the COVID-19 pandemic. This fact may have compromised the quality and continuity of health care for families admitted to the ESF territories.

The findings showed the multidimensional dynamics of mental health. They helped to understand the relationship between community violence, COVID-19, quality of life, age, and time working in the ESF with the mental health of ACS. The results of this study are expected to subsidize strategic actions that seek to promote the mental health and quality of life of the ACS so that these professionals can overcome the emotional sequelae suffered throughout the COVID-19 pandemic and fully develop their activities.

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