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Mental Health Care in Primary Care: reflections based on realities in Brazil

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Maria Dionisia Do Amaral Dias Osvaldo Gradella Junior Sveli Terezinha Ferreira Martins

 

Maria Dionísia do Amaral Diasi Osvaldo Gradella Juniorii
Sueli Terezinha Ferreira Martinsiii

The Unified Health System (SUS) was enshrined in the Constitution of the Federative Republic of Brazil (1988) and is the result of a social movement called ‘health reform', which was supported by health professionals and organized society. Health as a right to all and duty of the State, with universal and egalitarian access meant a radical change in the Brazilian health system, which until then was ensured only to part of the population - those inserted into the formal labor market who contributed to Social Security.
Fullness of care can also be understood as a revolution in terms of healthcare and has two implicit meanings: the vision of the human being as whole and integral - not divided into body/mind or in systems and functions, nor seen as disease; the vision that providing healthcare involves promotion, protection and recovery. It has been a difficult task constructing this vision, which involves profound changes in health service work processes, both in Primary Care and throughout the System.
The main goal to be achieved in providing fullness of care seems to be in "humanization", in the sense of placing relationships again as essential to healthcare, and prioritizing "light technologies"1, as a basis for care, as advocated by a number of Public Health researchers (Campos, Merhy, and others) and promoted by the Ministry of Health for the last few years. Humanization refers to interactions that positively affect people and provide greater autonomy to the subjects, and may produce a doubly positive effect: the user becomes a more active participant in the care, instead of passively receiving prescriptions from health professionals; and healthcare workers perform their professional function in a more active and less authoritarian manner, regaining real power by freeing themselves from false omnipotence, which results in better quality and more effective care and consequent work satisfaction.
The System is organized with Primary Healthcare as the first point of care in the Network and main gateway into the system, "forming a multidisciplinary team that covers the entire population, integrated, coordinating care and meeting people's healthcare needs." (BRAZIL, 2011).
Basic Care2, according to the National Policy3 (BRAZIL, 2011) is characterized by a broad set of activities:
a) within the individual and collective spheres;
b) covering health promotion and protection, prevention of worsening conditions, diagnosis, treatment and rehabilitation, damage reduction and health maintenance;
c) full care that has an impact on the health situation and autonomy of people and collective health determinants and conditioning factors;

 

1 According to Merhy (2002), the healthcare process involves three "technologies": "hard", tools and machines; "hard-soft", knowledge on well-structured forms of professional knowledge; "soft", the process of relationships among persons, who act upon one another, in which a set of expectations and outcomes is at play, creating an inter-subjectivity at times, such as talking, listening and interpretation.
2 Within the Unified Health System in Brazil, the term Basic Care is used to denote primary level healthcare.
3 A National Policy at SUS issues guidelines for structuring and organizing different levels or fields of care within the system. It is always the result of a consensus between the three levels of government (federal, state and local) and representatives of users, called by order of the Ministry of Health.

d) care and management practice that are democratic and participatory, working as teams;
e) populations from defined geographical areas, for which they are responsible health-wise;
f) team utilizes complex and varied healthcare technologies that should aid in managing health demands and needs of greatest frequency and relevance within its geographical area, considering criteria of risk, vulnerability, resilience and the ethical imperative that all health or suffering needs must be addressed (BRAZIL, 2011).
Family Health is a reorientation strategy of the Primary Care assistance model, seeking primarily its expansion, consolidation and enhanced qualification. This strategy is considered to favor a reorientation of the process of work at the healthcare unit, and has the potential of expanding resoluteness and impact on the health condition of people and groups (BRAZIL, 2011). Family Healthcare teams are responsible for follow-up of a defined number of families located within a specific geographical area, which encourages involvement with their clientele, and is one of the potentials of Mental Health care.
These teams have a minimum staff of a general practitioner physician, a general nurse, an assistant nurse and community health agents (ACS in Portuguese). Dental healthcare professionals may also be added to this multidisciplinary team: a general dental surgeon, aid of dental health technician. Each family healthcare team may be responsible for no more than 4,000 persons, following criteria of equity and considering the degree of vulnerability of the households in that geographical area. The number of community health agents "must be sufficient to cover 100% of the registered population, with no more than 750 person per ACS and 12 ACSs per Family Healthcare team" (BRAZIL, 2011).
Family Healthcare teams are expected to perform the following within their areas of activity: actions directed towards health problems, focusing on families and the community, providing long-term care to people, always maintaining a proactive stance regarding healthcare-disease problems of the population. Certain strategies and tools are used to accomplish this, such as registering households, situational diagnoses and local planning of activities, as well as seeking partnerships with social institutions and organizations. The family healthcare units (USFs in Portuguese) are expected to be venues for the construction of citizenship values. Teams should build ties with members of the community within their areas of activity in order to achieve the objectives proposed for Family Healthcare, taking responsibility for their full healthcare.
Some authors point out common principles between Family Health and Mental Healthcare: ties, de-institutionalization, reception, development of citizen values, full care, responsibility of team linked to community base geographical area, inter-sectorial nature and integration into the healthcare network, from primary to specialized care, with an inter-institutional focus. These characteristics make the Family Healthcare Strategy (ESF in Portuguese) particularly powerful for Mental Healthcare, especially the tie and proximity to the population. They also, however, bring certain psycho-social aspects to light that impact the subjectivity of workers, which place their mental health at risk (Rosa, Labate, 2003; Medeiros, Guimarães, 2002; Ribeiro, 2006; Vecchia, Martins, 2009).
Research conducted trying to understand the two abovementioned aspects, and two intervention-study reports carried out in municipalities within the state of São Paulo, Brazil, are described hereinafter.
An experiment is being conducted in a municipality with roughly 350,000 inhabitants, in terms of joining ESF/Mental Health with mapping mental health demands. The Family Healthcare Unit involved in the intervention-study has three teams, organized in three different areas, each with about 3,000 families. One area is divided into six micro-areas, each under the responsibility of a community health agent.

Two instruments were used in the mapping activity: Form 1 - Mental Health Information Survey and Form 2 - Mental Health Cases Research Questionnaire. Data was collected in late 2010 and early 2011 to obtain information on the population within the area covered by the ESF regarding mental health demands, with monthly house visits. Then, information was categorized using the Statistical Package for the Social Sciences (SPSS) program.
One hundred and seventy six mental health-related topics were detected in the three areas covered by the USF, 65 cases in Area X, 64 cases in Area Y and 47 cases in Area Z. There was a prevalence of cases in two micro-areas of area X and one inside area Y.
The most recurrent topics were: Depression (20.8%); Mental Disorders - deliria, hallucinations etc. (15.4%); Illicit Drugs (15%) and Alcoholism (14.6%). The major complaint in Area X was Alcoholism (6.3%), in Area Y, Mental Disorders with 7.1% and Depression with 7.9% and in Area Z it was Depression (7.1%).
Most of the patients were aged between 45 and 59 (36%) and female (55.4%). The main issues detected for men were alcoholism (13.3%) and use of illicit drugs (11.3%), while depression (18.8%), anxiety (6.7%) and difficulty sleeping were the predominant issues in women (6.3%).
In terms of education, 43.2% had Incomplete Elementary School while 11.4% did not know how to read or write; 12.5% had Completed Elementary School and 6.3% had gone to High School. We should add that there was no information available in 26.7% of the cases.
After this preliminary survey, a map of the area was used to illustrate this information and facilitate visualization people's household relationships and life problems by members of the Family Healthcare and Housing teams. This enabled an understanding of the users' problems in their multiple dimensions, facilitating reception, guidance and promoting psych-social care to both users and their families. The aim during this process of knowledge and involvement of the users and their families is to refer the users and their families to group processes, some already underway with technical teams, thus providing group support and social and cultural participation.
Thus, this study demonstrates that in primary care health services, there are significant and important demands for Mental Health care and that the Family Healthcare Strategy is a powerful tool to address these issues.
On the other hand, other experiments conducted by other Family Healthcare unit teams in another municipality with roughly 130,000 inhabitants identified significant issues related to work and mental health of workers. Some were related to community health agents, a category of professional that works in the area, primarily to conduct household visits to families living within the area of coverage of the healthcare unit. Others were identified during contact with the entire team of workers from the basic healthcare unit (UBS in Portuguese).
Generally speaking, what was detected was that psychological suffering of healthcare workers originated from how work was organized, related to being overworked and daily routines that work against the type of care that the population that uses the unit needs. On the other hand, although the work is perceived by the majority of workers as a fundamental activity in people's lives and also in their process of illness, we detected that the history of the users' work practically disappears in the contact they have with the population under their care. There are few reports on this important dimension of life in users' records at the healthcare unit.
At the ACS, people report psychological trauma related to their living conditions
usually limited to observing and listening to people's troubles. The sensation of impotence, added to the lack of collective venues to share and define activities lead to ongoing psychological suffering (Ribeiro, 2006, 2011; Ribeiro and Martins, 2011). Moreover, more recently, the ACSs have established a close link between their suffering and the impact of daily violence, especially when they have to deal with people who abusively use alcohol and other drugs, since their work involves direct, continuous and non-stop contact with the community and they suffer the positive and negative consequences of living and working in the same geographical area (Jardim and Lancman, 2009; Bornstein and Stotz, 2008; Habimorad, 2010). As mentioned in other studies (Ribeiro, 2011; Lancman, Ghirardi, Tuacek & Castro, 2009; Lancetti, 2000), life in the community, feeling the threatening presence of drug trafficking and violence, without any support from the team or other professionals, has been shown to present obstacles to the practice of the ACSs with their users and causes or to enhance workers' psychological suffering.
This experiment identified several needs of health workers and detected a lack of a collective venue to share their experiences and anxieties. Therefore, we began working in two areas: a) a weekly collective session with ACS so that they could share about their daily work and psychological suffering, as well as positive outcomes for their problems; b) an inter-professional commission was organized to discuss how organization of labor at the UBS was affecting the health of workers and quality of care provided to the populace. Regarding the organization of labor, care that was categorized as "occasional"4 were in fact taking an undue proportion of the daily work load, happening as many as forty times a day, and was the cause of much discomfort. The second area worked on a series of collective actions using group dynamics: spontaneous drama workshops with workers who participated on the commission (Lane, 1984; Martin-Baró, 1989; Ribeiro and Martins, 2007); workshops with all workers from the two teams and representatives from the community.
In summary, implementing ESF within Primary Healthcare in the Brazilian SUS has led to addressing a series of issues linked to the field of Mental Health, both in identifying important demands among the communities served by the healthcare teams, as well as mental health issues affecting healthcare workers, especially Community Health agents who work and live in the same geographical areas.


References
BRAZIL. Ministry of Health. Ordinance no. 2488, of 21 October 2011. Approves the National Basic Care Policy. Federal Daily Gazette. Brasília, DF, 22 Oct. 2011.
BORNSTEIN, V.J.; STOTZ, E.N. O trabalho dos agentes comunitários de saúde: entre a mediação convencedora e a transformadora. Trab. Educ. Saúde, 6(3), 457-480, Nov.2008/Feb.2009.
CAMPOS, G. W. S. A saúde pública e a defesa da vida. São Paulo: Hucitec, 1991.

 


4 Daily care activities at the Basic Healthcare Units are to be organized to respond to the needs of the community, including promoting and protecting health, preventing worsening of situations, diagnoses, treatment and rehabilitation, reduction of damage and maintenance of health. Therefore the majority of the activities must be planned, individually or collectively, ensuring the community ongoing and close follow-up by health professionals. Unforeseen occurrences and those requiring immediate and unplanned care are called occasional care and should be a minor part of the daily work of the health team. Nevertheless, in the municipality where the study was conducted, these had become the most numerous type of occurrence in the team`s daily work.

 



CAMPOS, G. W. S. Um Método para Análise e Co-Gestão de Coletivos: a constituição do sujeito, a produção de valor de uso e a democracia em instituições: o método da roda. 3rd ed. São Paulo: Hucitec, 2007.
HABIMORAD, P.H.L. A atenção às pessoas com dependência ou uso abusivo de drogas: estudo de caso a partir de uma unidade de saúde da família no município de Botucatu. Relatório de Iniciação Científica, 2010. (Bolsista IC - PIBIC Reitoria, 2009-2010).
JARDIM, T.A. & LANCMAN, S. Aspectos subjetivos do morar e trabalhar na mesma comunidade: a realidade vivenciada pelo agente comunitário de saúde. Interface - Comunic., Saúde, Educ., 13(28), 123-35, 2009.
LANCETTI, A. Saúde mental nas entranhas da metrópole. In: (Org.). Saúde mental e saúde da família. São Paulo: Hucitec, 2000. p. 11-52. (SaúdeLoucura, 7).
LANCMAN, S.; GHIRARDI, M.I.G.; CASTRO, E.D. & TUACEK, T.A. Repercussões da
violência na saúde mental de trabalhadores do Programa Saúde da Família. Rev Saúde Pública.
43(4):682-8, 2009.
LANE, S. T. M. O processo grupal. In S. T. M. Lane & W. Codo (Eds.), Psicologia Social: O homem em movimento (pp. 78-98). São Paulo, SP: Brasiliense, 1984.
MARTÍN-BARÓ, I. Sistema, grupo y poder. Psicología social desde Centroamérica II. San Salvador: UCA Ed., 1989. (Colección Textos Universitarios, 10)
MEDEIROS, M.S.; GUIMARÃES, J. Cidadania e saúde mental no Brasil: contribuição ao debate. Ciênc. Saúde Colet., v.7, n.3, p.571-579, 2002.
MERHY, E.E. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec, 2002.
RIBEIRO, S.F.R. O sofrimento psíquico dos trabalhadores de uma equipe do Programa Saúde da Família na organização do trabalho. Dissertation (Masters Degree in Collective Health), School of Medicine of Botucatu, UNESP, Botucatu, 2006.
RIBEIRO, S.F.R.; MARTINS, S.T.F. Oficina de teatro espontâneo com trabalhadores do Programa de Saúde da Família: um espaço de expressão e reflexão. Pesquisas e Práticas Psicossociais, 2(1), São João Del-Rei, Mar./Aug., 2007.
RIBEIRO, S.F.R.; MARTINS, S.T.F. Sofrimento psíquico do trabalhador da Saúde da Família na organização do trabalho. Psicologia em Estudo, Maringá, v. 16, n. 2, p. 241-250, Apr./Jun. 2011.
RIBEIRO, S.F.R. Sofrimento psíquico e privacidade do Agente Comunitário de Saúde. Doctoral Thesis in Education, State University of Campinas, Campinas, 2011.
ROSA, W.A.G.; LABATE, R.C. A contribuição da saúde mental para o desenvolvimento do PSF. Rev. Bras. Enferm., v.56, n.3, p.230-235, 2003.
VECCHIA, M.D.; MARTINS, S. T. F. Concepções dos cuidados em saúde mental por uma equipe de saúde da família, em perspectiva histórico-cultural. Ciência & Saúde Coletiva. V.14, n.1, p.183-193, 2009.

 

 

 


i Department of Public Health, School of Medicine, Paulista State University (UNESP), Brazil. dionisia@fmb.unesp.br
ii Department of Public Health, School of Sciences, Paulista State University (UNESP), Brazil. gradella@fc.unesp.br
ii Department of Neurology, Psychology and Psychiatry, School of Medicine, Paulista State University
(UNESP), Brazil. stfm@fmb.unesp.br

 

 


 
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