Training of Professionals from the Family Health Strategy for Psychosocial Care for the Elderly

1 Physician. Professional MSc in Family Health, UNINOVAFAPI. Teresina, Piauí, Brazil. 2 Dentist, Doctor. Professional MSc in Family Health, UNINOVAFAPI. Teresina, Piauí, Brazil. 3 Nutritionist, Doctor. Professional MSc in Family Health, UNINOVAFAPI. Teresina, Piauí, Brazil. 4 Nurse, Doctor. Postgraduate Program in Nursing. Federal University of Piauí, UFPI. Teresina, Piauí, Brazil. 5 Physician, Doctor. Professional MSc in Family Health, UNINOVAFAPI. Teresina, Piauí, Brazil.


Introduction
The Brazilian population aging becomes a challenge for the Unified Health System (SUS).By 2025, the country will house the sixth largest elderly population worldwide, with more than 32 million people aged 60 or older [1].Chronic diseases develop more easily at that stage of life, compromising the functional capacity of the elderly and making them dependent on care [2].
Mental disorders are among the most common health problems in the elderly, affecting about one third of the elderly population.
The disorders can vary from discrete neurological, such as varying degrees of senile dementia, to more serious syndromes, such as Alzheimer's and Parkinson's disease, in addition to a variety of cases of depression, concluding that there is a high prevalence of mental, behavioral disorders and psychodynamic factors in the Brazilian elderly population [3].
According to data from the World Health Organization (WHO), in 2020, depression will be the biggest cause of disability on the planet and, by 2030, it will be the most prevalent evil in the world.Currently, it affects more than 121 million people [4].
In Brazil, depression is prevalent in 18% of the population, according to data from São Paulo Megacity, a study from the Institute of Psychiatry of the University of São Paulo, which evaluated the prevalence of psychiatric disorders in the metropolitan area of the city, based on 5,037 interviews [5].
The inclusion of mental health actions in the SUS context contributed to the consolidation of the Brazilian Psychiatric Reform.The expansion of the Psychosocial Care Network (RAPS), which be-came part of the set of indispensable networks in the constitution of the health regions, enabled the articulation between Mental Health and Basic Attention [6].
Despite its importance, mental health practices in Primary Care raises many doubts, curiosities and fears in health professionals, who need to feel prepared to provide assistance that will bring positive results in order to reduce the caused damages [6].
Concomitant to that, professionals face difficulties of coordination among levels of attention, with restricted access to specialized services and social support.The disarticulation of the network and the inexistence or unawareness of the available back-up services, in addition to compromising the resolution of basic care, deplete the professionals and incapacitate the Unified Health System to provide comprehensive care to the elderly's health [7].
In Brazil, most graduate courses in the health area still prioritize training focused on individual and curative care, emphasizing the specialized training and learning of those specialties, which prevents the student from having a general view of the patient.That professional profile does not correspond to the one desired by the labor market of the Unified Health System and the Family Health Strategy [8].
In view of this problem, the study aims to analyze the training of professionals from the Family Health Strategy on psychosocial care for the elderly in the context of the Psychosocial Care Network -RAPS, and discuss how professional training influences the care provided to the elderly.
to specialized health services and to develop actions for social reintegration, prevention and harm reduction, it is necessary to implement a policy of ongoing training and education for health professionals to improve care for the elderly.

Method
Descriptive study, of qualitative approach, carried out with 31 professionals, 13 physicians and 18 nurses, who work at the Family Health Strategy of the city of Picos, Piauí, Brazil.
The study included professionals who were active in the Family Health Strategy for one year or more, excluding those professionals who performed voluntary activities, trainees.
Data were collected in 2016, through a semistructured interview guide, with open questions related to the training of Family Health Strategy professionals in psychosocial care for the elderly.The interviews were conducted in a reserved room, recorded by the researchers with audio equipment (Mp4), and, later, fully transcribed.
The data were processed using the software IRA-MUTEQ (Interface de R pour les Analyses Multidimensionelles de Textes et de Questionnaires) and analyzed by the Descending Hierarchical Classification (CHD), which classifies the texts according to their respective vocabularies [9].
The Research Ethics Committee of the UNINOVAFA-PI approved this study-CAAE 49538315.6.0000.5210,opinion number 1,265,925, and the Secretary of Health of Picos authorized the study.All the professionals who accepted to participate in this research, after verbal acceptance, signed the Informed Consent Form (ICF).

Results and Discussion
IRAMUTEQ recognized the separation of the Corpus in 30 initial context units (ICUs), or interviews, 84 elementary context units (ECUs) and 99 text segments.There were 3,276 occurrences, with use of 84.85% of the total corpus.
The Descending Hierarchical Classification enabled identifying and analyzing the textual domains, besides interpreting meanings, giving them names with their respective meanings in classes.The classified segments were divided into seven classes according to the dendrogram shown in Figure 1.
The corpus analyzed in its entirety contained elements that approached the training of professionals from the Family Health Strategy for psychosocial care for the elderly and was divided into three segments, as follows: Segment 1.The practice of professionals from the Family Health Strategy in psychosocial care in the family context, with classes 4 and 5.

Class 4. Home visit: getting to know the elderly in their family context
Class 4, consisting of 10 ECUs, concentrates 11.9% of the classified ECUs, highlighting the words domicile, visits, patient, perform, orientation, when, family, assess, physical, how.
Home visits assume an important role in psychosocial care from the psychiatric reform, which highlights the importance of the family in the care and social reintegration of the subject with mental disorder.
Given the professionals' discourses, the home visit not only provides the active search for patients with mental disorders, but also the perception of the elderly in their family environment and the relationship with the caregiver and/or family members.
We perform the active search for the elderly patient with mental disorder through home visits [...].

Dep. 5.
Our meeting with the elderly within the scope of the FHS occurs preferentially during the home visit, when the care provided to the elderly is evaluated, in addition to the prescription of care that the family should have with the elderly.It is possible to identify psychosocial changes of the elderly, in the teamwork done by the professionals of the Family Health Strategy, during the home visits.The multiprofessional assistance enables diagnosing, with clarity, the problem experienced by the elderly in their residences.
That multiprofessional team needs to know and understand the context that involves the relationships between the person with mental disorder and the family, being able to offer support and assist them in all their needs, seeking to improve the quality of life of both [10].
In this sense, the home visit, above all, enables knowing the reality of the person with mental disorder and his/her family, favoring the understanding of psycho-affective-social and biological aspects, promoting links among users, family members and workers [11].
The proposal for social reintegration of the mentally ill and their rapprochement with the family is not an easy task.At the same time that families long to have all their members close, they also reflect the fear and prejudice in our society, which can often make them resistant to accept the entity that became ill [12].
Until the 1970s, having a family member diagnosed with a mental disorder was a major problem for the family because they did not know how to deal with the disease and its stigma, and the treatment was strictly the institutionalization. Therefore, the Psychiatric Reform represented a profound change in mental health care, since it replaced the hospitalcentered model by the community services established in the territory [13].
In psychosocial care, the object of care of mental health teams is the family unit in all their complexity, understanding them as a fundamental element in the treatment, recovery and process of psychosocial rehabilitation.It is, therefore, imperative that substitute mental health services accompany the family in order to meet their needs [11].
Home health care does not end by taking the team to the individual's home.It implies understanding and interpreting adequately the family, socioeconomic and cultural context, extrapolating the borders of the biomedical model, and demanding the integration of support networks and the development of differentiated technologies [7].

Class 5. Actions developed in psychosocial care for the elderly
Class 4, consisting of 15 ECUs, concentrates 17.86% of the classified ECUs, with emphasis on the words, focused, support, activity, promotion, development, educational, social, caregiver, psychosocial.
The following statements enable observing the importance of the involvement of the multidisciplinary team in the psychosocial management of the elderly, as well as in the development of health education practices in the community.The educational activities are directed towards the interrelational development between users and professionals.

[...] we have developed education and health promotion actions, we have already performed jokes contest and play activities, which are very well accepted by the elderly.
Dep. 12.

Educational lectures and group therapies for caregivers and the elderly. Dances and stretching of the body and music therapy, performed by the NASF.
Group of elderly people with health promotion actions and also recreational activities with the help and support of NASF professionals, Social Worker, Psychologist, Matrix Support and capoterapia activity developed by a physical educator.
Professionals are concerned with the promotion of the health of the elderly under their responsibility, mainly through health education practices.
All educational health actions of the elderly, as stated by the National Policy on Elderly Health, should ensure that the elderly remain in the community, participating in preventive activities with their family, in the most possible dignified and comfortable way [14].Being attentive to those nuances of the aging process, especially for health professionals who deal with the elderly at the basic care level, refers to the precepts of the humanization of care and the provision of comprehensive care [15].
The social support networks have a potential role in assisting the elderly in the assisted communities, since the training of human resources in the area of elderly health is linked to an understanding of the aging process and its biopsychosocial repercussions [16].In the following testimonies, one perceives that the presence and support of trained professionals in the care of the elderly are essential, since the receptiveness, bond, early diagnosis, treatment and referral to other sectors of greater complexity depends on the knowledge of the professionals.
To recognize the reality of the elderly and their families, to identify risk factors to which the elderly are exposed and to intervene appropriately in them, to create a bond of trust with the elderly.

[...] the bond between the professional and the user creating a plan of care according to the patient's needs.
Dep. 6.

Referral for specialized evaluation, orientation of the patient and their relatives [...].
Dep. 15.
It is possible to observe, in the speeches of the deponents, a concern of the professionals with regard to their preparation and specialized knowledge to make the correct orientations and treatments.
It is necessary that the professional has an extended understanding of the living conditions of the elderly, because it is fundamental to understand the factors related to the psychological, family and social aspects, since reaching a successful old age extrapolates the functional conditions and the morbidity profile of the elderly [15].
Primary Health Care performs most of psychiatric consultations, since, even in the countries that most invest in mental health, there is a gap between supply and demand for specialized services.In Brazil, one recommends that the Family Health Strategy assists patients with mental health problems, and matrix support is a tool to qualify that work [17].
In this sense, it is worth mentioning that matrix support is an exceptional tool to qualify that work, and, thus, with the optimization of the resolution capacity and credibility of the Family Health Strategy, better care can be provided through psychosocial attention, as well as guaranteeing the right to adequate treatment, since it has the model of promoting integral assistance to the person, being the object of intervention mediated by the family and the community where it is inserted [18,19].Class 3. Difficulty in training the professionals from the Family Health Strategy for the management of psychosocial care services for the elderly Class 3, consisting of 10 ECUs, concentrates 11.9% of the classified ECUs, highlighting the words, training, difficulty, good, treatment, easeness, management, displacement, adhesion, lack, well and participation.
The context of the Psychosocial Care Network directs professionals to develop prevention and promotion of mental health of the elderly through the Family Health Strategy, aiming to reinsert them in society and rehabilitate them.For this to happen, professionals need to know the mental health strategic actions that will be developed in primary care.
The participants' discourses evidenced that some of those professionals did not know or had difficulty in dealing with mental disorders on a daily basis because they did not receive the training and capacity to develop that care.

[...] They directly relate to the inefficient training offered to the professionals, because there are not available qualification courses to better manage the situation.
Dep. 4.

[...] Need for management incentive to motivate professionals, through traiing to work with this specific demand.
Dep. 16.

[...] Lack of management investment, lack of training of professionals in the implementation of the Psychosocial Care Network.
Dep. 22.

Lack of training and training courses on this subject.
Dep. 23.In the interviews, the professionals mentioned the lack of incentive of health service managers to develop mental health training and qualification, which could result in an impoverishment of that assistance and, to certain extent, delay the recovery of health improvement in elderly in psychological distress.
The participants' speech, they was mentioned that the lack of training courses to deal with the demand for mental health often means that the physician only repeats the medication previously prescribed by the specialist and that, given those circumstances, the role of basic care as organizer of the care network, as advocated by the Ministry of Health, is partially compromised.
One of the reasons for the difficulties in strengthening and promoting mental health may have been the lack of preparation of professionals allocated to primary care [20], since the execution of mental health actions developed in primary care is not uniform and depends on the qualification of the professional or the manager's political decision, indicating that professionals must take advantage of new practices to develop comprehensive care [21].
Moreover, health professionals' understandings about the elderly interfere with the way they treat and assist them.
Therefore, training or skills can improve not only the training but also the attitudes of those professionals, so that they can assess and treat the conditions that afflict the elderly, as well as provide tools that strengthen them in the path of a healthy aging [22].Class 7. Need for more professionals from the Family Health Support Center, (NASF) specialized in care for the elderly, in the Family Health Strategy Class 7, consisting of 12 ECUs, concentrates 14.29% of the classified ECUs, with emphasis on the words, more, NASF, team, professional, psychologist, education, same, continue, group, still and Community Health Agent -ACS.
The following statements enable observing that the training of primary care professionals to care for the elderly with mental disorder becomes even more urgent when more complex cases arise, requiring interdisciplinary follow-up, with matrix support from other services for greater resolution .

In addition, for complex cases, it is necessary to develop a unique therapeutic project by the FHS and NASF professionals and the matrix support of other health services.
Dep. 8.

The difficulties are the lack of specialized professionals in the area of psychiatry for the elderly and the lack of multidisciplinary team and training.
Dep. 25.

Dep. xx.
Faced with the professionals' discourses, it was possible to identify the concern to maintain comprehensive care for the elderly with mental disorder, using strategies such as NASF support, the elaboration of a unique therapeutic project and the support of specialists from other levels of complexity, as well as the importance of training for the performance.
The Family Health team faces, in its daily service, adverse situations, which require resolution, besides offering a good receptiveness and establishing links with the users of the health system.Therefore, it is important to perform training and continuing education for the multiprofessional team, whether acting in the assistance, in planning or programming of actions [23].
That new model of health care bases on the pedagogy of problematization, intrinsically related to the actions developed at the work.The insufficient knowledge of the professionals about that assis-tance model, which does not integrate the training curricula of the professionals, makes the qualification prior to their performance in the Family Health Strategy necessary [24].
Therefore, qualifying professionals in the Family Health Strategy is a necessary and priority condition for achieving goals, solving problem and organizing the health service.Parallel to that, permanent education is configured as a policy institutionalized by the Unified Health System, which advocates the transformation of health work involving professionals, managers and health managers to integrate education and service [25].
Permanent Education works with tools that seek to reflect critically on the daily practice of health services, enabling the identification of the training and development needs of health workers and to qualify care and management in health, strengthening social control, aiming at the production of a positive impact on individual and collective health [26,27].
Potentially, it can either avoid the accumulation of cases of low complexity in specialized services, or allow quick and agile access to treatments that only specialized professionals can perform for cases/ situations of greater complexity/severity.Thus, the strategy of specialized Mental Health support to primary care teams is in line with the principles of the Family Health Strategy in order to provide integral health care, facilitating the user's access to the necessary specialty without losing the continuity of the treatment nor the link with the primary health care team [28].

Segment 3. The Psychosocial Care
Network in the care of the elderly user of alcohol and other drugs, with classes 1 and 6.

Class 1. Assistance to the elderly user of alcohol and other drugs in the Psychosocial Care Network
Class 1, constituted by 11 ECUs, concentrates 13.1% of the classified ECUs, with emphasis on the words, drug, alcohol, user, use, point, free, crack, circulation, care, include, disorder and mental.
Based on the professionals' discourses, it was possible to perceive their lack of knowledge about the Psychosocial Care Network, since many said they knew only the Psychosocial Care Center (CAPS) as the only service for the elderly with mental problems.
I think the network should work in a structured way and be presented to professionals so that we can insert the user into it.
My knowledge is limited exclusively to CAPS, which our city offers.However, it is ad modality for alcohol and drugs [...] Dep.18.
They are proposals for actions for the care of people with psychic suffering in addition to the receptiveness, treatment and follow-up of users with mental disorders including drug and alcohol use.

Dep. 23.
Many of the interviewees were unaware of the role of basic care in the care of the person with mental disorder, and they did not understand primary care as an organizer for the psychosocial care for the elderly.
The inclusion of mental health actions in the context of the Unified Health System has contributed to the consolidation of the Brazilian Psychiatric Reform, as well as the reorientation of the practice of family health teams among users with mental health needs [29].
The Psychiatric Reform represented a profound change in mental health care.Along with it, the process of reflection and transformation at different levels of care came, which, for more than three decades, has been a growing movement to demystify the stigma of mental disorder and, above all, to guarantee the right of citizenship to those people.
One of the participatns also mentioned that the network is a set of actions necessary to develop an integrated care, through the receptiveness, treatment and follow-up of individuals with mental disorders, including users of alcohol and other drugs.
The disarticulation of the network and the inexistence or lack of knowledge of the available back-up services, in addition to compromising the resolution of basic care, deplete the professionals and incapacitate the Unified Health System to provide comprehensive care for the elderly's health [7].
Therefore, it is of fundamental importance that the network works in a structured and adequate way to the reality of each municipality.The network space is where the professionals develop an adequate follow-up and treatment for the elderly with mental problems, in which they present a substitution to the treatment in hospitalization and concretise a new way of dealing with the mental disorder [30].
Therefore, the Psychosocial Care Network works under the logic of territoriality, promoting the articulation among levels of complexity, in order to provide the development of diversified strategies for individuals with psychic disorders, so that those individuals can resume their relationships and activities within the community, meeting the needs expressed by their relatives [11,31].Class 6.The policy of psychosocial care of the elderly through the Psychosocial Care Network -RAPS Class 6, consisting of 11 ECUs, concentrates 13.1% of the classified ECUs, highlighting the words, care, integral, network, attention, integrality, guarantee and know.
In the context of the National Policy on the Health of the Elderly, it is possible to observe that this policy reveals the primary care as the means of initial insertion of the elderly in the health services of the Unified Health System, and must rely on the refe-rence network of specialized services from health promotion to rehabilitation [32].
The following statements confirm that.
[...] Comprehensive care for the elderly begins with the Family Health Strategy and goes to the outpatient referral service, CAPS, and emergency care units.
[...] Access is guaranteed and priority to the elderly population to health services, comprehensive and multidisciplinary care.
Besides being one of the priority networks among health care networks, it is extremely important for the strengthening and integrality of care.
The professionals' positions demonstrate that it is of fundamental importance the presence of the Psychosocial Care Network to guarantee the integral care to the elderly person.They emphasized the importance of preventive actions and the early diagnosis carried out by the professionals of the Family Health Strategy.
The Family Health Strategy was designed to reorient health care to the population by promoting quality of life through the promotion of a healthy aging.Thus, adequate care for the elderly requires a coordinated health system, with each instance contributing to the actions developed, aiming to provide better care [16].
A consolidated health promotion in the Family Health Strategy reinforces the principles of the Unified Health System, especially the one of integrality in health care and social participation.As well as the integration of mental health in primary care favors the practices of comprehensive care, since it includes the concomitance of physical and mental disorders, improving access to mental health services [33,34].
It is essential that health policies contribute to people's longer life and with better quality, achieving an active and healthy aging in their integrality [2].
One of the reasons for the difficulties in strengthening and promoting mental health may have been the lack of preparation of professionals allocated to primary care [20], since the execution of mental health actions developed in basic care is not uniform and depends on the qualification of the professional or the manager's political decision, indicating that the professionals must take advantage of new practices to develop integral care [29].
Thus, the National Curricular Guidelines for Graduate Courses in Medicine [35] and Nursing [36] consist of orientations whose philosophical basis conceives the student as subject of his/her formation process, breaking the conservative conceptions of teaching and the political, historical and economic moments, already experienced in the context of education in Brazil.In this sense, the formation process in higher education bases on the development of skills and abilities in a perspective of change for the formation of critical, reflexive professionals inserted in the historical-social context, based on ethical principles to intervene in the problems of health care of the population.
Thus, one argues that training or qualifications can improve not only the formation but also the attitudes of those professionals, so that they can assess and treat the conditions that afflict the elderly, as well as provide tools that strengthen them in the path of a healthy aging [22].
Therefore, qualifying professionals in the Family Health Strategy is a necessary and priority condition for achieving goals, solving problem and organizing the health service.Parallel to that, permanent education is configured as a policy institutionalized by the Unified Health System, which advocates the transformation of health work involving professionals, managers and health managers to integrate education and service [25].
All educational health actions of the elderly, as foreseen in the National Policy on Elderly Health, should guarantee the elderly permanence in their community, participating in preventive activities with their family, in the most possible dignified and comfortable way [14].

Conclusion
The result of this study revealed important aspects about the relevance of the training of professionals of the Family Health Strategy in the psychosocial care of the elderly, concomitant with the implementation of the Psychosocial Attention Network.
In Brazil, even if higher education bases on the development of skills and abilities in a perspective of change for the formation of critical, reflexive professionals inserted in the historical-social context and based on ethical principles to intervene in the problems of attention to the population health, health professionals have difficulties in dealing with the elderly who have mental disorders in primary care.It is necessary to implement a policy of ongoing training and education for health professionals to improve care for the elderly.
International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q1 in category Medicine.

Segment 2 ., 3 and 7 . 2 .
Training of specialized professionals in the care to the elderly, in the Family Health Strategy, with classes 2Class Specialized knowledge of the Family Health Strategy professionals for psychosocial care for the elderly Class 2, consisting of 15 ECUs, concentrates 17.86% of the classified ECUs, with emphasis on words, relation, specialization, aging, elderly, physician, lack, area, politicy, hyperdia and articulation.

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com 4 Figure 1: Dendrogram
of classes derived from the corpus.Training of Professionals from the Family Health Strategy for Psychosocial Care for the Elderly.
NASF: Núcleo de Apoio à Saúde da Família (Family Health Support Center); ACS: Agente Comunitário de Saúde (Community Health Agent) InternatIonal archIves of MedIcIne sectIon: PsyquIatry & Mental health ISSN: 1755-7682We carry out a home visit, we go to the CAPS II if there is some mental disorder, we guide the caregiver in relation to care.These actions are carried out with patients with mental disorders, with the Family Health Strategy as the gateway.Dep.27.