Seeing Inside: How Stigma and Recognition Shape Community Health Worker Home Visits in São Paulo, Brazil.

Abstract

Community Health Worker (CHW) home visits are central to primary care provision in São Paulo, Brazil. Yet CHWs receive little training prior to conducting these visits. In the neighborhood where I conducted ethnographic fieldwork, nearly half of patients were immigrants to Brazil, adding a layer of sociocultural and linguistic difference. I thus investigated how interactions between CHWs and patients unfolded and were shaped by cultural processes. Analyzing fieldnotes and interview data, I found that CHWs cherished relationships with older adult Portuguese-speaking patients, while expressing exasperation and even disgust with more recent immigrants and patients living with stigmatized health conditions. The cultural processes of recognition and stigma shaped CHWs' perceptions of and interactions with patients. I ground these analyses in the history of state-sponsored discourse linking immigrants with poor hygiene, concluding that home visits deserve greater scrutiny as a public health tool that may increase access to care at the expense of health equity.