Factors affecting the interventions of the Family Health Strategy team towards individuals with mental disorders

Abstracts

Estudo qualitativo com equipes da Estratégia Saúde da Família do município de Maringá - PR que visou conhecer os fatores que interferem nas ações ao portador de transtorno mental. Os dados foram coletados através da metodologia do grupo focal e submetidos à análise de conteúdo. Foram citadas questões pessoais, profissionais e relacionadas à estruturação do serviço, tais como sentimentos negativos, despreparo profissional e priorização de ações curativas. Na rede de saúde mental há os critérios para atendimento, a referência e contra-referência deficiente e a atividade matricial. Na realização das ações encontrou-se o vínculo, a falta de envolvimento da família, a recusa da atuação da equipe e a baixa adesão a terapêutica. Foram detectados poucos fatores que contribuem para as ações enquanto muitos as dificultam, contudo, identificá-los permite que as equipes trabalhem para fortalecer a assistência em saúde mental.

Transtornos mentais; Programa Saúde da Família; Serviços de Saúde Mental; Atenção Primária à Saúde; Enfermagem psiquiátrica

ARTIGO ORIGINAL

Factors affecting the interventions of the Family Health Strategy team towards individuals with mental disorders^*

Factores que interfieren en las acciones del equipo de la Estrategia Salud de la Familia al afectado de transtorno mental

Jéssica dos Santos Pini^I; Maria Angélica Pagliarini Waidman^II

^IRegistered Nurse. MSc in Nursing of the Post-graduate Program in Nursing of the Maringá State University. Maringá, PR, Brazil. [e-mail]

^IIRegistered Nurse. PhD in Philosophy of Nursing. Professor of the Post-graduate Program in Nursing of the Nursing Department. Maringá State University. Maringá, PR, Brazil. [e-mail]

Correspondence addressed

ABSTRACT

This qualitative study was performed with Family Health Strategy teams in Maringá – PR. The objective of the study was to identify the factors that affect interventions provided to individuals with mental disorders. Data were collected through focal groups and were subjected to content analysis. Participants reported personal and professional issues related to the structure of the service, such as negative feelings, lack of professional skills, and a prioritization towards curative interventions. The mental healthcare network establishes criteria for assistance, deficient reference and counter-reference and the matrix activity. Factors affecting the interventions included attachment, lack of family involvement, lack of team participation and poor patient adherence. It was found that few factors contributed to the interventions while many were viewed as hindrances; however, by identifying these factors, the teams can work to improve mental health care.

Descriptors: Mental disorders; Family Health Program, Mental Health Services; Primary Health Care; Psychiatric nursing

RESUMEN

Estudio cualitativo con equipos de la Estrategia Salud de la Familia del municipio de Maringá-PR-Brasil, objetivando conocer los factores que interfieren en las acciones al afectado por transtorno mental. Los datos fueron recolectados por metodología de grupo focal, y sometidos a análisis de contenido. Fueron citadas cuestiones personales, profesionales y de estructuración del servicio como percepciones negativas, falta de preparación profesional y priorización de acciones curativas. En la red de salud mental existen los criterios de atención, la referencia y contra-referencia deficiente y la actividad matricial. En la realización de las acciones, se encontró el vínculo, la falta de participación familiar, la denegación de la actuación del equipo y la baja adhesión terapéutica. Se detectaron pocos factores que contribuyan con las acciones, aunque muchos que las dificultan. De todos modos, identificarlos permite a los equipos trabajar para fortalecer la atención en salud mental.

Descriptores: Trastornos mentales; Programa de Salud Familiar, Servicios de Salud Mental; Atención Primaria de Salud; Enfermería psiquiátrica

INTRODUCTION

The Psychiatric Reform process, initiated in many countries after World War II and intensified in Brazil in the 1990s, is responsible for the return of individuals with mental disorders (IMD) to the community⁽¹⁾. Its consolidation occurred with Law 10.216/2001, which guaranteed to the users of the mental health services the universality and integrality of access and the right to care, decentralizing the care model. A structuring of the care network was begun, bringing together the services and the users and implementing actions based on the needs of the population⁽²⁾. Due to the reduction of psychiatric beds/hospitals and the deinstitutionalization of people hospitalized for long periods, services were implemented to substitute the traditional model, as well as mental health actions in the Primary Healthcare, constructing a care network within the community itself⁽³⁾. This whole process of psychiatric reform led to the deinstitutionalization of the IMD and their return to the family and society, where they should be reintegrated and assisted.

As there were changes in mental health care, primary healthcare was also reorganized, in 1994, with the creation of the Family Health Program, defined in 1997 as the Family Health Strategy (FHS) and presented as a tool for changing the concepts of professional practice⁽⁴⁾. Both sought to institute new technologies to improve the quality of life and they converged in the attempt to break with the hegemonic medical model, in the challenge of taking the family in their socio-cultural dimension as the object of attention, in the planning and execution of actions in a given territory and in the promotion of citizenship/community participation⁽⁵⁾. Thus, it is the responsibility of the FHS to integrally assist the individuals and families, developing actions for the needs of the mental dimension, with a focus on the prevention and promotion of mental health and monitoring of the IMD and their families in the primary actions, contributing to a better quality of life for all⁽⁶⁾.

It is known that the FHS teams are organizing themselves to assist the individuals with mental disorders (IMD) and their families, and that, as in other areas, they face difficulties and contributions. While the contributing factors drive the development of the actions, the difficulties can be identified as the reasons not to implement them or to justify failures in the care. It is important that professionals identify the factors that impact on these actions, reviewing their practices and attempting to resolve/mitigate the difficulties and consolidate what is contributed.

AIM

This study seeks to highlight the contributing factors or difficulty pointed out by the family healthcare teams in the development of care for the individual with mental disorders/family.

METHOD

This descriptive exploratory study of qualitative analysis used the focus group methodology for the data collection, allowing the reflection of the group about the theme, based on the perceptions and experience of each participant regarding this, collecting the data from the statements of the group⁽⁷⁾. To select the Primary Health Units (PHUs) where the study would be developed, a list from the Municipal Health Secretariat of Maringá with 2005 data was used, the last year with this information available, containing the PHUs that referred more individuals to the Emergency Psychiatric Unit of the Municipal Hospital of Maringá (EP-HMM) and those that had in their population the greatest number of individuals enrolled in the Integrated Center of Mental Health (CISAM). The EP-HMM service is the site of care for the individual with mental disorders (IMD) at the moment of the crisis, while the CISAM is the service that performs the dispensing of medication and specialized monitoring for the mental disorders. This allowed the choice of the PHU which has, in its coverage area, the greatest number of IMD using the services mentioned which leads to the inference that the teams develop, in the quotidian activities, actions for them and their families, as they are under their care in the community.

In the first two PHU of the list, two focus groups were formed, one in each PHU, composed of the complete team of the FHS, because it is believed that the presence of all the professionals would lead to the expression of all the actions taken, with greater reflection of the group. A team was considered complete when it contained all the professional categories (community health worker, auxiliary nurse, nursing technician, registered nurse and physician) and in sufficient numbers to care for their catchment area, which can be complemented by an oral health team. However, the physicians and odontological professionals did not participate in the focus groups. One session was conducted with group 01 and two with group 02, always after the weekly staff meeting of the FHS, within the PHU, ensuring privacy and tranquility in the sessions. The groups were started with an explanation of the study and methodology, revelation of the research aims and introduction of the observers and coordinator. A self-completed form to characterize the participants was distributed, starting the exploration of the focus of the study through a script addressing the research questions of this project. After this point the entry of new participants was not allowed. The data were subjected to content analysis⁽⁸⁾.

The study was approved by the Research Ethics Committee of the Maringá State University, under protocol No. 110/2007, as part of the project Mental Health in Primary Healthcare: Perspectives and Intervention carried out in this municipality. It was also approved by the Center for Healthcare Professional Training, responsible for permission to study in the services of the Secretariat of Health of Maringá. The participants signed the Terms of Free Prior Informed Consent and agreed to the recording of the focus group, following the necessary ethical precepts.

RESULTS AND DISCUSSION

The groups initially reflected on mental health actions undertaken by the team of the FHS and identified factors that hinder or contribute to caring for the IMD, presenting more of the former. They cited factors arising from the professional field, the staff, and community services, considered by the professionals as important and with the potential to impact on the unique way to care for the IMD.

Personal and professional structuring issues of the Family Health Strategy service impacting on the actions to the IMD

It is considered in this study that the personal difficulties of each individual are due to their concepts, prejudices and previous experiences that influence many areas of life and lead to different acceptances in the care for the IMD. The professional questions come from the background and formation/knowledge in the area of practice. The structuring of the service includes the working conditions, being physical or organizational. The professionals reported that there is differentiation in the affinity for dealing with the IMD and their families, with some presenting less willingness to develop these actions, claiming not to like to care for them and identifying reasons for this.

I do not feel good about caring for the IMD and their families because you have to have a profile for it, it is very delicate. I'm afraid of the patients, because once I went to visit a boy who wanted to put his hands on me. He was in the sanatorium, he had a real problem. I don't feel prepared to work with them, I still have much to learn (Team 02).

It is evident that an uncomfortable experience or one that generates negative feelings tends to limit care for the IMD, since the professionals may distance themselves for fear of a repeat of the situation. Feelings were reported that were generated by the popular imagination, by information from other people and exchanges of experiences, and by the prejudice rooted in society. These originate from concepts inherited from the period of institutionalization, in which the individual was considered dangerous to society and to the social order, and needed to be segregated. The proximity between the FHS professional and IMD is hampered by the fear generated when the professional is faced with certain behavior, as there is still the belief that they have sudden loss of control, with violent and aggressive attitudes. The possibility of experiencing this situation and the sharing of the experiences of people close to them create and strengthen the fear⁽⁹⁾. The lack of knowledge was also indicated by the groups, such as difficulty in developing the actions. Not knowing about what they need to intervene and to monitor the patient results in superficial actions without much impact.

There is a concern for us to do as much as we can, but I have not received any guidance outside the university to treat these patients and their family members. If there were courses regarding this it would be good. Of course, I should also seek more knowledge, and we need conditions for this, we need infrastructure and time. It is an important service, one of responsibility, which needs to have a base (Team 02).

In this quote it can be observed that many professionals perceive the importance of the actions to the IMD, however, the lack of knowledge about mental disorders and their particularities results in the deficient development of these actions. In a previous study⁽¹⁰⁾, professional development was indicated as an important criterion for a team to be good in their practice. The limitation in knowledge identified by the teams can originate from the small amount of updating after the professional formation and from the modifications in the care due to social transformations and new models of healthcare, factors present in mental healthcare. It is worth noting that the professionals who had been working for more time needed to change the way they care for the IMD, since the de-institutionalization and the need to monitor them in the community is recent. Thus, access to new knowledge, beyond that acquired in the professional formation, through courses and incentives, is essential. Ongoing education becomes the instrument for the professionals to develop mental healthcare in accordance with the changes that are occurring within the public health context, since the FHS is currently configured as a gateway into the care for the IMD and their families. They must be prepared for the increase in the complexity of the cases under their responsibility, since de-institutionalization brings the mentally ill into the primary healthcare rather than hospitalizing them, resulting in the inverse of the existing model, where the more complex cases would be far from the primary healthcare, with it responsible only for low complexity cases.

According to the statements and other discussions a deficit is perceived in the continuing/permanent education. It is important that health services consider the need for professional development, as this significantly impacts on the care to the population. However, the professional must be aware that, in addition to the employer providing the conditions, it should be the responsibility of the professional to seek to acquire and deepen knowledge, being the responsibility of both to work together towards this goal. Another situation highlighted was the condition of the teamwork, which often does not allow the development of the care directed towards the IMD, as reported below:

In our unit, based outside the PHU, all the promotion and prevention activities are difficult, including those intended for the IMD. It is an area of almost 6,000 individuals. It has only one function of the FHS which is in the pharmacy, to provide a welcome and give out medication. I perform prevention, puericulture, hold a group for hypertensive and diabetic patients, consultations with pregnant women, team meetings, registration of the prenatal monitoring. Apart from the reports that we have... The CHA helps in the administrative part. Hence there is not enough free time for us to do FHS (prevention and health promotion). We have good ideas and good will, but can not perform outside activities (Team 01).

In the above cases, the difficulties in developing, in FHS unit, all the activities expected from a PHU were described, since there is only the team to do this work. It was verified that the professionals based their production on the curative view of the care, giving priority to activities that agree with this view at the expense of prevention and promotion activities. However, they need to reflect on whether the actions that are defined as prevention and health promotion really have this aim, or are based on the curative concept even when performed outside the PHU. For health promotion to occur, the FHS team should work to change the values and attitudes of their professionals and engage in health education, seeking to develop in the population the ability of self-care, with the family and community⁽¹¹⁾.

The factors originating from the mental health care network

Factors were highlighted that originate from the reference services, where the IMD is referred when in crisis or for specialized monitoring, and from the pre-hospital support services, such as the Mobile Emergency Care Service (SAMU), responsible for the transport to the psychiatric emergency service.

We refer the patient, but the patient will not go of their own accord. And then, to call an ambulance to take these patients by force, there is a series of criteria, which is not easy (Team 01).

It is interesting to observe in this statement that the professionals identified as difficult the standardization of the transport of the IMD in crisis. Due to the preference for hospitalization, inherited from the asylum period, it was necessary that the pre-hospital support services adopt criteria, such as the presence of symptoms and behavioral change, to provide the transport to the emergency services when they do not have the consent of the IMD. This measure aims to protect individuals and to reduce the hospitalizations or referrals without the consent of the patient, unless there is a real need.

It was evidenced in the discussions that the teams find it difficult to use the pre-hospital support service to refer the individuals with mental disorders to the emergency care when they do not present the criteria required for transport, even after a coherent evaluation of the team indicates that this intervention is necessary. The refusal of some services of the mental healthcare network to give continuity to the decisions of the FHS suggest that the analysis of the needs of the IMD carried out by them is incorrect, and may result in the distrust of the community in relation to the practice of these professionals. This conflict between the criteria for each service is difficult to comprehend for the population and family members, being that they are often anxious and confused when they feel they are in the midst of disagreements, polemics and arguments between healthcare professionals. To alleviate this situation, the team should offer attention and guidance to the families living with mental illness, especially as regards the disease, its particularities, needs, and the way of caring⁽¹²⁾. While the criteria of the network services were identified as hindering the care to the IMD, at the same time the lack of them, in some situations, was indicated as harmful for the development of actions.

The fact that some services do not require the presence of a family member in the monitoring consultations makes access to information difficult. When the family member goes along, they can inform us about what happened there. When the IMD goes alone, we never know anything about what happening in the consultations, neither does the family. We also do not have the feedback (Team 02).

This statement highlights that it is not obligatory for the family to attend some services, hampering the access of the team to information. It was pointed out that in the majority of cases, the family accompanies the IMD only when requested, with few who perceive this need and its contribution in the therapy. Therefore, if there is no requirement from the service that the family participate in the specialist consultations, the family members feel their presence irrelevant because they believe that if it is necessary, they will be sent for. In this way, the presence of the family in the services that have no such requirement is restricted to a few. It was observed that the participation of the family in the monitoring of the IMD is considered a bridge for the access to information, since it is through this that the procedures and guidance provided by the other healthcare services come to the attention of the FHS. It is important that the action and the planning of the different teams of the mental healthcare network occur together and involve the family, which creates and strengthens the bond with them, with the IMD and between the teams, facilitating communication and the exchange of information⁽¹³⁾. Another situation identified as difficult for the care of the IMD is the lack of feedback about the individuals referred to other services, as when they are discharged or when their specialist consultations are not frequent enough, they require monitoring in the primary healthcare.

Sometimes the IMD being monitored here is discharged from the CISAM, or they continue with consultations intercalated with those of the PHU. Only they do not bring the information about the problem and medication. They arrive wanting a prescription, continuity of treatment, but without any proof of this use. In the CAPS the problem is the information on who is performing the monitoring, activities and consultations. We know from other people, not from the service (Team 02).

In the Municipal (psychiatric emergency sector) the feedback comes in a pouch, but what happened, what medication they take, and how to continue the treatment does not come in writing. It takes too long to arrive. Sometimes the informed address is not there, or it does not have the block or the apartment number. In the Psychiatric (long term hospital,) it is worse, there is no such feedback when the patient is discharged (Team 01).

It is perceived that the services of specialized monitoring, emergency care and inpatient psychiatric care are still not informing the PHU who the individuals are that are assisted, how the treatment is developed and what the existing needs are. This lack of information and integration results in a deficiency of the actions, since the team is not focused on what needs to be performed nor what actions are important to monitor the IMD in the FHS. Also highlighted is the lack of interest of the services in developing the feedback when the existence is pointed out of erroneous data to identify and assist the IMD/family.

Among the many difficulties encountered in the healthcare network, the professionals identified a contributing factor in developing mental health actions: these are the actions they carry out with the support of the Center for Psychosocial Care (CAPS), taken advantage of by one of the teams, while the other was unaware of this work. The support of the CAPS occurs through meetings with the professionals of the PHU, with the discussion of cases, domicile visits to the individuals monitored by the mental health services and guidance on how to act. It is important to highlight that these activities in the initial phase already present results as explained in the following statements:

For some time the CAPS has been holding meetings here in the PHU. There is one every 15 days and each time an FHS team is responsible. They require the presence of all the personnel of the team. The psychologist and social workers come from the CAPS. They perform domicile visits, discuss the case with us and suggest what can be done to improve. So we can learn more, we have contact with those who know and feel more secure. We also know who to look for when we need it (Team 02).

Despite not being a matricial team, it is perceived that the CAPS professionals who participate in this activity, try to incorporate some assumptions of those that are matricial. This logic is guided by the performance of specialist technical support to qualify and expand the field of practice of the interdisciplinary teams, seeking consistency for the interventions in the area of mental health through discussions or joint actions, increasing the resolution capacity of the FHS and offering integral care to the individuals⁽¹⁴⁾. The security of feeling supported in performing mental health actions was identified in the statements of the group. The fact that to discuss ideas and ways to care with those who they consider to be holders of knowledge in this area means that gradually the professionals acquire the confidence to develop ways of caring. The presence of those who deal, in their quotidian, with the IMD and their families results in the acquisition of knowledge required to implement the care, stimulating the FHS to rely on the decisions they make and to solicit increasingly less support from the CAPS.

The performance of the actions: interference inherent in caring for the IMD

In this category the teams identified the difficulties and the factors that contribute to the care. To encounter factors contributing to the care denotes the conquest of the space of the FHS, with acceptance of the IMD, of the family and the community. The contribution indicated is the existence of a bond between individuals and professionals, objectified in many of their quotidian activities and with an impact in their actions.

The bond is important for us to perform our work. With it the IMD has enough confidence to come here and look for someone to solve their problems. Hence we can act. Often there is great trust, such a good bond that the patient asks for help when they are going to do something crazy (Team 01).

Conforming to that presented, along with the discussion of the groups, it was perceived that the IMD that establishes the bond with the team permits higher performance from them and undertakes to respond in a way so as not to disappoint them. This becomes a cycle: the professional offers committed and quality care, which results in the bond; with this, the individual develops confidence in the team, allowing them to intervene in a more active way, getting better responses in the activities developed and intensifying it still further. The qualifications of the professional and the organization of the team are necessary to create and strengthen the bond, resulting in a closer relationship between service and users, because they feel welcomed, respected and have a greater possibility to participate in community activities⁽¹⁵⁾. It is important therefore that the professionals assume a posture that does not weaken the existing bond nor hamper the establishment of this, because there are few factors that contribute to the care for the IMD as much as this.

Some issues originating from the mental healthcare were also identified as difficulties, with those related to the responsibility and support of the families in developing the actions mainly mentioned. It was felt that this afflicts the professionals, since they conceptualize the family as the born caregivers of the IMD and expect them to engage in a unique way in their care.

It's difficult when there is no family responsibility, and this is common. You make a domicile visit, but the IMD does not know how to clarify some things, the family know even less and also do not ask questions about the disease, about the treatment. They do not know how to care. (...) We try to guide the family, but they are not interested, at least the majority are not, as if it was not their responsibility to understand. (Team 01).

It is clear that some families do not participate in the monitoring of the IMD, and, consequently, do not provide information to the FHS to guide their actions. To become involved in the care of the sick person, it is necessary to know about the disease and its characteristics. Thus, it is essential that the team works with the responsibility of the family, through guidance regarding the existing needs and the contributions of their involvement in maintenance of the condition. The family that perceives these advantages emanating from their involvement encounters reasons to seek to know about what was not important before, feeling themselves part of the care strategy and engaging in the monitoring of the IMD. Sometimes the family believes that the health professionals are holders of knowledge and that their own information is irrelevant to those who know and work with this. It is necessary to change this view, and, therefore, the team has to be receptive to hear what the family members have to say, even if the initial information is of little significance for the development of the actions. It is believed that caring for them will result in greater involvement and responsibility, because feeling cared for they will be more likely to contribute to the maintenance of health of all their individuals

It is the family that determines changes in the health condition of the patient, both for better and for worse. Thus, to recognize the family members as a focus of care becomes a major challenge for the professionals, who must identify their difficulties and potentials and establish goals and objectives to assist them in the context of their needs⁽¹⁶⁾. In the care to the family of the IMD it is important to comprehend that their troubles can be resolved in a simple way, easily, often by providing simple guidance to reassure them and relieve them. Reflecting the lack of knowledge of the family regarding the disease and its implications, the professionals identified the difficulty in dealing with them in cases of chronic disease.

Many families do not like that we refer to the emergency (psychiatric) because they say, 'Look, you go there, you go to the sanatorium and it does not solve anything, you return worse than when you went'. And that creates a great distrust. When we go to do a visit they not want to receive us. They think the person is more nervous, more stressed, more difficult to deal with (Team 02).

The family begins to reject the actions of the FHS judging that the services have failed when actually the situations are expected due to the pathology or stage of the disease. In the discussions, the professionals showed that this reaction is probably the result of a hope for resolution different from the reality, i.e. occurs when the desired changes related to a referral to other services, such as a cure or a significant improvement in the condition, do not happen. Thus, when considering the team as responsible for care without the expected results, the family members refuse or hinder other actions developed by it. With the reflection produced, the group realized that it is necessary to guide the family members about the reasons for referral and what to expect upon the return of the IMD, so that there are no expectations that can not be achieved and, consequently, they are not disappointed with the services developed.

Interestingly, despite the rejection of care from the FHS, the family also refuses the hospitalization of the mentally ill individual, recognizing itself able to provide better care than that currently offered in the hospitalization sites, consolidating the changes expected from the de-institutionalization. Even with this view, they should receive guidance regarding the necessary and immediate intervention indications in the case that the IMD present a risk to themselves or others. It was mentioned in the discussion that, while some families understand the importance of maintaining the IMD in their care, others still want hospitalization. This difference was explained by the professionals as the existence of a greater or lesser involvement and commitment in the care. The participation of the family members and the social reintegration pursued by the team demonstrates the absorption of the principles of deinstitutionalization in the way of thinking about mental healthcare, even though there was no express reference to these⁽⁹⁾.

Another difficulty presented by the professionals is the low adherence to the actions aimed at the IMD due to the chronicity of the condition or defiance of the guidelines provided. In these cases, the care has no effect due to the low acceptance found.

I have patients who experience a crisis because they do not take their medication, they become violent, do not stay at home, they make a lot of work for the family. There are those who do what they want, they make a point of saying that they are IMD to take advantage of the care, but when we give guidance they don't do anything. Neither medicine nor consultation...nothing! (Team 02).

It was verified that the resistance of the IMD uniquely impacts in FHS care, making it important that the FHS develops means to improve adherence to its guidelines, reducing the resistance to the use of medication and monitoring. Therefore, it is necessary that the professionals seek to know the reasons given to justify the refusal of these actions and develop sincere arguments and effective alternatives to reverse them. Sociodemographic, clinical (diagnosis and treatment), psychopathological and interactive characteristics can interfere in the abandonment and non-adherence to the mental health treatments. This suggests the need for differentiated approaches for the subgroups of individuals with specific characteristics in order to seek their adherence to the indicated treatment⁽¹⁷⁾.

The fact that the professionals do not know how to deal with the chronicity of the IMD also generates failure in the actions, since sometimes they tend not to become involved in the care by considering that which is consistent with the condition of chronicity as a lack of cooperation of the patient.

CONCLUSION

It is noticeable that there are factors that impact in the mental healthcare actions, which originate from various fields and that end up significantly influencing the care for the IMD and their families. The fact that the teams identify these factors makes them able to seek ways to mitigate or eliminate the difficulties and to consolidate the contributions. In discussing the difficulties involved in the care to the IMD, the professionals manage to highlight with precision what they are and how they impact in their actions, which demonstrates that the teams are likely to discuss them and seek ways to act so that the care is not impaired, abandoning the concept that the responsibility is outside the team.

In the environment of the reconstruction of the care model and based on the deinstitutionalization of the IMD, the team is made responsible for developing means to face the difficulties and to consolidate the contributing factors. One way to mitigate the difficulties that constituted a significant part of the focus group discussions and, consequently, of this study, is for the professionals, managers and community to conduct work in conjunction, each acting on those difficulties related to them, with the intention to make them impact less in the actions that the FHS needs to develop together with the IMD. The provision of information about mental disorders to the community, technical training of the professionals, the identification of the services as part of a healthcare network and their joint action, with support from specialized professionals, are highlighted as alternatives to reduce the difficulties.

It is interesting to observe that the contributing factors were mentioned few times, but that they present a major impact on the care and should be harnessed by the teams in the development of their actions. It is important to see that, with the focus groups, the professionals perceived that they perform many actions for the IMD, some of which were not identified as mental healthcare actions because they are linked to the daily work aimed at the entire population within its coverage. These actions become strictly necessary, since a modification in the complexity of the care to the IMD in the community is occurring, as the primary healthcare is assuming the care prior to the specialized services. This modification demand, as well as efficient actions, the participation of the FHS in a network that is still under construction, and the reformulation of the way of thinking of the professionals about mental health and their concepts regarding individuals with mental disorders and the care they need, should culminate in the consolidation of care in primary healthcare, mainly by the Family Health Strategy

REFERENCES

• ¹
  1. Brasil. Ministério da Saúde. Legislação em Saúde Mental: 1990 – 2002. Brasília; 2002.
• 2. Brasil. Ministério da Saúde; Secretaria Executiva; Coordenação Nacional de DST e AIDS. A Política do Ministério da Saúde para a Atenção Integral a Usuários de Álcool e outras Drogas. Brasília; 2003.
• ³
  Brasil. Ministério da Saúde; Secretaria de Atenção à Saúde; Departamento de Ações Programáticas Estratégicas; Coordenação Geral de Saúde Mental. Reforma psiquiátrica e Política de Saúde Mental no Brasil. Conferência Regional de Reforma dos Serviços de Saúde Mental: 15 anos depois de Caracas – OPAS [Internet]. Brasília; 2005 [citado 2010 mar. 12]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/Relatorio15_anos_Caracas.pdf
• 4. Lucchese R, Oliveira AGB, Conciani ME, Marcon SR. Saúde mental no Programa Saúde da Família: caminhos e impasses de uma trajetória necessária. Cad Saúde Pública. 2009; 25(9):2033-42.
• 5. Souza AJF, Matias GN, Gomes KFA, Parente ACM. A saúde mental no Programa de Saúde da Família. Rev Bras Enferm. 2007;60(4):391-95.
• 6. Leopardi MT, Beck CLC, Nietsche EA, Gonzales RMB. Metodologia da pesquisa na saúde. Santa Maria: Pallotti; 2001.
• 7. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2006.
• 8. Barros MMM, Chagas MIO, Dias MSA. Saberes e práticas do Agente Comunitário de Saúde no universo do transtorno mental. Ciênc Saúde Coletiva. 2009;14(1):227-32.
• 9. Ronzani TM, Silva CM. O Programa Saúde da Família segundo profissionais de saúde, gestores e usuários. Ciênc Saúde Coletiva. 2008;13(1):23-34.
• 10. Machado MFAS, Vieira NFC, Silva RM. Compreensão das mudanças comportamentais do usuário no Programa Saúde da Família por meio da participação habilitadora. Ciênc Saúde Coletiva. 2010;15(4):2133-43.
• 11. Waidman MAP, Elsen I. Os caminhos para cuidar da família no paradigma da desinstitucionalização: da utopia a realidade. Ciên Cuidado Saúde. 2006;5 Supl:107-12.
• 12. Zambenedetti G. Dispositivos de integração da rede assistencial em saúde mental: a experiência do Serviço de Saúde Dr. Cândido Ferreira. Saúde Soc. 2009;18(2):334-45.
• 13. Figueiredo MD, Campos RO. Saúde mental na Atenção Básica à Saúde de Campinas, SP: uma rede ou um emaranhado? Ciênc Saúde Coletiva. 2009;14(1):129-38.
• 14. Monteiro MM, Figueiredo VP, Machado MFAS. Bonding to implement the Family Health Program at a basic health unit. Rev Esc Enferm USP [Internet]. 2009 [cited 2010 July 15]; 43(2):358-64. Available from: http://www.scielo.br/pdf/reeusp/v43n2/en_a15v43n2.pdf
• 15. Botti ML, Leite GB, Prado MF, Waidman MAP, Marcon SS. Convivência e percepção do cuidador familiar ao portador de HIV/Aids. Rev Enferm UERJ. 2009;17(3):400-5.
• 16. Ribeiro MS, Alves MJM, Vieira EMM, Silva PM, Lamas CVD. Fatores associados ao abandono de tratamento em saúde mental em uma unidade de nível secundário do Sistema Municipal de Saúde. J Bras Psiquiatr. 2008;57(1):16-22.

Correspondência:

Jéssica dos Santos Pini

Rua São João, 8 – Apto. 51 - Zona 7

CEP 87030200 - Maringá, PR, Brasil

*

Extraído da dissertação "Saúde mental na atenção básica: atuação das equipes da Estratégia Saúde da Família", Programa de Pós-Graduação em Enfermagem da Universidade Estadual de Maringá, 2009.

Publication Dates

• Publication in this collection
  10 May 2012
• Date of issue
  Apr 2012

History

• Received
  01 Apr 2010
• Accepted
  20 Aug 2011