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Mental Health Indicators and Coverage of the Psychosocial Care Network for Indigenous Populations in the state of Ceará

Abstract

This study aimed to analyze the coverage of the Psychosocial Care Network (RAPS) and mental health indicators in municipalities in the state of Ceará with and without indigenous populations. Different public databases on the mental health situation and services offered by the Unified Health System (SUS) were used. Descriptive analyses and the Mann-Whitney and Kruskal-Wallis non-parametric tests were carried out. The coverage of Primary Care and some of the Psychosocial Care Network equipment is more present in municipalities with indigenous settlements. This backup of services does not prevent the aggravating prevalence of mental health indicators (deaths from suicide, suicide by self-inflicted violence, suicide by exogenous intoxication) in municipalities with indigenous populations. In dialogue with indigenous authors, violence, discrimination, and erasure based on colonization still impact the mental health of indigenous people, as seen in the health outcome indicators found. Health services still need to advance in coverage and action to focus on this alarming reality of mental health indicators for indigenous populations.

Keywords: Mental Health in Ethnic Groups; Health of Indigenous Populations; Health Services; Health Service Coverage.

Introduction

This article discusses the coverage of the Psychosocial Care Network (RAPS) and mental health indicators in municipalities in the state of Ceará with and without indigenous populations, resulting from quantitative studies using several sources of secondary research data, including a study by the Management Program for the Unified Health System (PPSUS in portuguese) funded by the Ministry of Health, the National Council for Scientific and Technological Development, and a state research funding agency. The research consisted of two integrated and complementary studies, evaluating mental health indicators and the coverage of the Psychosocial Care Network. There is an innovation in integrating several databases focusing on two major dimensions: health services and indicators . On the other hand, there is difficulty in integrating the indicators with the services of the Psychosocial Care Network . Information about the mental health situation, as well as coverage and access to care by indigenous communities, is available in different sources and public databases but is largely fragmented and unknown by he scientific community . Thus, this article is innovative by carrying out an integrated analysis of the coverage of the Psychosocial Care Network and the Psychosocial Indicators of all municipalities in a state in Northeastern Brazil, comparing them with indigenous populations in settlements, non-settled, and without indigenous populations. The objective was to analyze the coverage of the Psychosocial Care Network (RAPS) and the mental health indicators in municipalities in the state of Ceará with and without the presence of indigenous populations. In this way, the article contributes to elucidating and reflecting two issues poorly discussed within the scope of the indigenous problems: mental health in public health services and the (re)existence of indigenous peoples in Northeastern Brazil.
The guiding framework for formulations and implementations of the Unified Health System (SUS), as well as the National Policy for Healthcare of Indigenous Peoples (PNASPI), is the struggle for the redemocratization of the Brazilian State, with the 1988 Constitution representing this paradigm shift . Their main banner was the defense of a notion of health that went beyond an exclusively biological issue - as it had been treated until then and was resolved solely through medical services. In this way, they understood health as a social and political issue to be addressed in the public space .
The notion of health as a citizen’s right and a duty of the State was only approved in 1986, at the 8th National Health Conference, a fundamental event in the construction of a new National Health Policy. The reformulations proposed by the health reform movement and approved that year provided the necessary institutional basis for outlining the foundations of the SUS . Concomitant with the 8th National Health Conference, also in 1986, the 1st National Conference for the Protection of Indigenous Health took place, the stage for the first discussions about the health care model for these populations. Based on the main themes of the creation of a single agency linked to the ministry responsible for coordinating the Unified Health System (SUS) for the management of indigenous health and the participation of indigenous people in the formulation of health policy, structuring principles related to tolerance and respect for the cultural differences present in the various indigenous peoples were included on the agenda, as well as the recognition and incorporation of their different therapeutic practices in the services that would be directed to them .
The 1988 Constitution laid the foundations for the creation of Public Policies (PP) aimed at enforcing the differentiated rights of indigenous peoples, as it began to recognize indigenous people as Brazilian citizens, overcoming the notion of guardianship and welfare . It is only through the recognition of indigenous people as citizens that it becomes possible to think about specific social rights and, therefore, the creation of legislation and PPs that ensure this population. Thus, Law 9836/99, known as the Arouca Law, complements the Organic Health Law in that it creates, within the SUS, an Indigenous Health Care Subsystem (SasiSUS), thus incorporating the notion of differentiated care for this population, which would only be implemented in 1999 through the creation of the Special Indigenous Health Districts .
Also in 1999, Decree 3156 regulated the National Policy for Indigenous Health Care, delegating to the National Health Foundation (FUNASA) the responsibility for managing and implementing the policy. However, in 2010, Presidential Decree 7336 transferred the responsibility for managing the subsystem to the Special Secretariat for Indigenous Health Care (SESAI), created that same year by the Ministry of Health (MS) .
The PNASPI, approved by Ordinance 254 in 2002, is integrated into the National Health Policy, to make Law 8080/90 compatible with the 1988 Constitution. The need for differentiated health care for this diversity of peoples is set forth, primarily, in the first guideline of the policy, through the creation of the Special Indigenous Health Districts (DSEI). The DSEI is configured as a model for organizing services in the form of health districts and Base Centers at the local level, where primary care and referral services are located .
Each district, oriented towards a dynamic, geographical, populational, and administratively well-defined ethnocultural space, will organize a network of basic health care services within the indigenous areas, integrated and hierarchized with increasing complexity and articulated with the SUS network. The districts, therefore, follow the principle of regionalization and hierarchization of health services provided for in Law 8080/90. In this sense, the service network of each DSEI foresees the existence of Basic Health Units (UBS in Portuguse) in the settlements or base centers, located in an indigenous community or the reference municipality. The functions of the base centers are to cover a group of settlements and their staff, providing, in addition to health care, the training and supervision of Indigenous Health Agents (AIS) .
The institutionalization of the policy will actually occur with the publication of Ordinance 2759 of October 25, 2007, which “Sets general guidelines for the Policy of Comprehensive Mental Health Care for Indigenous Populations and creates the Management Committee”. Indigenous Health must be integrated into the Psychosocial Care Network (RAPS). This network is focused on receiving and treating people in situations of suffering, with demands resulting from mental disorders or the abuse of alcohol and other drugs . The incorporation of psychosocial care actions into primary care requires that teams be sensitive to identifying situations, demands, and possibilities for action that go beyond the biological dimension . The perspective is that points of cohesion in the social fabric are spaces that produce mental health and well-being and can reduce social and individual vulnerabilities. The problems related to the mental health of indigenous populations are strongly related to the fraying of the social fabric of communities and this will be one of the main areas of action for professionals .
Although we have a universal and public health system such as the Unified Health System (SUS) and strong tools such as the Family Health Strategy (ESF) and the DSEI in Primary Care, one of the great challenges is to ensure that its actions in the area of Mental Health are effective among ethnic groups . Rural contexts, where almost all indigenous peoples who live organized as collectives in the country live and work, are spaces that are difficult to access, with precarious infrastructure conditions (roads, transportation, health centers), marked by models of public administration and management that impede the functioning of integrated and intersectoral networks, such as clientelism, corruption, and bureaucracy, aspects that represent disadvantageous conditions for guaranteeing coverage and the qualified provision of care, especially in mental health .

Method


A quantitative study was carried out using several secondary data sources: microdata retrieved from the database of the Brazilian Institute of Geography and Statistics (IBGE); data from the National Indigenous Foundation (FUNAI) and the Special Secretariat for Indigenous Health (SESAI) and the Secretariat for Health Care (SAS), the Subsystem for Health Care for Indigenous Peoples (SasiSUS) and the Special Indigenous Health Districts (DSEIs); data from the National Coordination of Mental Health (CNSM/MS) – equipment from the Psychosocial Care Network (RAPS); the National Registry of Health Establishments (CNES/DATASUS) – health equipment according to public or private management, number of professionals by Brazilian Classification of Occupations (CBO), history of qualifications, number of beds; database of the Department of Primary Care (DAB) – PHC teams; and DATASUS, by health region and municipality to the following indicators: number of deaths, proportional mortality and mortality rate due to mental and behavioral disorders, use of psychoactive substances and suicide in the historical series 2010-2020.
Initially, a general characterization of the 184 municipalities that served as a sample for the analyses was made. Most municipalities belonged to the Fortaleza region (54.89) and were small (80.98). Regarding indigenous communities: 9.24% had indigenous communities in settlements and 6.52% had non-settled communities. Additionally, we identified that nine municipalities simultaneously had indigenous communities in settlements and quilombola communities, namely: Crateús, Itapipoca, Acaraú, Caucaia, Tamboril, Monsenhor Tabosa, Novo Oriente, Quiterianópolis and São Benedito. Furthermore, there was no municipality with both non-settled indigenous communities and quilombola communities.
Indigenous settlements are mostly located in small and medium-sized municipalities, while non-settled communities are mostly in small municipalities. The percentage of municipalities in socioeconomic development and low service provision is higher for those with non-settled communities, followed by those without indigenous communities and those with indigenous settlements. There are, in percentage terms, more municipalities with medium/high socioeconomic development and low service provision with settled communities than those without indigenous communities or with non-settled communities. All municipalities with medium socioeconomic development and medium/high service provision do not have an indigenous community. Finally, municipalities with high socioeconomic development and high service provision are proportionally more those with non-settled communities, with settled communities, and without indigenous communities.
Descriptive analyses were conducted to understand the general characteristics of the municipalities included in the analyses. For comparisons between municipalities according to the presence of indigenous communities (settled, non-settled, or without community), the t-test and Analysis of Variance were performed on data with normal distribution. The respective nonparametric tests, Mann Whitney and Kruskal-Wallis, were conducted on data that violated normality. Normality was analyzed by graphical inspection and the variation of asymmetry and kurtosis , and data with distribution between +1 and -1 was considered normal. For comparisons of mental health equipment, the criterion used was whether or not such equipment was present; therefore, the comparison was made using the chi-square test. The data were analyzed using the statistical program JASP 0.16.0.0.
The interpretation of effect size was performed from different cutoff points . For Cramer\'s V (chi-square), point biserial correlation effect size (Mann Whitney), and Dunn\'s post hoc effect size (Kruskal-Wallis specific effect of comparison between groups; Dunn\'s post-hoc), the parameters were as follows: 0.1-0.3 (small), 0.4-0.5 (medium) and >0.5 (strong). To interpret Cohen\'s t-test: 0.2 - 0.3 (small), 0.5 (medium), and >0.8 (strong). To interpret εε epsilon squared (Kruskal-Wallis overall effect) and ε2 eta squared squared (ANOVA): 0.01 (small), 0.06 (medium), and 0.14 (large).


Results

Kruskal-Wallis, ANOVA, and chi-square tests were run to compare municipalities with settled, non-settled, or without indigenous communities, in relation to a series of social indicators. The first round of these comparisons was in relation to the maximum number of Community Health Agents (ACS) established by the Department of Primary Care (DAB) in December 2019, Community Health Agents (ACS) accredited by the Department of Primary Care (DAB), to the maximum number of Family Health Strategy (ESF) established by the Department of Primary Care (DAB) in December 2019, and to Family Health Strategy (ESF) teams accredited by the Department of Primary Care (DAB).
The results were significantly different for all indicators, with a scaling of the medians from highest to lowest following the order of municipalities with a settlement, municipalities with a non-settled community, and municipalities without an indigenous community (Table 1).
Table 1

The Dunn-Bonferroni posthoc test identified a significant difference between municipalities without indigenous communities and those with settled communities for the maximum number of Community Health Agents (ACS) established by the Department of Primary Care (DAB) in December 2020 (H = 41.274, standardized H = 3.033, adjusted p < 0.01, effect size = 0.23), Community Health Agents (ACS) accredited by the Department of Primary Care (DAB) (H = 39.976, standardized H = 2.938, adjusted p < 0.01, effect size = 0.22), the maximum number of Family Health Strategy (ESF) established by the Department of Primary Care (DAB) in December 2020 (H = 41.734, adjusted p < 0.01, standardized H = 3.071, effect size = 0.23), the Family Health Strategy (ESF) teams accredited by the Department of Primary Care (DAB) (H = 42.113, adjusted p < 0.01, standardized H = 3.101, effect size = 0.24). In all cases, the municipalities with settled communities presented the highest medians. In other words, there is a better provision of health services in these municipalities.
Next, the number of Family Health Support Centers type 1 (NASF 1) accredited by the Department of Primary Care, the sum of accredited Family Health Support Centers (NASF), Basic Health Units (UBS), Family Health Strategy (ESF) teams, Multidisciplinary Indigenous Health Teams (EMSI) and Family Health Support Centers (NASF) were compared. The results were significantly different for all indicators; municipalities with settled communities presented the highest medians for all indicators (Table 2).
Table 2

The Dunn-Bonferroni posthoc test evidenced a significant difference between municipalities without indigenous communities and those with settled communities for Family Health Support Centers type 1 (NASF 1) accredited by the Department of Primary Care (H = 38.711, adjusted p < 0.01, standardized H = 3.050, effect size = 0.23), the sum of accredited Family Health Support Centers (NASF) (SUM of accredited NASF) (H = 38.537, adjusted p < 0.01, standardized H = 3.422, effect size = 0.26) and UBS (H = 40.927, adjusted p < 0.01, standardized H = 3.013, effect size = 0.23), ESF (H = 36.675, adjusted p < 0.05, standardized H = 2.701, effect size = 0.21). In all cases, the highest medians were for municipalities with settled communities. Thus, there are more provision of Family Health Support Centers (NASF), Basic Health Units (UBS), and Family Health Strategy (ESF) in these municipalities.
Regarding the frequency of municipalities with or without a Psychosocial Care Center for Alcohol and Other Drugs III (CAPS ad II), Psychosocial Care Center I (CAPS I), Psychosocial Care Center (CAPS II), and Child Psychosocial Care Center (CAPSi), according to the classification as having a settled, non-settled community, and without an indigenous community, the difference was significant for the provision of Psychosocial Care Center II (CAPS II) and Child Psychosocial Care Center (CAPSi), in which municipalities with a settled community presented a higher frequency of supply than those without an indigenous community (Table 3). The supply of Psychosocial Care Center I (CAPS I) and Psychosocial Care Center for Alcohol and Other Drugs III (CAPS ad II) did not differ significantly.
Table 3

Below, Table 4 presents a comparison of general hospital (HG) beds, total beds, hospitalizations, and hospital and general deaths from mental and behavioral disorders, deaths due to the use of psychoactive substances, and due to the use of alcohol.
Table 4

The Dunn-Bonferroni posthoc tests identified a significant difference between municipalities without indigenous communities and those with settled communities for overall deaths from mental and behavioral disorders (2008-2020) (H = 49.935, adjusted p < 0.001, standardized H = 3.637, effect size = 0.28), deaths from psychoactive substance use (2008-2020) (H = 45.384, adjusted p < 0.01, standardized H = 3.337, effect size = 0.25), deaths from alcohol use (2008-2020) (H = 47.384, adjusted p < 0.001, standardized H = 3.484, effect size = 0.26). In all cases, the highest medians were observed in municipalities with settled communities. The indicators analyzed were more frequent in these municipalities with village communities.
Below, Table 10 presents a comparison of several indicators related to suicide, as well as cases of interpersonal and self-inflicted violence.
The Dunn-Bonferroni posthoc tests revealed a significant difference between municipalities without indigenous communities and those with settled communities for deaths from suicide (2008-2020) (H = 47.633, adjusted p < 0.001, standardized H = 3.502, effect size = 0.27), suicide by self-inflicted violence (2008-2020) (H = 47.322, adjusted p < 0.01, standardized H = 3.479, effect size = 0.26), suicide by exogenous intoxication (2008-2020) (H = 41.974, adjusted p < 0.01, standardized H = 3.327, effect size = 0.25), attempted suicide by exogenous intoxication (2008-2020) (H = 40.180, adjusted p < 0.01, standardized H = 2.954, effect size = 0.22), and cases of interpersonal and self-harm (2009-2020) (H = 44.026, adjusted p < 0.01, standardized H = 3.252, effect size = 0.25). In addition, there was a significant difference between municipalities without an indigenous community and those with non-settled communities for suicide due to exogenous intoxication (2008-2020) (H = 35.751, adjusted p < 0.05, standardized H = 2.337, effect size = 0.19).

Discussion

The results indicate that municipalities in the state of Ceará with settled indigenous communities have higher indicators compared to other municipalities regarding Primary Care equipment and services. However, for health network coverage, the averages were generally higher for municipalities with non-settled indigenous communities but were influenced by the presence of a few municipalities with a large coverage in this group. Likewise, due to the premise of comprehensiveness and universality of the Unified Health System, Primary Care coverage has a significant national scope . The appropriate analysis for the maximum number of Community Health Agents (ACS) established by the Department of Primary Care (DAB), Community Health Agents (ACS) accredited by the Department of Primary Care (DAB), the maximum number of Family Health Strategy established by the Department of Primary Care (DAB), Family Health Strategy (ESF) accredited by the Department of Primary Care (DAB), Family Health Support Center I (NASF I) accredited by the Department of Primary Care (DAB), Sum of Family Health Support Center I (NASF I) accredited by the Department of Primary Care (DAB), Basic Health Units (UBS), and Family Health Strategy (ESF) is based on the median, with significantly higher values for municipalities with settled indigenous communities followed by municipalities with non-settled indigenous communities. There was a strengthening of the Family Health Strategy teams in Brazil . This fact, together with the prevalence of Indigenous Health teams, can strengthen the coverage of Primary Care in municipalities with indigenous peoples . This indicates a tendency for these municipalities to have better health coverage compared to municipalities without indigenous communities, especially municipalities with settled indigenous communities.
Specifically about mental health coverage, there was a significant difference when comparing municipalities, with municipalities with settled indigenous communities presenting, proportionally, the highest percentages of Psychosocial Care Center II (CAPS II) and Child Psychosocial Care Center (CAPSi). This indicates a tendency for municipalities with indigenous communities to have more of this equipment, especially those with settled communities. The coverage of Psychosocial Care Centers in Brazil still needs to be expanded, especially for small and medium-sized municipalities .
Although Primary Care coverage and CAPs are more present in municipalities with indigenous communities that already have access to Indigenous Health services, negative mental health indicators are prevalent in these communities. This is likely to occur because, firstly, the causes of indigenous psychosocial illness are social and historical, as we discuss later. Furthermore, as other studies have already pointed out , Primary Care is not prepared to receive cases of psychological distress, mental disorders, and abuse of alcohol and other drugs considering cultural specificities.
In most cases of mental illness, the highest median was for municipalities with settled communities, except for the indicators of suicide due to exogenous intoxication (2008-2020) and suicide rate due to exogenous intoxication per 100,000 (2008-2020). For the first indicator, municipalities with settled and non-settled communities had the same median, differing in having a higher median than municipalities without indigenous communities. As for the second indicator, despite having a significant difference in the general comparison, there was no difference in the post-hoc test, that is, there was no difference in the pairwise comparisons of the groups.
Regarding the mental health outcome indicators, the difference was significant, with municipalities with indigenous communities, especially those with settled communities, showing a tendency to have more cases of interpersonal and self-inflicted violence and a greater number of deaths in general from mental and behavioral disorders, use of psychoactive substances, alcohol use, and suicide. Linked to this last indicator, they also showed a greater tendency for suicides due to self-inflicted violence and exogenous intoxication (absolute values and per 100,000 inhabitants). In short, municipalities with indigenous communities tend to have the worst mental health outcomes.
In addition to the data explained above, there is a growing number of documents denouncing the high rates of suicide, mental disorders, and psychological distress among indigenous populations in Brazil . The economic, social, cultural, political, and environmental aspects that make up the social determinants of health and have a direct influence on the quality of life of populations that traditionally live in the countryside and forests, such as indigenous peoples, must be taken into account . These aspects are intrinsically associated with illness and death. Besides mental health indicators, rural areas, where most of these traditional communities are located, have the highest rates of food insecurity, infant mortality, incidence of endemic diseases, unhealthiness, and illiteracy in Brazil .
Therefore, to discuss the results found, the underlying historical-social context must be taken into account. In agreement with Edinaldo dos Santos Rodrigues , an indigenous psychologist from the Xukuru do Ororubá People who worked in indigenous health at the Special Indigenous Health District (DSEI) in the state of Pernambuco, “the events that lead indigenous populations to mental illness, specifically those who live in the northeast region, are social conflicts and cannot be treated individually.” (p. 231).
Based on a critical reading of the scenario of the research, we point out how such findings reflect a historical process based on violence, expropriation, and exploitation of these populations that continues to this day . Despite the end of colonial political administrations, the independence of the colonies, and even the conquest of fundamental rights, forms of domination continue to constitute the social structure . We experience the reproduction of power schemes and hierarchies in and among ourselves daily, at home and in institutions, in books and common sense, in the self-image of peoples , and we add, in the invalidation of traditional knowledge and its exclusion from Primary Care health equipment and services, in the centrality of certain themes, forgetting others, such as indigenous illness.
Here, on the periphery of the world, where the effects of this hierarchical network are accentuated, the settled and non-settled indigenous communities located throughout the state of Ceará have their existence and territories historically denied, persistently invaded, increasingly pressured by real estate and tourism developments, crossed by roads or wind turbines and, for the most part, have not yet been fully regularized. Of the fifteen ethnic groups declared indigenous today in the state of Ceará and twenty-one lands claimed, only two, belonging to the Tremembé people of Córrego João Pereira and Barra do Mundaú, have been regularized. Other violations arise from or overlap with territorial conflicts, including the worsening of mental health, as seen in the health outcome indicators presented above.
The constant threat to indigenous territories changes environmental and relational characteristics, consequently putting at risk the quality of life of the people and the stability of their collective modes of organization . This setting has negative effects on the psychosocial health of the populations that have historically resisted in Brazil and Latin America in general . It is no coincidence that municipalities with indigenous communities have the worst mental health outcomes and a tendency to have more cases of interpersonal and self-harm and a greater number of deaths in general from mental and behavioral disorders, due to the use of psychoactive substances, alcohol use, and suicide.

Final Considerations


Despite the worsening prevalence of mental health indicators (deaths from suicide, suicide by self-inflicted violence, suicide by exogenous poisoning) in municipalities with settled indigenous populations, Primary Care coverage and some equipment of the Psychosocial Care Network are more present in these municipalities. Nevertheless, given the above, it is worth highlighting that this support of services does not prevent mental illness among indigenous populations. Psychosocial health services and equipment still need to advance in professional education, in order to enable them to act attentively to this alarming reality of mental health indicators for indigenous populations.
Mental health care for indigenous populations has its specificities and cannot be transposed from the practices and models used with non-indigenous populations. Furthermore, despite the Western framework present in the indicators and formal health services that make up this article, we emphasize the presence of historical and socioeconomic factors in the process of illness of these populations. In this sense, the challenge is to think about how professionals in Primary Care and the Psychosocial Care Network can, together with communities and leaders, build interventions that impact and consider such social factors, also ensuring the recognition and incorporation of the different and traditional indigenous therapeutic practices in the services that would be targeted to them.

Scielo Data Repository: https://doi.org/10.48331/scielodata.A3RHWN

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