Street clinic : the care practices with users of alcohol and other drugs in Macapá

Objective: To analyze the care practices of professionals from the Street Clinic team (SCt) about the care provided to users of alcohol and other drugs in Macapá, capital city of the state of Amapá. Method: Descriptive, qualitative study, carried out between April and June 2017. Ten SCt professionals participated. Five guiding questions were used for data collection, later analyzed through Bardin’s Thematic Content Analysis. Results: Facilitating care strategies involved harm reduction, teamwork, creating the link with users, team commitment and partnership with other members of the Psychosocial Care Network (PSCN). Of the factors that make care difficult, are the deficit of self-care, structural and human resources, and prejudice. Conclusion: Professionals are aware of the purpose and importance of SCt in strengthening PSCN. Conclusion: When conducting a practice based on public policies, care for the street population is facilitated.


INTRODUCTION
The World Drug Report published in 2018 pointed to the expansion of the world market for illicit drugs, such as opium and cocaine, and Cannabis was among the most used illicit drugs in 2016, including in Brazil, with a tendency to increase worldwide.In addition, the use of medications without prescription has presented itself as a threat. 1 The study also showed that, in Brazil, cocaine-paste use has increased; 5% of Brazilian respondents reported having used illicit drugs in 2018. 1 Data published in 2017 2 on alcohol and tobacco use in Brazil indicated that 10.1% of the respondents reported being smokers, being men (13.2%) and women (7.5%); the highest incidence of smokers was in Curitiba, and the lowest in Salvador 2 .Regarding alcohol, 19.1% of the interviewees consumed five or more doses of alcohol in the month prior to the interview, being men (27.1%) and women (12.1%); the highest frequency of abusive users was in the Federal District, and the lowest in Manaus.
In relation to Macapá, 7.2% of the adults reported being smokers, being 11% men and 3.4% women.In relation to alcohol, 15.9% reported having used alcohol in the last month, being men (23.7%) and women (8.6%). 2 Many are the consequences of abusive use of alcohol and other drugs, among them being one of the reasons why people start living on the street.However, the street condition can also lead to drug addiction. 3One study pointed to alcohol and crack as the most used drugs by homeless people (26.7%, and 23.37, respectively), as well as drugs of higher addiction, especially when there is an association between them 3 .All interviewees in the study reported making use of drugs; only 25.3% reported not being dependent on the drugs used. 3n this sense, the inclusion of the Street Clinic teams (SCt) by the National Primary Care Policy of 2011, and as a care device of the Psychosocial Care Network (PSCN), through ordinance 3088/2011, was essential for the population especially for those with problems related to the use of Alcohol and Other Drugs (AOD).
According to ordinance 122 of 2011, the SCt act as a component of basic care in the PSCN, constituting the gateway of this segment of the population in care services, and has as guidelines of care the actions of psychosocial attention, Harm Reduction (HD), educational activities, and follow-up, being integrated with the Basic Health Units and the Psychosocial Care Centers (PSCN). 4The SCt can be proposed in three different modalities and its financing is in accordance with the population census of the people in street situation of the municipality, being one team for every 80 to 1000 street dwellers 4 .The city of Macapá is served by two Modality I teams, with five higher and mid-level education professionals.
Although few studies that analyze the practices of these teams with AOD users in Brazil -which include nurses and nursing technicians, social workers, psychologists, occupational therapists, social agents and oral health technicians -the studies show that the welcoming practice, free of prejudice and promoter of social reintegration as essential, but also evidence that the professionals working in the SCt team face difficulties to provide assistance to the population.] Thus, in light of the above, it is important to carry out studies that, like this one, aim to analyze the SCt professionals' care practices on the care provided to AOD users in the city of Macapá-AP, as they will serve as evidence for the proposing of new policies for the street population and improving the working conditions of SCt, both in Macapá and in other Brazilian cities.They will also serve to strengthen the issue under discussion, since studies that involve the care of the users of AOD by SCt are scarce in the Brazilian literature.

METHOD
This is a descriptive qualitative study.In Amapá, the municipality of Macapá has approximately 1000 street dwellers, and, therefore, it is the only municipality served by SCt in the state, with two SCt in Modality I, which have been functioning since 2012 and are coordinated by the Municipal Health Secretariat in partnership with the Resident Program in Collective Health of the Universidade Federal do Amapá, with a team of nurses, a psychologist, a nursing technician, a social worker and a social educator, totaling five professionals in each SCt.Considering that the professionals of both teams had been working in the services for more than 6 months (inclusion criterion), all ten professionals were included in the study.
Data collection took place from April to June 2017.The interviews were held in a reserved place, ensuring neutral and calm environment where there were no interruptions and where it was possible to take advantage of the time reserved by the team to plan the routes of activity.The interviews were recorded and transcribed and lasted approximately one hour.In order to preserve the identification of the interviewees, it was chosen to refer to the participants in the body of the work by the letter "E", followed by the number of interviews.
The interviews were composed of the following guiding questions: "What is the Street Clinic's proposal to approach the user of alcohol and other drugs?How does the approaching of users of alcohol and other drugs occur?What are the facilities in caring for alcohol and other drug users?What are the difficulties in caring for alcohol and other drugs?How does articulation between the team and other health sectors occur that also serve these users?" For the analysis of the interviews, the strategy of the Analysis of Thematic Categorical Content 7 was used, which includes the following steps: 1) Pre-analysis; 2) Exploitation of material; 3) Treatment of results obtained and interpretation 7 .In the pre-analysis, the material was read, allowing orientation and direction in the analysis of the impressions.In the exploration stage, the distribution, classification scheme and organization of sentences, phrases and other characteristic parts of the investigated phenomenon were carried out, dialoguing with part Street Clinic: care for chemical dependents Bittencourt MN, Pantoja PVN, Silva Júnior PCB, Pena JLC, Nemer CRB, Moreira RP of the texts of the analysis.
In the interpretation, the topics that emerged from the files were grouped and analyzed using the thematic categorical content analysis method, which is characterized as a set of communication analysis techniques, using systematic and objective procedures of description of message content. 7he research complied with Resolution 466/12 of the National Health Council, which establishes guidelines and norms regulating the ethical aspects of research involving human beings.The project was appraised and approved by the Universidade Federal do Amapá (UNIFAP), with an opinion nº 1919.549.

RESULTS
The subjects' ages ranged from 34 to 39 years old, nine of them female.Through the analysis of the content of the speeches, three thematic areas of analysis and subcategories emerged adjacent to them, which are: Thematic I: The strategies of care of the professionals of the SCt with the user of AOD -with two subcategories; Thematic II: Factors that facilitate the care to AOD users by SCt -with three subcategories; and Thematic III: Factors that make it difficult for SCt to care for AOD users -with three subcategories.

Thematic I: The strategies of care of the professionals of the SCt with the user of AOD
This first thematic is related to the strategies used by SCt professionals to promote AOD user care in Macapá.From this theme, two subcategories emerged: a) Harm Reduction Proposal; and b) Promoting the access of users of alcohol and other drugs to health services.

Subcategory 1: Harm Reduction
This subcategory refers to discourses that point to harm reduction as a care strategy carried out by the SCt of Macapá-AP: [...] Specific to the user of alcohol and other drugs, we work with harm reduction.In this case it is not to force the user to stop using drug [...] (E1).

Subcategory 2: Promoting the access of users of alcohol and other drugs to health services
This subcategory presents the promotion of access of alcohol and other drug users to health services as a strategy for the care of SCt professionals, as indicated in the following speeches: [...] The street clinic was implanted to make a link between users of alcohol and other drugs, to have access to health.Being that they are a public that do not go to the BHU [Basic Health Units], have difficulties to reach the BHU because of the prejudice, which is very big [...] (E3).
[...] Our first proposal is first to gain the confidence of the majority, since many of them no longer have contact with relatives and the matter of the bond is fundamental so that we can take the health services to this population that lives in the street.[...] (E4).

Thematic II: Factors that facilitate the care to AOD users by SCt
This second theme refers to the discourses that point out the main facilitating factors encountered by SCt professionals from the municipality of Macapá-AP during the exercise of their care activities directed to alcohol and street drug users.From this theme, three subcategories emerged: a) Link as facilitator; b) Availability of SCt; c) Articulation between SCt and other PSCN services.

Subcategory 1: Link as facilitator
This subcategory points out, in the speeches, the creation of bond as a facilitating tool of care, since it assists in the development of trust between SCt and the user.Professionals reported that bonding is the least invasive way of insertion into the environment of use and abuse of alcohol and psychoactive substances, which facilitates care: [...] The most important is the bond, so they adhere to our proposal.Create a bond, always be going there, accompanied by continued care to strengthen bonds [...] (E1).
[...] What we get of ease comes from the talk and the bond.When they already know us, they already arrive and say what they need, such as a consultation schedule, for example.This makes our work a bit easier [...] (E4).
[...] Through the link, which enables us to talk to him, and this makes our work easier, we are going after consultation for those who need it, it's best for them to go to the BHU as well, to follow up on some medication treatment, all of this makes it easier [...] (E5).

Subcategory 2: Availability of SCt
This subcategory stands out in the speeches available to face the adversities, facilitating the care of the users attended by SCt professionals.Professionals suggest that a SCt, to be effective, should be staffed with professionals willing to promote care, as in the following speeches: [...] What facilitates this approach to these people is the availability of the team, because if we arrive unavailable, it becomes difficult to create any tie [...] (E7).

[...] I think that since the team is made up of health pro-
Street Clinic: care for chemical dependents Bittencourt MN, Pantoja PVN, Silva Júnior PCB, Pena JLC, Nemer CRB, Moreira RP fessionals, and they like to help others, is that everyone is willing to help, that's the ease.We are gradually conquering, trying to understand.Keeping yourself available [...] (E8).
[...] In relation to services, it is easy when our access to our patients is facilitated, when professionals are willing to attend to them, which sometimes does not happen immediately [...] (E9).

Subcategory 3: Articulation between SCt and other PSCN services.
This subcategory presents the discourse on the importance of the articulation between the services that make up the Psychosocial Care Network as a facilitating factor of the care of the professionals who work in the SCt, as pointed out in the speeches: "This interconnection happens through partnerships, through people we already know and help us when we need to, because the user alone cannot, the Popular Center helps us in the matter of documents, PSCN also help, especially PSCN AD and PSCN I, but in general it is through these partnerships" (E9) "We say that we're from the Streert Clinic and if there's someone we know there, it's accessible and they're taken care of.There at the Emergency Hospital, in the PSCN, works through acquaintances of ours in other health sectors, examinations also, most of our access is through our life contacts" (E8) "It is through the contact that the team has with professionals who can facilitate the care of these people that we know people at BHU, PSCN AD, and so we get something" (E7) "Through partnerships, PSCN AD, with the popular center, the health units where we can get care with a psychologist, a doctor, we get in touch and can make the appointment" (E5) Thematic III: Factors that make it difficult for SCt to care for AOD users.
This third thematic refers to the speeches that point out the main difficulties encountered by SCt professionals from the municipality of Macapá-AP during the exercise of their professional activities directed to alcohol and drug users.From this thematic, three subcategories emerged: a) Self-care of users; b) Structural and human resources deficit; c) Prejudice and stigma

Subcategory 1: Self-care of users
This third subcategory is related to the negative effect that the self-care deficit of the homeless has on the professionals, who have prejudice and, about themselves who, without wanting to take care of themselves, do not seek help, as stated below: [...] with the user who makes use of psychoactive substance, self-care will depend on him and this ends up creating resistance from him, because due to the effect of the drug, he ends up neglecting his own body, his health, just seeking any help when he is already in a lot of pain or in a more serious state [...] (E9).
[...] the first difficulty is to make him take more care of himself, because addiction causes a lot of trouble and is our barrier to try to raise awareness that his health is more important than addiction, the prejudice in the units and other services, both health and social, because these people are viewed badly by society, the appearance, lack of hygiene, all this influences the in terms of care [...] (E8)

Subcategory 2: Structural and human resources deficit
In this subcategory, the professionals at the Macapá-AP SCt put the lack of vehicles and professionals as main obstacles in their practice with users of alcohol and other drugs on the street, according to the following speech extracts: [...] The car is for two teams and has to wait the route of each one and the gasoline is limited, it is only 15 liters, and sometimes it is not only the route, you have to take them to the consultation, to do examination [...] (E8).
[...] the number of professionals in the teams is not enough, especially in health, since many users do not accept to go to the health unit to receive care because they have already been abused before [...] (E9).

Subcategory 3: Prejudice and stigma of other health professionals
This third subcategory presents in the discourses the consequences of the prejudice and stigma of health professionals from other services to the homeless, situations that end up interfering in the care, as explained in the excerpts of speeches that follow: [...] One of the difficulties faced is the prejudice in the units and in other services, both health and social, because many of them owe to Justice, or are sex workers and also have a stigma with these people, who are looked at in a bad way by society [...] (E9).

[…] Most of the time, we arrive at the place of care and people start to cover their noses, look different at them, we often do the medication at the place where they are due to the resistance of not wanting to go to the UBS. Some physicians and the UBS staff have a resistance to attend to the homeless, this prejudice with homeless person makes our work very difficult [...] (E4).
To conclude, Table 1 presents the themes and subcategories that emerged from the interview content.Also, the code and the number of the statements that represented each of the subcategories were presented -Table 1.

DISCUSSION
It was observed that the professionals evidenced the harm reduction and the promotion of access to health care as care strategies to the users of AOD by SCt.In relation to the facilities, they present the formation of the link between users and professionals and the availability of the team, as well as the articulation between SCt and other PSCN services.In relation to the difficulties, they pointed out the self-care deficit of the homeless, the precariou-sness of the structure to carry out the work and the shortage of human resources in the team, as well as the prejudice associated with stigmatization of the homeless.
In the first Thematic, subcategory 1 demonstrated that SCt professionals use the harm reduction strategy as one of the care strategies for AOD users.The identification of harm reduction as a care strategy for Macapá SC professionals is relevant and positive, as it is a strategy that is one of the actions of the National Policy of Basic Attention 8 , the Policy for the Integral Attention to Alcohol and Other Drugs Users 9 , and SCt operating guidelines 4 , thus demonstrating that Macapá's SCt professionals conduct informed practices through policies that direct care to the street population using AOD.
The data also pointed out that professionals saw SCt as an important tool in promoting access of AOD users to health services, strengthening the importance of SCt role in promoting articulation among the other PSCN services, since, as pointed out by them, this articulation allows an integral look at this user and strengthens the care initiated by them. 4,10-13However, it is worth emphasizing that, in addition to the SCt being a health care service for this population living on the street, it is also a tool that allows us to problematize the forms of care that permeate this assistance in the face of the fragilities that these networks have. 10,13t was also observed that the professionals identified the bond as a facilitating means, and that it potentiates the care done by them.This is a relevant finding because the creation of links permeates the healthy interpersonal relationships that are built together with the subjects who need care and who, according to a previous study with users of a Psychosocial Care Network for Alcohol and Drugs (PSCN AD), these harmonic relationships with professionals enable them to be better understood, and professionals recognize the real needs presented by them 14 , creating bonds of empathy and trust, which may reflect healthier life choices.
In addition, the professionals raise the commitment of the SCt to the care and they point that the availability and the commitment of the team in the creation of the therapeutic environment can be stimulated when the professionals who work in the SCt have profile to act free of fears, constructed from a social stigma with which the street person suffers in society. 12t is important to point out that the Street Clinic is the priority entrance door of the homeless population to the Basic Health Care of the Unified Health System (UHS) and that, therefore, it is also a space that is a priority for strengthening care and the creation of a link in the health care network 12 .Thus, the clarity of these teams is evident as to their real role as primary care professionals, since they point not only to the creation of a link as an important practice, but also the availability of the team with care free of stigmas and facilitator of the therapeutic relationship.These findings also refer to the approach of this team to the practice of the Expanded Clinic, since the promotion of a singular care and link promoter also permeates the guidelines that involve this clinic.
They also cite the existing link between SCt and the other services that make up their Health Network and how much this contributes to promoting better care for people on the street who are AOD users. 5,13,15This finding corroborates what is stated in the Policy for the Integral Attention to Alcohol and Other Drugs Users, which points to the use of AOD as a serious public health problem and, for that, requires the collective construction to its confrontation, focusing on the existing networks in the territory.
The interviewees' speeches in the subcategory "Self-care deficit" point to this deficit as a factor that makes it difficult to insert these individuals in a street situation in the network.It is observed that the street population, including AOD users, are in a situation of social vulnerability, which ends up affecting their self-esteem and self-care, as well as health care directed to the street population. 12Thus, it is essential that the SCt stimulate and strengthen the self-care of these users, since it is one of the specific attributions of the professionals who work in primary care, in which the SCt is included 12 , and realize that by strengthening their self-care, they will be strengthening as well as their citizenship, as they become more empowered to seek for their right of access to health, work and housing.
On the other hand, poor self-care is not the only factor that influences the difficulty of the practice in the SCt.The present speeches in the subcategory "Structural and human resources deficit" point out that these deficits negatively influence the possibility of a service being executed in a timely manner, as these tasks depend on the basic physical, structural and operational means that, in many cases, do not exist.Unfortunately, in recent years, UHS has suffered several budget cuts, which worsened after the approval of the Proposed Constitutional Amendment 241/2016, which has been reflected in several parts of Brazil, including the State of Amapá, where users of PSCN Alcohol and Drugs also pointed to structural deficit as a factor hindering care 14 .
6] This discrimination against the street population may be related to the influence of the hygienist eye, which can trigger acts of segregation and violence directed at these subjects in health centers.
In addition to the hygienist's look on the street person, stigmatization by health professionals can be justified by the fact that drug consumption is not seen as a health problem, but as a character flaw, assigning to the user the responsibility for the appearance and for solving of their problem 5 .
This stance of stigma and discrimination towards drug users negatively affects the quality of the services provided, harming the reception and constituting a barrier to the search for help, besides limiting the access and the use of the services.Therefore, it is important that strategies be designed with the objective of minimizing these negative attitudes of health professionals, since universal access to this population will only be achieved when they are seen as part of the same collective. 6,5,16

FINAL CONSIDERATIONS
The results showed that Macapá's SCt carry out assistance practices based on the ideals of the UHS and the Policy for the Integral Attention to Alcohol and Other Drugs Users, having as its main strategy to facilitate harm reduction, as well as other facilitating elements such as the creation of the link between the user and the professional, the commitment of the team and the partnership with other health sectors and other PSCN elements.Among the factors that hinder care, they pointed to a lack of self-care, structural and human resources, and the prejudice associated with stigma.
This study has limitations, since it was carried out in a small Brazilian capital, with very peculiar characteristics -cultural, geographic, economic, and of health -, which can cause the subjects of the study to have an understanding permeated by these local peculiarities.
Nevertheless, the study becomes relevant, since the findings raise the importance not only of the commitment of the teamespecially the nursing team, which is the majority in the study -to the fulfillment of the public policies that support their work with AOD users in the basic services, but also in the formation of partnerships and strengthening PSCN as key elements, which in addition to facilitating users' access, also sensitizes the other components of the UHS so that they follow its guidelines for completeness, universality and equity.
However, it should be noted that the other professionals of the Network, especially the Basic Health Units, also need to be made aware of the importance of the informed practice of public policies regarding reception and extended clinical practice, and that these guidelines should also be applied to street users of AOD who still suffer prejudices from different segments of society.

Table 1 .
Themes and subcategories of the study.Macapá, AP, 2018