Barriers to Care in São Paulo Home Visiting Programs

The skyline of São Paulo, Brazil. Source: Flickr, Júlio Boaro
The skyline of São Paulo, Brazil. Source: Flickr user, Júlio Boaro


I consider myself to be a person who likes being surrounded by people in small, cozy spaces. However, that didn’t seem to the case when I found myself in the middle seat of a ten-hour red eye flight this May.

Though there is only a one-hour time difference between New York and São Paulo, I felt groggy, as if it shouldn’t have quite been morning. I should still have been tucked away in my cubicle at the Yale School of Nursing, gathering the materials that I now carried in my luggage. My travel companion, Dr. Lois Sadler, and I looked around the international terminal, trying to catch the eye of anyone who even vaguely resembled the professor we had met via Skype several weeks before.

Soon enough, Dr. Lislaine Fracolli burst through the door of the terminal with more enthusiasm and energy than I could even pretend to muster. She was to be our colleague, guide, and close companion at the University of São Paulo (USP), where Lois and I were consulting that week. She explained that since we couldn’t check into our hotel until the afternoon, we would be going on a driving tour of the city with her and her family. At the time I was overwhelmed by conflicting senses of gratitude for her hospitality and dread at the thought of spending a few more hours without much legroom. I didn’t know then how important such a tour would be to understanding the work that we were about to do.

The University of São Paulo. Source: Flickr user Gaf.
The University of São Paulo. Source: Flickr user Gaf.

When I first began telling my friends and family about my summer internship with Minding the Baby® (MTB), an interdisciplinary home visiting intervention for young mothers in New Haven, I would always mention that I was getting the chance to go to Brazil. A fairly common follow-up question was, “Why Brazil?” Honestly, that was the question I was trying to answer for myself as well. I didn’t know much about Brazil, its people, and its specific health concerns when I got off the plane. Having started my internship just a week ago, I was only beginning to acknowledge my stacks of papers about toxic stress, attachment theory, and reflective parenting. The simple answer to the question “Why Brazil?” was that Dr. Fracolli and a group of researchers at the USP were establishing a home visiting program similar to MTB—a program that would help young, first time mothers achieve better health, mental health, and attachment outcomes despite often extremely stressful conditions.

Though the team at USP was incredibly eager to hear about the challenges that MTB faced in its beginning stages and the lessons learned since, there was a lot for us to learn as well. They weren’t exactly replicating MTB; they needed a unique program to address the needs of their community. There are certain barriers to access to care that make home visiting programs necessary yet difficult. We saw this most pointedly when we toured a Primary Care Health Service Center located on the outskirts of the city. After touring the facility, we drove around the neighborhood with several of the community health workers. Many of the families in the neighborhood live in extreme poverty. I was shocked to discover, however, that just a few streets away members of the upper classes enjoyed a much more privileged lifestyle.

Minding the Baby, a New Haven organization. Source:
Minding the Baby, a New Haven organization. Source:

The good news for this community is that the community health workers and the future home visitors of Dr. Fracolli’s Young Mothers program are extremely dedicated to improving the health and overall wellbeing in such neighborhoods. This, however, is no easy task. The streets in the neighborhood are so narrow that it wasn’t possible for our standard size mini van to pass through them. The steep hills that characterize this neighborhood become slick and dangerous during the rainy season. And the sheer size of the city, not to mention its world-renowned traffic, makes it difficult for home visitors to visit multiple homes in the same day.

When we spoke to the future nurse home visitors about the work they were taking on, they seemed nervous. This could partly be due to the language barrier that slowed many of our discussions. I also suspected, though, that they were worried about their safety during the home visits. It was evident from the amount of security we saw in houses how extensively the city is affected by crime. As the home visitors from MTB often say, “You never know what you’re going to find on the other side of that door.” For the most part, MTB home visitors are referencing the possibility of a recent breakup between parents, a foreclosure notice, or the arrest of a close family member. The two young Brazilian nurses are at risk of finding much worse behind the heavily locked doors they’ll be entering or even on the sidewalks in front of these homes.

However, in order to truly make a difference in the lives of these fifteen- or sixteen-year-old mothers, to help them ensure a bright future for their children and themselves, these nurses will stand on the front steps of what could be a disaster but what inevitably is an opportunity, waiting to hear the click of the last lock being undone.


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