BARRIERS PREVENTING PHC SERVICES FROM MEETING MENTAL HEALTH DEMANDS IN CABO VERDE

BARRERAS PARA ATENDER LA DEMANDA DE SALUD MENTAL EN LOS SERVICIOS DE ATENCIÓN PRIMARIA A LA SALUD DE CABO VERDE

ABSTRACT

Objective:

this study aimed to identify among Cape Verdean professionals working in Primary Health Care services the barriers impeding care from being provided to people with mental disorders in this context.

Method:

data in this qualitative study was collected between February and March 2020 using semi-structured interviews with 43 workers from five Health Centers in the urban areas of Cape Verde/Africa. The interviews were treated with content analysis.

Results:

the barriers included: the professionals’ perception regarding people with mental disorders concerning a feeling of being threatened by these patients, such as a fear of having their physical integrity at risk; lack of coordination between the team and the services; lack of knowledge of protocols; and distancing from care in the mental health field.

Conclusion:

the barriers identified here show a need to qualify PHC professionals. In this sense, matrix support is an alternative for continuing education to leveraging existing resources.

DESCRIPTORS:
Primary health care; Mental health; Patient care team; Mental disorders; Barriers to access of health services

RESUMEN

Objetivo:

este estudio tiene como objetivo identificar - en los profesionales de Cabo Verde que actúan en la Atención Primaria a la Salud - las barreras que en ese contexto dificultan la atención de personas con trastorno mental.

Método:

estudio cualitativo; los datos fueron recogidos entre febrero y marzo de 2020, por medio de entrevistas semiestructuradas, realizadas en 43 profesionales que trabajaban en cinco Centros de Salud, localizados en regiones urbanas de Cabo Verde, en África; posteriormente los datos fueron sometidos al análisis de contenido temático.

Resultados:

las barreras referidas fueron: la visión de los profesionales acerca de la persona con un trastorno mental que representa el sentimiento amenaza que coloca en riesgo su integridad física; la desarticulación entre el equipo y los servicios; el desconocimiento de los protocolos de atención; y, el distanciamiento en relación a los cuidados en el área de la salud mental.

Conclusión:

las barreras identificadas evidenciaron la necesidad de aumentar la calificación de los profesionales de la Atención Primaria; en ese sentido, una organización matricial puede ser un medio para la formación continuada, con el objetivo de potencializar los recursos existentes.

DESCRIPTORS:
Atención primaria a la salud; Salud mental; Equipo multiprofesional; Trastornos mentales; Barreras al acceso a los cuidados de salud

RESUMO

Objetivo:

este estudo tem como objetivo identificar junto aos profissionais caboverdianos, que atuam na Atenção Primária à Saúde as barreiras que, nesse contexto, dificultam o atendimento das pessoas com transtorno mental.

Método:

estudo qualitativo, cujos dados foram coletados entre fevereiro e março de 2020, por meio de entrevistas semiestruturadas, realizadas com 43 profissionais que trabalham em cinco Centros de Saúde localizados em regiões urbanas de Cabo Verde/África, e posteriormente submetidos à análise de conteúdo temática.

Resultados:

as barreiras referidas foram: a visão dos profissionais acerca da pessoa com transtorno mental representativa de sentimento de ameaça que coloca em risco a sua integridade física; a desarticulação entre a equipe e os serviços; o desconhecimento dos protocolos de atendimento e o distanciamento em relação aos cuidados na área de saúde mental.

Conclusão:

as barreiras identificadas evidenciam a necessidade de qualificação dos profissionais da Atenção Primária e, nesse sentido, o matriciamento pode ser uma via para a formação continuada, com vista a potencializar os recursos existentes.

DESCRITORES:
Atenção primária à saúde; Saúde mental; Equipe multiprofissional; Transtornos mentais; Barreiras ao acesso aos cuidados de saúde

INTRODUCTION

Including mental health in Primary Health Care (PHC) has been one of the most insubstantial investments in the health system of several countries, especially developing countries. According to the World Health Organization (WHO), more than 80% of people with severe mental disorders do not receive treatment in low-income countries, where the vicious cycle between health and poverty is particularly prevalent due to the absence of social safety nets and accessibility to effective treatments1.

Additionally, the COVID-19 pandemic exposed the already considerable gap in mental health care services in middle and low-income countries, when there was considerable tendency for such a gap to expand and worsen. As a result, new demands for mental health care emerged, which, together with already fragile health systems and scarce resources, imposed numerous challenges for the delivery of effective care2.

The literature lists several barriers hindering the inclusion of mental health in primary health care, including ingrained beliefs concerning mental disorders; a conviction among health professionals on the patients’ inability to adhere to treatment; the legal implications of misdiagnosis; the complexity of interventions, and a lack of knowledge and specific mental health skills; insufficient training in the use of evidence-based screening and treatment tools; and lack of knowledge regarding the structures and processes for mental health management3^-4.

Other barriers related to the organization of this work include: lack of support to mental health at the community level; limited resources for service provision; lack of in-service training; inadequate coordination between general health workers and mental health experts; low prioritization of mental health care at primary care level5.

These barriers compromise the implementation of effective actions to prevent diseases, promote health, and rehabilitate individuals with mental disorders. Additionally, these barriers contradict the principles and guidelines defined by the health systems in several countries. Consequently, people with mental disorders become a substantial burden for their families, who often deal with these conditions alone without any support provided by health services, causing much suffering and decreasing quality of life, besides causing other health problems6.

Particularly in the Cape Verde region/Africa, integrating mental health services in PHC has been more difficult than in other regions, negatively impacting the achievement of universal coverage for the population in that region. Although there are services at the city level based on the principles of universality, equity, and integrality, aiming to provide essential care to promote health, prevent and treat diseases, and recover health, there are weaknesses in the care provided to people with mental disorders.

A survey conducted in 2019¹ verified that such a context leads families to seek hospital services more frequently. In 2019 alone, 837 consultations were held in the hospitals’ psychiatry services in Cape Verde’s capital, where the estimated population was 106,348 inhabitants. The patients seeking such services lived in areas covered by PHC. This situation undoubtedly favors a cycle of readmissions.

Thus, considering the increasing demand for mental health care in the general population worldwide, especially after the pandemic, and the diversity of problems preventing equitable and effective care from being provided to people within PHC services, studies are needed to explore the professionals’ perceptions, considering they are at the forefront where mental health integration policies are operationalized in these services.

Therefore, this study aims to identify the perceptions of Cape Verdean professionals working in Primary Health Care concerning the barriers hindering care from being provided to people with mental disorders in this context.

METHOD

This qualitative, exploratory, descriptive study addresses the care provided to people with mental disorders and their families within Primary Health Care services in Praia, Santiago Island, in Cape Verde/Africa.

This study is based on a conceptual structure comprising the principles governing the National Health Service of Cape Verde: universality, equity, and integrality. The first is a principle that defines health as a right for all and a duty of the State; the second is a multidimensional concept that includes aspects related not only to the distribution of health care but also to attentive justice so that there is no discrimination in care delivery; and Integrality ensures the population the right to receive full and integral assistance according to their needs, by integrating curative and preventive actions at the primary, secondary and tertiary levels7^-8.

The use of this structure is explained by the fact that the fundamental rights of people with mental disorders are at the base of the movements intended to restructure the mental health care model triggered worldwide9 several years ago. It is the same in Cape Verdean communities, where the health services integrating the Primary Care Network also need to be organized to tend to the needs of people with mental disorders. Therefore, it is a conceptual structure that can support a reflection on the barriers hindering care from being delivered to people with mental disorders. Including these individuals in the practice and organization of services is the first step towards providing effective care to these people within PHC.

The study was conducted on the island of Santiago, Praia, capital of Cape Verde, an island country composed of ten islands, nine of which are inhabited. The total estimated population is 544,081 inhabitants10. The National Health Service in Cape Verde is organized into three levels: City level, where essential primary care actions are provided; Regional or supra municipal level, which groups and reorganizes health structures located in Santiago or on other islands and provides secondary and hospital care; and the Central level, or national referral, organized to ensure the provision of tertiary care, especially differentiated hospital services11.

This study’s first author, a nurse, collected data for this study in Health Centers (HC), considering the ease of accessing HCs located in the urban area, integrated at the city level, and coordinated by the Health Department of Praia. These HCs have teams comprising nurses, physicians, psychologists, social workers, physical therapists, and administrative staff. These teams must ensure easy access to at least 70% of the population in their coverage area, considering geographical and economic aspects12.

Of a universe of 91 professionals from the Health Department of Praia, 43 participated in this study. Of these, 13 were physicians, 19 nurses, six social workers, and five psychologists; the first author personally contacted them. Only two refused to participate in the study because they reported never treating a person with a mental disorder.

The inclusion criterion was working at the service for at least six months, except for professionals on vacation or leave during data collection.

Data were collected through semi-structured interviews according to a script developed by the authors that consisted of four parts: the first addressed sociodemographic information, including degree and field of training, time since graduation in years, age, sex, marital status, residence, and experience in years. The second part comprises questions related to the principles of universality, equity, and integrality and their application in the care provided to people with mental disorders. The third part concerns the care the professionals provide to people with mental disorders who seek a health center and their families. The fourth part concerns the barriers, which, in the participants’ opinions, hinder the delivery of care to people with mental disorders.

Data obtained in the fourth part of the instrument were addressed in this study, in which the guiding question was: What are the barriers that, from the professionals’ point of view, prevent care from being provided to people with mental disorders in HCs?

Individual interviews were held in a private room on the services’ premises at a time previously agreed with the participants. The interviews lasted 60 minutes on average and were recorded and transcribed verbatim.

Data were submitted to content analysis, which consists of pre-analysis, exploration of the material or coding, and treatment of results - inference, and interpretation13. Initially, the material collected during the interviews was organized according to the parts of the data collection instrument. Next, data were read in order to obtain first impressions. After successive readings, key expressions were identified based on the concepts of universality, equity, and integrality, from which categories and their elements emerged, leading to the interpretation of results.

This study received an ethical certification from the National Health Research Ethics Committee of the Ministry of Health and Social Security of Cape Verde (N^o. 57/2020). All participants received clarification of the study’s objectives, that they were free to withdraw from the study at any time, about their rights, and signed free and informed consent forms. The participants were identified by the letter P followed by a number according to the order in which they were interviewed (P₁...P₄₃) to ensure confidentiality.

RESULTS

Among the 43 participants, 37 were women and six were men; 24 were single, 12 were married, five were in a stable relationship, and two were divorced. As for the age groups, 19 were between 31 and 40; 11 were between 41 and 50; eight were between 51 and 60; and five were aged between 20 and 30. As for their level of education, 35 reported an undergraduate degree, three had a master’s degree, two had a specialization, and three participants reported technical training.

Regarding time since graduation, 24 participants had an experience between five and 10 years; eight between 11 and 15; six between 16 and 20; three between 21 and 25, and two between 26 and 30 years since graduation. The predominant training field was nursing, with 17 professionals, followed by 13 physicians, five social workers, five psychologists, and three nursing technicians. Regarding the time working in the service, 42 participants had worked between five and 10 years, and one had worked between 15 and 35 years.

The barriers mentioned by the participants preventing PHC care from being delivered to people with mental disorders were grouped into three thematic categories: macro-contextual barriers, barriers from the service, and the professionals’ barriers.

Macro-contextual barriers

The constituent elements of the participants’ discourses reveal that the professionals’ perception of individuals with mental disorders is represented by a feeling of being threatened by the presence of people with mental disorders, and this feeling interferes with the care they provide and the service organization itself. When asked about the care they provide, they reported fear and difficulty in interacting with these patients: [...] sometimes it's a feeling of fear, fear of them becoming aggressive. But we provide assistance to everyone and then refer them to a psychologist, even though I get a little apprehensive that the patient might hurt me (P8). [...] it is challenging for me trying to find out what the patient is feeling because, most of the time they are unable to tell. The biggest challenge is interacting with these patients (P5).

Fear is intensified by seeing patients as aggressive individuals who may, at any time, endanger the professionals’ physical integrity. As they do not know how to deal with the patients or even their own feelings, they refer patients to other mental health professionals or specialized services. In the case of Cape Verde, patients are referred to the existing psychiatric hospital.

[...] the biggest challenge is in the matter of aggressiveness, especially when a patient is in a decompensated condition. We try to ensure he doesn't stay too long at the Health Center, as we could be at risk. I provide fast, priority service because patients with mental illness do not like to be contradicted (P14).

P14's report suggests that the patient is not the priority. Because they feel threatened, these professionals promptly provide care to quickly dismiss these patients, as they consider that the Health Center is not the appropriate place to care for them. [...]I think it has to do with the organization [of the service] because, within our [National Health] Plan, mental illness is not included in primary health care (P13).

The participants’ reports suggest that how Cape Verdean society and its structures see individuals with mental disorders anchored on strong social stigma is projected in the professionals and the services’ functioning. Consequently, it influences their behavior, evidencing the existence of difficulties in caring for people with mental disorders within PHC services.

Barriers within the service

It encompasses aspects of the service’s organization, particularly teamwork when caring for people with mental disorders. The idea that the team is disconnected from the service, without adequate resources to provide care to patients with mental disorders, and that communication between services is faulty prevails among the participants.

The service is considered merely a physical space where professionals meet patients and perform tasks. When asked how their colleagues respond, feel, or behave when a person with a mental disorder arrives, they answered: [...] I realized I was all by myself with a patient in a state of aggressiveness. And that wasn't correct; it couldn't be. When the others [professionals] realized that a mental patient could enter their office, they closed their doors out of fear. So, the psychologist and I were left to tend to the patient (P9).

The participants’ reports suggest no teamwork, as they occupy the same physical space, but their work is disconnected. They arrive at the workplace, enter their offices, perform their practice in isolation, and are unaware of their colleagues’ work, especially regarding what concerns the care provided to people with mental disorders.

The professionals also mention barriers related to the physical space, which is considered inadequate for the care provided to people with mental disorders and insufficient human and material resources. [...] we try to do everything we can, but the physical space… I think it should be better suited to this type of care, considering the patients who may cause disturbances at any time. Therefore, they should have a space where they would be more comfortable and feel calmer (P23). [...] we are not sensitized nor have the conditions for it; there is an insufficient number of professionals to care for these patients (P2). [...] I can only say that the Health Center is not the place to treat decompensated patients because we have no means to contain people (P10).

When asked about what they considered necessary for people with mental disorders to receive effective care at the service, the professionals reported: [...] we need resources here and outside. We used to go out into the field and identify unknown mentally ill individuals, but then we stopped going into the field because of a lack of human and material resources. We also need training for people not from the mental health field, such as doctors and nurses, to deal with these patients in the field(P26).

The professionals noted that for people with mental disorders to receive effective care, they need adequate physical space because the service does not provide safety conditions. At the same time, they make it clear that the service is not the ideal place to provide mental care, suggesting that a more peaceful place be built where only these patients would receive care. Another point concerns a lack of human resources and support from the health system, considering the high demand for such care in the services and a lack of time to tend to those with mental disorders.

The professionals report a lack of communication between the services assisting people with mental disorders. Therefore, it is a weakness in terms of bilateral reference and counter-reference.

P5's report shows a communication deficit between the service that refers people with mental disorders and the service that receives them. There is no feedback from the service receiving these patients for better organization or continuity of care. From the moment a patient is referred to a mental health service, contact with him/her is lost, and it is unknown what treatment has been provided. The participants’ reports reveal this weakness, as the statement below shows: [...] the patients who pass through here are referred to psychiatry or emergency and we don’t even receive information about them, unless they come back here; there is no communication between the services (P5).

The professionals acknowledge such a lack of communication between services as a barrier that needs improvement to provide quality care. It reinforces what was said earlier about referrals being intended to remove patients from the service.

The professionals’ barriers

This category addresses aspects inherent to the professionals that interfere in providing care, i.e., lack of knowledge regarding official documents, unpreparedness, and failure to assume responsibility for those with mental disorders.

The professionals’ reports show a lack of knowledge of the protocol guiding the care to people with mental disorders and distancing from health care provided in the mental health field. On the other hand, they claim that the demand from these patients is low, and the reasons for seeking the service were other than psychiatric ones. [...] I don't know about that [whether there are care protocols]. I never asked (P1). [...] if there is, I don't know about it, I've never seen it; it never came to my attention (P15).

All participants report feeling unprepared to care for people with mental disorders, especially agitated and aggressive patients. The reports of P9 and P31 refer to the need for training on how to behave in these situations and how to proceed with the various cases in the service. In this context, as most participants feel unprepared and left to deal with cases alone without team support, the most frequent alternative is to refer these patients to specialized professionals. Hence, they transfer their responsibility to the patient to those in mental health or social services.

[...] I was lost and felt like a fish out of water because it was my first time, right at the beginning, when I arrived at the health center, and I didn't know how to deal with it [...]. Perhaps I could have done more or differently, but at the time, that was it (P31). [...] I feel lonely. We did not have psychologists before. She would come only twice a week. Once, I asked her to help me with a schizophrenic patient, and she said she couldn't tend to him. The doctors did not respond either. So, what am I supposed to do with the patient? (P9).

The professionals’ reports indicated a need for training as an essential mechanism for managing people with mental disorders, conditioning the care provided in these situations, which has been restricted to referring patients to another service, exempting them from the responsibility of providing effective care.

DISCUSSION

This study’s results highlight a stigmatizing behavior toward people with mental disorders in primary health care services. The professionals identify these individuals as aggressive patients who could harm their physical integrity. This perception is reflected in care actions intended to quickly dismiss the patients from the service as a form of self-protection. Additionally, there is no cooperation between hospital-level services and the Health Centers, which, coupled with the professionals’ lack of knowledge regarding official documents guiding the organization of services, compromises care delivery.

Such a situation is not unique to Cape Verde. A study conducted in Ethiopia indicated a high prevalence of negative attitudes towards people with mental disorders, being significantly associated with one’s level of education and training in the mental health field and knowledge about mental illnesses. This evidence points to the need to provide continuing education on an ongoing basis to decrease such negative attitudes14.

However, despite this study’s findings indicating a lack of qualification or training as a barrier to the care provided to people with mental disorders, it is important to highlight that a survey conducted in India showed that specific knowledge about mental health alone does not suffice to prevent negative attitudes or discriminatory beliefs towards patients. Even in these situations, stigmatizing attitudes prevail among PHC professionals15.

On the other hand, we need to consider that the stigma related to mental illness permeates the health sector in general. In other fields, people with mental disorders are usually perceived as dangerous, unpredictable, and less competent16. Evidently, stigma compromises the integrality of the care provided to patients and their families.

In this sense, intervention research carried out with PHC teams in Brazil shows that continuing education needs to be jointly developed, based on a discussion of these professionals’ needs, to transform practices from a reflective perspective17. Considering the historical, cultural, and contextual similarities between Brazil and Cape Verde, this finding can be replicated for the context in which this study was conducted.

Preventive and health promotion actions in the mental health field also permeate the organization of PHC services. In this regard, the National Health Service in Cape Verde implemented teams comprising psychologists and social workers and determined psychiatrists to be displaced to PHC services weekly. The objective was to ensure mental health care delivery and decrease the need for patients and their families to commute to a psychiatry service to obtain medical prescriptions and attend consultations. However, there is a need for greater coordination between the professionals working in these services for this strategy to be effective, considering that the professionals identified a disconnection within the teams as one of the barriers impeding effective care.

Additionally, successful experiences that generate significant results in countries like Brazil can be adopted, considering the similarities in the challenges faced in integrating mental health within PHC. One of these experiences is implementing the collaborative care model, matrix support, which aims to qualify care and reduce unnecessary referrals18. In the case of Cape Verde, matrix support could be a valuable strategy to contribute to the engagement of the professionals working in these services.

In another context, evidence supports the effectiveness of inter-professional collaboration. A study in Belgium showed the positive effect of team collaboration, increasing the professionals' confidence, insofar as the interventions alleviated stress during patient encounters. The underlying mechanisms that led to these results are related to team members recognizing their emotions and clearly understanding their role19.

The results of another study conducted in the United States to test the implementation of a team-based approach show that it is a viable and highly acceptable strategy, which led to positive changes in the professionals' self-efficacy in managing mental illness and team-based care20.

The lack of communication between referral and counter-referral services was another barrier the professionals mentioned. The lack of feedback from the services regarding the referred patients compromises the continuity of care. It corroborates a survey showing that 89% of the professionals did not know what happens to patients after they are referred to a specialized service, and 100% do not follow up after referring patients to a specialized service21.

Additionally, this study’s findings include a lack of professional knowledge regarding official documents guiding the practice with people with mental disorders. Such a lack of knowledge negatively impacts the care of people with mental disorders. It highlights the importance of managers and the team responsible for the mental health field being aware of the existing protocols. Similar results were found in another survey21 in which the professionals were unaware of the proposal to include mental health actions in Primary Health Care.

Fostering actions that favor integrating mental health care in PHC means increasing the possibilities of considering the social and health determinants of people with mental disorders; care in this field involves legal, political, educational, ethical, and political aspects. Thus, when these aspects are taken into account, it is no longer possible to think of mental health care restricted to medicine, centered on the physician and standardized solutions; rather, the individuals’ integrality and psychosocial peculiarity must be considered17.

As in other fields, PHC services implement strategies in collaboration with schools, universities, and non-governmental organizations; these strategies also need to occur within mental health care to develop actions from a broader health perspective. These collaborations can contribute to better management of scarce resources and improve the care provided to patients with mental disorders and their families.

Regarding the principles that should guide the care provided to people with mental disorders, integrality is a direction for adopting individual-centered mental health practices. Equity is a challenge to materialize in practice, so it is necessary to improve the organization of services to meet the different demands, in addition to considering people with mental health conditions in their peculiarities and their right to be different22. In addition to the team's engagement, the reception that strengthens interpersonal relationships constitutes PHC strengths that can promote the provision of integral care23.

This study’s main limitation concerns the fact that it was developed in a single delimited region of Cape Verde; nonetheless, this study is expected to be an opportunity to expand the investigation to other islands in the country, where other barriers may be identified, considering the country’s insular nature. Such an expansion will enable examining other contexts, with the possibility of qualifying mental health care in primary services.

CONCLUSION

This study’s results show that the professionals’ lack of knowledge of official documents, social stigma, lack of physical structure, professionals’ unpreparedness, and lack of communication between services are barriers that negatively affect the care delivered to people with mental disorders in an urban area of Santiago, Cape Verde.

The complexity and weaknesses in the care provided to people with mental disorders indicate the need for greater investment to include mental health in PHC, considering it is still incipient in the country. These findings raise concerns regarding the care of these patients in other regions of the country, particularly in rural areas, where difficulties in accessing services, added to the unfavorable socioeconomic conditions, place them in a situation of greater psychosocial vulnerability.

Thus, there is a need to assess local managers to promote greater investment in the training of professionals and the creation of protocols to guide mental health care. Another suggestion is for studies to be conducted in other regions of the island of Santiago and other islands in Cape Verde.

ACKNOWLEDGMENT

Coordination for the Improvement of Highter Education Personnel- Brazil facilitated the scholarship, Social Demand, to the first, fourth and fifth author.

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• 1
  Information about the psychiatric appointments done in 2019, facilitated by Doctor Agostinho Neto University Hospital- Trinity Extension. Information collected in october 2020.

NOTES

• ORIGIN OF THE ARTICLE

  Article extracted from the thesis - Mental health in primary attention: barriers that the Cape Verdeans with mental disorders and their families deal with, presented in the Nursing Post-Graduation, from the Nursing School of the Universidade Federal do Rio Grande, in 2022.

• FUNDING INFORMATION

  PHD scholarship- Social Demand facilitated by the Coordination for the Improvement of Highter Education Personnel - CAPES- Financing Code 001.

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Comitê Nacional de Ética em Pesquisa para a Saúde, Ministério da Saúde e Segurança Social de Cabo Verd deliberation nº57/2020. All the determinations of the Resolution 510/2016 applied in Brazil, were respected.

Edited by

EDITORS

Associated Editors: Melissa Orlandi Honório Locks, Ana Izabel Jatobá de Souza. Editor-in-chief: Elisiane Lorenzini

Publication Dates

• Publication in this collection
  11 Dec 2023
• Date of issue
  2023

History

• Received
  04 Apr 2023
• Accepted
  31 July 2023