Factors Associated with Provision of Patient-Centered Mental Health Care in Brazil's Unified Health System

Background and Purpose: Brazil has a unique mental health care system, characterized by universal coverage provided by interdisciplinary teams, comprised of physicians, nurses and community health workers (CHWs). Care is delivered both in the community and in specialized psychosocial care centers. Provision of patient-centered mental health care is a priority for Brazil’s Unified Health System’s Family Health Strategy, a nationwide policy affecting low-income populations at-risk for mental issues. Yet, little research has been conducted on interdisciplinary teams’ mental health care provision. Our study addresses this gap by specifically examining how socio-demographics, caseload, trandisciplinary collaboration and engagement in evidence-based practice might be related to interdisciplinary team members’ patient-centered mental health care provision. Based on trends in other settings, we hypothesized that transdisciplinary collaboration would be associated with mental health care provision.

Methods: We analyzed data from a cross-sectional survey of 92 CHWs, 39 nurses, and 20 physicians (N=151) in Santa Luzia, Minas Gerais State, Brazil. We used Chi-squares and t-tests, followed by multivariate regression analyses, to examine differences in socio-demographics, caseload, engagement in evidence-based practices (EBPs), and transdisciplinary collaboration between providers who reported providing high levels of patient-centered mental health care and those who did not.

Patient-centered mental health care provision was measured by a composite of three items- how often providers listened to what patients think about their mental health disorder, their treatment, and the origin of their disorder. Transdisciplinary collaboration was measured by items on team participation, on engaging other treatment sectors in treatment planning, and on whether participants felt their opinions were considered by other team members. EBP engagement was measured by items on use of research, standardized protocols, and multiple information source integration.

Results: One hundred participants were categorized as providing patient-centered mental health care and 51 as not. Participants providing patient-centered care were more likely to be CHWs (69%) than nurses (20%) or physicians (11%; χ²(1)=8.19, p<.05). Those providing patient-centered care also had lower caseloads (697 vs. 1091, χ²(1)=8.19, p<.05). Regarding transdisciplinary collaboration, team meeting participation was not associated with care provision, but engaging other sectors in treatment planning (M=2.97 vs. 2.51; t=-2.31) and feeling opinions were considered by team members were (M=3.58 vs. 3.22; t=-3.07; both p<.05). EBP engagement and sociodemographics were not associated with patient-centered mental health care provision. In multivariate regressions, CHWs remained significantly more likely to provide patient-centered care, and the same components of transdisciplinary collaboration were associated with care provision (p<.05). Caseload was no longer significant, likely because of collinearity between provider role and caseload.

Conclusions and Implications: This study provides needed data on factors that might influence the provision of patient-centered mental health care in Brazil’s unified system. Findings may inform practice in other countries with similar health care systems. Results suggest that training efforts to improve patient-centered mental health care in Brazil ought to draw upon CHWs’ unique skills and focus on transdisciplinary collaboration. There is potential for Brazil’s approach to improve the efficiency, cost, and quality of mental health care, helping reduce the burden of mental illness.