Utility of oral fluid samples for hepatitis B antibody detection in real life conditions.

BACKGROUND: Hepatitis B virus (HBV) testing in oral fluid samples may provide advantages in diagnosis, screening or prevalence studies, especially among individuals with venous access difficulties. This study aims to optimize one commercially available assay for detecting total anti-HBc marker in oral fluid samples and to evaluate its utility under real life conditions in different settings for the purposes of prevalence and diagnostic studies. METHODS: Oral fluid was collected using a Salivette device and some parameters were initially evaluated: type of elution buffer and sample volume. Thereafter, the utility of oral fluid samples for detection of anti-HBc was evaluated in real life conditions in which, 1296 individuals gave serum and oral fluid samples. All serum samples were submitted to commercial EIAs to detect total anti-HBc, according to the manufacturer's instructions and oral fluid samples according to previous optimization. RESULTS: In optimization evaluation, PBS/BSA 0.5% and 100 µL of oral fluid (volume was two-fold increased compared to serum in EIA) were chosen as transport buffer and sample volume. In the field study, anti-HBc was detected in 211 out of 1296 serum samples giving overall oral fluid sensitivity of 52.6% and specificity of 96%. Concordance was higher in ambulatory setting (67.7) compared to general population (31.8). Mean ± standard deviation values of optical density/cutoff (OD/CO) in serum samples were higher in false-negative oral fluid samples than those seen in true positive samples. Sensitivity was higher in those presenting active infection compared to anti-HBc isolate and past infection. Sensitivity also increased in the ambulatory group when HCV individuals were excluded. CONCLUSIONS: It was possible to optimize a commercial EIA for detecting anti-HBc in oral fluid samples and where the highest concordance was found in ambulatory settings and among individuals with active infection.

Poor sensitivity of rapid tests for the detection of antibodies to the hepatitis B virus: implications for field studies.

Rapid tests (RTs) can be used as an alternative method for the conventional diagnosis of hepatitis B virus (HBV). This study aims to evaluate antibodies to HBsAg (anti-HBs) and antibodies to HBeAg (anti-HBe) RTs under different Brazilian settings. The following three groups were included: GI: viral hepatitis outpatient services; GII: low resource areas; and GIII: crack users and beauticians. Imuno-rápido anti-HBsAg™ and Imuno-rápido anti-HBeAg™ RTs were evaluated and showed specificities greater than 95% in all groups. The sensitivity values to anti-HBs were 50.38%, 51.05% and 46.73% and the sensitivity values to anti-HBe were 76.99%, 10.34% and 11.76% in the GI, GII and GIII groups, respectively. The assays had a low sensitivity and high specificity, which indicated their use for screening in regions endemic for HBV.

Evaluating HBsAg rapid test performance for different biological samples from low and high infection rate settings & populations.

BACKGROUND: Rapid tests (RTs) might have several advantages over standard laboratory procedures, increasing access to diagnosis, especially among vulnerable populations and/or those living in remote areas. The aim of this study was to evaluate the performance of RTs for the detection of hepatitis B virus surface antigen (HBsAg) in samples from different populations/settings. METHODS: Three RTs for HBsAg detection (Vikia® HBsAg, HBsAg Teste Rápido®, and Imuno-Rápido HBsAg®) and different biological specimens (serum, whole blood, and saliva) were evaluated. Analyses comprised a reference panel and samples from field studies targeting suspected cases of hepatitis B virus (HBV) (G I), individuals living in deprived areas (G II), and highly vulnerable individuals (G III). Enzyme immunoassay (EIA) was defined as the gold standard in this study. Reproducibility, repeatability, and cross-reactivity with other infectious agents such as dengue, immunodeficiency (HIV), and hepatitis C (HCV) viruses and T. pallidum were determined. RESULTS: For the reference panel, the sensitivity and specificity of all HBsAg RTs were higher than 93.00 %. G I presented the highest kappa values for all rapid assays using sera samples. When using serum, the sensitivity values were higher than 93.40 for G I, 60.00 % for G II and 66.77 % for G III, and the specificity values were higher than 99.50 for GI, 97.20 for G II and 99.10 % for G III for all tests. For whole blood samples & the Vikia® HBsAg assay, the best performance was achieved for GIII (k = 79.75 %). For saliva samples, the Imuno-Rápido HBsAg® assay showed the highest concordance values with EIA for G I (40.68 %) and G II (32.20 %). The reproducibility and repeatability of all RTs for serum and saliva were excellent, and the concordance between HBsAg EIAs and RTs using samples reactive with other infectious agents varied from 70.10 % to 100.00 %. CONCLUSIONS: The overall performance of RTs for HBsAg in serum was high/moderately high for all groups, thereby promoting increased access to HBV diagnosis among vulnerable populations as well as samples from individuals in emergency settings or remote areas. Rapid tests for HBsAg using whole blood could be used in prevalence studies, though these assays should not be used for saliva samples.

Exploring sex differences in drug use, health and service use characteristics among young urban crack users in Brazil.

INTRODUCTION: Studies have shown important gender differences among drug (including crack) users related to: drug use patterns; health risks and consequences; criminal involvement; and service needs/use. Crack use is prevalent in Brazil; however, few comparative data by sex exist. We examined and compared by sex key drug use, health, socio-economic indicators and service use in a bi-city sample of young (18-24 years), regular and marginalized crack users in Brazil. METHODS: Study participants (total n = 159; n = 124 males and n = 35 females) were recruited by community-based methods from impoverished neighborhoods in Rio de Janeiro and Salvador. Assessments occurred by an anonymous interviewer-administered questionnaire and serum collection for blood-borne virus testing between November 2010 and June 2011. Descriptive statistics and differences for key variables by sex were computed; in addition, a 'chi-squared automatic interaction detector' ('CHAID') analysis explored potential primary factors differentiating male and female participants. RESULTS: Most participants were non-white, and had low education and multiple income sources. More women had unstable housing and income from sex work and/or panhandling/begging, whereas more men were employed. Both groups indicated multi-year histories of and frequent daily crack use, but virtually no drug injection histories. Men reported more co-use of other drugs. More women were: involved in sex-for-drug exchanges; blood-borne virus (BBV) tested and HIV+. Both groups reported similar physical and mental health patterns; however women more commonly utilized social or health services. The CHAID analysis identified sex work; paid work; begging/panhandling; as well as physical and mental health status (all at p < 0.05) as primary differentiating factors by sex. CONCLUSIONS: Crack users in our study showed notable differences by sex, including socio-economic indicators, drug co-use patterns, sex risks/work, BBV testing and status, and service utilization. Results emphasize the need for targeted special interventions and services for males and female crack users in Brazil.

Patterns, determinants and barriers of health and social service utilization among young urban crack users in Brazil.

BACKGROUND: Crack use is prevalent across the Americas, and specifically among marginalized urban street drug users in Brazil. Crack users commonly feature multiple physical and mental health problems, while low rates of and distinct barriers to help service use have been observed in these populations. This study examined profiles and determinants of social and health service utilization, and unmet service needs, in a two-city sample of young (18-24 years), marginalized crack users in Brazil. METHODS: N = 160 study participants were recruited by community-based methods from impoverished neighborhoods in the cities of Rio de Janeiro (n = 81) and Salvador (n = 79). A mixed methods protocol was used. Participants' drug use, health, and social and health service utilization characteristics were assessed by an anonymous interviewer-administered questionnaire completed in a community setting; descriptive statistics on variables of interest were computed. Service needs and barriers were further assessed by way of several focus groups with the study population; narrative data were qualitatively analyzed. The study protocol was approved by institutional ethics review boards; data were collected between November 2010 and June 2011. RESULTS: The majority of the sample was male, without stable housing, and used other drugs (e.g., alcohol, marijuana). About half the sample reported physical and mental health problems, yet most had not received medical attention for these problems. Only small minorities had utilized locally available social or health services; utilization appeared to be influenced by sex, race and housing characteristics in both sites. Participants cited limited service resources, lack of needs-specific professional skills, bureaucratic barriers and stigma as obstacles to better service access. However, most respondents stated strong interest and need for general social, health and treatment services designed for the study population, for which various key features were emphasized as important. CONCLUSIONS: The study contributes substantive evidence to current discussions about the development and utilization of health and treatment interventions for crack use in Brazil. Based on our data, crack users' social, service needs are largely unmet; these gaps appear to partly root in systemic barriers of access to existing services, while improved targeted service offers for the target population seem to be needed also.

Evaluation of accuracy of hepatitis B virus antigen and antibody detection and relationship between epidemiological factors using dried blood spot.

Dried blood spots (DBS) testing might increase the access for Hepatitis B virus (HBV) diagnosis, but little is known about the performance of these assays in real life conditions. This study aims to evaluate the diagnostic accuracy of HBsAg, anti-HBc and anti-HBs detection in DBS in clinical settings and field studies and to evaluate demographic and risk behaviour according the presence of HBsAg and anti-HBc. Paired sera and DBS samples were obtained from 2309 individuals from 3 groups, defined as follows: G1: clinical setting (n = 5-19), G2: general population (n = 1305) and G3: vulnerable individuals that could be more exposed to blood contact (n = 485). Sera and DBS were tested using commercial enzyme immunoassay (EIA), with some modifications added. Using DBS samples, the specificity values were above 90 % for HBsAg and anti-HBc in all groups and for anti-HBs range from 58.6%-85%. HBsAg testing had the best performance in GI (sensitivity = 84.4 %) and among those samples that the paired serum also presented anti-HBc marker (sensitivity = 91.6 %). High sensitivity of anti-HBc testing in DBS samples was observed in GI (80.8 %) and among HBV active cases (HBsAg+/anti-HBc+) (98.4 %). Testing of anti-HBs in DBS showed the highest sensitivity in GIII (65.5 %), in previous HBV exposed and cured individuals and when serum titers were above 100 IU/mL (86.7 %). DBS samples could be used for screening and prevalence studies for HBsAg and anti-HBc, particularly in clinical settings and among HBV active cases in field studies.

Experiência de adoecimento e estratégias de "tocar a vida" de pessoas com esquizofrenia acompanhadas na Atenção Primária: estudo qualitativo orientado pelo Recovery / Illness experience and strategies to "get on with life" of people with schizophrenia admitted to primary care: qualitative study oriented by the Recovery

Resumo A Reforma Psiquiátrica Brasileira produziu grandes transformações no cuidado em saúde mental, porém ainda é um desafio tornar as experiências pessoais o eixo central dos tratamentos. O movimento do Recovery, em que a remissão dos sintomas é descentralizada e a ênfase recai na busca de vida gratificante na comunidade, pode trazer ensinamentos. A pesquisa descreveu a experiência de adoecimento e estratégias para "tocar a vida" de pessoas com esquizofrenia no contexto da Atenção Primária à Saúde, conhecendo o que fazem para se ajudar na lida diária com os problemas gerados pelo transtorno mental. O cenário é uma Unidade Básica de Saúde no centro do Rio de Janeiro e a pesquisa, de inspiração etnográfica, realizou entrevistas narrativas com quatro pessoas com esquizofrenia com autonomia e acompanhadas exclusivamente na APS e dois familiares. Resultados sugerem que religiosidade, trabalho e renda foram relevantes para a recuperação dos entrevistados e o olhar da família reforçou o estigma. A análise exigiu superação de olhar esquemático sobre reabilitação psicossocial e o conceito de Recovery. A importância deste estudo é trazer para o centro da análise caminhos construídos pelos próprios sujeitos para a tocar a vida, além de debater o conceito de Recovery no cenário da APS.

Abstract The Brazilian Psychiatric Reform produced major transformations in mental health care, but it is still a challenge for personal experiences to become the central axis of treatments. The Recovery movement, in which the remission of symptoms is decentralized, and the emphasis of care is on the search for a fulfilling life in the community, can bring lessons. This research describes the illness experience and strategies to go on with the life of people with schizophrenia finding what they do to help themselves in their daily struggle. The study setting is a Basic Health Unit in the center of Rio de Janeiro. The research, which has ethnographic inspiration, conducted narrative interviews with people diagnosed with schizophrenia who preserved autonomy, followed exclusively in Primary Care and their relatives. The results suggest that religiosity, work, and income were relevant to the recovery of the interviewees and that family care reinforced the stigma of the disease. The analysis required overcoming the schematic view of psychosocial rehabilitation and the Recovery concept. The relevance of this study is to place paths that subjects built themselves to go on with life in the center of the analysis and to debate the concept of Recovery in Primary Care. Resumo: A Reforma Psiquiátrica Brasileira produziu grandes transformações no cuidado em saúde mental, porém ainda é um desafio tornar as experiências pessoais o eixo central dos tratamentos. O movimento do Recovery, em que a remissão dos sintomas é descentralizada e a ênfase recai na busca de vida gratificante na comunidade, pode trazer ensinamentos. A pesquisa descreveu a experiência de adoecimento e estratégias para "tocar a vida" de pessoas com esquizofrenia no contexto da Atenção Primária à Saúde, conhecendo o que fazem para se ajudar na lida diária com os problemas gerados pelo transtorno mental. O cenário é uma Unidade Básica de Saúde no centro do Rio de Janeiro e a pesquisa, de inspiração etnográfica, realizou entrevistas narrativas com quatro pessoas com esquizofrenia com autonomia e acompanhadas exclusivamente na APS e dois familiares. Resultados sugerem que religiosidade, trabalho e renda foram relevantes para a recuperação dos entrevistados e o olhar da família reforçou o estigma. A análise exigiu superação de olhar esquemático sobre reabilitação psicossocial e o conceito de Recovery. A importância deste estudo é trazer para o centro da análise caminhos construídos pelos próprios sujeitos para a tocar a vida, além de debater o conceito de Recovery no cenário da APS.

Grupos de medicação e experiência do adoecimento: compartilhamento de narrativas no contexto da atenção psicossocial / Medication groups and illness experience: sharing narratives in the context of psychosocial care

Resumo A experiência do adoecimento é entendida enquanto dimensão subjetiva, estruturada socialmente, sobre a doença e suas repercussões pessoais, referidas ao campo das práticas, crenças e valores compartilhados. O grupo de medicação discutido neste estudo estimulou a produção de narrativas sobre a experiência do adoecimento para abordar o empoderamento do usuário, a partir do diálogo sobre uso e manejo de psicotrópicos. Trata-se de um estudo qualitativo, descritivo-exploratório. A questão de pesquisa foi: Como a experiência do adoecimento é apresentada nas narrativas dos participantes dos grupos de medicação? Vinte e dois usuários de serviços comunitários de saúde mental e cinco familiares destes participaram de duas reuniões do grupo de medicação e três grupos focais. A análise dos resultados materializou-se na perspectiva da antropologia médica e da psicopatologia fenomenológica. As categorias de análise deste artigo são: experiência de participação em grupos de medicação, experiência de uso e manejo da medicação, experiência com o adoecimento e diagnóstico. As narrativas produzidas indicaram que os diálogos em grupo sobre medicamentos subsidiam a formulação e o compartilhamento de significados atribuídos à experiência do adoecimento mental e de seu tratamento medicamentoso. Deste modo, os grupos de medicação reforçaram a atuação conjunta de profissionais, familiares e usuários, ampliando as possibilidades de cuidado sensível à experiência vivida.

Abstract The illness experience is understood as the subjective dimension, socially structured, about the disease and its personal repercussions, referred to the field of shared practices, beliefs and values. The medication group discussed in this study stimulated the illness experience narratives production, to address the user's empowerment, starting from the dialogue about the psychotropics use and self-management. This is a qualitative, descriptive-exploratory study. The research question was: How is the illness experience presented in the narratives of medication groups participants? Twenty-two community mental health service users and five family members participated in two medication group meetings and three focus groups. The results analysis materialized from the perspective of medical anthropology and phenomenological psychopathology. The analysis categories in this article are: experience of participation in medication groups, use and medication self-management and experience of illness and diagnosis. The narratives produced indicated that group dialogues about medicines supports meaning formulate and sharing assigned to the mental illness experience and drug treatment. Therefore, these medication groups reinforced the joint performance of professionals, family members and users, expanding proposals of sensitive care to lived experience.

Methodological challenges in the use of focus groups with people with severe mental illness.

This study addresses the practical, methodological and ethical challenges that were found in three studies that used focus groups with people with severe mental illness, in the context of community mental health services in Brazil. Focus groups are a powerful tool in health research that need to be better discussed in research with people with severe mental illness, in the context of community mental health facilities. This study is based on the authors' experience of conducting and analyzing focus groups in three different cities - Campinas, Rio de Janeiro and Salvador - between 2006-2010. The implementation of focus groups with people with severe mental illness is discussed in the following categories; planning, group design, sampling, recruitment, group interview guides, and conduction. The importance of connecting mental healthcare providers as part of the research context is emphasized. Ethical issues and challenges are highlighted, as well as the establishment of a sensitive and empathic group atmosphere, wherein mutual respect can facilitate interpersonal relations and enable people diagnosed with severe mental illness to make sense of the experience. We emphasize the relevance of the interaction between clinical and research teams in order to create collaborative work, achieve inquiry aims, and elicit narratives of mental health users and professionals.

O que estudantes nos contam sobre as entrevistas narrativas / What students tell us about narrative interviews

Romper com o modelo biomédico é necessário, e o ponto inicial pode vir com a compreensão da narrativa do usuário ou da usuária. Este estudo buscou avaliar a compreensão de estudantes de medicina das narrativas de adoecimento, utilizando a entrevista McGillIllness Narrative Interview (MINI). Trata-se de estudo exploratório, descritivo e qualitativo, realizado durante cinco semanas com 11 estudantes do quinto ano de uma universidade privada, no internato de Medicina de Família e Comunidade, que prestavam atendimento a 29 pessoas usuárias de unidades de saúde. Por meio de encontros individuais on-line, foram levantadas questões sobre essa experiência. Os relatos foram inseridos em núcleos argumentais, o que possibilitou o estabelecimento de relações com o referencial teórico da Medicina Narrativa, da Antropologia Médica e da Clínica Ampliada. Para os alunos e alunas houve uma nova experiência de entrevista clínica, uma valorização da narrativa e o desejo de incorporar uma abordagem mais ampliada à sua prática, embora não contemplem incorporar o MINI na sua forma integral, atribuindo a isso dificuldades na rotina médica. Acreditamos que o MINI pode colaborar com a aquisição de competências interpretativa e narrativa em estudantes, embora o ensino esteja ainda, emparte, vinculado ao modelo biomédico.

It is essential to break with the biomedical model. The starting point for that can come from the understanding of patients' narratives. This study sought to evaluate medical students' comprehension of illness narratives using the McGill Illness Narrative Interview (MINI). This is an exploratory, descriptive, and qualitative study, carried out with 11 fifth-year students at a private university in the internship of Family and Community Medicine, for five weeks, involving the care of 29 patients in health units. Through individual online meetings, questions were raised about the experience.The reports were inserted into categories, which allowed us to establish relationships among the theoretical referential elements of Narrative Medicine, Medical Anthropology, and Expanded Clinic. It was a new experience of clinical interviews for the students, with a new appreciation of narratives and a desire to incorporate a more extended approach to their practice, although they do not contemplate incorporating the MINI in its full form due to difficulties in the physician's routine. We believe that MINI can collaborate with the acquisition of interpretative and narrative competence in students, although teaching is still partly linked to the biomedical model.

The McGill Illness Narrative Interview - MINI: translation and cross-cultural adaptation into Portuguese. / McGill Entrevista Narrativa de Adoecimento - MINI: tradução e adaptação transcultural para o português.

This paper presents the process of translation and cultural adaptation into Portuguese of the McGill Illness Narrative Interview - MINI, an interview protocol that is used to research meanings and modes of narrating illness experiences, tested, in the Brazilian context, for psychiatric and cancer-related problems. Two translations and their respective back-translations were developed. In addition, semantic equivalence was evaluated, a synthesis version and a final version were prepared, and two pre-tests were administered to the target populations (people with auditory verbal hallucinations or breast cancer). A high degree of semantic equivalence was found between the original instrument and the translation/back-translation pairs, and also in the perspective of referential and general meanings. The semantic and operational equivalence of the proposed modifications was confirmed in the pre-tests. Therefore, the first adaptation of an interview protocol that elicits the production of narratives about illness experiences has been provided for the Brazilian context.

Implementação de um ambulatório psicossocial para pessoas expostas a situação de violência em um hospital universitário / Implementation of a psychosocial outpatient clinic for people exposed to violence in a university hospital / Implementación de una clínica psicosocial ambulatorial para personas expuestas a la violencia en un hospital universitario

RESUMO Discute-se o processo de implementação de um ambulatório que oferta psicoterapia de grupo com base psicanalítica às crianças, adolescentes e adultos expostos à violência, adscritos à região Norte de Campinas-SP. A implementação acontecerá no Hospital Universitário - Unicamp, em parceria com o Laboratório de Saúde Coletiva e Saúde Mental - Interfaces, a Assistência Social e de Saúde da Prefeitura Municipal de Campinas. Objetiva-se qualificar a assistência e articulação da rede de serviços públicos no território (Atenção Primária à Saúde e Assistência Social), ofertando-se apoio matricial e seguimento conjunto dos casos; e construir evidências sobre a efetividade da psicanálise de grupo na terapia de transtornos associados à exposição à violência. Utilizar a psicanálise justifica-se no contexto da abordagem e da prevenção à violência na medida em que espaços seguros de escuta possibilitam à pessoa em situação de exposição à violência um lugar de legitimação do sofrimento, elaboração e ressignificação da experiência traumática; do contrário há riscos de invalidar, negar, calar e perpetuar a violência naturalizando-a. A psicanálise tem contribuições significativas para compreensão das causas e consequências individuais e coletivas da violência, bem como para intervir e prevenir a transmissão transgeracional por meio de dispositivos terapêuticos que consideram os níveis coletivo, intersubjetivo e intrapsíquico.

ABSTRACT The process of implementation of an outpatient clinic offering psychoanalytic group psychotherapy to children, adolescents and adults exposed to violence, assigned to the northern region of Campinas-SP, is discussed. The implementation will take place at the University Hospital - Unicamp, in partnership with the Collective Health and Mental Health Laboratory - Interfaces, the Social and Health Care of the Campinas City Hall. The objective is to qualify the assistance and articulation of the public services network in the territory (Primary Health Care and Social Assistance), offering matrix support and joint follow-up of cases; and to build evidence on the effectiveness of group psychoanalysis in the therapy of disorders associated with exposure to violence. Using psychoanalysis is justified in the context of the approach and prevention of violence as safe listening spaces allow the person in a situation of exposure to violence a place of legitimation of suffering, elaboration and resignification of traumatic experience; otherwise there are risks of invalidating, denying, silencing and perpetuating violence by naturalizing it. Psychoanalysis has significant contributions to understand the individual and collective causes and consequences of violence, as well as to intervene and prevent transgenerational transmission through therapeutic devices that consider the collective, intersubjective and intrapsychic levels.

RESUMEN Se discute el proceso de implementación de una clínica ambulatoria que ofrece psicoterapia grupal psicoanalítica a niños, adolescentes y adultos expuestos a la violencia, asignados a la región norte de Campinas-SP. La implementación tendrá lugar en el Hospital Universitario - Unicamp, en colaboración con el Laboratorio de Salud Colectiva y Salud Mental - Interfaces, la Atención Social y de Salud del Ayuntamiento de Campinas. El objetivo es calificar la asistencia y articulación de la red de servicios públicos en el territorio (Atención Primaria de Salud y Asistencia Social), ofreciendo apoyo matricial y seguimiento conjunto de casos; y para construir evidencia sobre la efectividad del psicoanálisis grupal en la terapia de trastornos asociados con la exposición a la violencia. El uso del psicoanálisis se justifica en el contexto del enfoque y la prevención de la violencia, ya que los espacios seguros de escucha permiten a la persona en una situación de exposición a la violencia un lugar de legitimación del sufrimiento, elaboración y resignificación de la experiencia traumática; de lo contrario, existe el riesgo de invalidar, negar, silenciar y perpetuar la violencia al naturalizarla. El psicoanálisis tiene contribuciones significativas para comprender las causas y consecuencias individuales y colectivas de la violencia, así como para intervenir y prevenir la transmisión transgeneracional a través de dispositivos terapéuticos que consideran los niveles colectivos, intersubjetivos e intrapsíquicos.

Revisão sistemática qualitativa sobre avaliações de serviços em saúde mental na perspectiva dos usuários / Quatitative systematic review of mental health services from the users' perspective / Revisión sistemática cualitativa sobre evaluación de servicios de salud mental desde la perspectiva de los usuarios

OBJETIVO: identificar publicações nacionais brasileiras e internacionais na área de saúde mental sobre avaliação de serviços, destacando as formas de participação dos usuários. MÉTODO: trata-se de uma revisão sistemática qualitativa da literatura, que seguiu as orientações do PRISMA e utilizou duas plataformas internacionais que agregam um número significativo de bases de dados, com os descritores (saúde mental e avaliação) no período de 2004 a 2016. RESULTADOS: levantou-se 4.735 artigos completos; tendo elegibilidade final de 137 artigos para leitura integral, sendo 44 incluídos na análise final. Percebe-se que há pesquisas sobre avaliação de serviços de saúde mental com a participação dos usuários no Brasil, mas ainda em número menor em comparação com Inglaterra, Austrália e EUA. CONCLUSÃO: a forma de participação dos usuários nas avaliações dos serviços, tanto no Brasil quanto em outros países, ainda é um desafio. Há pouco protagonismo dos usuários. No Brasil, coloca-se o desafio ainda de estruturar avaliações sistemáticas dos serviços públicos, com multiplicidade de métodos avaliativos e envolvendo todos os atores.

OBJECTIVE: to identify, based on qualitative systematic literature review, Brazilian national and international publications in mental health area, addressing service's evaluation on their users perspective. METHOD: a qualitative systematic literature review, which followed PRISMA orientations and criteria. For that, two international platforms that include a significant number of databases were used, with “mental health” and “evaluation” descriptors and 2004 to 2016 period. RESULTS: 4,735 full articles were initially collected, with final eligibility of 137 for integral text reading, of which 44 were included in the final analysis. Research studies on mental health services evaluation with users' participation are present in Brazil, but still in reduced number when compared to countries like England, Australia and USA. CONCLUSION: in Brazil, as well as in other countries, the ways by which users participate in services evaluations are still a challenge. Mental health service users' protagonist is insufficient. In Brazil, there is also a challenge to structure public services systematic evaluations, incorporating diversity of evaluative methods and stakeholders' participation.

Escrita, memória e cuidado - testemunhos de trabalhadores de saúde na pandemia / Writing, memory and care - testimonies by health workers in times of the pandemic / Escritura, memoria y cuidado - testimonios del trabajador de la salud en tiempos de pandemia / Écriture, mémoire et soins - témoignages des travailleurs de la santé en temps de pandêmie

Apresentamos, no presente artigo, o percurso teórico e prático que envolveu a criação do projeto Pausas e Pousos - Vivências do Trabalhador de Saúde em Tempos de Pandemia. A inciativa tem por objetivo conhecer as vivências dos trabalhadores de saúde na pandemia de COVID-19, no cenário nacional. Apresentamos o modo de conhecimento narrativo e o testemunho como uma modalidade particular de produção narrativa, examinando modalidades morais da recepção de testemunhos de profissionais de saúde. Discutimos ainda como o uso de plataformas digitais pode servir como recurso para a produção de memória. Por último, descrevemos a construção de um espaço de escrita, memória, cuidado e diálogo através de intervenções artísticas em ferramentas digitais, afirmando a aposta no poder que o compartilhamento de histórias pode exercer sobre as angústias e sofrimentos emocionais dos trabalhadores de saúde.

This article presents the theoretical and practical path involving the creation of the Pausas e Pousos (Pauses and Landings) Project - Health Worker Experiences in Times of the Pandemic. The initiative aims to take a closer look at the experiences of health workers in the Brazilian scenario of the COVID-19 pandemic. Narrative knowledge and testimony are presented as special modalities of narrative production, analyzing the moral modalities of receiving the health professionals' testimonies. The use of digital platforms as a resource for the production of memories was also discussed. Last, we describe the creation of a space for writing, memories, care and dialogue through artistic interventions using digital tools and highlight the power that sharing stories may have on coping with fear and emotional distress of health workers.

Cet article décrit le cheminement théorique et pratique qui a impliqué la création du projet Pauses et Poses - Expériences de travailleurs de la santé en temps de pandémie. L'initiative vise à connaître les expériences des travailleurs de la santé pendant la pandémie de COVID-19 au Brésil. Nous présentons le mode de connaissance narrative et de témoignage comme un mode particulier de production narrative en examinant les modalités morales de réception des témoignages de professionnels de santé. Ensuite, nous décrivons comment l'utilisation des plateformes digitales peut servir de ressource pour la production de mémoire. Pour finir, nous présentons la construction d'un espace d'écriture, de mémoire, de soins et de dialogue à partir d'interventions artistiques sur les outils numériques, affirmant le pari sur le pouvoir que le partage d'histoires peut exercer sur l'angoisse et la souffrance émotionnelle des travailleurs de la santé.

En este artículo presentamos el camino teórico y práctico de la creación del Proyecto Pausas y Aterrizajes - Experiencias del Trabajador de la Salud en Tiempos de Pandemia. La iniciativa tiene como objetivo conocer las experiencias de los trabajadores de la salud durante la pandemia de COVID-19, en el escenario brasileño. Presentamos el modo de conocimiento narrativo y el testimonio como modalidad particular de producción narrativa, examinando modalidades morales de la recepción de testimonios de los profesionales de la salud. También discutimos cómo el uso de plataformas digitales puede servir como recurso para la producción de memoria. Finalmente, describimos la construcción de un espacio de escritura, memoria, cuidado y diálogo mediante intervenciones artísticas en herramientas digitales, reafirmando el poder que el intercambio de historias puede ejercer sobre la angustia y el sufrimiento emocional de los trabajadores de la salud.

Além da compulsão e da escolha: autonomia, temporalidade e recuperação pessoal / Beyond compulsion and choice: autonomy, temporality and personal recovery / Au-delà de la contrainte et du choix: autonomie, temporalité et rétablissement personnel / Mas allá de la compulsión y la elección: autonomía, temporalidad y recuperación

Este artigo discute a autonomia da pessoa que faz uso problemático de substâncias psicoativas (UPSP). Após o exame da ideia de autonomia de quem faz UPSP, a partir dos paradigmas médico, psicológico e moral, que oscilam entre as compreensões do uso como compulsão ou escolha, discute-se os aspectos psicopatológicos envolvidos no UPSP, em especial a experiência da temporalidade e suas implicações para o debate da autonomia dessas pessoas e para o seu processo de recuperação pessoal.

This paper discusses the autonomy of subjects engaged in substance misuse (SM). After examining the concept of autonomy of subjects engaged in SM, based on medical, psychological and moral paradigms that range between understanding SM either as a compulsion or a choice, we discuss the psychopathological aspects involved in SM, i.e., the experience of temporality and its implications regarding the autonomy of these subjects and their recovery process.

Cet article discute l'autonomie de personnes sujettes à l'utilisation problématique de substances psychoactives (UPSP). Après avoir élaboré la notion d'autonomie de ces sujets à partir de paradigmes médicaux, psychologiques et moraux qui comprennent l'UPSP soit comme une contrainte, soit comme un choix, on discute les aspects psychopathologiques liés à l'UPSP, en particulier l'expérience de la temporalité et ses implications pour le débat sur l'autonomie de ces personnes et leur processus de rétablissement.

Este artículo discute la autonomía de la persona que sufre con el consumo problemático de sustancias psicoactivas (CPSP). Después examinar la idea de autonomía en quien tiene un CPSP, a partir de los paradigmas médico, psicológico y moral, que oscilan entre las comprensiones del uso como compulsión o elección, se discuten los aspectos psicopatológicos involucrados en el CPSP, en especial en la experiencia de la temporalidad, y sus implicaciones para el debate de la autonomía de esas personas y para su proceso de recuperación personal.

Dieser Artikel ergründet die Autonomie von Personen, die einen problematischen Gebrauch von psychoaktiven Stoffen machen. Wir analysieren den Begriff der Autonomie dieser Subjekte basierend auf medizinischen, psychologischen und moralischen Paradigmen, die den Drogenkonsum entweder als Zwang oder Wahl verstehen. Nachfolgend diskutieren wir dann die psychopathologischen Aspekte des Drogenkonsums, vornehmlich die Erfahrung der Temporalität und ihren Einfluss auf die Debatte über die Autonomie dieser Subjekte während ihres Rehabilitationsprozesses.

Saúde da população LGBT+ no contexto da atenção primária em saúde: relato de oficina realizada no internato integrado de Medicina de Família e Comunidade/Saúde Mental em uma universidade pública / LGBT+ Health on Primary Care: the experience report of a workshop during the medical internship on Family Medicine and Mental Health in a public university / Salud de la población LGBT + en el contexto de la atención primaria en salud: relato de taller realizado en el internado integrado de Medicina de Familia y Comunidad/Salud Mental en una universidad pública

Introdução: A saúde da população LGBT+ apresenta particularidades e vulnerabilidades que requerem atenção diferenciada. Sensibilizar e qualificar profissionais de saúde para as necessidades dessa população é fundamental para garanti-la o direito à saúde. Os currículos das graduações em saúde, que em geral não incorporam tais questões, têm sido interrogados pelo alunado com denúncias de LGBTfobia no curso médico e reivindicação de capacitação prática. Nesse contexto, o Internato Integrado de Medicina de Família e Comunidade e Saúde Mental da Faculdade de Medicina da Universidade Federal do Rio de Janeiro organizou oficina sobre Saúde da População LGBT, apresentada neste artigo. Métodos: Realizada em maio de 2018, teve como público alvo internos em estágio curricular na Atenção Primária em Saúde (APS), no município do Rio de Janeiro. Sensibilizar para o tema e apresentar ferramentas úteis para o cuidado na APS, e em outros cenários, foram os objetivos. Graduandos de medicina autodeclarados LGBT+ foram convidados a assumir a condução da atividade, preparada sob orientação de professoras do internato. O protagonismo dado a esses alunos permitiu articular à expertise científica, promovida nos estudos regulares sobre o tema, a expertise experiencial. A oficina ocorreu em 4 tempos: i) sensibilização; ii) discussão de casos; iii) informação e exposição de orientações para boas práticas em saúde; iv) dúvidas e avaliação. A duração total foi de 4 horas, com metodologias ativas e participativas. Resultados: Os objetivos foram alcançados e a atividade bem avaliada em sua organização e execução. Avaliação narrativa foi realizada com alunos e professores organizadores. Os internos participantes responderam questionário online com perguntas abertas e fechadas e também avaliaram positivamente a atividade nos quesitos metodologia e conteúdo. Conclusão/Desdobramentos: A oficina foi incluída nas atividades regulares do internato. Estão em construção, com vistas a difundir esses conhecimentos a outros estudantes do curso médico e a profissionais da rede de saúde municipal, disciplina eletiva e projeto de extensão. A inclusão longitudinal do tema no currículo permanece como desafio.

Introduction: The LGBT+ healthcare is marked with particularities and vulnerabilities that require differenced attention. Sensitizing and qualifying healthcare professionals to these population's needs is fundamental to guarantee the right to health. The curriculum from health degrees, that usually does not address this issue, have been questioned by students along with LGBTphobia reports among the medical education and revindication for practical capacitation. In this context, the Integrated Family & Community Medicine (MFC) and Mental Health Internship at Faculty of Medicine of the Federal University of Rio de Janeiro, prepared a workshop on LGBT Health, presented in this article. Methods: A workshop took place in May of 2018, having a target audience of interns of MFC. It aimed to sensitize medical students regarding the referred theme and to give practical tools to be used in primary medicine and other healthcare environments. Medical undergrads who identify themselves as LGBT+ were invited to conduct the activity under the orientation of tutors from the internship. Given that those medical students were protagonists in this activity, it was possible to articulate the scientific knowledge, accomplished with regular studies on the theme, and the experiential expertise. The workshop was divided in four acts: i) sensitization; ii) case discussion; iii) information and orientations on good practice; iv) questions and feedback. The workshop lasted 4 hours, using active and participatory learning methods. Results: The objectives were achieved with a highly good evaluation as to the workshop's organization and performance. The students and professors that coordinated the activity prepared a narrative evaluation. The workshop's subjects, the MFC interns, took later an online feedback questionnaire, in which they positively evaluated the methods and acquired knowledge. Conclusion/Future works: The workshop, firstly implemented as an experimental activity, is now part of the regular medical internship curriculum. An optative course and an extension project are being planned, aiming to reach other medical students and public healthcare providers. Including the subject in the medical curriculum as a longitudinal discussion remains a challenge.

Introducción: La atención médica LGBT + está señalada con particularidades y vulnerabilidades que requieren una atención diferenciada. Sensibilizar y calificar a los profesionales de la salud de las necesidades de esta población es fundamental para garantizar su derecho a la salud. El plan de estudios de las carreras de salud, que en general no abordan este tema, ha sido cuestionado por los estudiantes junto con los informes de LGBTphobia entre la educación médica y la reivindicación de la capacitación práctica. En este contexto, la Pasantía Integrada de la Medicina de la Família y la Comunidad y Salud Mental de la graduación en medicina de la Universidad Federal de Rio de Janeiro elaboró un taller sobre salud LGBT+, presentado en este artículo. Métodos: Realizado en mayo de 2018 con los internos en pasantía curricular en la APS como el público-objetivo. Los objetivos eran sensibilizar a los estudiantes de medicina sobre el tema presentado y ofrecer herramientas prácticas para que las utilicen en la medicina primaria y en otros entornos de atención médica. Se invitó a los estudiantes de medicina que se identifican a sí mismos como LGBT+, para realizar la actividad bajo la orientación de tutores de la pasantía. Como los estudiantes de medicina fueron los protagonistas de esta actividad, fue posible articular el conocimiento científico, realizado con estudios regulares sobre el tema y la vivencia experiencial. El taller se dividió en cuatro partes: i) sensibilización; ii) discusión del caso; iii) información y orientaciones sobre buenas prácticas; iv) preguntas y comentarios. El taller tuvo una duración de cuatro horas, utilizando métodos de aprendizaje activo y participativo. Resultados: Los objetivos se lograron con una evaluación muy buena de la organización y el desempeño del taller. Los estudiantes y profesores que coordinaron la actividad realizaron una evaluación narrativa. Los pasantes presentes contestaron a un cuestionario en línea con preguntas objetivas y abiertas y evaluaron positivamente la actividad tanto por su metodología como por el contenido. Conclusión/Desarrollo: El taller, implementado como una actividad experimental, ahora forma parte del plan de estudios de prácticas médicas regulares. Se está planificando un curso optativo y un proyecto de extensión, con el objetivo de llevar eses conocimientos a otros estudiantes de medicina y proveedores de la salud pública. Incluir el tema en los planes de estudios médicos como una discusión longitudinal sigue siendo un desafío.

[Access to first-person experience in research into mental health]. / Acesso à experiência em primeira pessoa na pesquisa em Saúde Mental.

This article presents and discusses the epistemological and methodological challenges related to the empirical study of first-person experience in mental health research. Considering the field of qualitative research, the methodological principles of phenomenology and medical anthropology are examined from a historical and conceptual perspective. The main operational concepts of the phenomenological method applied to empirical research, as well as their two main lines of approach, namely descriptive and psychological/transcendental phenomenology and hermeneutical or interpretative phenomenology, are described. The contributions of medical anthropology are studied especially with respect to the experience of illness and its forms of narrative. Lastly, considering the distinction between experience and narrative based on the theoretical benchmarks of phenomenology and medical anthropology, a more in-depth debate on access to first-person experience is conducted.

Key drug use, health and socio-economic characteristics of young crack users in two Brazilian cities.

BACKGROUND: Crack use constitutes a major problem in cities across Brazil. While existing data suggest that crack use is generally concentrated among disenfranchised young people with extensive health problems and crime involvement, extensive data gaps exist. To address this issue, this study aimed to assess key characteristics of young crack users in two Brazilian cities. METHODS: N=160 regular and young adult (ages 18-24) crack users were recruited by community-based methods in the cities of Rio de Janeiro (Southeast) and Salvador (Northeast). Assessments included an interviewer-administered questionnaire on key social, drug use, health and service use characteristics, as well as serological testing of HBV, HCV and HIV status, and were conducted anonymously between November 2010 and June 2011. Participants provided informed consent and received transportation vouchers following assessment completion. The study was approved by institutional ethics review boards. RESULTS: The majority of participants were: male, with less than high school education, unstably housed (Rio only); gained income from legal or illegal work; arrested by police in past year (Salvador only); had numerous daily crack use episodes and shared paraphernalia (Salvador only); co-used alcohol, tobacco, cannabis and cocaine; had no injection history; rated physical and mental health as 'fair' or lower (Salvador only); had unprotected sex; were never HIV tested; were not HIV, HBV or HCV positive; and did not use existing social or health services, but desired access to crack user specific services. CONCLUSION: Crack users in the two Brazilian sites featured extensive socio-economic marginalization, crack and poly-drug use as well as sexual risk behaviours, and compromised health status. Social and health service utilization are low, yet needs are high. There is an urgent need for further research and for targeted interventions for crack use in Brazil.

[Narratives in the study of mental health care practices: contributions of the perspectives of Paul Ricoeur, Walter Benjamin and of medical anthropology]. / Narrativas no estudo das práticas em saúde mental: contribuições das perspectivas de Paul Ricoeur, Walter Benjamim e da antropologia médica.

Narratives are ever more frequent in qualitative studies seeking to interpret experiences and the different viewpoints of individuals in a given context. Starting from this concept, the tradition that addresses narrative is reexamined, including the philosophy of Paul Ricoeur, the historical perspective of Walter Benjamin and the field of medical anthropology grounded in phenomenology. In Ricoeur, with hermeneutics as a variation derived from phenomenology, narrative is linked to temporality. In Benjamin, narrative comprised of bits and pieces, always inconclusive, emerges in spite of the official stories. If Ricoeur retrieves tradition from Gadamer as a fundamental component for the construction of the world of a text that makes imitation of life possible, Benjamin, faced with the collapse of tradition, suggests the invention of narrative forms outside the traditional canons, making it possible to hark to the past in order to change the present. Assumptions of medical anthropology are also presented, as they consider narrative a dimension of life and not its abstraction, namely an embodied and situated narrative. Lastly, three distinct research projects in mental health that use narrative linked to the theoretical concepts cited with their differences and similarities are presented.

Methodological challenges in the use of focus groups with people with severe mental illness / Desafios metodológicos para o uso de grupos focais com pessoas com doença mental grave / Desafíos metodológicos para el uso de grupos focales con personas que sufren enfermedades mentales graves

Abstract: This study addresses the practical, methodological and ethical challenges that were found in three studies that used focus groups with people with severe mental illness, in the context of community mental health services in Brazil. Focus groups are a powerful tool in health research that need to be better discussed in research with people with severe mental illness, in the context of community mental health facilities. This study is based on the authors' experience of conducting and analyzing focus groups in three different cities - Campinas, Rio de Janeiro and Salvador - between 2006-2010. The implementation of focus groups with people with severe mental illness is discussed in the following categories; planning, group design, sampling, recruitment, group interview guides, and conduction. The importance of connecting mental healthcare providers as part of the research context is emphasized. Ethical issues and challenges are highlighted, as well as the establishment of a sensitive and empathic group atmosphere, wherein mutual respect can facilitate interpersonal relations and enable people diagnosed with severe mental illness to make sense of the experience. We emphasize the relevance of the interaction between clinical and research teams in order to create collaborative work, achieve inquiry aims, and elicit narratives of mental health users and professionals.

Resumo: O artigo trata dos desafios práticos, metodológicos e éticos identificados em três estudos que utilizaram grupos focais com pessoas com doença mental grave, no contexto dos serviços comunitários de saúde mental no Brasil. Os grupos focais são uma ferramenta poderosa para a pesquisa em saúde que merece uma discussão ampliada nos estudos com portadores de doença mental grave, no contexto dos serviços comunitários de saúde mental. O estudo tem como base as experiências dos autores na realização e análise de grupos focais em três cidades - Campinas, Rio de Janeiro e Salvador - entre 2006 e 2010. Discute-se o uso de grupos focais com pessoas com doença mental grave, de acordo com as seguintes categorias: planejamento, formato do grupo, amostragem, recrutamento, roteiro de entrevista em grupo e condução. O artigo destaca a importância de envolver os profissionais de saúde mental no contexto da pesquisa. Os achados enfatizam as questões e os desafios éticos, além da criação de um ambiente sensível e de empatia dentro do grupo, onde o respeito mútuo facilite as relações interpessoais e permita que as pessoas com diagnóstico de doença mental grave possam construir sentidos para a sua experiência. Os autores destacam a relevância da interação entre as equipes clínicas e de pesquisa para fomentar a colaboração, alcançar as metas da pesquisa e evocar as narrativas dos usuários e profissionais de saúde mental.

Resumen: El artículo trata sobre los desafíos prácticos, metodológicos y éticos, identificados en tres estudios que utilizaron grupos focales con personas con una enfermedad mental grave, en el contexto de los servicios comunitarios de salud mental en Brasil. Los grupos focales son una herramienta poderosa para la investigación en salud, que merece una discusión ampliada en los estudios sobre pacientes con enfermedades mentales graves, en el contexto de los servicios comunitarios de salud mental. El estudio tiene como base las experiencias de los autores en la realización y análisis de grupos focales en tres ciudades -Campinas, Río de Janeiro y Salvador- entre 2006 y 2010. Se discute el uso de grupos focales con personas con una enfermedad mental grave, de acuerdo con las siguientes categorías: planeamiento, formato del grupo, muestra, reclutamiento, guía de entrevista en grupo y ejecución. El artículo destaca la importancia de involucrar a los profesionales de salud mental en el contexto de la investigación. Los hallazgos enfatizan cuestiones y desafíos éticos, además de la creación de un ambiente sensible y de empatía dentro del grupo, donde el respeto mutuo facilite las relaciones interpersonales y permita que las personas con un diagnóstico de enfermedad mental grave puedan dar sentido a la experiencia. Los autores destacan la relevancia de la interacción entre los equipos clínicos y de investigación para fomentar la colaboración, alcanzar las metas de la investigación y evocar las narrativas de los usuarios y profesionales de salud mental.