CARE FOR DRUG USERS IN A FAMILY HEALTH STRATEGY: POTENTIALS AND CHALLENGES^*

ABSTRACT

Objective:

To assess the potential and challenges in caring for users of psychoactive substances in a Family Health Strategy through the perception of professionals.

Method:

A qualitative case study was carried out using the Fourth Generation Evaluation, developed in 2023, in a Family Health Strategy in a municipality in Rio Grande do Sul, Brazil, with 19 professionals. Previous ethnographic techniques were used, interviews were conducted using the hermeneutic-dialectic circle, and the constant comparative method was used to analyze the data.

Results:

Team commitment and matrix support are potentialities. The challenges are difficulties establishing bonds with users, fears, and stigmas, the team’s lack of preparation, and the lack of physical structure and professionals.

Conclusion:

This study has helped to uncover the challenges encountered in caring for drug users and aims to promote care that embraces and integrates the individual.

KEYWORDS:
Family Health Program; Drug Users; Health Care; Mental Health; Primary Health Care

RESUMO

Objetivo:

Avaliar as potencialidades e desafios existentes no cuidado a usuários de substâncias psicoativas em uma Estratégia de Saúde da Família através da percepção dos profissionais.

Método:

Estudo de caso qualitativo, realizado por meio da Avaliação de Quarta Geração, desenvolvido em 2023, numa Estratégia de Saúde da Família de um município do Rio Grande do Sul, Brasil, com 19 profissionais. Foram utilizadas técnicas de etnografia prévia, entrevistas com aplicação do círculo hermenêutico-dialético, para análise dos dados utilizou-se o método comparativo constante.

Resultados:

ão potencialidades o comprometimento da equipe e matriciamento. Os desafios são as dificuldades dos vínculos com os usuários, os medos, os estigmas, os despreparos da equipe, a falta de estrutura física e profissionais.

Conclusão:

Este estudo contribuiu para o desvelamento dos desafios encontrados no cuidado à usuários de drogas e pretende fomentar um atendimento voltado para o acolhimento e integralidade do sujeito.

DESCRITORES:
Estratégia de Saúde da Família; Usuários de Drogas; Atenção à Saúde; Saúde Mental; Atenção Primária à Saúde

RESUMEN

Objetivo:

Evaluar las potencialidades y desafíos en la atención a usuarios de sustancias psicoactivas en una Estrategia de Salud Familiar a través de la percepción de los profesionales.

Método:

Estudio de caso cualitativo, realizado utilizando la Evaluación de Cuarta Generación, desarrollada en 2023, en una Estrategia de Salud Familiar en un municipio de Rio Grande do Sul, Brasil, con 19 profesionales. Se utilizaron técnicas etnográficas previas, así como entrevistas con la aplicación del círculo hermenéutico-dialéctico, y se empleó el método comparativo constante para analizar los datos.

Resultados:

El compromiso del equipo y el apoyo de la matriz son potencialidades. Los retos son las dificultades para establecer vínculos con los usuarios, los miedos, los estigmas, la falta de preparación por parte del equipo, la falta de estructura física y de profesionales.

Conclusión:

Este estudio ha contribuido a desvelar los retos a los que se enfrenta la atención a los consumidores de drogas y pretende promover una atención orientada a acoger e integrar al individuo.

DESCRIPTORES:
Estrategia de Salud Familiar; Consumidores de Drogas; Atención a la Salud; Salud Mental; Atención Primaria de Salud

HIGHLIGHTS

The potentialities are the multi-professional team and the matrix support.

Stigma and staff unpreparedness are considered challenges.

Fragmentation becomes insufficient in the care of drug users.

Receptive and comprehensive care for the subject.

INTRODUCTION

Primary Health Care (PHC), represented by the Family Health Strategy (FHS), is responsible for providing the population with the necessary care for their health problems, including prevention, promotion, and rehabilitation. It can solve around 80% of problems¹. In addition, the FHS plays an important role in advancing mental health policies, as it uses soft technologies for care that take into account risk and vulnerability criteria, welcoming people’s health needs and suffering, including users of psychoactive substances (PAS)².

However, PHC practices are still geared towards traditional clinical practice, such as diagnosing and treating clinical illnesses, with no defined care instruments for meeting mental health demands. This means there is no continuity of care, considered a central element of effective PHC.

It is, therefore, necessary to be attentive to the care of PAS users in PHC, as this is often based on the logic of medicalization and fragmentation of subjects, making the method reductionist and medical-centered. This reality tends to change more easily in scenarios where PHC professionals are willing to develop skills to welcome, listen to, and include people and families who use PAS, promoting an affective and committed bond between users, professionals, and families^3,4. That said, professionals who believe in the concept of comprehensive, person-centered health and not just labels and diagnoses should carry out care for PAS users in PHC.

Among the actions that reflect this broader concept of health and can be carried out by FHS, professionals are welcoming, dialog, qualified listening, home visits, groups, and therapeutic workshops. However, some challenges to PHC hinder or jeopardize these actions, such as low public incentives, precarious infrastructure conditions, low territorial coverage, and a shortage of professionals⁵.

In addition, the bureaucratization of Healthcare Networks and the tenuousness of permanent and continuing education actions are challenges for consolidating mental healthcare in the FHS. Stigma, the weaknesses of public policies related to PAS users, and the low approach to this issue in professional training processes also create barriers to effective care⁶.

From this perspective, we believe that the consolidation of singular and comprehensive care for PAS users in the FHS depends on the perception and knowledge of professionals. This study aimed to assess the potential and challenges of caring for users of psychoactive substances in a family health strategy through the perceptions of professionals.

METHOD

This is a case study with a qualitative, descriptive, and exploratory approach, with an evaluative character based on Fourth Generation Evaluation and supported by Hermeneutic-Dialectics⁷. The data was collected from January to June 2023 through prior ethnography and interviews with 19 workers from an FHS at a medium-sized municipality on the western border of Rio Grande do Sul, Brazil. The inclusion criteria for the workers were that they had been working in the FHS for at least six months and had not interrupted their work during the data collection period. The exclusion criteria were that they were on sick leave or vacation.

The investigated service serves approximately 9,000 inhabitants and has two Family Health teams. It is a pilot unit for PLANIFICA SUS, a project aimed at organizing and integrating Primary Health Care (PHC) and Specialized Care (SC), which serve users of the Unified Health System (SUS). Through matrix support, the service began the process of expanding care for users of psychoactive substances.

The teams comprised the following professionals: a physical education teacher, two doctors, two nurses, five nursing technicians, seven community health workers, a psychologist, a nutritionist, a dentist, and an oral health assistant. The service occurred in three shifts, a structured hybrid based on receiving spontaneous demand and scheduling appointments. In addition to these professionals, there were residents in collective mental health and academics from different undergraduate health courses.

Data collection was divided into the operational aspects of the evaluation process: contacting the field, organizing the evaluation process (prior ethnography), identifying interest groups, developing joint constructions, expanding joint constructions, preparing the negotiation agenda, carrying out the negotiation, and organizing the results report. The central focus was to evaluate care for users of psychoactive substances in a family health strategy, recognizing care, potential, and what can be improved in the care of this population. It was carried out using the Fourth Generation Evaluation. The Dialectical Hermeneutic Circle was used to conduct the interviews.

The methodology used in this study required data analysis to be carried out concurrently with data collection, one guiding the other, based on the Constant Comparative Method⁸. This method allows the interview to be analyzed beforehand, constituting an analytical development, and then taken to the focus groups for validation. Thus, each respondent’s constructions are identified, and the content of the previous interviews is presented in subsequent interviews to make new formulations about the issues raised in the testimonies.

The first stage of data analysis was identifying the units of information that served as the basis for defining the categories. The units were found in the material collected by reading the interviews and observations horizontally. After locating a unit, care was taken to record the information understandably, making it clearer. Coding was carried out according to the source and type of respondent, accompanied by the excerpt from the interview that gave rise to it. Once all the information units had been obtained, they were brought closer together to make it possible to analyze them from the point of view of the group of interest.

The questions were regrouped in the data analysis, which allowed for constructing evaluation markers. The following markers were delimited: the care provided to PAS users in the FHS, the potential and challenges encountered in this care, the mental health care network based on the FHS, matrix support as a tool to enhance care, and what can be improved in the care provided to users in the FHS. This article will discuss the potential and challenges of caring for PAS users in the FHS from the professionals’ perspective.

This study was approved by the Research Ethics Committee of the Universidade Federal do Rio Grande do Sul under opinion number 5.788.530/2022.

RESULTS

Nineteen FHS professionals participated in this study, including three nurses, a physiotherapist, two psychologists, a nutritionist, a physical education teacher, a doctor, seven community health workers, two nursing technicians, and an administrative technician.

Potential of care for users of psychoactive substances in the FHS

Some FHS professionals believe that the team is one of the unit’s strengths, even though they have little knowledge of mental health. The team considers itself willing to learn and recognizes that the bond with the user generates a great opportunity to bring them closer to the health service. In addition, the statements also point to the Residency in Collective Mental Health and the matrix support as potentialities since both make it possible to expand and share care.

Matrix support is a potentiality; it’s where all the planning is done, studying each case... This is essential for resolving problems. (P4)

The proximity that the service has with the territory, the fact that it has, especially the health agents who bridge the gap between the service and the people, I think it allows for a slightly closer look... a team that can identify and look for its patients and can articulate strategies to think about care. (P10)

The residency (in mental health) helps a lot; they know how to talk to people and get to the point where the person is talking...and the welcome they get at the FHS is very good. (P11)

The multi-disciplinary team... we have a team that no other unit has, which can provide clinical support for users undergoing specialized treatment. (P12)

It’s a strategic place for many users; we have a lot of people here who are socially vulnerable and even use substances...secondly, we have some professionals who are sensitive to this issue who like to take these users in... the matrix support and the mental health residency, which left us very weak in this regard after the unit left. (P19)

Challenges reported by the team in caring for users of psychoactive substances

In addition to the challenges inherent in professional knowledge, some challenges concern the user, such as making them feel comfortable talking about their drug use. However, when this happens, staff report feeling fear and prejudice, directly reflecting on the care provided to users.

The team still has much prejudice when it comes to the issue of alcohol and drug use [...] Ah...you’re going to help the drug user first when there are other demands to attend to? I think it is a big challenge to change the way professionals think, you know? (P2)

One challenge is for people to understand that it’s a more complex problem than it seems and that the patient isn’t in the situation just because they want to be and like it. It is a challenge to understand that this is something so important to be noticed, to be treated like cancer, like diabetes and hypertension, and generally, even in the health sector, many people end up treating it as if it were, they use the name, right, “throw a temper tantrum”, that the patient is trying to attract attention, I think that’s the main challenge, to understand that it’s not that. (P17)

I think the biggest thing is getting them to come here, which is quite difficult. It’s easier for us to go there and take a professional than for them to come on their own. (P16)

The team identified several challenges related to weaknesses in the care of PAS users, such as the lack of professional training to meet this demand.

Professionals aren’t trained to deal with these users, so training professionals is a very important challenge, not least because you don’t have a team, you don’t know who to ask for help to bring this training, right? (P1)

It’s more of a question of training for us; sometimes we come here and end up, yeah, I’ve been learning in practice, but how do we deal with it, with the staff? How do we pay attention, how do we look at things differently, and how do we be more special? In short, sometimes we miss this training, but we do it in practice. (P18)

We don’t have any concrete information, or at least I don’t know what to do or how to proceed if he comes here and goes through a screening, and then they send him there; I don’t know what to do. (P6)

Other points identified by the team are the lack of professionals and the lack of physical structure in the FHS to meet this demand, as well as the difficulty of the PHC in communicating and articulating, which is a major barrier to continuity and resolutive care.

But maybe there’s a need for more professionals in this area; who knows? For greater resolution, because there’s always a demand, right? There’s a big problem: getting these users to come to the health center and accept this health care. With help from health professionals, some patients are very resistant. That’s why it’s so difficult for us, as a health team, to reach them. (P4)

What I notice is a lack of physical structure because, for example, they’re in mental health training in a residency, right? You can do N situations, launch various groups, and invest in other activities, but we lack structure here. When you don’t have the structure, there’s no point in wanting to do a group of this, a group of that; you have to have it because, another thing, the patients, many of them have the reference of the unit, they’re not going to want to go somewhere else, right? (P14)

A challenge? At the moment, I would say the lack of professionals... whether we like it or not, this overloads the professionals here, and we cannot give them the attention they deserve. We’re attending a lot, and we’re overloaded. (P19)

We sometimes see this network communication that the FHS is trying to articulate. Still, other services resist sharing and exchanging because they sometimes feel the patient is separate, right? Like, ah, he’s a PHC patient; you don’t have to know what’s going on here. Since it’s what I said before, right? The same patient is circulating, so everyone can know they’re not. It’s not exclusive to one service, and sometimes I see that mental health services, in this case, he, I’m referring to other services, right? As a challenge. But I think it would be more or less communication. (P10)

DISCUSSION

The professionals recognize that, amid the existing potential, having a multi-professional team and being inserted in the subjects’ territory makes a difference in the care of substance users. The professionals can learn and share their knowledge with other members of the FHS. It is important that within the multi-professional team, there is collaboration between members and that the various professionals work in an integrated manner, with dialog, respect, and positive reinforcement from all members⁸.

New knowledge is built through collaboration, exchange, and willingness to acquire new learning. In addition to overcoming the logic of just occupying the same space, a collaborative team supports co-responsible care for a population’s health needs, and collective action in the territory intensifies the team’s belonging^8-9.

With collective action in mind, the experience of matrix support emerged as a device recognized by the team as an enhancer of care for PAS users in the territory. Each case is studied in the matrix, and support meetings and care actions are planned. Mental health matrix support depends on commitment, availability, and change on the part of everyone involved. It is a negotiation between the different types of knowledge present, seeking care strategies for an individual or population. It proposes a new way of producing health, qualifying care in the FHS, and reducing unnecessary referrals^10-11.

From the interviews and the monitoring carried out in the previous ethnography, it is possible to see that this team still lacks a greater understanding of what matrix support and matrix support are; considering this device to be more than just a simple discussion of cases, but a respectful sharing of knowledge that strengthens and instrumentalizes both professionals and users. Although the team identified itself as having potential, the interviews mentioned some challenges in caring for PAS users, such as prejudice on the part of professionals, fear of drug users, lack of technical knowledge to manage the user, lack of professionals, and lack of physical structure to provide better care.

The perception of drug use in determining how “professionals” see the person can hinder the perception of the user as a social subject inserted in a common world, constituting a barrier to building a bond between professional and user, especially when the professional has prejudiced and stigmatizing attitudes, anticipating the judgment of someone for using drugs¹². This anticipation can threaten mental health care, as it strengthens stigmas and supposed social “truths”, such as intervention for drug users with no positive return, or the question “why attend a user who has had attitudes to get sick and not the other patients?”¹³.

This segregation and stigmatization related to drug use, which is still perpetuated in our society, is what fosters neglect in the field of health care. Professionals go through experiences that lead to inaccurate feelings and classify the subject as a “victim” or “culprit”, directly reflecting on the care provided to service users, in this case, users of psychoactive substances. These feelings can make it difficult for care to come and go in the relationship between the professional and user¹².

The discourse that drug users are problematic and difficult to treat is a barrier to providing care. Thus, according to Merleau-Ponty¹³, professionals can only perceive what is shown (figure) without considering the whole context (background) experienced by the consumer.

Care based on moralism leads professionals to expect abstinence from the user and to treat the subject as the only one responsible for their social problems, the development of addiction, and their behavior, which can sometimes be violent. By persisting in the moral discourse, these professionals will find it very difficult to establish a bond with the user precisely because they don’t perceive their world to be the same as that of the user who habitually consumes drugs¹².

According to the data from this study, the popular imagination has much influence on the conduct of professionals, as there is a great deal of prejudice and value judgment on the part of the community, revealing the stigmatization of drug users. These issues can make it difficult for FHSs to access and accommodate this demand, and the speeches corroborate the difficulty that professionals often have in approaching these users due to the fear caused by the strangeness of some behaviors¹³.

Thus, while recognizing the need to care for drug users, the absence of care is also revealed when it appears in the speeches that there is no specific care or training to care for those who use drugs.

This study’s findings include the professionals’ reports on their unpreparedness and lack of training to care for these individuals. Given this, it is believed that the preparation of professionals, whether in primary care or other care network devices, is considered a strategy for care and the work of the health team. Professionals should receive continuing training to manage crises, thus creating a context of care¹⁴.

Mental health actions in PHC depend a lot on the individual mobilization of professionals. The best strategy observed to assist PAS users in the FHS successfully was to invest in the qualification of professionals through permanent education and training in this area. Given this scenario, the study’s limitation arises because it is known that we still have a primary care model centered on programs or health areas, which is different from the PHC proposal. PHC should act as the system’s main gateway and not “choose” or classify users according to the available programs and resources but offer comprehensive responses and care coordination regardless of the user’s problem³.

It’s important to make referrals to specialized care, when necessary, not making this a practice that happens without at least assessing the drug user’s conditions and needs.

As a limitation of the study, it is estimated that the scope of this research provides partial answers to what was evaluated, as only one reality was detailed and studied.

CONCLUSION

The data from this study made it possible to assess the potential and challenges encountered by professionals in caring for psychoactive substance users in the FHS. It was found that the search for reception and treatment for people who use PAS still faces barriers, even though the team is willing and open to new knowledge. The team recognizes that being close to the subjects’ territory is an opportunity to bring them closer to the health services.

However, social imagination influences the behavior of professionals, who make care based on moralism. This moralistic discourse alienates users from health services and distances the creation of a bond between professional and user. The professionals report that matrix support has emerged as a tool to enhance the follow-up of these cases in the territory.

There are many challenges involved in caring for psychoactive substance users. However, this study has helped to unveil this context and, in this way, will be able to foster care that is geared towards welcoming and integrating the subject since fragmented actions are not enough to meet the demands of psychoactive substance users.

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• *
  Article extracted from the doctoral thesis: “AVALIAÇÃO QUALITATIVA DAS AÇÕES DE CUIDADO À PESSOAS USUÁRIAS DE SUBSTÂNCIAS PSICOATIVAS EM UMA ESTRATÉGIA DE SAÚDE DA FAMÍLIA”, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil, 2023.

Edited by

Associate editor:

Dra. Maria Helena Barbosa

Publication Dates

• Publication in this collection
  22 July 2024
• Date of issue
  2024

History

• Received
  12 Nov 2023
• Accepted
  14 Apr 2024