Psicologia, saúde e território: experiências na Atenção Básica / Psicología, salud y territorio: experiencias de atención básica en salud / Psychology, health and territory: Primary health care experiences

RESUMO. A saúde mental é um nó-crítico para a gestão da Atenção Básica, convocada diariamente a acolher o sofrimento psíquico individual e coletivo contando com equipes mínimas. Pouco antes da VIII Conferência Nacional de Saúde, que estabeleceria bases para um novo sistema brasileiro de saúde, estruturava-se na periferia da cidade de Porto Alegre-RS um serviço de saúde comunitária antecipatório à Estratégia Saúde da Família, em que algumas equipes já contavam com psicólogos. Este artigo procura refletir acerca do atual lugar do psicólogo no nível primário de atenção, discutindo a experiência de mais de duas décadas de trabalho da psicologia como integrante de unidades de saúde daquele Serviço. Finalmente, discute o potencial da inserção da psicologia no nível primário ao considerar a complexidade de uma prática que envolve atenção, gestão, formação e participação, no processo de trabalho em equipe multiprofissional.

RESUMEN La salud mental es un crítico-nodo para la gestión de la atención primaria de salud, convocado al día para recibir a la angustia psicológica individual y colectiva y contando con equipos mínimos. Justo antes de la Conferencia Nacional de Salud VIII, que establecería bases de un nuevo sistema de salud brasileño, un servicio de salud comunitario fue estructurado en las afueras de Porto Alegre-RS de anticipación a la Estrategia Salud de la Familia, en el que algunos equipos ya contaban con psicólogos. En este artículo se pretende reflexionar acerca del lugar del psicólogo en el ámbito de la atención primaria, basado en la experiencia de más de dos décadas de trabajo de la psicología como parte de los centros de salud de ese Servicio. Por último, se analiza el potencial de la inserción de la psicología en el nivel primario a considerar la complejidad de una práctica que implica la atención, gestión, formación y participación en el proceso de trabajar en equipos multiprofesionales.

ABSTRACT. Mental health is a critical node for the management of Primary Health Care, convened daily to welcome the individual and collective psychological distress and counting on minimum teams. Shortly before the VIII National Health Conference, which would establish foundations for a new Brazilian health system, a community health service was structured on the periphery of Porto Alegre-RS anticipatory to the Family Health Strategy, in which some teams already counted on psychologists at that time. This article seeks to reflect on the psychologist's current place in the primary care level, based on more than two decades of experience work in psychology as part of the health care facilities of that service. Finally, it discusses the potential of the psychology's insertion at the primary level when considering the complexity of a practice that involves attention, management, training and participation in the process of working in multi-professional teams.

The psychosocial impact of vitiligo in Indian patients.

BACKGROUND: Vitiligo has a special significance in Indian patients both because depigmentation is obvious on darker skin and the enormous stigma associated with the disease in the culture. AIMS: This study was carried out to determine the beliefs about causation, aspects of the disease that cause concern, medical, and psychosocial needs of the patients, expectation from treatment and from the treating physician, and effects of disease on the patient's life. METHODS: Semi-structured interviews were conducted in 50 patients with vitiligo. Purposive sampling was used to select subjects for the study. Each interview was recorded on an audio-cassette and transcripts were analyzed to identify significant issues and concerns. RESULTS: Patients had a range of concerns regarding their disease such as physical appearance, progression of white patches onto exposed skin and the whole body, ostracism, social restriction, dietary restrictions, difficulty in getting jobs, and they considered it to be a significant barrier to getting married. The condition was perceived to be a serious illness. Stigma and suicidal ideation was reported. While there were several misconceptions about the cause of vitiligo, most patients did not think their disease was contagious, heritable or related to leprosy. Multiple medical consultations were frequent. Complete repigmentation was strongly desired, but a lesser degree of repigmentation was acceptable if progression of disease could be arrested. The problems were perceived to be more severe in women. The disease imposed a significant financial burden. CONCLUSION: Addressing psychosocial factors is an important aspect of the management of vitiligo, particularly in patients from communities where the disease is greatly stigmatizing.

Vitiligo impact scale: an instrument to assess the psychosocial burden of vitiligo.

BACKGROUND: Vitiligo is a disease that significantly impairs quality of life. Previous studies have shown that vitiligo has an impact that may not correlate with the size and extent of depigmentation, indicating a need for an independent measure of the psychosocial burden. AIMS: To develop a rating scale to assess the psychosocial impact of vitiligo. METHODS: The study was undertaken in three broad phases: item generation, pre- and pilot testing, and test administration. Items were generated largely from a qualitative study using semi-structured interviews of patients. Face and content validity were assessed through pre- and pilot testing in 80 patients and the final version was administered to 100 patients who also received the Dermatology Life Quality Index (DLQI) and the Skindex-16. Each patient also underwent a physician global assessment (PGA) of the impact of vitiligo. Test-retest reliability was assessed in 20 patients. RESULTS: Of 72 items initially generated for the scale, 27 were retained in the final version. Subjects were able to comprehend the items and took about 5-7 min to complete the instrument. The scale was internally consistent (Cronbach's α = 0.85). Scores on the scale correlated moderately well with the DLQI and the Skindex (Spearman rank correlation: 0.51 and 0.65, respectively). The scale was able to discriminate between patients having mild and those having moderate and severe impact as assessed by PGA. The test-retest reliability coefficient (Spearman rank correlation) was 0.80. CONCLUSION: The Vitiligo Impact Scale appears to be a valid measure of the psychosocial impact of vitiligo and this instrument may be useful both in the clinic and in clinical trials.

O mundo da vida do ser hanseniano: sentimentos e vivencias / ?

A proposta deste estudo foi a de compreender, por meio de uma abordagem fenomenologica, os sentimentos e vivencias de hansenianos com relacao a sua doenca. A investigacao teve o objetivo de evidenciar o significado da hanseniase na vida dos pacientes, as repercussoes da doenca sobre as relacoes intra e interpessoais, a elaboracao de projetos de vida, as implicacoes em seu trabalho, as percepcoes das distintas fases do tratamento e os sentimentos implicados neste processo. Este estudo se realizou no periodo de dezembro de 1998 a dezembro de 1999, na cidade de Porto Alegre - RS. Os "locus" deste estudo foi a Ambulatorio de Dermatologia Sanitaria, da Secretaria de Saude e o Meio Ambiente do Estado do Rio Grande do Sul. Participaram desta pesquisa onze doentes

Leprosy: between acceptance and segregation. Community behaviour towards persons affected by leprosy in eastern Nepal.

This study describes community behaviour towards persons affected by leprosy in the eastern Terai districts of Nepal. The results show that 95% of the persons affected by leprosy recognized by the community have visible signs such as wounds, swellings and deformed feet or hands. Persons affected by leprosy still experience negative behaviour. Motives for negative community behaviour are mostly found in the fact that people fear infection by germs, but fear of a curse from God is also mentioned. This study shows that negative community behaviour is still present in eastern Nepal. Leprosy is more than a disease; the disease can nowadays be medically cured, but the sickness of leprosy still remains. Leprosy control programmes should focus on prevention of impairments and disabilities, because it seems that a visible sign is an important trigger for negative community behaviour.

Consciência do eu e transtornos mentais em hanseniano asilados há mais de dez anos / ?

A consciência do eu e a ocorrência de transtornos mentais foi avaliada em hansenianos internados no asilo de Curupaiti, localizado no Rio de Janeiro. O objetivo principal da investigação foi elucidar a psicopatologia dessa afecção somática crônica que, quando não tratada adequadamente, implica a perda da integridade física e psíquica, além de prejuízos à inserção social dos acometidos. Submetemos a avaliação qualitativa e quantitativa 30 casos tratados previamente ou em tratamento, acometidos ou não por mutilações e vivendo asilados há, pelo menos 10 anos. Investigamos aspectos referentes ao esquema cognitivo do eu, à metaidentidade, à identidade no tempo e à representação da doença. Aplicamos, também, os instrumentos diagnósticos: Structured Clinical Interview for DSM-IV (transtornos do eixo) e Structures Clinical Interview for DSM-III-R (transtornos do eixo II) e as escalas de Hamilton, para ansiedade e depressão, nessa amostra. Categorias discursivas repetidas nos discursos dos casos e resultados diagnósticos compuseram um inventário aplicado ao grupo controle. Esse grupo incluiu 20 membros da comunidade, não acometidos pela hanseníase, mas vivendo em Curupaiti por um tempo mínimo de 10 anos. No grupo de casos, o fator mais importante relacionado à conciência do eu foi a preocupação envolvendo a perda da integridade corporal, tanto nos aspectos estéticos quanto funcionais. A conciência ligada a atributos negativos do eu, nesse grupo, envolveu fatores morais, sociais e estéticos relacionados à vivência de adoecimento e asilamento. A prevalência de transtornos mentais é alta na amostra estudada. As principais ocorrências foram: distimia (30 por cento), transtorno do uso de substância - álcool - 20 por cento, transtorno dissociativo (10 por cento), fobia a altura (10 por cento) e quadro histriônicos. As preocupações envolvendo o estigma vinculado à doença e suas repercussões foram relevantes no grupo controle. O estudo propõe que se destine maior atenção à eleboração do esquema corporal e da conciência do eu para compreensão da psicopatologia sofrida por esses hansenianos. Recomenda, também, que se procurem entender melhor os fatores históricos, culturais e morais vinculados ao estigma da lepra e do asilamento, para que os programas de prevenção, tratamento e reabilitação psicossocial tenham êxito e incluam uma ampla abordagem informativa e motivadora aplicada a pacientes, à sociedade e aos profissionais de saúde.

Social marketing to eliminate leprosy in Sri Lanka.

PIP: Leprosy is a chronic infectious disease which, if untreated, can lead to permanent and progressive nerve damage and thus to deformities of the limbs, eyes, and face. People with leprosy have long been ostracized by society. The clinical signs of leprosy include insensitive skin lesions and thickened peripheral nerves. Untreated infectious leprosy cases are the main source of infection, transmitting the disease through nasal secretions. People with low cell-mediated immunity are at risk of developing clinically active leprosy irrespective of gender, age, or social class. The World Health Organization (WHO) has, since 1982, recommended multiple drug therapy (MDT) against leprosy, an approach capable of curing the disease within 1 year and interrupting its transmission. According to WHO, leprosy is currently a public health problem in 55 countries and more than 20% of the estimated 1.15 million cases of leprosy worldwide remain undetected. Although Sri Lanka was the first country in South Asia to provide MDT to all registered leprosy patients, first making it available in 1984, the disease continues to be transmitted due to the large number of undetected cases in the country. An ongoing social marketing program was therefore launched in 1990 by the local health ministry and the Novartis Foundation for Sustainable Development to eliminate leprosy from Sri Lanka. The program encourages people with suspicious skin lesions to seek diagnosis and care, teaches health care providers to recognize leprosy and refer cases for treatment, and helps the general public to understand that leprosy is just a normal disease. The socially marketed product is MDT, provided free-of-charge by the Novartis Foundation to all leprosy patients.^ieng