Occupational stress , work engagement and coping strategies in Community Health Workers

Objectives: to evaluate the levels of occupational stress, work engagement, and coping strategies among community health workers. Methods: cross-sectional study with 133 Community Health Workers. We used a questionnaire with socioeconomic and professional variables, the Work Stress Scale, the Utrecht Work Engagement Scale, and the Coping Modes Scale. Results: The mean occupational stress score was 2.7. Work engagement levels were high for dedication (4.0), vigor (4.3), and overall score (4.0). Problem-focused coping modes (3.9; ±0.6) and based on religious practices and fantasy thinking (3.4; ±0.7) stood out. Conclusion: there is a high percentage of professionals with significant occupational stress. The levels of work engagement were medium for absorption and high for dedication, vigor, and overall score. The coping strategies are focused on problem solving, religious practices and fanciful thoughts of positive character. Descriptors: Primary Health Care; Community Health Workers; Work Engagement; Occupational Stress; Adaptation, Psychological. RESUMO Objetivos: avaliar os níveis de estresse ocupacional, work engagement e estratégias de enfrentamento em agentes comunitários de saúde. Métodos: estudo transversal com 133 Agentes Comunitários de Saúde. Foram utilizados um questionário com variáveis socioeconômicas e profissionais, a Escala de Estresse no Trabalho, a Utrecht Work Engagement Scale e a Escala Modos de Enfrentamento de Problemas. Resultados: o escore médio do estresse ocupacional foi 2,7. Os níveis de work engagement foram altos para dedicação (4,0), vigor (4,3) e escore geral (4,0). Destacaram-se os modos de enfrentamento Focalizados no Problema (3,9;±0,6) e Baseados na busca de práticas religiosas e pensamento fantasioso (3,4;±0,7). Conclusão: há um percentual elevado de profissionais com estresse ocupacional importante. Os níveis de work engagement foram médios para a absorção e altos para dedicação, vigor e escore geral. As estratégias de enfrentamento estão voltadas para a focalização na resolução do problema, práticas religiosas e pensamentos fantasiosos de caráter positivo. Descritores: Atenção Primária à Saúde; Agentes Comunitários de Saúde; Engajamento no Trabalho; Estresse Ocupacional; Adaptação Psicológica. *Extracted from the dissertation “Estresse ocupacional, engagement e estratégias de enfrentamento em Agentes Comunitários de Saúde”, Faculdade de Medicina de São José do Rio Preto, 2020. 1Faculdade de Medicina de São José do Rio Preto. São José do Rio Preto, São Paulo, Brazil. 2Universidade Federal do Rio Grande. Rio Grande, RS, Brazil. 3Secretaria Municipal de Saúde. São José do Rio Preto, São Paulo, Brazil. Corresponding author: Luciano Garcia Lourenção Rua General Osório, s/n. Campus da Saúde, Sala 10. Centro. CEP: 96200-400. Rio Grande, RS, Brazil. E-mail: lucianolourencao.enf@gmail.com EDITOR IN CHIEF: Ana Fatima Carvalho Fernandes ASSOCIATE EDITOR: Renan Alves Silva Francielli Regini Carvalho de Faria1 Luciano Garcia Lourenção2 Albertina Gomes da Silva1 Paula Canova Sodré3 Jussara Rossi Castro1 Márcio Andrade Borges2 Cláudia Eli Gazetta1 How to cite this article: Faria FRC, Lourenção LG, Silva AG, Sodré PC, Castro JR, Borges MA, et al. Occupational stress, work engagement and coping strategies in Community Health Workers. Rev Rene. 2021;22:e70815. DOI: https://doi.org/10.15253/2175-6783.20212270815 Faria FRC, Lourenção LG, Silva AG, Sodré PC, Castro JR, Borges MA, et al Rev Rene. 2021;22:e70815. 2 Introduction Community Health Workers are part of the Family Health Teams as health professionals because they have the technical knowledge that allows them to transmit information on health promotion and disease prevention, and as community residents, they bring with them the culture, customs, and popular knowledge of the local society, so that this proximity creates the desired links with the health service(1). In the current panorama of the health of workers in the Brazilian Unified Health System, there is a growing precariousness of work, with temporary employment contracts and low wages, which generate overload and emotional stress, and can compromise the quality of life and health of community workers. Moreover, this situation impacts the relationship between these professionals and the community, due to the great proximity they have with users(2-3). From a set of relationships and interactions, these professionals play an important role in facilitating community access to services and health care actions developed by Primary Care. However, they are often pressured by the community regarding the flows and the resolution of demands, such as scheduling appointments and exams, and may feel guilty for the weaknesses of the system(4-5). In this context, there is an overload of community health workers, resulting from the set of work demands, associated with the intense emotional involvement with the user, the low recognition and little appreciation of their efforts by the community, managers, and public authorities, which can cause demotivation and illness in these professionals(6-8). Although occupational stress is part of work life and is considered useful in small levels, continuous stress, or an inadequate response to it is harmful and can produce negative impact on work and worker health, affecting the community that suffers with absenteeism, emotional problems, and irregular performance of professionals, besides their impatience with the population(2). The development of strategies to minimize stress is important to avoid damage to the worker’s health and improve their job satisfaction, producing motivation. Besides the individual care with the workers, it is necessary to think and act collectively with all the actors involved in the labor process. However, the intense work routine makes community health workers seek help only when they feel completely worn out or exhausted(6-7). Coping strategies consist of the different ways professionals deal with daily stress situations and involve behavioral and cognitive efforts created to control the demands and circumstances that overwhelm individuals or exceed their personal resources(9). They are necessary to prevent health damage and produce motivation, improving job satisfaction. One of the most common strategies among community health workers is to find affective and social support to face the problems and difficulties in dealing with the limits of personal life(6-7). Despite the stress present in the work practice of these professionals, there is pleasure and satisfaction in their occupational activities when there is appreciation and recognition and situations such as manifestations of affection and gratitude of users for the work done, which shows a relationship where there is integration of professionals with the team and managers(10). And, despite all the difficulties, the engagement of community health workers in the work is noted(1). Which shows that when professionals are engaged, greater investments in their physical, psychoemotional, and cognitive development are made, leading to an increase in their work performance, because they present higher levels of extrafunction behavior, performing actions that go beyond their responsibilities. Therefore, they become more focused on their tasks and responsibilities and work more intensely(11). Considering that engaged professionals are essential for the efficiency and success of the organization, it becomes relevant to study work engagement. On the one hand, professional wear and loss of energy


Introduction
Community Health Workers are part of the Family Health Teams as health professionals because they have the technical knowledge that allows them to transmit information on health promotion and disease prevention, and as community residents, they bring with them the culture, customs, and popular knowledge of the local society, so that this proximity creates the desired links with the health service (1) .
In the current panorama of the health of workers in the Brazilian Unified Health System, there is a growing precariousness of work, with temporary employment contracts and low wages, which generate overload and emotional stress, and can compromise the quality of life and health of community workers. Moreover, this situation impacts the relationship between these professionals and the community, due to the great proximity they have with users (2)(3) .
From a set of relationships and interactions, these professionals play an important role in facilitating community access to services and health care actions developed by Primary Care. However, they are often pressured by the community regarding the flows and the resolution of demands, such as scheduling appointments and exams, and may feel guilty for the weaknesses of the system (4)(5) .
In this context, there is an overload of community health workers, resulting from the set of work demands, associated with the intense emotional involvement with the user, the low recognition and little appreciation of their efforts by the community, managers, and public authorities, which can cause demotivation and illness in these professionals (6)(7)(8) .
Although occupational stress is part of work life and is considered useful in small levels, continuous stress, or an inadequate response to it is harmful and can produce negative impact on work and worker health, affecting the community that suffers with absenteeism, emotional problems, and irregular performance of professionals, besides their impatience with the population (2) .
The development of strategies to minimize stress is important to avoid damage to the worker's health and improve their job satisfaction, producing motivation. Besides the individual care with the workers, it is necessary to think and act collectively with all the actors involved in the labor process. However, the intense work routine makes community health workers seek help only when they feel completely worn out or exhausted (6)(7) .
Coping strategies consist of the different ways professionals deal with daily stress situations and involve behavioral and cognitive efforts created to control the demands and circumstances that overwhelm individuals or exceed their personal resources (9) . They are necessary to prevent health damage and produce motivation, improving job satisfaction. One of the most common strategies among community health workers is to find affective and social support to face the problems and difficulties in dealing with the limits of personal life (6)(7) .
Despite the stress present in the work practice of these professionals, there is pleasure and satisfaction in their occupational activities when there is appreciation and recognition and situations such as manifestations of affection and gratitude of users for the work done, which shows a relationship where there is integration of professionals with the team and managers (10) . And, despite all the difficulties, the engagement of community health workers in the work is noted (1) .
Which shows that when professionals are engaged, greater investments in their physical, psychoemotional, and cognitive development are made, leading to an increase in their work performance, because they present higher levels of extrafunction behavior, performing actions that go beyond their responsibilities. Therefore, they become more focused on their tasks and responsibilities and work more intensely (11) .
Considering that engaged professionals are essential for the efficiency and success of the organization, it becomes relevant to study work engagement. On the one hand, professional wear and loss of energy are linked to high work demands, poor job structure, and low levels of resources, which can lead to physical and mental exhaustion and cause health problems; on the other hand, even in the face of adversity and scarcity of resources, work can become motivational and lead professionals to high engagement and high performance at work (12) .
Therefore, this study aimed to evaluate the levels of occupational stress, work engagement, and coping strategies among community health workers.

Methods
Cross-sectional study, conducted in the period from February to June 2017, with community health workers of the Family Health teams in the municipality of São José do Rio Preto, São Paulo, Brazil.
At the time of data collection, the municipality was divided into five Health Districts with 27 Primary Care units, 10 Basic Health Units and 17 Family Health Units with 40 Family Health Strategy teams covering 24% of the population. The study population consisted of 260 Community Health Workers from the municipality's Family Health teams. The study sample was defined by convenience and composed of 133 professionals who answered the instruments.
Data were collected during team meetings, after scheduling with the managers of the health units. The researchers explained the objectives of the study and delivered the questionnaires and the Informed Consent Forms in separate sealed envelopes, which could be answered at the workplace or in another environment and were returned after a week in the respective separate sealed envelopes to preserve the anonymity of the study participants.
Four self-applied instruments were used, one with sociodemographic and professional variables; the Work Stress Scale (WSS) (13) ; the Brazilian version of the Utrecht Work Engagement Scale (UWES) (14) ; and the Problem Coping Modes Scale (15) . The WSS consists of 23 negative statements and with answers on a five-point Likert scale, ranging from: 1 -strongly disagree, 2 -disagree, 3 -partially agree, 4 -agree and 5 -strongly agree and the higher the score, the higher the stress. The internal consistency (Cronbach's alpha) of the scale was equivalent to 0.91 (13) . The UWES consists of 17 self-assessment items with three dimensions (Vigor, Dedication and Absorption) and a general score (11,14) . The internal consistency of the scale in the Brazilian population was high (Cronbach's alpha = 0.95), indicating good validity for our cultural context (14) .
The Problem Coping Modes Scale is composed of 45 items that address four factors: coping strategies focused on the problem (Factor 1); coping strategies focused on emotion (Factor 2); search for religious practices/fantastical thinking (Factor 3) and search for social support (Factor 4). The Problem Coping Modes Scale items are answered on a Likert type scale with five possible responses: 1 -I never do this; 2 -I do this a little; 3 -I do this sometimes; 4 -I do this a lot; 5 -I do this always. The Problem Coping Modes Scale adapted for the Brazilian population showed the following consistency values: Factor 1: α=0.84; Factor 2: α=0.81; Factor 3: α=0.74, and Factor 4: α=0.70 (15) .
For the professionals who were not present at the meeting, the questionnaires and the Informed Consent Form were left by the researchers with the managers of the units, who delivered and collected them in separate, sealed envelopes and handed them to the researchers later, no later than 30 days.
Data were analyzed using the Statistical Package for the Social Sciences, version 20.0. The population was characterized by sociodemographic and professional variables. For the evaluation of occupational stress, the overall mean score obtained by the community health workers was calculated, as well as a score for each item of the scale, to identify the most stressful factors. Mean values equal to or greater than 2.5 indicate important levels of stress (13) .
To calculate the scores of the dimensions of work engagement, the proposed statistical model was used, indicating mean and standard deviation for each dimension of the UWES scale. Based on the calculation of the scores, we proceeded to interpret the values obtained, according to the decoding of the UWES Preliminary Manual, being: Very Low = 0 to 0.99; Low = 1 to 1.99; Medium = 2 to 3.99; High = 4 to 4.99; Very High = 5 to 6 (14) . For the analysis of the problem coping modes, a mean score was calculated for each factor of the WSS, considering the items that make up each factor and each item of the scale, identifying those with higher means (15) .
The levels of community health workers' work engagement ranged from 3.8 to 4.3 and were classified as medium for the absorption dimension and high for the dedication, vigor, and overall score dimensions, as shown in Table 2. Cronbach's Alpha Coefficient values ranged from 0.827 to 0.936 and point to the reliability of the results (Table 1). The internal consistency of the WSS for this study was α=0.91. In the analysis of the overall occupational stress score, 74 community health workers (56.4%) presented scores compatible with major occupational stress (>2.5). The mean stress level of the sample was 2.7 (SD = ±0.7; 95% CI = 2.6 -2.8). As shown in Table 2  Regarding the coping mode used by community health workers, the strategies of Problem-Focused Coping (3.9±0.6) and Coping based on the search for religious practices and fanciful thinking (3.4±0.7) stood out (Table 3). The Problem Coping Modes Scale items that showed higher mean scores were: I pray/pray (4.7±1.0); I try to be a stronger and more optimistic person (4.4±0.8); I focus on the good things in my life

Discussion
The main limitations of this study are its cross--sectional design, which makes it impossible to esta-blish cause and effect relationships; and the inclusion of professionals from a single municipality, which does not allow the generalization of the results.
On the other hand, the results show important aspects of the relationship between community health workers and their work, especially because these workers have their main assignment linked to the practice of health care. In addition, they show the importance and the need for community health workers to work under low levels of occupational stress, with good levels of work engagement and coping strategies that allow them to overcome adversities, contributing to expand the coverage of the Family Health Strategy and increase the effectiveness of access to basic health services by the population.
It is observed that during their work in the territory of the Family Health Unit, community health workers are often pressured and penalized by users about the network flows, which generates an important emotional pressure on these professionals (5) . The impact of this pressure is evidenced in this study by the high levels of stress related to lack of training, poor dissemination of information on organizational decisions, lack of autonomy and performance of tasks that are beyond the professional capacity of community health workers.
These results are reinforced by the literature, which points out the suffering of many professionals in Primary Health Care with occupational stress, especially community health workers for being among the professional categories with the highest level of stress and dissatisfaction with their work performance (16) .
The high percentage of community health workers with an important level of occupational stress can be explained by the time these professionals have been working in primary health care services, since the literature describes that stress is greater after the first year of work (6)(7)16) . In this context, occupational stress can be a risk factor for abandonment of the function, generating high turnover of these workers in the Family Health Care teams and hindering the development of a bond with families and the community, which can compromise the resolutivity capacity of the Family Health Strategy in the territories (6)(7)16) .
In addition, these results highlight the importance of community health workers receiving training to deal with the psychic burdens present in their work activity, such as living with people in poor socioeconomic and health situations, hunger and unemployment, chemical dependency, situations of violence abandonment and neglect, lack of understanding and resistance of users, high emotional load resulting from the involvement with the community, severity of health problems and family relationships, intense work rhythm and low recognition, in addition to the overvaluation of violence and bureaucracy as factors of insecurity (17) .
Another factor pointed out as fundamental for the reduction of occupational stress is the guarantee of more stable working conditions for the professionals of the Family Health Strategy, especially hiring, since the singularity of the work in this care model and the requirement of full time reinforce the need for greater stability for workers, such as hiring through public competitions (5) .
Professional satisfaction, pointed out in this study by more than 60% of community health workers, is widely discussed by specialists in organizational behavior, especially in relation to the impacts caused on the workers' health (6)(7)(8) . When the community listens and receives community health workers with attention, these professionals feel extremely valued and satisfied, because they can bring about positive changes that reflect in the quality of care provided (16)(17) .
In turn, job satisfaction is associated with occupational stress to the extent that professionals with higher levels of satisfaction have better levels of stress and can better cope with stressors (16) . The results of this study are in line with such statement, since, despite being satisfied with their profession, it was observed that most community health workers have high levels of occupational stress, the professionals studied show high levels of work engagement, mainly related to: high energy and mental toughness; high desire to invest in the work, with effort and persistence; and the strong involvement with the work, with feelings of enthusiasm, inspiration and pride, corroborating studies with professionals in Primary Health Care (16)(17) .
And, although some researchers consider that work engagement levels are independent of the degree of organizational commitment, of the level of satisfaction with the job and of organizational citizenship behavior, there are others who defend the existence of a positive relationship between work engagement and job satisfaction and consider that job satisfaction is a variable that precedes work engagement. Thus, the high level of work engagement presented by community health workers may explain their feeling of satisfaction, regardless of the presence of occupational stressors (10,12) .
In addition, engaged workers tend to experience more positive emotions and have better physical and mental health status due to greater participation in social and leisure activities that promote relaxation and psychological detachment from work, such as physical exercise (10) .
Nevertheless, the ways of coping presented by community health workers can also corroborate to the strengthening of satisfaction levels and engagement at work, since these professionals use their own interventional measures to minimize the psychological stress arising from the work process, such as the search for religious practices; of support in affective networks, such as family, friends, and people who bring security or sustenance in social support, such as co-workers who allow the sharing of emotions (18) .
In this sense, it is believed that nurses who are responsible for coordinating and managing community health workers, as well as municipal managers, can create institutional spaces in the Units and health teams to listen and reflect on the demands of community health workers, helping them to manage their difficulties in developing their functions as mediators between the health system and the attached users, in order to meet the demands of users of the Unified Health System, without the mental illness of these community health workers.

Conclusion
The main stressors, in the perception of the professionals, were training deficits; and in the disclosure of information about organizational decisions; lack of career growth perspectives and discrimination/favoritism in the work environment.
The problem coping strategies are focused on problem solving, religious practices, and fanciful thoughts of positive character. And, regarding the levels of work engagement of community health workers, these are favorable, especially regarding dedication (involvement with the work, feelings of enthusiasm, inspiration, and pride) and vigor (mental energy and stamina desire to invest in the work, effort, and persistence).