ORIGINAL ARTICLES

Users' expectations with regard to mental health actions: a phenomenological study

Marcio Wagner Camatta¹, Christine Wetzel², Jacó Fernando Schneider²

¹Federal University of Health Sciences of Porto Alegre
²Federal University of Rio Grande do Sul

ABSTRACT
Aim: To understand the expectations of users with regard to actions aimed at mental health, as developed as part of the Family Health Strategy. Method: This is a qualitative approach in which we use a social phenomenological perspective. Sixteen users were interviewed in two  family health units in Porto Alegre/Rio Grande do Sul. Results: Users focus on access to the services and supplies offered by the staff of the two family health units, and the establishment of a social relationship. Discussion: Users sought the services of the units in order to meet the demand for the prevention of mental illness and its complications, to promote and restore health, or even to establish social relationships with the units’ professionals. Conclusion: Meeting these expectations is crucial to ensuring the users' access to health services at different levels of complexity, and to strengthen the care elements of the involvement of professionals and users by means of the recognition of social interaction as a therapeutic device.
Keywords: Mental Health, Primary Health Care, Family Health Program; Nursing; Qualitative Research.

INTRODUCTION

Since the 1980s the Brazilian field of mental health has been in a process of transformation through the implementation of mental health policies aimed at redirecting the hospital-centered model of care (through the use of asylums) for the Community Model (focusing on psychosocial care). This transformation has accelerated the establishment of mental health services in the community, such as by the creation of  Centers for Psychosocial Care, as well as influencing the organization of health services in general, among which we may highlight the role of the Family Health Strategy (FHS)⁽¹⁾.

Both the psychiatric reform and the FHS has targeted the reorientation of health care models in the health field. The first is focused on the mental health field and the second on the primary health care (PHC) field. In either way, the challenge associated with the reorientation of these models involves not only the political and organizational aspects, but also the transformation of the practices of the professionals involved⁽²⁾.

Traditionally, the organizational logic of the health care services was grounded in epidemiological data⁽³⁾, from which health professionals and managers proposed and implemented individual and collective actions in terms of healthcare. Without ignoring epidemiology as a labor and management tool, allowing users to offer their opinions about their expectations and interests may work as an important strategy in terms of involving them in the process of building a quality care service that meets their needs⁽⁴⁾.

The users (individuals in psychological distress) have recognized the important role that FHS staff play in providing mental health care in the region, especially in terms of having a family focus rather than simply an individual one⁽⁵⁾. Therefore, the satisfaction of users with the FHS is related to the satisfaction of their needs through care for all the family, the comprehensive care taken by the health professional when they conduct home visits, make physical examinations, order laboratory tests, provide medication and ensure the quality of the relationship between the staff and the community, thereby gradually establishing a professional-client bond⁽²⁾.

The conception that the mental health service is a synonym for psychiatric action is very common, making those terms almost inseparable in the minds of the respondents in many studies⁽⁶⁾. This perception might hinder the construction of more creative ways of approaching mental health care which are potentially producers of subjectivity, social inclusion and citizenship.

However, it is acknowledged that typical psychiatric actions may become mental health activities, and vice versa. The actions regarding mental health in the community should focus on prevention and health promotion and the assistance of sick patients (intervention with regard to the illness involved)⁽⁶⁾.

From this perspective, the actions that characterize community mental health in Porto Alegre/Rio Grande do Sul include actions directed at individuals (cures, promoting health improvement, preventing recurrences, promoting protective factors and dealing with risk factors); at groups and the community (illness prevention and health promotion through the identification of vulnerable groups) and at institutions (humanization of health practices with the involvement of all social subjects)⁽⁶⁾.

Identifying the expectations of users regarding health practices performed by the FHS teams on a daily basis can be an important way to transform the job of the professionals who work in this context, since the reflections which emerge may provide support for the review of the organization and of the work processes of these teams.

This article aims to develop an understanding of the expectations of users regarding actions towards mental health developed by the FHS teams.

METHOD

The present study is a qualitative approach, in which we use the referential social phenomenology of Alfred Schutz. This approach seeks to work with the significance of the motivations that social subjects attach to their actions in life⁽⁷⁾.

The identification of the special meanings attached to these motivations makes possible the revelation of the typical characteristics of a given social action⁽⁸⁾, which allows the construction of the typical action of these subjects (users). In other words,  to find out know how they usually act regarding the phenomenon under consideration - their expectations when it comes to seeking care as part of the FHS.

The study was conducted in two Family Health Units (FHU) and dealt with the performance of three basic FHS teams (doctor, nurse, nursing technician and Community Health Agents - CHA), located in a neighborhood of Porto Alegre. This choice was intentional, since these are training units involving undergraduate disciplines in the health area. They belong to a public university to which the researchers are linked. The FHSs have been implemented for over ten years and most of the professionals have worked in these teams for at least five years.

From a socioeconomic perspective, the population of the catchment area of the units is characterized by a high incidence of violence, drug trafficking, unemployment, poor living conditions and poverty. These FHSs have approximately 2,625 registered families, representing a population of 9,287 people (43% children and adolescents, 50% adults - 20 to 59 years of age - and 7% elderly people). Almost all the registered population rely solely on public health services.

Sixteen users were interviewed in May and June 2010, seven from one unit and nine from another. The interview location was the most convenient one for the users. Of these, nine were undertaken in the respondent’s home and seven at the FHU. In the interviews carried out at home, we received support from a CHA due to the difficulty of access to the residences and also because of the danger of walking through the neighborhood unaccompanied by someone who was recognized by the other residents of the area.

The inclusion criteria of the respondents were: being 18 years or older and being assisted by the FHS staff at the FHU selected; being identified by the team as a person diagnosed with mental illness and; being able to communicate verbally. In the interviews the following guiding questions were asked: 1) why did you seek the assistance of the FHS team? 2) What do you expect from the team?

In terms of organizing and categorizing the results, the following steps were used⁽⁸⁾: careful reading of the interview data to capture the situation experienced and the motivations of the respondents; identification of concrete categories which harbor the acts of the respondents; rereading the interview data to select and group excerpts that contained significant aspects similar to the respondents' actions and; from the typical characteristics of the interview data, to establish the meaning of the respondents’ actions, seeking to describe a typical action.

The study was approved in 2010 by the Research Ethics Committee of the Municipal Health Department of Porto Alegre, under number 001.015735.10.9.

RESULTS

Of the 16 respondents interviewed of both FHUs, 13 were females and 12 were aged between 30 and 59 years. The main psychiatric diagnoses reported by users, families and FHS professionals were depression (n=6) and crack addiction (n=4). Alcohol dependence, schizophrenia, suicide attempts, among others were also mentioned.

Regarding the previous history of psychiatric hospitalization, eight users reported they had not been hospitalized, although two of them had been under observation in a psychiatric emergency service unit. Among those who had been hospitalized, six of them attended a psychiatric hospital. When faced with any situation related to their mental health, six users said they had sought the support of the FHS team, followed by psychiatric emergency service and Psychosocial Care Centers, as well as the support of people from their social circle (spouse, child, siblings and neighbors).

Of the 16 users, 12 had been assisted by the team for at least a decade This reveals the considerable period of time over which the respondents and the FHS healthcare professionals had known each other and related socially.

The respondents intention when seeking assistance from the FHS team was organized into two concrete categories as revealed in their interview responses: to access services and/or supplies offered by the FHS staff and to establish a social relationship, thus configuring the typical action.

Therefore, when the respondents sought the care of the FHS staff, their intentions were translated by their expectations of being able to access services and/or supplies offered by the FHS team, to meet a demand that is widely recognized as being performed by the team, and to get a referral to a specialized health care establishment in order to access other services and specialized professionals; to establish a social relationship through face-to- face interaction with the professionals of the FHS team, so that their life story, their interests and their concerns were recognized by them.

Access to services/supplies offered by Family Health
With regard to the category, to access services and/or supplies offered by the ESF teams, the respondents go to the FHU to fulfil their needs.  The teams in the units offers a response through the provision of certain services. Furthermore the interviewed users sought FHU assistance in terms of prevent illnesses and associated complications by means of vaccinations and the monitoring of blood pressure.

I went there to pick up the drugs. (U2)

I had to take hepatitis vaccine, I took it there ... that's it. (U4)

If I go there to get medicines, if they have it, they give it to me. If I'm feeling bad they know it, then they measure my blood pressure. (U6)

] to have a consultation with the doctor [...] this consultation is to get medicine for depression. (U9)

I always come at least once a month because this drug, fluoxetine. I have to get the prescription every month, so [...] every month I have to come only for a consultation, that is the reason. (U12)

Moreover, they seek to promote and restore health through treatment offered by the FHS teams, particularly by means of medical consultation, drugs prescription or even the medicine itself that was dispensed at the unit.
Among the respondents, expectations also involved obtaining a referral to a specialized healthcare institution:

I was feeling bad. I was too depressed, then I sought help from them to see if they would help me look for a psychologist or a psychiatrist, because I want to seek treatment to see if I could get better. (U7)

I wish they helped me [alcoholism] directing me to some proper place to get some help, but a place that doesn't hospitalize me. A place where I can go, get some paper and take it to a place where they send me. (U15)

Thus, the expectations with regard to seeking help at the FHS is to get support from the health team in order to access specialists who can respond to their needs, especially in the form of psi professionals (psychologists and psychiatrists), or even to be able to access other healthcare facilities to obtain psychiatric treatment other than hospitalization as an option.

Moreover, the demand for referral to other health facilities occurs in situations beyond their control, leading them to seek the initial care at the FHU, to "…search for some help urgently." Then, after the physical signs are stabilized (blood pressure, vomiting and headache), they seek referral to other services.

To search for urgent help, when I need it, and then, as is my case, that is not very common, they can refer me to another place [...] to get a quicker response, because I get my blood pressure under control. If I have vomiting or a headache, then I get medicated and relieved, leaving me only with that anguishing feeling for which there is no medicine, only getting hospitalized. (U3)

The special reason that brought me here was when I was working, [...] and I had high blood pressure and it got very low and I was especially attended by the doctor [...]. The whole team treated me, all together in one room. (U10)

A regular visit to the FHS to seek different services offered by the team expresses the credibility that users place in the service provided:

The whole team treated me, all together in one room, my blood pressure dropped very low. Somebody called the SAMU and they took me to the emergency room. (U10)

I hope they are always the way they are. If they continue as they are it's great for me. I have nothing to complain about and they are all good. [...] They are good and we are well attended here [FHU]. (U12)

They are always good to me. When I expect something they are already at my door. (U13)

Establishment of social relationships
This category proved important because it focuses on social relationships as relating to the interests of the respondents when seeking the help of the FHS team. Therefore, in their interview responses, the respondents demonstrate that they expect the establishment of a social interaction with the FHS professionals:

] I always look for them [FHS team] to talk. [...] I like to talk because sometimes I am depressed and have no one to talk to. I like to go there to talk about my problems. (U7)

Sometimes I have trouble at home so I come here to unburden myself [FHS]. (U8)

However, the respondents say that they do not always have this opportunity, and there are times when the professionals did not give them the attention they wanted:

I hope they continue assisting me the same way they did the last time I went there. Not the way it was before when they wouldn't even look at me. They would just send me to the psychiatry unit at the secondary health care center [postão]. (U5)

The intersubjective relationship, as an act of care, appears as an essential action to working in mental health at the FHS, when the respondents suggest, as expected, that the service provides mutual help groups:

There was a group I loved taking part in last year. In this group we talked, we would open up, but we wouldn't say a word, it would be just between us. [...] I liked the group because I felt well there ... I'd talk about things that had happened, and I felt good talking to people. And it wasn't only me; there were several women and each one had a problem. I had mine and each one spoke of theirs. I wish the group [of women] would get together again. (U7)

They could have a program, something to help [...]. This is what I think they could have there. They should have a program with these meetings so we could get together and give our testimonies to try to help ourselves. (U16)

The respondents' expectations seem to be far from being achieved when they use a hypothetical future tense, such as "would" and "could." This issue indicates a yearning on the part of the respondents, which is important for the teams to take into consideration in care planning.

DISCUSSION

The comprehensive analysis of the typical action of the respondents reveals the intentionality of their expectations in seeking care at FHUs from Alfred Schutz's referential and research results related to the phenomenon under consideration.

The significance of typical respondents' actions allows the identification of concrete categories with regard to the access to services and/or supplies offered by the FHU teams and establishing a social relationship.

The search for resources at the FHU does not differ from the needs of users in general, as pointed out in a study conducted in a primary healthcare unit that used the same theoretical and methodological framework as this study⁽⁸⁾. As with any other users, the respondents used the resources offered by FHU, such as consultations, home visits and the participation, for example, in groups dealing with the needs of pregnant women and hypertension and diabetes patients⁽²⁾.

It is noteworthy that, among the features mentioned by the respondents, those dealing with actions centered particularly in medical activities such as consultations and the prescription of medication, are highlighted.

A previous study has found that, for the users, mental health promotion at the FHS concerns the solution to the health problems of people through medical intervention⁽⁵⁾. This view reinforces the idea that many users have regarding the work of the ESF teams. That is, they expect health care in this context to be specialized, focusing on medical consultations and medicine prescription⁽²⁾.

Such a projection on the part of the respondents reflects the way, customarily, that health professionals have been operating, still clearly guided by the traditional healthcare model (biomedical, organicist, hospital-centered and curativistic, with the excessive use of diagnostic and medication procedures).

On the other hand, it is important to understand that the users may need medical consultations, drugs, examinations (as offers that are more traditionally perceived by users). However, they may have other needs. Thus, user's demands may not represent their most complex needs, that is, their demands are "…needs molded by the offers" made by the service providers⁽⁹⁾.

In view of this, it can be seen that the respondents’ socio-historical and political contexts, as well as their subjective dimensions, are essential in the process of understanding a user’s health situation. The completion of a care program aimed at integrality should focus on exploring, not only the biomedical aspects, but also to knowing and understanding the subject (subjectivity) and its context (its history and relationships). This allows us to take a glimpse into the social reality beyond the demand of users who seeks the help of the FHU, thus revealing their needs.

This reflection is important because it is in the relationalship dimension between the subjectivities (professional and user), a greater governability of health professionals in the production of care⁽⁹⁾. Therefore, one can say that the health care/mental health care provided by the FHS is an expression of the ethical and political choice of the professionals who aim to look after others, thus  getting involved with the situation of the user and his/her family.

Regarding the emphasis placed on specialized mental health services, it reveals that the dependence on specialized care as a means of achieving a healthy state among users seeking FHS, reinforces their lack of autonomy when it comes to defining their own needs concerning health professionals, since only a skilled professional, not including those employed by the FHS, could solve the situation experienced by the user⁽⁵⁾.

Among the reasons that justify the need for professionals from the PHC to be able to look after mental health patients includes the guarantee of physical care, since they have a high rate of comorbidity and mortality due to physical illnesses, and the guarantee of immediate, early and continuous care⁽¹⁾. This demonstrates the relevance of the FHS teams when they are sensitized towards the situations faced by the users in the community, whether to provide care at the FHU, or to make this care possible elsewhere.

The search for a referral by the respondents reflects the hierarchization of health services, in which the establishments of the PHC, as the ESF, are the main doorway to the health system. This attitude, in addition to demonstrating the safety and confidence felt by the respondents in terms of the service offered by the team, can express their lack of autonomy to seek other services.

The speed and diligence with which the teams provide referrals are aspects that influence the degree of user satisfaction with the work offered by the FHS teams. This shows the potential of the FHS to provide care for users with mild and moderate mental disorders by offering home care, and through referrals to other services⁽²⁾.

Regarding the search for a social relationship with members of the FHS team, what is explicit in the discourse of the respondents is the need to meet each other, especially when they say: "I'll go there to talk [...] I like to go there and talk about my problems" and "I come here to unburden myself [FHS]." It is evident that the professionals at the FHU serve as a support when it comes to expressing troubles. So the visit to the FHU aims to meet a needs of the user in terms of sharing their experiences with the professionals.

The respondents highlighted the need for the subjectivity of meetings on the part of the producers of healthcare through the recognition of the importance of meetings in which the face-to-face relationships are essential to making the respondents feel cared for, especially when they state that the professional should "look me in the eye".

The face-to-face relationship highlighted by the respondents is based on overcoming a social relationship with an anonymous type⁽⁷⁾, in which the healthcare professional, when assisting someone, does not promote an interaction in which the particularities of the user are dwelt upon. Thus, the user expects a kind of inter-subjective relationship in terms of familiarity⁽⁷⁾, in which his life story, his social relationships, interests and concerns are recognized by the health professionals in the production of care.

To provide comprehensive care, it is important to think about the individual, ranging from his physical body condition to his insertion in the local, social, economic, political and cultural context, in constant interaction. This means knowing how the users live, what are their life stories.  This in turn means different expectations, experiences and potentialities for each individual and for each context⁽¹⁰⁾.

The search for a social relationship is related to the opportunity for the users to have a space where they can talk about their lives, their paths, how they overcome obstacles and, at the same time, allows them to come to know other individuals who are facing similar situations.

The attendance in groups can promote a social exchange between users and enable the professionals to view the needs and the potential of the user alone and in a group as a whole, thus helping them to develop care strategies. This way it is possible to set up meetings that enable experiments to be carried out, in which different perspectives regarding the world of each individual can be revealed and, therefore, can serve as an object of reflection (individual and/or collective), enhancing the transformation of the self and of the surrounding environment.

The work within a group gives users the opportunity to expand the power of performing affective, material and message exchanges, and consequently expands their power of social contractualism, that is, with regard to deciding and negotiating the ways in which the user wants to conduct his/her life⁽⁶⁾. Thus, the professionals at PHC, when taking actions aimed at promoting the mental health of its population, should pursue the idea of negotiating treatment, including listening to the user's voice with regard to the decisions which have to be taken. This implies the need to foster a supportive professional attitude on the part of its audience, but not as the holder of knowledge and those taking decisions which will be imposed on the users⁽⁴⁾. This attitude is in line with the view of working in the mental health field in the context of the consolidation of the assumptions of Psychosocial Care.

The meetings with the FHS professionals, whether individual or collective, planned or not, made up important moment for the user in terms of meeting their expectations of establishing a social relationship, being involved in important exchanges, and producing a degree of subjectivity.

CONCLUSION

This study has revealed the essence of the expectations of the respondents regarding the actions aimed at mental healthcare as developed in the FHS. It was noted that the intentionality of the respondents in terms of seeking care from the team focused on accessing services and/or supplies offered by the FHS teams and establishing a social relationship.

Users go to an FHU to fulfill some needs.  As a result, the staff provide some measure of response through the provision of certain services. Therefore, they try to prevent diseases and complications through vaccination and the monitoring of blood pressure, respectively. In addition, they promote and restore health through medical consultation, medicine prescription, or even the medicine provided.

In terms of user expectations, there is an interest in obtaining a referral to a healthcare specialist, to gain access to professional experts - especially psi professionals (psychologists and psychiatrists), or even to have access to other health facilities in order to obtain psychiatric treatment.

When seeking help, service users expect to establish a social relationship with the team members of the FHS. In this way, they hope the team can offer them certain activities that will foster interaction between people, such as meetings and/or groups that deal with the topics experienced by users.

The main implication of this study is related to the need of the FHS professionals to meet the expectations of users who seek a space legitimized by the team.  This provides them with the opportunity for social interaction, during which time they can talk about aspects of their lives, their careers and the obstacles overcome, sharing their experiences with other people who face similar situations.

Considering the recent discussion about the inclusion of mental health services at PHC, especially in the FHS, further studies to deepen our understanding of this interface are required, focusing on the perspectives of different actors involved in this process, namely: users, families and professionals.

This study has allowed us to give voice to the service users, and it is hoped that these findings will serve as an object of reflection on the part of the ESF teams regarding healthcare practices and service organizations focused on mental health in the region. This way, it is foreseeable that there will be greater possibilities for consolidation of this aspect of care in the context studied, and in similar contexts.

REFERENCES

1. Ribeiro MS, Poço JLC, Pinto AR. A inserção da saúde mental na atenção básica de saúde. In: Ribeiro MS, organizador. Ferramentas para descomplicar a atenção básica em saúde mental. Juiz de Fora: UFJF; 2007. p. 15-26.

2. Coimbra VCC, kantorski LP, Oliveira MM, Pereira DB, Nunes CK, Eslabão AD. Avaliação da satisfação dos usuários com o cuidado da saúde mental na Estratégia Saúde da Família. Rev Esc Enferm USP. 2011; 45 (5):1150-6.

3. Medeiros EN, Ferreira Filha MO, Vianna RPT. Epidemiology of mental health and insanity: a review of literature. Online Braz J Nurs. [ serial in the internet ]. 2006 [ cited 2011 Jan 11 ] 5(1). Available from: http://www.objnursing.uff.br/index.php/nursing/article/view/138/39.

4. Campos RO, Gama CA, Ferrer AL, Santos DVD, Stefanello S, Trapé TL. Saúde mental na atenção primária à saúde: estudo avaliativo em uma grande cidade brasileira. Cienc Saude Colet 2011;16(12):4643-52.

5. Vasconcellos MGF, Jorge MSB, Guimarães JMX, Pinto AGA. Saúde mental no contexto do Programa Saúde da Família: representações sociais de usuários e familiares. Rev RENE. 2008; 9(3):9-18.

6. Saraceno B. Libertando identidades: da reabilitação psicossocial à cidadania possível. Rio de Janeiro: Instituto Franco Basaglia; 2001.

7. Schutz A. El problema de la realidad social. Buenos Aires: Amorrortu editores; 2003.

8. Lima CA, Tocantins FR. Necessidades de saúde do idoso: perspectivas para a enfermagem. Rev Bras Enferm. 2009; 62(3): 367-73.

9. Cecílio LCO.  As necessidades de saúde como conceito estruturante na luta pela integralidade e equidade em saúde. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade. Rio de Janeiro: UERJ; 2001. p. 113-26.

10. Gerhardt TE, Riquinho DL, Rotoli A. Práticas terapêuticas e apoio social: implicações das dimensões subjetivas dos determinantes sociais no cuidado em saúde. In: Pinheiro R, Mattos RA, organizadores. Cuidar do cuidado: responsabilidade com a integralidade das ações de saúde. Rio de Janeiro: CEPESC; 2008. p. 143-75.

Authors’ contributions

Study conception and data collection: Marcio Wagner Camatta.

Analysis and interpretation of results: Marcio Wagner Camatta and Jacó Fernando Schneider.

Development and critical revision of the article: Marcio Wagner Camatta, Jacó Fernando Schneider and Christine Wetzel.

Recebido: 10/05/2012
Aprovado: 12/11/2012