Urban Violence and its effect on Primary Health Care

Abstract Urban violence (UV) adversely affects livelihoods, mental health, life expectancy, institutional functioning, and social cohesion. However, its impact on primary health care (PHC) remains understudied, particularly in highly violent contexts such as NE Brazil. This study assessed the prevalence and effects of UV on PHC from the perspective of Community Health Workers (CHWs) in eight municipalities in Brazil's Northeast-4 state capitals (Fortaleza, Recife, Teresina, João Pessoa) and 4 smaller cities (Sobral, Juazeiro do Norte, Crato, Barbalha). A total of 1,944 CHWs participated in 2021 and 1,915 in 2023. CHWs, who play a key role in delivering community-based health interventions, reported high levels of UV in their work environments (76.6% in 2021; 78.3% in 2023). Significant proportions reported adverse impacts on physical (41.2% in 2021; 48.8% in 2023) and mental health (64.7% in 2021; 62.5% in 2023), with nearly one-third ceasing care to families due to safety concerns. Overall, the feelings of threat during work increased (43.7% in 2021; 49.8% in 2023). There was an increase in violence in the city of Fortaleza (83.6% vs. 92.9%) where there was also an increase in the percentage of CHWs who felt threatened by violence while working (48.5% in 2021 vs. 63.2% in 2023), as well as a significant increase in the CHWs’ perceptions of drug trafficking (78.0% in 2021 vs. 84.9% in 2023) as causes of UV in their communities. Urban violence was more prevalent in larger cities, while domestic and institutional violence predominated in smaller municipalities. These findings highlight not only the conditions to which health professionals are exposed but also the social vulnerability of the population they serve, which has remained invisible/unreachable by public policies. Thus, it is necessary to rethink the ways in which we address UV in the territory, and an urgent need for public policies to address UV as a determinant of health and a barrier to effective PHC delivery. Key messages • Urban Violence is very prevalent in NE Brazil Primary Health Care territory and affects health professionals’ mental and physical health and their ability to care for the community. • Violence is a development constraint that erodes the assets of the whole society, but with disproportionate burden to the poorest and the most vulnerable, deepening inequalities.