Health Providers’ Perspectives on Quality of Adolescent Mental Health Services in Low- Resource Settings: a qualitative study in São Paulo City, Brazil

Abstract

Abstract Background: Quality in adolescent mental health services is instrumental to adolescents accessing and continuing care. There has been a growing interest and investment in adolescent mental health services, yet evidence on their quality remains inadequate, particularly in limited resource settings such as São Paulo city, Brazil. Health services in these settings experience a lack of financial and human resources. Adolescents within these settings are often exposed to poverty, community violence and limited access to resources and essential services; all of which contribute to the development of mental health conditions. The objective of the study was to explore health care providers definition of quality, as well as barriers and enablers to adolescent mental health services within resource-limited settings of São Paulo city, Brazil. Methods: Health care providers were purposively sampled in five primary health care facilities and two specialised mental health facilities, predominantly in the southwest zone of São Paulo city. Semi-structured interviews among 45 health care providers were conducted. Thematic analysis was used to explore their narratives. Results: No standardised definition of quality in adolescent mental health services emerged in the interviews. Definitions of quality revolved around a social determinants of mental health perspective; and aspects of service organisation including a trained, multidisciplinary workforce and person-centred care. These definitions were ideal and impossible to realise due to barriers identified by the health care providers, including underfunded and overburdened systems of care; the prioritisation of other age groups as set out by the primary care mandate; and the social and environmental context which adversely affected the provision of care. Ultimately, this resulted in the neglect of the adolescent by the health system. Conclusions: This is the first study to investigate health care providers’ definition of quality in adolescent mental health services in Brazil and in low-resource and violent settings. Based on health care providers’ definitions, a social determinants of health approach, in combination with a trained workforce and person-centred care, is key to addressing quality in adolescent mental health services. The findings have implications for local conceptualisations of quality, barriers to adolescent mental health services and reducing the treatment gap.