Questions/Answers

Jaboatão dos Guararapes is a Brazilian District in the State of Pernambuco, in the Northeast region of the country.It is the second District in the state in terms of population, estimated at 711,330 inhabitants (IBGE, 2021), and administratively divided into 07 regions. The District is managed by the Mayor, Deputy Mayor, and 08 District Secretaries, who, before the new Coronavirus pandemic, joined forces to ensure inclusive and equitable public services, promoting innovative ways of providing to the population an easy access to services. Regarding mental health care, the Psychology Council advised suspension of in-person consultations, considering that the professionals and patients commuting could be a vector for the virus to spread. In this context, the District Health Department (SMS) remodeled the psychological care to expand and guarantee this service, corroborating recommendations for social distancing as a measure of health promotion and prevention, avoiding unnecessary people transit, and, at the same time, promoting quality service. Supported by Information and Communication Technologies (ICTs), it was possible to continue the psychological follow-up to those who were already undergoing psychotherapy, however, aiming at expanding the service and promoting immediate care. After considering all scenarios, the Mental Health Coordination (CSM) created an innovative project – Telepsychology Service on Duty: expanded care. It is a space for immediate listening and deep care, offering positive and relevant perspectives on care and harm minimization in emergency situations. The project complies with the doctrinal principle of the Unified Health System (SUS), which is the universalization of care, that is, the guarantee that all citizens, without any type of discrimination, have direct access to health actions and services. Through the initiative, it was possible to minimize psychological vulnerabilities and psychosocial damage, such as: feelings of uncertainty, anguish, insecurity, loneliness, fear, and vulnerability related to social isolation during the COVID-19 pandemic.

In psychology, resilience means resistance to adversity and that was the idea: to place psychology consults at the front line when fighting the pandemic, responding immediately and innovatively to the need for emotional support in times of uncertainty, free of charge, as it is promoted by the Brazilian Unified Health System – SUS. Any person, regardless of socioeconomic status or any other factors, can use the service. The innovations included are: immediate service, deep and quality listening, online service, accessible and low cost, made through available technologies, thus facilitating user registry in other District devices.

The initiative aims to ensure a healthy life and promote well-being for everyone, encouraging people to mental health care without distinction of color/race/gender/sexual orientation/age (ODS3), guaranteeing this access in an equitable way. It is innovative, inclusive, and highly sustainable, since its implementation requires a very low use of natural resources, not damaging the environment (SDG11). The reduction of inequalities becomes intrinsic to the proposal, as it empowers and promotes social/economic inclusion for everyone, with greater representation, access to self-care opportunities, at low and accessible cost (SDG10). This initiative is concerned with gender equality, promoting reflection and awareness on ways of discrimination in each service; empowering women, children, adolescents, LGBTQIA+, so that they do not accept any type of violence; recognition and appreciation of unpaid domestic work; promoting comprehensive access to health, including sexual and reproductive health; expanding the use of communication technologies to promote empowerment (SDG5). During the sessions, psychologists use dialogue and mediation as pillars to resolve conflicts based on values such as tolerance and solidarity, rejecting any type of violence - especially against black people, women, children, adolescents, LGBTQIA+ and indigenous people - proposing a peaceful and inclusive society (SDG 16).

Due to the crisis created by the pandemic, the health services of the Psychosocial Care Network (RAPS) had to reinvent themselves to ensure the continuance of mental health care. Many users reported fear and financial difficulties to commuting to where the consults happen, in addition, people transit was limited by authorities. Thus, psychological care (considered essential, since there was already a repressed demand, which was aggravated by the pandemic) began to be offered remotely as well. The initiative is of low cost, as it used free technologies that are accessible to the population, with very low use of natural resources.

One of the gaps found in the services offered by SUS is the great demand for services which the system has difficulty meeting. In psychological consults, the case is worse since follow-ups tend to be mild to long-term, causing extensive waiting lists. Considering that, with the pandemic a large part of the population would need psychological support, the mental health care was remodeled, aiming to strengthen and guarantee immediate emotional support to the population in an online format, complying with the social distancing recommendations, quarantine, and/or home isolation as a measure of health promotion and prevention, thus avoiding unnecessary people transit and, at the same time, guaranteeing quality psychological care. The Telepsychology Service on Duty was set up as a space for listening and extended care, also having as a differential the guarantee of a quick response to the situation, without creating a waiting list.

In 2019, according to the World Economic Forum, Brazil was in 92/153 position in a ranking that measures equality between men and women. The Telepsychology Service on Duty - expanded care, following the guidelines of the District Public Administration, had the ethical duty to produce knowledge that would fight prejudice and promote dignity, respect, and otherness for all. The program did not make any distinctions when welcoming people in terms of gender, however, it took a stand towards women’s rights, homosexual rights, trans rights, and others, proposing a male identity different from that based on aggressiveness and oppression of feelings.

The target groups were people who needed psychological support in that period marked by insecurities, changes, and uncertainties aggravated by COVID-19. Everyone who was a part of the District of Jaboatão dos Guararapes benefited from the initiative since access to the Telepsychology Service on Duty was offered to the District's population and to network professionals, which demonstrated the importance of caring for people and ensuring quality support to everyone, while reinforcing social isolation, one of the main guidelines for containing the virus. We emphasize that this initiative, although planned to support the population from Jaboatão, also served people from other Districts. It was made qualitative research to gather the results and, out of 173 users who accessed the service, pointing out that 83.24% reported having received necessary help at that time; 27.5% considered that the demand for the consultation was resolved and 56.07% considered that this demand was minimized. Among those interviewed, 93.06% stated that they would recommend the Telepsychology Service on Duty.

On 03/11/2020, who declared Covid-19 a pandemic. Due to the global and local reality, the District developed a Contingency Plan for COVID-19, having as one of the strategies the strengthening and expansion of mental health care, which also started to be offered remotely. Also, in the first fifteen days after the pandemic was declared in Brazil, a psychological service was created, through the number +55 81 99937-3569, where effective psychologists of the District were called to work. The service operated from Monday to Friday, from 9:00 am to 4:00 pm, aiding through Skype, phone, or WhatsApp, depending on the users' availability. There was no need for prior scheduling, as the professionals were on duty. The user contacted the center and informed them which means they had to do the consult. One of the psychologists quickly returned the call and started the consult, with the possibility of referrals to other services in the District network and/or the Telepsychology Service on Duty (for more emblematic cases). The project was prepared in stages - 1: project elaboration; 2: alignment of the communication flow/regulation of essential information to support the psychological intervention involved in the care line; 3: identification of psychologists to work on the project; 4: site definition and hours for service provision; 5: monitoring. Assessments were carried out monthly, through technical meetings with case discussions and flows, which made it possible to identify whether the initiative was meeting the needs of the public that were using the service. The adjustments were made as the demands were presented, ensuring the offer of deep listening, strengthening the continuity of care as a measure of health promotion and prevention, and minimizing biopsychosocial damage, such as: feeling of uncertainty, anguish, insecurity, and feelings of loneliness, fear and vulnerability related to social isolation.

A relevant obstacle was the difficulty found by a portion of the to access technology. It was overcome through the provision of equipment from the social assistance, education, and health network as an alternative to offer internet access in the user's territory, promoting access to the service. Another challenge was the need for systematic follow-up on a portion of users, as the service was provided by the on-call system. Those who presented this demand were referred to outpatient psychologists, who were providing assistance remotely, and/or to CAPS (Psychosocial Care Centers), which provides in-person and remote assistance.

It is an innovative, creative, intelligent, replicable, low-cost, and accessible solution. It was necessary to break the standards used in the SUS psychology practice, offering online psychological practices. In addition to individual psychological care, professionals use technology to carry out therapy groups, share lists with indications for videos and activities, depending on demand, and make referrals to other services in the network. These good practices were innovative as they strengthened and guaranteed immediate reception in mental health, complying with the recommendations for social distancing and, at the same time, offering quality psychological care.

This is a pioneering initiative in the region. It was ethically supported by resolution 11/2018 of the Federal Council of Psychology, which authorizes online therapy, allowing Brazilians living in other countries or small towns to have access to consultations with trained professionals. Given the scenario of a mental health pandemic, the Jaboatão Mental Health Coordination considered it essential to offer immediate and accessible psychological care to the population, respecting the principles of SUS, which is universality (a guarantee that all Brazilian citizens, without any type of discrimination, have the right to access health care actions and services).

Technologies such as WhatsApp and Skype were used to help. The City's social media, such as Instagram and Facebook, were used to disseminate the service. It is important to emphasize that these tools were permanently incorporated into the routine of District mental health care services and will be continued after in-person consults restarts, promoting agility in listening and expanding the reach of psychological services, which is increasingly in demand. This increase in the demand for psychologists reflects both the pandemic and the population's new habits, such as the excessive use of social media and their “fabricated” happiness, trivializing social interactions.

Yes. In the Telepsychology Service on Duty, remote and immediate care was offered, without the need for appointments, bringing the population closer to the health network. Before protection and care factors, in addition to easy access and availability without generating any cost, the proposal for psychological telephone care in this District inspired other Districts in the Metropolitan Region of Recife. This initiative also served as inspiration for other services in the District network, such as the COVID-19 telemonitoring center, and in the associated network, such as the Giácomo e Lúcia Perrone Foundation, an entity that aims to offer multidisciplinary therapeutic treatment to underprivileged children with neuropsychomotor disabilities and Autism Spectrum Disorder.

It was already transferred.

A psychology call center was set up with the participation of effective psychologists of the District, without the need for new hires to compose the technical team. Only one receptionist was hired to initially screen the demands and make referrals to the psychology team, at an insignificant cost. Regarding the structure such as physical space, furniture, office supplies, and technological equipment, these were already made available by the City Hall of Jaboatão dos Guararapes, without generating costs in the short, medium and long term, which strengthened the initiative and guaranteed the project continuity in other contexts, when deemed necessary.

The project contributes to the promotion of sustainable development with health services, specifically mental health, as it does not generate additional costs, providing growth in care; efficiency, and innovation in health care; savings for the District and for the user, without commuting expenses; optimization and reduction of building maintenance expenses. By meeting the needs of the current generation, without compromising future generations, it became accessible and sustainable financially and institutionally, ensuring the perpetuation of the service.

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The evaluations were carried out through monthly team meetings, which involved psychologists and managers of the initiative, with clinical case discussions and flows. After 12 months, qualitative research was carried out with users and quantitative analysis was carried out with profile reports of the assistance provided. Such assessments formed the internal report of the Telepsychology Service on Duty. The assessment identified that, with this initiative, it was possible to offer a space for deep listening, ensuring and strengthening the continuity of mental health care and minimizing psychosocial damage such as: anguish, insecurity, loneliness, fear, and vulnerability related to social isolation.

Main indicators: number of accesses (2,612 assistances), user profile; feedback during appointments; main complaints reported; qualitative research carried out with a sampling of users, evaluating the level of satisfaction, relevance, and solution of the initiative. Main tools: technical meetings with discussions of emblematic cases and flows and evaluation reports.

The evaluation was made with a sampling of 1,169 users, being 80.13% female, 19.87% male. With this data it was possible to observe that: 1st Regarding the relevance of the service offered, we obtained the following results: 43.35% satisfactory; 41.62% excellent and 15.03% reasonable and dissatisfied; 2nd On care quality: 86.71% rated as excellent or satisfactory; 3rd Regarding having the necessary help at the time of the service, 83.24% answered YES. It was observed in the analysis of the medical records that the initiative welcomed people reporting symptoms such as anxiety, depressive symptoms, self-inflicted and suffered violence, marital problems, suicidal thoughts, suicide attempts, psychoactive substances abuse, among others. The challenges are daily, and the results show the initiative as efficient and satisfactory. The professionals involved report success in adverse situations, such as a video call made by a user carrying a firearm pointed at his own head and then giving up on harming him/herself after receiving the service. There is also a user who participated in an online therapeutic activity, initially without showing his face, but after some sessions, he opened the camera, which would hardly have happened in face-to-face, as he possibly would not have participated because he's shy.

Horizontally, the initiative made articulations with several partners in the areas of health, social assistance, education, labor secretariat, administration, the mayor's office, psychology council, among others. Users who accessed the service are the main protagonists because, through the demands brought by them, other governmental spheres were activated. Users who reported social vulnerability, for example, were referred to the District Social Assistance Department, while users who reported the need for professional relocation were referred to professional courses offered free of charge by the Executive Secretary of Labor. Reports of family violence were referred to reference services for receiving this type of demand. The Telepsychology Service on Duty proved to be essential in addition to the need for mental health care, since many users accessed other devices from the District network through this service, making the reported complaints also accepted, thus enabling more referrals assertiveness and a more concrete perspective of the remission of symptoms brought to the appointments.

During the implementation period of the Psychology Call Center On Duty, teams from the Health Planning and Surveillance Managements, the District Health Department, professionals from the District Administration Department, and the Mayor's Office worked in partnership with the Mental Health Coordination. The planning team helped in the project's creation and surveillance supported the implementation with relevant information about the reality of the City. The District Secretariat of Administration made available all the necessary technological resources and the Mayor's Office made available the entire physical structure and PPEs to carry out the services and facilitated the dissemination via social media, television, radio, newspapers, among others. Users were heard when communicating the suspension of in-person consults, pointing out the most appropriate communication technologies for online care. The District management monitors the success of the initiative through result indicators.

The effort, commitment and availability of the professionals who were directly involved, made possible the quality of the service provided; the importance of focusing on both quantity and quality of care; the ease of access and the ability for articulation and resolution of public agents directly and indirectly involved in the project contributed to the success of the initiative, which is necessary for the population at a time of crisis; the online service facilitates communication in some situations (as an example, we mentioned a situation with a shy teenager who picked up the guitar and expressed his feelings by singing); psychology can and should act as a front line in pandemics, offering emotional support to the person served and their entire context; this initiative also works with prevention; it is possible to offer effective public services without relevant additional costs; successful actions can serve as a reference for managers who consider investment in mental health as a means of caring for the individual.The initiative is a powerful and available strategy for implementation in times of crisis, defined in Ordinance 262/2021, published by the District Health Department of Jaboatão dos Guararapes in November 20, 2021.