Descriptive information on included participants are provided below in table 1.
Table 1. Descriptive Statistics of Participants (n=45)
|
Construct
|
Distribution
|
|
Gender
|
|
|
Male
|
24% (n=11)
|
|
Female
|
76% (n=34)
|
|
Occupation
|
|
|
General Practitioner
|
38% (n = 17)
|
|
Nurse
|
24% (n = 11)
|
|
Social worker
|
9% (n = 4)
|
|
Occupational therapist
|
9% (n = 4)
|
|
Psychologist
|
9% (n = 4)
|
|
Psychiatrist
|
9% (n=4)
|
|
Neuropaediatrician
|
2% (n=1)
|
|
Level
|
|
|
BHU
|
69% (n=31)
|
|
PCCca
|
31% (n=14)
|
|
District
|
|
|
Campo Limpo
|
62% (n=28)
|
|
Vila Andrade
|
36% (n=16)
|
|
Lapa
|
2% (n=1)
|
Participants defined quality using a perspective that focussed on the social determinants, in that quality of care would be attained by collaborating with services outside of the health facility to address the social, economic and environmental needs of adolescents. Health care providers also considered quality as having a trained and multidisciplinary workforce, as well as providing person-centred care. Themes on barriers to quality, as reported by participants, were focussed on neglect of the adolescent by the health system and the social and environmental context; while enablers to quality included spontaneous demand and approaches to care.
Quality
Health care providers gave various definitions of quality in adolescent mental health care. They considered these definitions ideal and impossible to realise given the limited resources and challenging contexts within which participants worked.
Social determinants perspective
According to health care providers at the BHU and PCCa, quality of adolescent mental health services was defined as addressing the social determinants of mental health. For example, participants spoke of addressing education, unemployment and poverty. Health care providers were of the opinion that the social determinants within the adolescent’s environment had a greater influence on the adolescent’s mental health than the care they provided at the health facility. Participants perceived their individual level actions as ineffective and that intersectoral societal level changes would lead to improvements in the adolescent’s mental health. Furthermore, it suggested that the current way of identifying, diagnosing and treating adolescents with mental health conditions at the individual level was ineffective, with changes needed beyond what was provided at the health facility.
Participants defined the social determinants approach as activities and services implemented in the community to improve adolescent mental health, such as cultural, leisure, education and employment activities in places the adolescent frequented. The aim of these actions would be to strengthen the adolescent’s social capital, skills training and employment opportunities to improve their mental health. They believed these activities would increase the adolescent’s engagement and thus the quality of the service, as opposed to delivering services solely through the health facility. They were of the opinion that these activities would improve not only the adolescent’s mental health, but also their current and future prospects within these limited-resource and violent settings. Health care providers spoke of how social determinants approach would focus on prevention and promotion, building mental health care into the adolescent’s daily routine, and helping the adolescent integrate into society.
As one participant articulated: Quality is the promotion of a life project [career]. It is not about reinforcing recovery from illness but to be able to access new possibilities in life that these adolescents had before they got ill. That would be quality, not to focus on the recovery of the illness... When we are able to reach more [adolescents] by conducting activities in the community. It’s actually changing the focus, the structure of the agenda to one of promotion and not recovery (P30, Psychologist).
They were also of the opinion that these services would be able to reach a wider audience of adolescents through the implementation of outreach services with other sectors. Some health care providers reported that outreach community activities had been implemented in the past, involving education activities at schools, but that these centred on other health issues, such as adolescent sexual and reproductive health. There was a lack of clarity, however, on how outreach activities and intersectoral collaboration would be financed, developed and implemented, particularly as they acknowledged the dangerousness of the environment within which the adolescent lived. Despite the lack of clarity, some participants reported developing case-by-case therapeutic plans for adolescent patients within the community. These activities were outside of the remit of their work plan and facility resources, and was largely based on their values and beliefs in being able to enrich the adolescent’s development and mental wellbeing.
I stopped to think about a life project [career] for this teenager. Because if not, he will easily slip back into the life he knows: substance use, vulnerability. Anyway. So how do we build this network [for him]? We think of our friends who do this and those that would agree to an internship. So you make an underground network. So we’ve talked to a colleague and arranged for him to go twice a week, to learn about [making] tattoos [becoming a tattoo artist]. We build this with them… we build a kind of private network to be able to think about care (P26, Nurse).
Trained, multidisciplinary workforce
Participants described quality as a trained, multidisciplinary team, providing targeted care to adolescents. Aligned with a social determinants perspective, this involved identifying, learning and comprehensively responding to issues related to the adolescent’s mental health condition.
Health care providers stated that quality in adolescent mental health care involved valuing different perspectives when discussing cases; trouble-shooting service and network challenges; exchanging ideas and learning from each other; and developing, implementing and monitoring a comprehensive therapeutic care plan for the adolescent.
It is clear that access in itself is not quality. He [the adolescent] needs to have professionals who are adequate and updated on adolescent mental health care to be able to absorb it better. And in addition to absorbing this better, to understand what are the other issues related to this, whether there is violence or not, and based on that, take the necessary steps (P10, GP).
Person-centred care
Participants described quality as providing services that were person-centred, in which services responded to adolescents’ mental health needs and demands. Person-centred was articulated as adherence, continuity of care, improved outcomes and reintegration into society, with the health care provider trying to provide the best care possible within the resources and time available. They also were of the opinion that it involved listening to, and developing a bond with, the adolescent, providing confidential services.
One participant articulated: I think one of the points could be the adolescent’s adherence to the service, a response to treatment that involves not only a clinical response to the medication, but an expansion of the repertoire, an expansion of desire, an expansion of possibilities, and offer of expansion of possibilities for this teenager and a space for the teenager to be recognised, listened to and understood as a place of reference. From a clinical point of view, I understand it as quality. (P34, Psychiatrist).
To develop a bond, health care providers reinforced to the adolescent that their role as provider was to listen, take care of them and ensure they felt safe. They stated this involved empathic listening and a judgement- or criticism-free space where there was no right or wrong. They also reported that they would insist with the adolescent that they were equal partners in the care relationship. As a result, participants perceived that bonding allowed adolescents to feel at ease and more relaxed around them.
Health care providers also defined quality as providing confidential services. They reported that confidentiality was a concern for adolescents. They would approach each initial consultation by telling the adolescent that nothing would be shared with parents or families, unless authorised by the adolescent and that everything was confidential.
Other participants defined quality as having ample consultation time to ensure that the adolescent communicated what they wanted, while providing time for treatment. Health care providers believed that mental health problems required more time than other health services, and that quality would be compromised if there was not enough consultation time for the adolescent. There were a mix of factors that contributed to limited mental health services for adolescents. Not only was there a lack of available health care providers, limited time per consultation, but there was also a lack of trained health care providers to provide quality of mental health care.
Relatedly, quality, according to some participants, was defined as continuity of care, providing long-term mental health care services to the adolescent. Continuity of care was expressed as how much the adolescent wanted to return to the service and that one consultation would not be enough time to resolve mental health issues.
Barriers to Quality
Overall, health care providers at the BHU and PCCca perceived quality and the provision of adolescent mental health services to be adversely influenced by the limited-resource and challenging contexts within which they worked. Indeed, they were of the opinion that adolescents were largely neglected by the health system. They also acknowledged the role that the social and environmental context played in the provision and uptake of these services.
Neglect of the adolescent by the Health System
According to participants, adolescents remained largely neglected by the health system, with services failing to meet their mental health needs (52,53). This theme articulated neglect in terms of a lack of prioritisation of adolescents within the system; a paucity of trained providers and mental health specialists; as well as stigmatising health care provider attitudes about adolescents.
Not prioritised within the system
Health care providers, particularly at the BHU level, reported that they experienced limited human and financial resources within the provision of adolescent mental health services. Participants acknowledged that adolescent mental health services were limited, with the current system not conducive for adolescent mental health care. Participants noted that the historical priorities of the UHS at the BHU level meant that some population groups (mothers, children and older populations) were prioritised over adolescents. These priorities illustrated a lack of collective and organisational effort to improve the mental health of adolescents within health services. It also illustrated that health care providers’ knowledge of how to respond to adolescents’ mental health needs within the community was limited, as adolescents were not part of the goals or priorities of the service. Although mainly expressed by health care providers at the BHU level, some health care providers at the PCCca acknowledged that the specialised mental health services were targeted more towards younger children as opposed to adolescents.
Participants recognised a need to help adolescents and engage them in the services, yet the services remained limited in their response due to a lack of resources, adolescent strategies, approaches and targeted actions to improve the uptake and utilisation of these services for adolescents (mainly at the BHU level) and meet their mental health needs. There was also a lack of physical space within health facilities to deliver mental health services to adolescents. Also, health care providers acknowledged that with only one PCCca in the region, there was not enough supply to meet the needs and demands of adolescents within the territory.
One participant expressed: I think services may be missing in health care facilities that are more targeted to the adolescent… we offer a lot of things like that for the elderly, to assess the elderly’s health … and consultations with prenatal care for pregnant women, there is childcare there that we have to do, regular childcare monitoring. Now for adolescents, there is no program for adolescents. (P21, Nurse)
At the BHU level, health care providers reported no clear service protocols, organisational flow or structure for adolescent mental health services. Rather, BHU services were described as being provided in an ad-hoc manner, instead of an organised package based on the mental health needs of adolescents within the community. FHS participants, in particular, stated that they lacked the knowledge and capacity to respond to adolescent mental health cases and relied on FHSN team members. However, FHSN team members were restricted to supporting FHS teams due to working at multiple BHUs per week in the region with limited hours at each facility. There was also an acknowledgement by FHSN team members that there were no targeted and specific actions aimed at adolescents either.
As one health care provider stated: So unfortunately, the workload is very reduced. 15 hours for the Occupational Therapist… it’s 15 hours for 6 teams, she distributes those 15 hours among 6 teams. And all the teams have an average of 4,000 people. We identify the cases and we end up not being able to respond, manage and refer the cases fluidly. We have this problem that we don’t have the fluidity to discuss cases, to trigger other services, because we have other demands, many other demands. And then we choose what the priorities are and adolescents are not always prioritised. Sometimes what is prioritised is dictated by the national primary care policy. Adolescents are not prioritised because the national policy gives priority to pregnant women and children up to 2 years of age, diabetics, hypertensive patients, chronic diseases. So basically this is our priority, that we have to be accountable to. As there are many people and this is a place of extreme vulnerability, there are other demands as well, acute demands from acute illnesses… And then we end up not being able to prioritise adolescents (P1, GP).
Health care providers also acknowledged that they were not effectively reaching adolescents in the community with these services. They perceived that there needed to be greater outreach services for adolescents. This is despite the operation of CHA as part of the Family Health Strategy in the region (43), illustrating that adolescents were not prioritised within this programme, leading to a lack of service provision targeting adolescents.
Relatedly, health care providers were of the opinion that a lack of prevention efforts by the facility to improve adolescent mental health in the community led to adolescents arriving at services already in mental health crisis mode.
So we are not providing care to the adolescent in a preventive manner; we are already caring for them for a curative issue. We are not achieving this prevention, we arrive too late [to provide care]. So this is still failing, this is our failure, it is a failure that we need to correct (P23, Nurse).
Health care providers also recognised the importance of intersectoral collaboration through the network to coordinate care and activities for adolescents, yet they often faced unstable network support. At both the primary and secondary level, health care providers were frustrated at working with other service levels and sectors to provide quality mental health care. There were several reported reasons intersectoral collaboration of the formal support network was a barrier to quality care, including overburdened systems; bureaucracy; as well as a lack of successful referrals and proper case management. Participants also attributed it to limited communication, limited training on adolescent mental health and a lack of integration in the network to provide adolescent mental health care. Health care providers perceived that these barriers led to a lack of timely and appropriate care, as well as delayed treatment. As such, health care providers were wary of triggering intersectoral mechanism as this may not necessarily lead to appropriate or quality care for the adolescent.
At the same time, participants at both the BHU and PCCca reported experiencing a high demand for services, yet low supply of health care providers. One of the consequences of this barrier, as expressed by participants, was an overburdened work schedule. This was described as adhering to schedules that did not prioritise adolescent mental health, and a lack of working hours and consultation time to respond to each case appropriately. Some perceived that overburdened schedules negatively impacted the provision of quality care as their work schedules and the institutional goals did not allow for longer consultation time and the opportunity to develop a bond. This time constraint was also perceived as affecting the adolescent’s therapeutic plan and trust in the system, and a barrier to planning and strategising on adolescent mental health within the facility. Participants recognised this as a gap in service provision wherein they felt they were responding to emergencies and not providing adequate or appropriate care to the adolescent. To respond to all of the needs and demands and provide quality mental health care, they acknowledged that they needed more health care providers within the region, a smaller number of patients per team and another PCCca in the region.
As one health care provider articulated: If there are a lot of people to be served, and few professionals, there is no way to have quality. There is no way to see this teenager as an individual and determine how to respond to them. You know? In many scenarios, especially within the peripheries of the region or in places with a lot of people, it ends up being more about mass care, something like an industrial production. And teenagers don’t usually fit into that (P31, Psychiatrist).
Lack of training and available mental health specialists
Relatedly, health care providers, predominantly at the BHU level, expressed a lack of training as a barrier within the provision of adolescent mental health care services. This lack of training adversely impacted their ability to respond to adolescents’ mental health needs and manage workloads. It also illustrated that quality would not be possible to implement given this barrier to care. Despite all participants acknowledging that training in adolescent mental health was important, the majority of health care providers (n=30) reported they had not received any prior training on adolescent mental health, while 15 health care providers (three from the BHU and 12 from the PCCca) stated they had received training in the past. Indeed, participants at the PCCca acknowledged that mental health providers at the PCCca level were better trained and equipped at providing and responding to adolescents with mental health conditions compared to the primary care level (BHU).
Participants discussed how a lack of training left them feeling unprepared, not having the skills to communicate with adolescents while not being able to appropriately provide support and quality care to the adolescent in these low-resource and violent settings. They also expressed frustration, helplessness and insecurity.
One participant articulated how this lack of training negatively impacted the entire service: It is an accumulation of people without purpose, without justification, without knowing what the material and methods are, without evaluating the impacts of the action with the participants and with the professionals who are performing it. And then this execution is hampered because the planning was not done, the professionals sometimes don’t understand why they would form a group [for adolescents], what are the types of groups? And what impact that may or may not have (P22, Nurse).
Similarly, participants at the BHU perceived the lack of mental health specialists as a barrier within the provision of adolescent mental health care. They were of the opinion that there needed to be greater training and expansion of the FHSN teams in the region. They expressed frustration at the limited hours the FHSN team (psychiatrists, psychologists, occupational therapists and social workers) spent at their facility and how they were unable to meet adolescents’ mental health needs and demands.
As one health care provider articulated: So today, for example, we are 11 teams in a unit that serves over 40,000 people. There are 3,000 people on my team [treated by their team], a little more than 3,000 people, and we have a multidisciplinary team only 3 days per week. So it’s very difficult to make shared consultations with a psychologist, speech therapist or whatever the other professionals are, the social worker. So we end up doing a lot of personal contact, face-to-face, text messaging. That sharing consultations, sharing care, sometimes it’s something that’s a little bit, I see this as a barrier, a great difficulty that could grow. And this multidisciplinary perspective is also where we fail a lot too, due to unavailability (P9, GP).
Relatedly, there was a lack of knowledge and awareness about mental health policies that target adolescents. Participants were asked if there were policies or protocols on adolescent mental health that they followed: 14 health care providers stated that they followed specific policies or protocols on adolescent mental health (5 health care providers from PCCca and 11 from BHU) while 28 providers stated that they did not follow any (6 PCCca and 22 BHU health care providers). Those that stated that they followed policies and protocols mentioned following institutional goals and primary and secondary health care protocols, nothing specific to adolescent mental health. Some health care providers analogised the lack of policies and protocols on adolescent mental health to neglect by the system and entire country.
Although health care providers acknowledged that to improve services there needed to be specific policies and protocols on adolescent mental health, they also expressed hesitancy over its implementation. They worried that national-level policies and protocols would not represent the diverse city and local needs and lead to inflexible adolescent mental health treatment and therapeutic plans. Participants were of the opinion that each treatment and therapeutic plan should be tailored to each case.
Ultimately, plans to implement quality in adolescent mental health services would remain elusive as services currently operate, due to the high demand, lack of prioritisation and the goals and priorities set by the UHS primary care mandate in terms of maternal and child health, elderly health and NCDs.
Stigma
Participants expressed stigmatising attitudes towards adolescents, contributing to neglect by the health system. Some participants blamed adolescents for not accessing or adhering to mental health care. They were of the opinion that adolescents were rebellious; lacked self-care; were not patient, or trusted and respected authority figures such as parents and health care providers. They also considered that adolescents made up excuses not to seek care. They expressed frustration at the difficulty of engaging adolescents in the service.
Social and Environmental Context
Health care providers were of the opinion that quality mental health care was difficult to implement within the resource-limited and challenging contexts of São Paulo city. Participants perceived that, regardless of whether (or not) the health facility was implementing quality mental health services, the services were ineffective. This was attributed to the adolescent’s exposure to social and environmental conflicts and risks within the family and community.
As one participant expressed: I think that the effectiveness of the health service is greatly harmed because no matter how much you offer all of this quality that we are discussing, I think that when he returns to his environment in which he lives, and often the environment does not change, you realise that then you have the chronicity of certain conditions. Because you realise that for him to improve, other aspects of life need to improve, and they are not always related only to the health service. So for sure, this most vulnerable teenager in mental health, even if he has access to quality health care, with the challenges and problems that he faces, I realise that this type of teenager will have a harder time evolving (P5, GP).
At both the BHU and PCCca, parents and families were perceived as barriers to the uptake and utilisation of adolescent mental health care services. Participants reported that adolescents who experienced family conflict and did not have family support were less likely to access and engage in services compared to those with more supportive and involved families. Health care providers attributed these challenges to limited education, social vulnerability, cultural norms and an intergenerational transmission of social disadvantage. Others attributed this to families having to work and a lack of time to care for their adolescent children.
Participants also touched on the influence of the drug cartels and having to work within these high-risk neighbourhoods. They felt that this was out of their control and impacted their ability to provide mental health services, with some describing a fear of retaliation for the provision of services and concerns over their safety when making home visits and the provision of mental health services.
Within a serious case that I see like this, look, there are a lot of social factors that we do not control, and that will affect the response to treatment. We’re going to have to fight for everything to turn it into what it won’t. So, the adolescent lives in a vulnerable area, can I get him out of there? No. I can’t enter his territory today, because the cartels won’t let us in. What will I do? Will I enter by force? No. So I’m not going today, but I’m going tomorrow. So I was late, I didn’t provide the quality I needed to today, but I did it the way I could. So in this case, it’s more important to do it the way it was [the way care is delayed and subsequently delivered] (P35, Psychiatrist).
According to participants, one of the consequences of living in these limited-resource and violent settings was the issue of adolescent substance abuse. They were of the opinion that adolescents were vulnerable to substance abuse due to the influence of the drug cartels within the community; however, they did not mention how adolescents could be potentially integral to the organisation of the drug cartel itself. Health care providers acknowledged that these cases were the least likely to seek and engage in services at the health facility.
Despite acknowledging these social risks and the influence of the drug cartels in the community on quality of care, participants failed to identify ways in which to overcome these challenges. Some participants conceded an inability to understand the adolescent’s environment because they did not grow up or live in these challenging and resource-limited settings. This inability would adversely impact quality of care. The fear of retaliation and safety that health care providers described may have contributed to the lack of prevention and outreach services within the community and not being able to reach at-risk adolescents.
Enablers to Services
Health care providers were asked about enablers to adolescent mental health services. These revolved around spontaneous demand and care approaches.
Spontaneous Demand
FHS team members and PCCca providers were of the opinion that spontaneous demand, as an entry point to the mental health system, was a mechanism that enabled adolescents to turn up to the service and actively seek care, as well as, increase demand. They acknowledged that spontaneous demand meant that adolescents did not have to wait for an initial consultation to see the FHS team or the PCCca team (this did not apply to the FHSN team). To obtain an appointment at the BHU, FHS participants stated that adolescents had to arrive at the service early in the morning to attempt to schedule a morning appointment, or arrive at noon to schedule an afternoon appointment. At the same time, FHS team members at the BHU, as well as, PCCca health care providers reported that adolescents spontaneously sought services at their facilities (this did not apply to the FSHN team members).
Approaches to Care
There were several approaches to care that participants recognised as facilitating the provision and quality of services. Participants were of the opinion that group therapy was an enabler to the provision of adolescent mental health services. At the BHU, the FHSN team organised group therapy and involved activities, such as theatre and literature, and discussions about bullying, self-harm, mental health, sexuality, family conflict and their future plans. Participants considered that group therapy allowed adolescents an opportunity to interact and connect with others their age, facing similar challenges. Health care providers at the PCCca described these groups as helping treatment adhesion and continuity of care.
Participants from the PCCca only recognised that the organisation of mental health services involved using approaches that increased the adolescent’s continuity of care and improved their mental health. These approaches involved working with the adolescent to develop their therapeutic plan, while creating a safe, non-judgmental environment. They attributed this to the opportunities they had for continuing education and training courses, to meet the adolescent’s mental health needs and provide quality care.
As one health care provider at the PCCca stated: So the psychologist’s job is to build together with the patient, within the uniqueness of each patient’s case and potential opportunities, a plan that ends or alleviates their suffering, considering each patient’s personality, environment and the support of the network. So the main role of the psychologist, my main role within the institution is this. Looking for uniqueness, trying to build a therapeutic project for each specific patient, together with the network, together with professionals within the PCC (P32, Psychologist).
Due to the COVID-19 pandemic, telemedicine became a tool by which health care providers at the BHU and PCCca could reach adolescents with mental health services. Participants reported that this tool was quite successful among adolescents, in accessing and continuing mental health care. They perceived that adolescents felt more comfortable through telecommunication, such as WhatsApp and social media, and that it could expand their reach to more adolescents within the community.