A collaborative care psychosocial intervention to improve late life depression in socioeconomically deprived areas of Guarulhos, Brazil: the PROACTIVE cluster randomised controlled trial protocol.

BACKGROUND: The elderly population has been growing in most low- and middle-income countries (LMIC), and depression is a common condition among these populations. The lack of integration between mental health and primary healthcare services and the shortage of mental health specialists in the public health system contribute to underdiagnosis and undertreatment of depression. One of the strategies to reduce this gap is task shifting and collaborative care treatments. This study therefore aims to evaluate the effectiveness and cost-effectiveness of a collaborative care psychosocial intervention to improve the clinical management of depression among elderly people in poor neighbourhoods in Guarulhos, Brazil. METHODS: Two-arm, cluster randomised controlled trial with Basic Health Units as the clusters and a 1:1 allocation ratio. Twenty Basic Health Units have been randomly selected and randomised to control or intervention arms. We aim to recruit 1440 adults (72 per cluster) aged 60 years or over identified with depression (9-item Patient Health Questionnaire (PHQ-9) score ≥ 10). The control arm participants will receive an enhanced usual care, while the intervention arm participants will receive an enhanced usual care and a 17-week psychosocial intervention programme delivered at home by community health workers with the help of an application installed on tablet computers. The primary outcome is the proportion with depression recovery (PHQ-9 < 10) at 8 months' follow-up. We will also assess the maintenance of any earlier clinical gains and the cost-effectiveness of the intervention at 12 months. DISCUSSION: This is the first randomised trial to investigate a collaborative care intervention to treat depression among poor elderly in LMIC/Latin America. This is a major public health problem worldwide, but in these countries, there are no locally tested, evidence-based interventions available to date. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ISRCTN57805470 . Registered on 25 April 2019.

[Construction of the work process of the Family Health Support Nucleus: the experience of pharmacists in a city in the south of Brazil]. / A construção do processo de trabalho no Núcleo de Apoio à Saúde da Família: a experiência dos farmacêuticos em um município do sul do Brasil.

The Family Health Support Nucleus (NASF) was created in 2008 with the objective of broadening the range and scope of primary healthcare. The insertion of pharmacists in this multi-professional context represents an opportunity to enhance the working process and the rational access and use of medicines. The working processes of pharmacists in a city NASF was investigated. Field research was conducted using a qualitative approach with participant observation and semi-structured interviews. Two analytic dialectic categories emerged. The first was the pharmacists' dilemma in the construction of their working process as promoters of primary healthcare, while at the same time facing the need to deal with managerial functions mostly to cater to operational demand. The second was the reality experienced with guidelines and coordination of their work, where pharmacists can be free to structure their work as supporters, although at the same time it limits them due to lack of acknowledgment of their previously established working process. The lack of planning and a clear objective for work in the NASF, besides the deficiency of pharmaceutical services in primary healthcare make the development of any type of pharmacist activity important and essential even if it does not fully attend the NASF proposal.

A construção do processo de trabalho no Núcleo de Apoio à Saúde da Família: a experiência dos farmacêuticos em um município do sul do Brasil / Construction of the work process of the Family Health Support Nucleus: the experience of pharmacists in a city in the south of Brazil

Resumo Em 2008 foi criado o Núcleo de Apoio à Saúde da Família (NASF) com o objetivo de ampliar a abrangência e o escopo da atenção básica. A inserção do farmacêutico neste contexto multiprofissional representa uma oportunidade no seu processo de trabalho e no acesso e no uso racional de medicamentos. Investigou-se o desenvolvimento do processo de trabalho dos farmacêuticos nos NASF de um município. Foi realizada uma pesquisa de campo qualitativa por observação participante e entrevistas semiestruturadas. Duas categorias analíticas dialéticas emergiram: o dilema do farmacêutico na construção do processo de trabalho, como apoiador da atenção básica, mas que também lhe aprisiona em funções técnico-gerenciais atendendo as demandas operacionais; e outra representando a realidade vivenciada na sua relação com as diretrizes e a coordenação do trabalho, tendo ao mesmo tempo “liberdade” para estruturar as tarefas como apoiador, mas que impõe limitações pelo pouco reconhecimento do processo laboral construído. Conclui-se que a falta de planejamento e de objetivo claro para os NASF e a deficiência de serviços farmacêuticos na atenção básica tornam o desenvolvimento de qualquer atividade por este profissional importante e necessária, mesmo não atendendo integralmente a expectativa da proposta do programa.

Abstract The Family Health Support Nucleus (NASF) was created in 2008 with the objective of broadening the range and scope of primary healthcare. The insertion of pharmacists in this multi-professional context represents an opportunity to enhance the working process and the rational access and use of medicines. The working processes of pharmacists in a city NASF was investigated. Field research was conducted using a qualitative approach with participant observation and semi-structured interviews. Two analytic dialectic categories emerged. The first was the pharmacists’ dilemma in the construction of their working process as promoters of primary healthcare, while at the same time facing the need to deal with managerial functions mostly to cater to operational demand. The second was the reality experienced with guidelines and coordination of their work, where pharmacists can be free to structure their work as supporters, although at the same time it limits them due to lack of acknowledgment of their previously established working process. The lack of planning and a clear objective for work in the NASF, besides the deficiency of pharmaceutical services in primary healthcare make the development of any type of pharmacist activity important and essential even if it does not fully attend the NASF proposal.