The care provided to black-skinned children and adolescents with mental health problems in the intersection between gender and race

Objective: to characterize the sociofamily profile of black-skinned children and adolescents with mental health problems and to intersectionally describe who assumes responsibility for their care. Method: a descriptive and exploratory study with a quantitative approach, developed in the Psychosocial Care Center for Children and Adolescents from the North region of the municipality of São Paulo. The data were collected from 47 family members of black-skinned children and adolescents, using a script with predefined variables submitted to statistical analysis. Results: a total of 49 interviews were conducted: 95.5% women with a mean age of 39 years old, 88.6% mothers and 85.7% black-skinned. Family income comes from wages for all the male caregivers and for 59% of the women. Among the black-skinned female caregivers, 25% live in their own house, whereas this percentage is 46.2% among the brown-skinned ones. Of all the caregivers, 10% have a job, 20% live in transferred properties, 35% in houses of their own and 35% in rented places. The social support network is larger among white-skinned people (16.7%), followed by brown-skinned (3.8%), and absent among black-skinned individuals (0%). Conclusion: those responsible for the care of black-skinned children and adolescents monitored by the CAPS-IJ are almost entirely women, black-skinned (black or brown) “mothers or grandmothers”, with unequal access to education, work and housing, constitutional social rights in Brazil.


Introduction
Mental health quality is directly related to access to and guarantee of human rights because the social, economic, political, cultural, geographic and ethnic-racial conditions, intersected, exert impacts on people's lives (1) . According to the World Health Organization's Global Strategy for the Health of Women, Children and Adolescents (2016-2030), precarious living conditions significantly interfere with the health and well-being of these population segments, with inequalities in physical, cognitive, psychological and/or or socioemotional development (2) .

In Brazil, with the 1988 Constitution and the Unified
Health System (Sistema Único de Saúde, SUS), health policies focused on trying to reduce gender, race, age, social class, ethnicity and geographic inequalities (3)(4) . The agenda of mental health care for children and adolescents was included in the II National Conference on Mental Health in 1992, and the Psychosocial Care Centers for Children and Adolescents (Centros de Atenção Psicossocial Infantojuvenil, CAPS-IJs) were established by Ordinance No. 336/2002 (5) .

The United Nations (UN) Convention on Children's
Rights, ratified by all world countries (except USA), addresses children's rights to mental health. Children with impairments/disabilities frequently face marginalization and discrimination, and their vulnerabilities are compounded by poverty, social and humanitarian isolation, emergencies, and lack of institutional, family and social support networks (6) .
Historically, health care for the black-skinned population has, and still is, quantitatively and qualitatively inferior than for white-skinned people (7) . The National Policy for Comprehensive Health of the Black-Skinned Population (Política Nacional de Saúde Integral da População Negra, PNSIPN) is based on combating these inequalities and institutional racism in health services (8)(9) .

Regarding the profile of people who use Psychosocial
Care Centers (CAPS), a literature review pointed to the scarcity of Brazilian research studies using the "race/ skin color" variable, a fact that delays the formulation of adequate public policies to face social and racial inequalities. The recommendation is for the variable to be used in research studies as an analysis category, as it is an important social marker to contribute to practices and policies aimed at ensuring rights (10)(11) .
Regarding the family configuration of children and adolescents monitored by mental health services specialized in this population segment, a number of studies indicate that the majority belong to nuclear families and live with their parents (12)(13) . One study points out that mothers are the main caregiver of children and adolescents with mental health problems and that, in cases where they were responsible for the family income, they were also assigned the care of the children; on the other hand, when providers of these families, the fathers were not responsible for the care of the children (12) .
Family constitution, financial resources, the social support network and the individual resources of the caregivers exert an influence on children's and adolescents' health/disease process (14) . Care involves activities such as washing, cooking, cleaning, organizing the routine, establishing affective bonds, ensuring protection, health, offering affection and understanding, as well as in the development of physical, social and/or emotional capacities. This is social reproduction work fundamental for the wellbeing of societies, communities and consequent functioning of the economy, historically carried out by women, unpaid in the home space, or in an important work front when it passes from the family to the market (15) .
The physical and emotional burden imposed by the care work causes changes in the families' routines, habits and customs. These are processes that require organization, with repercussions in the financial, social, occupational and personal dimensions. The starting point is the way in which we respond to human life sustainability needs perpetuates the gender, race, and class inequalities (16) . In addition to the fact that, in order to provide care to black-skinned children and adolescents with mental health problems, it is necessary to take care of those who care for them. The objective of this study was to characterize the sociofamily profiles of black-skinned children and adolescents with mental health problems, as well as to intersectionally describe the people responsible for their care.

Study design
A descriptive and exploratory study with a quantitative approach with the intention of allowing for the sociodemographic understanding of historical and social processes, and supporting the formulation of care practices and public policies that guarantee equality and integrality for universal access to health. civil associations, and must be directly oriented towards serving the public interest (17) .
The CAPS-IJ is located in the North Area of the city; its coverage area is limited to the Freguesia/Brasilândia Technical Health Supervision Office, made up of the administrative districts Freguesia do Ó, where 30% of the population is black-skinned, and Brasilândia, where 50% of the residents are black-skinned. It is worth pointing out that the device is located in the noble and white area of the Health Supervision, away from the vulnerable communities, home to the majority of the black-and brown-skinned people monitored (18) .
The Brasilândia CAPS-IJ is a reference for a population of 420,000 inhabitants; it monitors children and adolescents with severe and persistent mental health problems and using crack and other drugs, open and of a community and territorial nature (19) .

Population
Family members of black-and brown-skinned children and adolescents undergoing monitoring in the Brasilândia CAPS-IJ.

Selection criteria
The following inclusion criteria were adopted: being a family member of black-or brown-skinned children and adolescents undergoing monitoring for at least one month and with preserved comprehension and communication skills. The exclusion criterion corresponded to medical charts with no monitoring activities in the last month.

Study variables
The script consisted of the following variables: kinship between the main caregiver and the child; age, gender, schooling and race/skin color of the main caregiver; number and description of the people with whom the child or adolescent lives; main income earner; family income; type of housing; characteristics of the house (own, rented, transferred, occupied, street situation); number of rooms; and type of material (coated masonry, trimmed wood, coated rammed earth, uncoated rammed earth, reused wood, straw, other).

Data collection
Data collection was in charge of some of the research team members, Scientific Initiation and scholarship fellows and of the project. The collection procedure was standardized and all the subjects were previously trained with the objective of ensuring data reliability.

Period
The data collection process was developed from May to July 2019.

Sample
The sample of people invited to take part in the study was non-probabilistic and followed the convenience method. The number of black-and brown-skinned children and adolescents monitored by the CAPS-IJ when collecting the data for this study was 264 (total n). It was possible to establish contact with 96 family members, who were invited to take part in individual and face-to-face interviews.
Considering the different barriers faced, such as low income, difficulty in urban mobility, school holidays, lack of social support network to share care and changes in telephone numbers and addresses, among others, frequency during the data collection period was low.

Data treatment and analysis
The continuous variables were described using mean values or medians and standard deviations. The categorical variables were described resorting to absolute and relative frequencies. To assess whether the distribution of the variables differed according to self-declared race/skin color, conservative hypothesis tests were performed taking into account the sample size, which was evaluated as statistically reliable. The Student's t test was used for the continuous variables. In the case of the categorical ones, Fisher's Exact test was employed (20) . The analyses were performed with the aid of the R 3.5.1 software (21) . A 5% significance level was considered for the hypothesis tests.
In order to understand the sociofamily profile of black- was used as an analytical tool through which it was intended to understand the way in which oppression and vulnerabilities overlap, through complex intersections that structure gender, race and class positions in the social fabric (22) .

Intersectionality investigates the way in which
intersectional power relations influence social relationships, as well as the individual experiences in everyday life.
As an analytical tool, it considers that the "race", "class", "gender", "sexual orientation", "disabilities", "nationality", "ethnicity" and "age group" categories, among others, are inter-related and jointly structured. "Intersectionality is a way to understand and explain the complexity of the world, of people and of human experiences" (23) .

Ethical aspects
The study followed the ethical and legal precepts set forth in Resolutions 466/2012 (18) and 510/2016 (19) of the National Health Council. It was approved by the  Table 1 presents the results related to the gender and kinship degree of the caregivers with the children and adolescents, which shows predominance of women responsible for the care of black-skinned girls, most of them monitored by the CAPS-IJ.          As for help from relatives, which is related to the social support network, among white-skinned people it is present in 16.7%, with lower percentages among brown-and black-skinned individuals (3.8% and 0%, respectively), a situation that aggravates the contractual condition of black-skinned families.

Discussion
The division and appreciation of care work in society's production mode and capitalist organization is perpetuated unevenly. Gender, race and class inequalities, intersected, impose on black-skinned women the work of sustaining life, social reproduction, caring for children, adolescents, the elderly and household chores, with a significant impact on well-being, due to overloads and invisibility of their own needs (24) .
The results support the patriarchal and sexist organization of families which, despite the feminist movement, does not present significant changes in the division of household tasks between men and women (25) .
They are responsible for the care work, which is invisible and unpaid, almost entirely depending on other women (26)(27) .
When the woman is the main caregiver, her quality of life is affected by lower schooling and remuneration levels, by informal and precarious work relationships and by limited access to specialized services, which results in higher morbidity and mortality rates, as well as with higher exclusion rates the darker the skin color (28) .
Considerably differentiated by gender, family income renders the discussion about gender inequality in accessing the labor market indispensable, as it is women that suffer the inequalities in terms of income and contractual power. Above all, black-skinned women, historically victims of slave labor, remain at a disadvantage in terms of access to formal work. The Brazilian "aesthetic model" of white privileges is highlighted, in the tradition of the "matriarchy of misery", which allocated few labor rights to black-skinned women, who are the majority of domestic workers (29) .
Black-and brown-skinned women are the majority in informality, without social security rights or a "formal contract", with lower wages and in menial jobs, with accumulation of working hours, in addition to adjusting their participation in the labor market, based on the needs regarding time for child and family care (30)(31)(32) .
Deconstruction of the patriarchal, racist and capitalist society has been one of the goals of the black feminist movement since the 1970s; however, racial differences between women have hardly diminished. The concept of intersectionality has its history rooted in the life experiences of black-skinned women, and not only concerns the different dimensions of identity but the interactions between them (33) .
The debate of "blackening the feminist agenda" and replacing issues with the black movement began at the end of the 20 th century and extends into contemporary times.
With the rise of black feminism, the racism that affects women, who have always been at the forefront of struggles for racial and gender equality, becomes explicit (36)(37) .
According to the National Household Sample Survey (Pesquisa Nacional por Amostra de Domicílios, PNAD), there are 11.6 million families consisting only of women and their children (38) . There is a phenomenon called "loneliness of black-skinned women", who mostly assume their children and remain alone, with the inequalities amplified when the children have mental health problems (26) .
The constitution of white and brown families with more social support network than in families of blackskinned people configures a system of discrimination by skin color, also called colorism. In colorism, women with darker skin are more discriminated against, have a smaller network, social place and access to rights, and blackskinned women are more vulnerable (39) .
Unequal access to education is a consequence of a Racism and Xenophobia, to guarantee access to work and higher education for black-skinned women (40) .
In relation to the condition of indigenous women, access to education is restricted, they end up "condemned to a cycle of poverty, fewer opportunities and lack of conditions for decision-making" and, according to the results, they are also made vulnerable with a small social support network (41) .
It is evidenced that gender, race, social class and ethnic inequalities, as well as situations of domestic violence, work devaluation, food insecurity, income and housing instability and absence of a social support network are social determinants of mental health (42) . Some authors point to "racism and denial of rights" as "a highpotential intrinsic factor in psychological distress" (43) . The international literature on intersectional inequalities in mental health shows that research is still limited in volume and not methodologically structured. However, it highlights the value of an intersectional analysis of the inequalities between population groups for establishing priorities in practices and policies (44) .
With the "gender" variable as a social marker for understanding the health of women responsible for taking care of people with mental health problems, overload, low quality of life and dissatisfaction with family relationships are identified (45) . By intersecting race/skin color and class, social inequalities are verified, which, when overlapped, maintain cycles of violence, oppression and power and structure the complex social fabric (16) .
In the current situation, we face intensification Network (46) . This reality is aggravated by the neglect in management of the COVID-19 pandemic in Brazil, which is not based on evidence and worsens the social, racial and gender inequalities (16) .
When discussing the sociofamily profile of black- it can be understood how racism and sexism impact on people's health, and strategies that guarantee equality and integrality in mental health care can be devised.