RESUMO
Tuberculosis (TB) and depression is common and is associated with poor TB outcomes. The World Health Organization End TB Strategy explicitly calls for the integration of TB and mental health services. Interpersonal Counseling (IPC) is a brief evidence-based treatment for depression that can be delivered by non-mental health specialists with expert supervision. The goal of this study was to explore potential barriers and facilitators to training non-specialist providers to deliver IPC within the TB Control Program and primary care in Itaboraí, Rio de Janeiro state. Data collection consisted of six focus groups (n = 42) with health professionals (n = 29), program coordinators (n = 7), and persons with TB (n = 6). We used open coding to analyze the data, followed by deductive coding using the Chaudoir multi-level framework for implementation outcomes. The main structural barriers identified were poverty, limited access to treatment, political instability, violence, and social stigma. Organizational barriers included an overburdened and under-resourced health system with high staff turnover. Despite high levels of stress and burnout among health professionals, several provider-level facilitators emerged including a high receptivity to, and demand for, mental health training; strong community relationships through the community health workers; and overall acceptance of IPC delivered by any type of health provider. Patients were also receptive to IPC being delivered by any type of professional. No intervention-specific barriers or facilitators were identified. Despite many challenges, integrating depression treatment into primary care in Itaboraí using IPC was perceived as acceptable, feasible, and desirable.
RESUMO
Mental disorders can affect up to 70% of individuals with tuberculosis (TB). The World Health Organization (WHO) End TB Strategy explicitly calls for TB and mental health service integration. The goal of this study was to explore the barriers and facilitators to integrating depression treatment in the TB Control Program and primary care system in the municipality of Itaboraí - Rio de Janeiro, using Interpersonal Counseling (IPC). IPC is an evidence-based treatment for depression that can be delivered by non-mental health specialists with expert supervision. This study was conducted between 2016 and 2017 in the municipality of Itaboraí. Data collection consisted of six focus groups (n = 42) with health professionals (n = 29), program coordinators (n = 7) and TB patients (n = 6). The main potential barriers identified were poverty, political instability, an overburdened and under-resourced health system, high levels of distress among professionals, violence in the community and stigma related to mental health and TB. Potential facilitators included a high receptivity to, and demand for, mental health training; strong community relationships through the Community Health Workers (CHW); overall acceptability of IPC delivered by non-specialists for the treatment of depression among individuals with and without comorbid TB. Despite many challenges, integrating depression treatment into primary care in Itaboraí using IPC was perceived as an acceptable and feasible option.
Os transtornos mentais podem afetar até 70% dos indivíduos com tuberculose (TB). A Organização Mundial da Saúde (OMS), como estratégia para o fim da TB, exige a integração do seu tratamento com a saúde mental. O objetivo deste estudo foi explorar as barreiras e facilitadores para integrar serviços de saúde mental no Programa de Controle de Tuberculose (PCT) e em Unidades de Saúde da Família (USF) do município de Itaboraí Rio de Janeiro, com a aplicação do Aconselhamento Interpessoal (AIP). O AIP é um tratamento para depressão baseado em evidências que pode ser aplicado por não especialistas em saúde mental com supervisão especializada. Seis grupos focais foram realizados entre 2016 e 2017 no município de Itaboraí. A amostra (n=42) incluiu profissionais de saúde (n=29), coordenadores de programas (n=7) e pacientes com TB (n=6). Os grandes desafios encontrados foram: pobreza, instabilidade política, um sistema de saúde sobrecarregado e com poucos recursos, alta frequência de estresse entre os profissionais, violência na comunidade e estigma relacionado à saúde mental e à TB. Os facilitadores potenciais incluíram uma grande receptividade e demanda para capacitações em saúde mental; boa relação com a comunidade pelos Agentes Comunitários de Saúde (ACS) e; aceitação geral do AIP aplicado por não especialistas em saúde mental para o tratamento de depressão em pessoas com e sem TB. Apesar de muitos desafios, integrar o tratamento de depressão na atenção primária de Itaboraí aplicando o AIP foi percebido como uma alternativa aceitável e factível.
