Implementing community handicraft groups for women at primary care units

To mark this year’s WMHD, the Mental Health Innovation Network is running a month long series (#WMHD2015 Blog Series) highlighting dignity in four areas of global mental health where dignity is most often compromised and/or redeemed. This week’s subtheme is “Dignity in Health Services”. 

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Primary care as part of the Brazilian National Health System (SUS), which is universal and free of charge, has a territorial basis where family health teams (FHT), consisting of a doctor, nurse, nurse technicians and community workers (CW), are responsible for caring for 3,500 people. Their responsibilities include health promotion and one of the key FHT aims is to promote citizenship and develop dignity and autonomy of people in their area, a service especially important given the location of the people -- mostly located in low resource and sometimes violent communities, usually slums.

I have worked in the SUS for more than 20 years, implementing primary mental health care, and have many times seen and heard about experiences of women’s handcraft groups developed by these teams, especially by the CWs. These are weekly groups that bring together women from the community to do handcrafts and talk together, including aspects related to health promotion and overcoming of social and personal problems,  promoting empowerment, self-esteem and dignity by increasing social support and integration. These groups are usually called “fuxico” groups: a word in Portuguese that stands both for specific manual work (see below) and also the act of speaking in a group about oneself and other people´s lives.

Several of these types of experiences had been related but I had never seen any scientific work analyzing these experiences, so that’s what we decided to do. Three years ago, in our research group ( at the University of State of Rio de Janeiro (UERJ), we decided to help develop these community groups in our region (the Tijuca Area or the 2.2 Programatic Area) in Rio and to analyze their experiences. Receiving funding from the National Secretariat of Policies for Women (SPM/PR) through the CEPESC (Social Sciences Research and Studies Center), we decided to start in five communities: Formiga, Borel, Casabranca, Morro dos Macacos and Alto da Boavista. Three of them already had existing community groups but had organizational difficulties and the one had stopped meeting.  In the other two communities we had to start from the beginning.

Although any woman could come to these groups, the FHT recommended them specifically for those that were anxious, depressed, isolated, and with family and social problems. These women faced very hard lives: several had lost their husband, either being abandoned, because they weren’t alive anymore or were in prison, leaving them alone with the kids. Several were old. They did not have any work and most were isolated at home. And they had very low self-esteem and felt really underpowered.

We decided to support them in many ways e.g. buying material, organizing the meetings, finding and paying women with different handcraft expertise to teach these skills and even organizing courses for those involved to develop business skills to they could make money from their work. We also assigned one psychologist facilitator in each area to work with the CWs, so that they would be able provide support to the women who were emotional suffering.

Over the course of this project, we were impressed with what we have found: the main problem was that these women felt that they didn’t have any value nor did they deserve anything – they had no dignity!! Other key messages that we found were:

  • Women thought they would never be able to do “something so nice”
  • Some families did not understand why they had to come to the groups instead of staying at home taking care of them
  • Some women were so depressed that they thought about killing themselves several times a day but still kept on taking care of their families
  • Some women with severe mental health problems, that had been taken to psychiatric hospital many times, went just to be with the people that worked there
  • Some women never went outside their communities and were very scared of doing so, therefore they did not know their city
  • Opening a bank account to receive payment is something very difficult when you do not have a job or if your family has taken loans using your name.
  • “Putting a price” for a product is very difficult when you do not know the value of your work.

But later we found out that taking part in these groups helped these women by offering them a place to enjoy themselves, talk to other women, make friends, develop abilities and creativity, earn some money but mainly to empower themselves and increase their self-esteem. The groups were a place that encouraged the development of dignity for these women: to be accepted, to be recognized, to be respected, to be encouraged, to be seen and heard, by their families, by the professionals from the teams, by their neighbors, by the NGOs and by the people that taught them their new skills.

We learned a lot about implementing these groups in the SUS, easily categorizable in two ways: favorable and unfavorable factors. We have analyzed them using the following situational analysis methods: defining strengths, weakness, opportunities and threats, both internal and external. Some examples are:

  • The presence of a local woman acting as a leader, supporting the others learning craft techniques. (favorable internal factors - strengths)
  • Engaging these women with the networks (mainly NGO´s) that offer courses on entrepreneurship and “solidarity economy”, further empowering them to collectively organize themselves to sell products and share the profits. (favorable external factors - opportunities)
  • Difficult to motivate women to participate regularly as they are overwhelmed by their family responsibilities and have little time for themselves. (unfavorable internal factors - weaknesses)
  • Managers of the Primary Health Care units, who coordinate the teams work, had difficulty in understanding that the community health workers should organize and be responsible for   these groups  as this was a health intervention to improve women self-esteem and to care for potential mental suffering, what meant empowering the CHW as a group able to deliver mental health care (unfavorable external factors - threats)

But what is the most important result for us? The changes in their faces, looks and attitudes: we can see that dignity is there. And our health system has helped to develop it.

Project Coordinator: Sandra Fortes

Researchers: Ana Paula Florenzano, Ana Cristina Lima, Angela Machado, Ellen Aragao, Kali Alves, Karen Athie

Faciliatators and Support: Andreza Souza, Andrezas Siqueira, Marilia Verdussen, Bianca Souza​

Image courtesy of Valentina Iemmi. Copyright © 2015 Valentina Iemmi. All rights reserved

South America
Empowerment and service user involvement
Prevention and promotion
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Lindo! Tratar a pessoa como alguém dotado de direitos, lembrando dos fundamentos constitucionais do Estado Democrático brasileiro, entre eles a cidadania e a dignidade humana, é uma forma de produzir saúde. Empoderamento e cidadania andam de mãos dadas.

yes, Debora, Empowerment is specially important for mental health ! Feeling worthless has been associated with depression for many years already. it is usually considered as a symptom of depression. But in reality they are associated in both directions: feeling worthless causes depression and depression increases your feelings of worthlessness. This association has to be broken: creating activities, initiatives, opportunities for empowerment, for developing our creativity, for enhancing social bonds, for being recognized for our intrinsic value makes us feel recognized and respected. This is Dignity ! This is Mental Health !
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