Research Report
“The potential of focus groups as a strategy for participatory technology
development for promoting mental health”[i]
Katyane
Heck Girardi[ii]
Universidade do Estado
de Santa Catarina (UDESC)
Florianópolis, SC - Brasil
lattes.cnpq.br/3045738475356608
Leila
Zanatta[iii]
Universidade do Estado
de Santa Catarina (UDESC)
Florianópolis, SC - Brasil
lattes.cnpq.br/8690234560867282
Denise
Antunes de Azambuja Zocche [iv]
Universidade do Estado
de Santa Catarina (UDESC)
Florianópolis,
SC - Brasil
lattes.cnpq.br/0777467805281716
Research Report “The potential of focus groups as a strategy for
participatory technology development for promoting mental health”
Abstract
Due to
the high demands in the mental health field, this study aimed to present the
use of FG as a tool for the participatory technology development for promoting
mental health in Primary Health Care (PHC). This action research was performed
in a city in the Midwest of Santa Catarina, Brazil. Data were collected through
a focus group that met once. Two professors from the Professional Master’s Program
in PHC Nursing and 15 PHC workers from the mental health field participated in
the focus group. The information was collected in October 2022, and the data
treatment was guided by content analysis. The health workers’ experiences in
mental health include a concern with adolescents and women, as they identify
the need to implement care practices to strengthen protective and preventive
mental health factors. Educational gymkhanas, online psychoeducational
interventions, and a podcast emerged as care strategies to be implemented in
mental health within PHC. The perceptions of the PHC workers regarding mental
health needs and demands enabled defining the public audience and the
educational technology that needs to be developed to promote and protect the mental
health of PHC service users.
Keywords: primary health care; focus
groups; mental health; educational technology.
Relato de Pesquisa “O potencial do grupo focal como
estratégia para o desenvolvimento participativo de uma tecnologia para promoção
da saúde mental”
Resumo
Devido à alta demanda de
atendimentos no campo de saúde mental, este estudo teve por objetivo apresentar
o grupo focal como uma ferramenta para o desenvolvimento participativo de
tecnologia para a promoção da saúde mental na Atenção Primária à Saúde.
Trata-se de uma pesquisa-ação, desenvolvida em um município localizado no Meio
Oeste de Santa Catarina. A coleta de dados se deu através de um grupo focal,
realizado em um único encontro. Dois docentes do Programa de Mestrado Profissional
de Enfermagem na APS e quinze profissionais de saúde, atuantes na APS, no campo
de saúde mental participaram do grupo focal. As informações foram produzidas no
mês de outubro de 2022 e o tratamento dos dados foi guiado pela análise de
conteúdo. Dentre as vivências relatadas pelos profissionais de saúde na
assistência em saúde mental está a preocupação acerca dos adolescentes e das
mulheres, identificando a importância e a necessidade da realização de práticas
de cuidado pensando em fortalecer os fatores de proteção e prevenção em saúde
mental. A gincana educativa, as intervenções psicoeducativas on-line, e o
podcast, emergiram como estratégias de cuidado em saúde mental na APS. As
percepções dos profissionais de saúde da APS, acerca das necessidades e demandas
locais de cuidado em saúde mental, possibilitaram definir o público-alvo e a
tecnologia educacional a ser construída, voltada à promoção e proteção da saúde
mental dos usuários na APS.
Palavras-chave:
atenção primária à saúde; grupo focal; saúde mental; tecnologia educacional.
1 Introduction
Primary Health Care (PHC)
professionals must develop technologies and care strategies to promote the
health of individuals and families, as between a third and half of the
population may experience psychological distress throughout life if no specific
interventions are implemented (Melo; Pauferro, 2020).
Caring-Educational
Technologies (CET) are understood as a set of knowledge/scientific concepts
derived from realized processes that support the operationalization of the
process of caring for and educating others (Salbego et al., 2018).
Health education
technologies emerge in the health field to facilitate care delivery and health
education processes. Implementing such technologies in individuals daily lives
effectively promotes reflective, creative, and transforming knowledge, enabling
people to become autonomous and understand their life and health conditions (De
Melo Lanzoni et al., 2015). Hence, actions in mental health services are
needed to prevent harm and promote healthier behaviors among individuals
(Fernandez et al., 2020).
The health field,
especially graduate programs, has contributed to the production of knowledge
and technologies to transform and change services through interventionist
research, including action research, which uses the collection of data and
collaborative strategies to jointly build new knowledge intending to solve
problems or transform contexts (Zocche; Primo; Leal, 2022). According to Vantil
and collaborators, the participants in this type of research share the
experience of producing knowledge to develop technologies and products
necessary to solve the problems identified in a given work context (Vantil et
al., 2020).
Studies have adopted the
focus group (GF) technique in the Seminar stage, which, in addition to
expanding the participation of research subjects, also serves as an instrument
to collect data, supporting the development of technologies and educational
products (Silva; Castilho, 2022). Focus groups within PHC in the nursing field
allow the participants to reflect and act upon professional practice, providing
helpful information to improve the quality of health services and guide public
policies (Zocche; Rosa; Zanatta, 2021).
Thus, this study’s
objective is to present the use of FG as a tool for the participatory
technology development for promoting mental health in Primary Health Care.
2 Method
This action research was
developed through five phases adapted from the method described by Thiollent
(2011). This paper presents the second phase, the Seminar stage, where the FG
technique was implemented. This technique enables the participants and
researcher to interact, promoting the exchange of experiences, concepts, and
opinions among the participants and encouraging them to play an active role as
they dialogue and collectively construct the study’s results (Kinalski et al.,
2017).
Inclusion criteria were:
being a PHC physician, nurse, nursing technician, physical therapist,
psychologist, or social worker involved with mental health care, or a community
health agent (CHA) who is in close contact with the community; and being
working in a PHC service for at least six months. The exclusion criterion was:
being on sick leave. The decision to include these PHC professionals was based
on the fact that even though each professional plays a specific role in care
practice, the demand of patients is the same; hence, all the team members must
apply the construct and commit collectively (Brasil, 2006).
The health professionals
were intentionally selected and personally invited to participate. Two
professors from the Professional Master’s Program in Nursing in Primary Health
Care (PHC) and 15 PHC professionals participated in the FG: one physician, four
nurses, five nursing technicians, one psychologist, one physical therapist, and
three CHAs working in the mental health service from a town located in the
Midwest of Santa Catarina, Brazil. The FG was held in October 2022 and lasted
75 minutes. The participants sat around a table so that everyone could see each
other and watch the multimedia exhibition, ensuring face-to-face interaction.
The activity was coordinated by a moderator (the study’s author, a master’s
student), with the support of the research co-advisor and an observer (research
advisor).
The FG was divided into
three parts: first, the participants were welcomed, the researchers were
introduced, and the study’s objective was presented, after which the
participants introduced themselves and received clarification about the FG’s
session and organization and the time the session would end. Next, the data
collected in the study’s first stage (exploratory stage) were presented,
including a) the characterization of the patients with psychological distress
attending the service, mostly women aged between 50 and 54. The most prevalent
health problem/condition was Anxiety; b) the individual interviews held
previously with the professionals, which aimed to identify health promotion
practices implemented in the work process; and c) the results of an integrative
literature review on Educational Technologies (ET) that collaborated to promote
the mental health of PHC users. Infographics containing the study’s results
were presented in the first part of the FG session to promote reflection and
debate. The debate followed a semi-structured script to promote a participatory
discussion around the topic and material presented. In the third part, after
the debate, the central ideas raised in the discussion were summarized and
validated, and the session ended. The focus group session was audio recorded
and transcribed for further analysis.
Bardin content analysis was
used in data analysis (Bardin, 2016). A field diary was also adopted for the
researcher to record observations and impressions. It was a recording and
support instrument, as the analyses were based on the participants’ reports.
According to Minayo (2000, p. 295), “the collection of impressions and notes on
the differences between reports, behaviors, and relationships can make field
research more real”.
The transcribed material
was read to enable an understanding of the meanings of the professionals’
reports, from which two thematic categories emerged.
The study complied with
Resolutions No. 466/12 and No. 510/2016 of the Brazilian National Health Council,
which guides research with human beings subjects. Additionally it was submitted
to and approved by the Institutional Review Board at the State University of
Santa Catarina (Opinion report No. 5.538.518, July 21st, 2022), CAAE n.
58479622.7.0000.0118. The participants’ identities remained confidential, so
the initials “CHA” (Community Health Agent), “SW” (Social Worker), “N” (Nurse),
“PT” (Physical therapist), “P” (Physician), “PSY” (Psychologist), and “NT”
(Nursing Technician) were followed by sequential numbers: SW1, P1, N2, NT2,
CHA3, respectively. All the participants signed free and informed consent
Forms.
3 Results
Most of the participants in
the FG were women (n=14), in relation to age group, 2 (14,3%) were between
25-29 years old; 4 (28,6%) were 30-34 years old; 3 (21,4%) were 35-39 years
old, 1 (7,1%) were 40-44 years old; 3 (21,4%) were 45-50 years old and 1 (7,1%)
51-54 years old, and had a professional experience of 8.5 years on average.
Next, the data composing the thematic categories are presented: the concerns
and difficulties health professionals experienced in mental health care and
mental health care strategies in primary care.
3.1 The concerns and difficulties health
professionals experienced in mental health care
This category presents the
participants’ perceptions of the difficulties experienced during assistance
provided to people with mental health conditions within PHC. Note that the
reports mainly focused on defining the public to whom the actions are intended.
The first weakness the PHC
professionals mentioned concerns the service users' difficulty acknowledging
their mental health problems. For example, denying that they have a mental
disorder configured a barrier that prevented the implementation of actions, as
the following report shows:
We note that patients
resist acknowledging their mental problems. They believe it is taboo, a
prejudice on top of that, not even relating the medication to their pathology
(N2).
Sometimes the patient takes
a medication, and when they are filing in the registration, they’d say that
they do not have a mental condition (N1).
Yeah, we live in a society that still has
“pre-conceptions”. You know, going to a psychologist or a psychiatrist is for
crazy people. But it is a change that takes time, and we see this situation
frequently in our population(N2).
Another concern the
professionals markedly mentioned was toward adolescents due to fear of the
impacts of the Covid-19 pandemic and its implications for this population’s
mental health.
You could see that she needed help. It’s a
phase; it will pass, but if you don’t bring her here, don’t seek help; how will
she be diagnosed? We can’t reach a diagnosis. We can visit and see her
condition, but the parents are the ones who have to bring her, especially when
it’s a minor. [...] I think that the pandemic was when young people became more
anxious and did not know how to deal with what happened. I think that nowadays
anxiety symptoms are the most prevalent among youngsters”(CHA1).
The participants mentioned
the importance and the need to implement care practices among adolescents to
strengthen protective and preventive mental health factors. “Considering health
promotion; if you prevent it now during adolescence, you won’t need to treat
them later” (P1).
Note that the participants
discouraged the use of digital technologies to provide education to
adolescents. “Young people are already in poor health because they are on their
mobile phones, playing games” (CHA3).
The discussion following
the data presentation showed that women were the population that most
frequently sought assistance in the last three years. Most participants
considered women to be the technology’s target audience.
Other issues the
professionals discussed concerned the family relationships of patients in
mental distress. This population, primarily women, often raised complaints from
their family context.
[...] We know that the
mother, as always, is concerned with her children and absorbs it all. So, there
are many problems, especially anxiety, the most frequent complaint, which is
strongly related to family problems.
[...] They are the ones who
hold down the fort, for their children, husband, and even the neighbor (N3).
Women are the ones making
the family stick (N1).
The FG also discussed that
the environment and family standards reflect on the behavior of family members,
and is a reference for children and/or adolescents, as the reports show:
Many children and
adolescents don’t know how to deal with parents with a disorder, anxiety, or
depression. So, they end up developing it; the condition is passed from the
parents to the children. I think this is an interesting subject to discuss
(P1).
We often associate the mother, who has been
dealing with a depressive condition for years, and then her daughter comes, and
we identify them both, including suicidal attempts (N2).
Regarding the definition of
the target audience, the results from the focus group’s discussion show the
importance and the need to implement care practices for two populations: women,
who comprise most patients experiencing psychological distress attending the
PHC service in the Vargem, SC, Brazil; and adolescents, intending to strengthen
protective and preventive mental health factors.
A crucial aspect is to keep the health of
these women facing illnesses balanced and implement preventive measures among
the next generation, the adolescents (N2).
3.2 Mental health care strategies in PHC
This category includes the
participants’ suggestions about health promotion and mental health care
strategies to be implemented among PHC patients, CET to be developed, and its
content. In this study, we addressed the suggestions related to mental health
promotion and interventions, considering that the work of PHC professionals
should go beyond the care provided to patients with mental disorders and
include activities to promote and prevent mental health problems in the
population.
Suggestions included online
psychoeducational interventions conducted by a psychologist (tele-psychotherapy)
as an opportunity to provide therapeutic support to decrease symptoms and
improve the patients’ physical and mental quality of life of both audiences.
Most participants mentioned
online psychological support as a resource to promote mental health and comfort
those in distress. The participants stated that such a service is an
alternative to facilitate the population’s access, enabling care to be provided
to those people who want to keep their treatment confidential and to those who
are shy and do not like face-to-face sessions, as noted below:
Many people are shy and
don’t even want to come to the health unit (NT3).
Without having a family
member accompanying the consultation, people feel more at ease to talk about
their complaints (M1).
Some participants suggested
refraining from using digital technologies in the educational environment
directed to adolescents because youngsters are already immersed in digital
technologies and social networks.
Adolescents already spend
much time on mobile phones (CHA3).
This increased prevalence
of mental health disorders in this age group, among adolescents [...] I think it’s because of
this (mobile phone). So, if we chose this method, we may lose a lot;
hence, the idea is to bring them for something different, something
face-to-face (P1).
Therefore, they proposed an
educational and recreational approach, such as a gymkhana, in which playful and
educational aspects can be integrated, in addition to developing didactic
materials, such as infographics.
A gymkhana involving all
the groups. I think this is something that involves teenagers, I see myself
back in my time when I was very involved in this sort of thing, and the whole
school would get involved. I think that it would get their attention (PT1).
Having fun, being
competitive, and having a goal (N2).
Learning too. We can use
some things, some aspects that they will have to research, they will have to go
after and build materials (P1).
The other strategy proposed
was an educational podcast, produced by the inter-professional team and radio
transmitted, providing relevant information related to the risk factors for
mental problems, the leading mental disorders, symptoms that affect PHC
patients, strategies and tools for promoting mental health care, encouraging the
use of Integrative and Complementary Practices offered within PHC. Such a
podcast would be directed to both audiences as a mental health care strategy.
Presenting this topic in depth to the population is essential to implement
preventive actions and promote mental health.
[...] a healthy habit that
was recently adopted, especially because of technology, is staying at home and
enjoying family time, forgetting about the mobile phone, having dinner
together, watching a TV show or reading something together (P1).
Health education addressing
the risk factors and showing that it is OK to experience anxiety, have
tachycardia, stress, sorrow, or feel like crying (N2).
Some participants mentioned
radio broadcasting because it facilitates access to most of the population:
Our population has easy
radio access, even in the interior. Some have difficulties accessing the
Internet, but we know everyone has radio (N2).
It’s in our culture to
listen to the radio, especially during the day, women, people in the interior,
listen to radio (N1).
The previous discussion
show that the FG was an opportunity for reflecting on the work process,
interacting and sharing different practices and demands, where the participants
expressed their opinions, suggestions, and understanding about the development
of educational technology to promote the mental health of the users attending
the city’s health service.
4 Discussion
The literature highlights
that people sometimes refuse treatment, therapy, and care, often abandoning it,
compromising their health and aggravating mental disorders. In such a context,
users may find it challenging to access the service, and professionals cannot
act and intervene in times of crisis. Thus, patients’ denial is a challenge
preventing the implementation of resolving actions, as people have an internal
struggle between their need for treatment and their willingness to accept it
(Rotoli et al., 2019).
As for concerns about
adolescents’ mental health, note that the literature points to the need to perform
health education activities focusing on the families to care for the
adolescents’ mental health (Almeida et al., 2020). Family members should
be sensitized to perceive changes in the adolescents’ behavior, seek help from
health professionals, and get guidance and treatment, preventing symptoms from
becoming chronic and causing more severe consequences (Prime; Wade; Browne,
2020). Santos (2021) notes that anxiety was one of the factors leading
adolescents to use the Internet and social media more intensively during the
Covid-19 pandemic.
Loiola et al. show
that mental disorders are more predominant among women than men, highlighting
some aspects such as potential external stressors, in which violence stands
out, the demand from the society that assigns roles and tasks to the female
figure, and hormonal factors and reproduction-related aspects, which can also
lead to frustration and distress (Loiola et al., 2020).
The diagnosed patient is
usually the “tip of the iceberg.” Most of the time, it is easier for people to
blame a family member for their misunderstood or unacceptable afflictions than
express, acknowledge, and work through their emotions, feelings, and thoughts
that permeate their families. Hence, this family member is the one to blame for
the family’s limitations, overloading one member but easing the tensions of
others (Knewitz; Boeckel, 2022).
Emotionally healthy
relationships are protective factors. The quality of interpersonal
relationships and their affective representations play an important role in
determining vulnerabilities to psychopathologies and promoting security and
psychosocial adjustment. On the other hand, insecure, disorganized, and
indiscriminate bonds are related to psychological distress among adolescents,
exposing them to emotional and affective vulnerability (Rodrigues; Mendes,
2019).
Among the therapeutic
practices adopted in the individuals’ routines to gradually reduce anxious and
depressive symptoms, online psychological care emerges as an alternative for
providing mental health care within PHC. It prevents the aggravation of mental
disorders and promotes mental health by providing active listening and comfort
to patients in distress (Araujo et al., 2020).
Studies suggest that online
treatments are as effective as the face-to-face model. Correia et al.
highlight that online psychological care is a feasible alternative to
implementing psychological interventions in times of crisis, confirming the
possibility of establishing bonds in the virtual model (Correia et al.,
2023).
We know the intersectoral
partnership between health and education is vital to building strategies to
promote adolescents’ health, favoring a broader understanding of their way of
life, and encouraging healthy behaviors (Tavares, 2020). The study developed by
Costa et al. considered gymkhanas an alternative to promote health
education, as it enabled uniting students as a team and aroused their interest
through competitiveness, providing a favorable environment for learning and
expanding skills (Costa et al., 2020). Such health education actions
should enable dialogue, inquiry, reflection, questioning, and professional
cooperation (Melo; Pauferro, 2020).
A podcast is a compelling
educational technology in the teaching and learning process (Gomes et al.,
2020). Bragé et al. report the use of a podcast as an educational
practice that allows listeners to easily access scientific information to
promote knowledge and learning (Bragé et al., 2020).
5 Final considerations
Note that a FG is a
valuable strategy to support the construction and collective definition of an
ET. The group made observations that enabled recognizing local needs and
demands, proposing solutions to collective problems, and bringing research
closer to clinical practice.
The conclusion is that the
perceptions and experiences of PHC health professionals regarding mental health
care needs enabled defining the target audience and collectively building CET
to promote and protect patients’ mental health within PHC.
Future research is
suggested, utilizing the FG technique for the collective construction of CET
that promote mental health in PHC.
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