Health in Brazil 6 Health conditions and health-policy innovations in Brazil: the way forward

Brazil is a large complex country that is undergoing rapid economic, social, and environmental change In this Series of six articles, we have reported important improvements in health status and life expectancy, which can be ascribed largely to progress in social determinants of health and to implementation of a comprehensive national health system with strong social participation. Many challenges remain, however. Socioeconomic and regional disparities are still unacceptably large, reflecting the fact that much progress is still needed to improve basic living conditions for a large proportion of the population. New health problems arise as a result of urbanisation and social and environmental change, and some old health issues remain unabated. Administration of a complex, decentralised public-health system, in which a large share of services is contracted out to the private sector, together with many private insurance providers, inevitably causes conflict and contradiction. The challenge is ultimately political, and we conclude with a call for action that requires continuous engagement by Brazilian society as a whole in securing the right to health for all Brazilian people.

Shared decision-making in mental health care : a user perspective on decisional needs in community-based services

BACKGROUND: Shared decision-making (SDM) is an emergent research topic in the field of mental health care and is considered to be a central component of a recovery-oriented system. Despite the evidence suggesting the benefits of this change in the power relationship between users and practitioners, the method has not been widely implemented in clinical practice. OBJECTIVE: The objective of this study was to investigate decisional and information needs among users with mental illness as a prerequisite for the development of a decision support tool aimed at supporting SDM in community-based mental health services in Sweden. METHODS: Three semi-structured focus group interviews were conducted with 22 adult users with mental illness. The transcribed interviews were analyzed using a directed content analysis. This method was used to develop an in-depth understanding of the decisional process as well as to validate and conceptually extend Elwyn et al.'s model of SDM. RESULTS: The model Elwyn et al. have created for SDM in somatic care fits well for mental health services, both in terms of process and content. However, the results also suggest an extension of the model because decisions related to mental illness are often complex and involve a number of life domains. Issues related to social context and individual recovery point to the need for a preparation phase focused on establishing cooperation and mutual understanding as well as a clear follow-up phase that allows for feedback and adjustments to the decision-making process. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The current study contributes to a deeper understanding of decisional and information needs among users of community-based mental health services that may reduce barriers to participation in decision-making. The results also shed light on attitudinal, relationship-based, and cognitive factors that are important to consider in adapting SDM in the mental health system.

Health and development with imperfect capital markets

This paper investigates the interaction between investment in education and in life-expanding investments, in a simple two-period model in which individuaIs are liquidity constrained in the first period. We show that under low leveIs of health and capital, investments in human capital and in health are complement: since the probability of survival is small, there is littIe incentive to invest in human capital; therefore the return on health investment is also low. This reinforcing effect does not hold for higher leveIs of health or capital, and the two investments become substitute. This property has many consequences. First, subsidizing health care may have dramatically different effects on private investment in human capital, depending on the initial leveI of health and capital. Second, the assumption that mortality is endogenous induces an increase in inequality of income: since health investment is a normal good, the return on education is also lower for poor individuaIs. Third,in a non-overlapping generation madel with non-altruistic agents, the hea1th leveI of the population has strong consequences on growth. For a very low leveI of hea1th, mortality is too high for the investment on education to be profitable. For a higher, but still low, levei of hea1th the economy grows on1y if the initial stock of capital is high enough; bad health and low capital create a poverty trapo Fourth, we compare redistributive income policies versus public hea1th measures. Redistributing income reduces both static and dynamic inequality, but slows growth. In contrast, a paternalistic health policy that forces the poor to invest in hea1th reduces dynamic inequality and may foster growth.

A atenção em Saúde Mental em municípios de pequeno e médio portes: ressonâncias da reforma psiquiátrica

A partir da análise da Política Nacional de Saúde Mental formulada nos últimos anos e das experiências desenvolvidas após 1987 no país, procura-se compreender como o Sistema Único de Saúde tem contribuído ao avanço da reforma psiquiátrica nos municípios; verificar como a assistência oferecida nesses municípios está viabilizando os princípios da reforma psiquiátrica e a melhora das condições de vida dos usuários, bem como pesquisar o papel dos trabalhadores e gestores na construção de novas práticas de cuidado em Saúde Mental. A análise das práticas discursivas aponta que os vários segmentos sociais envolvidos na Saúde Mental conhecem os princípios e propostas da reforma psiquiátrica. No entanto, as gestões municipais não assumem integralmente as propostas do Ministério da Saúde para a área, sob a alegação de falta de recursos financeiros para a contrapartida exigida. Os usuários e familiares têm aos poucos assumido as novas propostas de intervenção, mas os mecanismos de participação e organização popular ainda são incipientes. Por fim, deve-se destacar que, para uma efetiva consolidação das propostas atuais da reforma psiquiátrica, é necessário um maior compromisso dos gestores com a atenção em Saúde Mental, maior investimento nas equipes multiprofissionais, o estímulo à organização e à participação dos usuários e familiares e a integralidade dos dispositivos de saúde, de assistência social e de cultura existentes nas cidades.

Psychosocial factors for risk and protection to child malnutrition in mothers of malnourished and eutrophic children: the role of maternal mental health

In this study, the relationship between child malnutrition, depression, anxiety and other maternal socio-demographic variables was investigated in mothers of malnourished (MD) and eutrophic (ME) children. The causes attributed by mothers to malnutrition were also studied. Ten mothers from each group, with children aged from 11 months to three years and who were users of primary health care units, participated in the study. They answered Beck depression and anxiety inventory, a questionnaire on vital events and an open question concerning the causes of malnutrition. The evaluation instruments were corrected according to proper guidelines and comparative analyses between the groups were performed. The answers to the open question were qualitatively evaluated, submitted to content analysis. The mothers in the two groups were nearly 30 years old or older. They had a steady partner and were subject to very similar life conditions. They had attended school for 5.5 years and were housewives or worked in low-income jobs. Concerning mental health indicators, a significantly larger number of mothers in the MM group showed depression indicators when compared to mothers in the EM group. Most mothers attributed malnutrition to biological factors or to the lack of maternal care, with more moralist statements in the EM group, and statements filled with guilt in MM. Results suggest that in order to fight malnutrition, in addition to nutritional interventions, it is necessary to heed attention to maternal socio-emotional issues.

LEISURE AND MENTAL HEALTH IN PEOPLE WITH HYPERTENSION: CONVERGENCE IN HEALTH EDUCATION

People with hypertension constantly deal with issues related to mental health due to the psychosocial determinants of this illness, and leisure is an important control strategy. The objective of this study was to promote health education to a group of hypertensive patients, through research-action, based on critical-social pedagogy, and taking into consideration the participants' perception of leisure. Educational activities were conducted and, following, an evaluation was performed regarding the subjects' opinion about the impact of leisure on their lives and mental health. The group perceived leisure as a coping strategy for loneliness and also as a late development of independence; it was also regarded as a means of socialization and as a promotion of mental health. These perceptions revealed two themes: aging, leisure, and chronic disease; and knowledge and leisure experiences. Educational actions, such as group dynamics and discussions, were planned considering these themes with the purpose of providing the necessary conditions for socializing and exchanging experiences.

Therapeutic Project at Extra-Hospital Mental Health Services: a critical reflection on the elaboration and management of services' therapeutic projects

Based on a study conducted in Ribeirao Preto, SP, Brazil in extra-hospital mental health services that addressed the organization of these services, therapeutic projects and the inclusion of psychosocial rehabilitation in health actions available, a theoretical-critical reflection concerning the development process of the therapeutic projects by the services' teams is presented. The qualitative study was conducted in an outpatient clinic and a Psychosocial Care Center. Data were collected through semi-structured interviews and focal groups. Data analysis was based on the hermeneutic dialectic philosophy of Jurgen Habermas according to the techniques of reconstruction and interpretation. Data analysis revealed that professionals have difficulty developing and managing therapeutic projects. Health actions are made available without being concretely supported by a proposal guiding the service's practical activities. The therapeutic projects are referred by professionals as the result of guidelines provided by management levels or technical orientations inherent to each profession but not as an activity that represents a philosophy of work of the health team. When the therapeutic project is focused on as a type of consensus that results from a communicative action directed to a mutual and intersubjective understanding among the members of the mental health extra-hospital team, the difficulties of the services' team dialogically organizing themselves to collectively construct the therapeutic project is evidenced.

Basic assistance for mental health in Northeast Brazil

Introduction: Brazilian northeast region is historically affected by socioeconomic problems that made this region more needful for strategies regarding to psychiatric disorders assistance. Methods: This study includes original analysis based on data of secondary level health assistance, extracted from Brazil's Hospitalar Information System, Basic Assistance Information System and Brazilian Institute of Geographic and Statistics. Results: Between 2008 and 2010, more than two hundred million dollars were spent by Brazilian federal government to achieve better quality in the assistance for mental health in Northeast. The service network responsible for the treatment of mental disorders in primary care involves a wide range of professionals and establishments. Conclusion: In northeastern Brazil, socioeconomic and geographic conditions contribute to a particular state of vulnerability for the development of psychopathologies. The association of primary care and an integrated network of public health, however, have improved the attention to mental disordersin this region.

Parent psychopathology and offspring mental disorders: results from the WHO World Mental Health Surveys

Background Associations between specific parent and offspring mental disorders are likely to have been overestimated in studies that have failed to control for parent comorbidity. Aims To examine the associations of parent with respondent disorders. Method Data come from the World Health Organization (WHO) World Mental Health Surveys (n = 51 507). Respondent disorders were assessed with the Composite International Diagnostic Interview and parent disorders with informant-based Family History Research Diagnostic Criteria interviews. Results Although virtually all parent disorders examined (major depressive, generalised anxiety, panic, substance and antisocial behaviour disorders and suicidality) were significantly associated with offspring disorders in multivariate analyses, little specificity was found. Comorbid parent disorders had significant sub-additive associations with offspring disorders. Population-attributable risk proportions for parent disorders were 12.4% across all offspring disorders, generally higher in high- and upper-middle-than low-/lower-middle-income countries, and consistently higher for behaviour (11.0-19.9%) than other (7.1-14.0%) disorders. Conclusions Parent psychopathology is a robust non-specific predictor associated with a substantial proportion of offspring disorders.

Poverty and Mental Health. Tangible and Intangible Aspects of Microcredit

Microcredit, a small lending system, invests on an individual's creativity by stimulating the development of their own potential. This process leads to the attainment of various objectives which in turn allow individuals to develop their skill awareness. Consequently, this process also increases an individual’s self-esteem and self-confidence. These factors play an important role in the aetiology of a number of mental disorders. Namely, those characterized by a series of psychological conditions which impede the full development of a person’s personal, relational and social sphere. Furthermore, since Microcredit is thought to produce tangible goods, such as income, and intangible goods, such as self-esteem and mutual trust, it could also represent an innovative socio-economic tool. We therefore also hypothesize that, Microcredit would be valuable in maximizing abilities/skills in those subjects who are financially excluded and rarely perceived as a ‘resource’ for the Community The longitudinal study set the impact of the Grameen Bank microcredit program on new borrowers women from Noakhali District at the south Bangladesh. The impact evaluation assessment has been structured to detect individual, family and social changes. Manova Analysis allowed distinguishing from women with positive or negative outcomes related to the loan performance. Data revealed consistent differences in terms of economical outcomes and psychological well being amongst the groups of subject analyzed. The data gathered in relation to the changes arisen in the individuals should be looked into through future, continuous and systematic, monitoring.

Aging and Mental Health: Business as Usual?

Cautions that in developing training models in mental health and aging, psychologists must not overlook what experience has taught them about mental health intervention or what they know already about older adults. It is suggested that a life-span developmental view complements a community and preventive approach to the mental health needs of the elderly. Creation of a separate subspecialty of clinical geropsychology will not effectively serve older adults. What is needed is a synthesis ofalready existing expertise in areas such as life-span development, clinical psychology, and community psychology. This synthesis provides a conceptual foundation and set of intervention approaches on which to base training programs in mental health and aging.

Assessing Nursing Assistants' Knowledge of Behavioral Approaches to Mental Health Problems

Nurse's aides are the primary caregivers in nursing homes, a major receiving site for elders with behavioral and psychiatric problems. We describe the development, psychometric properties, and utility of a brief instrument designed to assess aides' knowledge of three specific mental health problems (depression, agitation, and disorientation) and behavioral approaches to them. The instrument was administered to 191 nurse's aides and 21 clinicians with training in behavioral management and experience with older residents. The nurse's aides averaged 11 of 17 correct answers, and the clinicians averaged 15 of 17 correct answers. Implications for staff training and consultation activities in nursing homes are discussed.

Mental Health and Aging at the 2005 White House Conference on Aging: Two Steps Forward, One Step Back

Success! At the 2005 White House Conference on Aging, three-quarters of the 1,200 national delegates voted to improve “recognition, assessment, and treatment of mental illness and depression among older Americans.” This resulted in mental health being ranked as #8 of the final 50 WHCoA policy resolutions resulting from the conference. Joining this resolution in the “top ten” were two resolutions intimately tied to hopes for addressing the mental health needs of older adults—at #6 “Support Geriatric Education and Training for Health Care Professionals, Paraprofessionals, Health Profession Students and Direct Care Workers,” and #9 “Attain Adequate Numbers of Healthcare Personnel in All Professions Who are Skilled, Culturally Competent, and Specialized in Geriatrics.”

Aging and mental health in the decade ahead: What psychologists need to know

Until relatively recently, most psychologists have had limited professional involvement with older adults. With the baby boomers starting to turn 65 years old in 2011, sheer numbers of older adults will continue to increase. About 1 in 5 older adults has a mental disorder, such as dementia. Their needs for mental and behavioral health services are not now adequately met, and the decade ahead will require an approximate doubling of the current level of psychologists' time with older adults. Public policy in the coming decade will face tensions between cost containment and facilitation of integrated models of care. Most older adults who access mental health services do so in primary care settings, where interdisciplinary, collaborative models of care have been found to be quite effective. To meet the needs of the aging population, psychologists need to increase awareness of competencies for geropsychology practice and knowledge regarding dementia diagnosis, screening, and services. Opportunities for psychological practice are anticipated to grow in primary care, dementia and family caregiving services, decision-making-capacity evaluation, and end-of-life care. Aging is an aspect of diversity that can be integrated into psychology education across levels of training. Policy advocacy for geropsychology clinical services, education, and research remains critical. Psychologists have much to offer an aging society

Maternal mental health in the first 3-week postpartum: the impact of caregiver support and the subjective experience of childbirth - a longitudinal path model

Acute stress reactions (ASR) and postpartum depressive symptoms (PDS) are frequent after childbirth. The present study addresses the change and overlap of ASR and PDS from the 1- to 3-week postpartum and examines the interplay of caregiver support and subjective birth experience with regard to the development of ASR/PDS within a longitudinal path model.