Risk factors for substance use : perception of student leaders

Objective: to analyze the perceptions of student leaders of the undergraduate course in Nursing about the motivations and/or risk factors for substance use in the university environment. Method: qualitative, transversal, descriptive study developed in a university campus in the state of São Paulo. Thirty members of associations affi liated with the course in Nursing participated. A questionnaire and a semi-structured interview were used, and the information was subjected to content analysis. Results: the infl uence of the social environment was the central element in the results. The circumstances of the context, some conditions that favor the use of substances and the students’ expectations regarding their use were perceived as risk factors, among which the infl uence of friends (96%), curiosity and search for fun (93%) stood out. Final considerations: alternatives in the university context, in conjunction with student leaders, aimed at reducing the exposure to physical and psychological suffering, constitute important resources to prevent substance abuse. Descriptors: Students, Nursing; Risk Factors; Alcohol Drinking in College; Street Drugs; Mental Health. RESUMO Objetivo: analisar a percepção dos líderes estudantis da graduação em enfermagem sobre as motivações e/ou fatores de risco para o consumo de substâncias no ambiente universitário. Método: estudo qualitativo, transversal, descritivo desenvolvido em um campus universitário no interior de São Paulo. Participaram 30 membros das entidades ligadas ao curso de Enfermagem. Utilizou-se questionário, entrevista semiestruturada, e as informações foram submetidas a análise de conteúdo. Resultados: a infl uência do ambiente sociocultural foi o elemento central nos resultados. As circunstâncias do contexto, algumas condições que propiciam o uso de substâncias e as expectativas dos estudantes em relação ao uso foram percebidas como fatores de risco, destacando a infl uência dos amigos (96%), curiosidade e busca de diversão (93%). Considerações fi nais: alternativas no contexto universitário, conjuntamente às lideranças estudantis, visando reduzir a exposição ao sofrimento físico e psicológico, constituem recursos importantes para prevenir o uso abusivo de substâncias. Descritores: Estudantes de Enfermagem; Fatores de Risco; Consumo de Álcool na Faculdade; Drogas Ilícitas; Saúde Mental. RESUMEN Objetivo: analizar la percepción de los líderes estudiantiles de la graduación en enfermería sobre las motivaciones y/o factores de riesgo para el consumo de sustancias en el ambiente universitario. Método: estudio cualitativo, transversal y descriptivo desarrollado en un campus universitario en el interior de São Paulo. Participaron 30 miembros de las entidades vinculadas al curso de Enfermería. Se utilizó cuestionario, entrevista semiestructurada, y las informaciones fueron sometidas a análisis de contenido. Resultados: la infl uencia del ambiente sociocultural fue el elemento central en los resultados. Se observó como factores de riesgo las circunstancias del contexto, algunas condiciones que propician el uso de sustancias y las expectativas de los estudiantes en relación al uso, destacando la infl uencia de los amigos (96%), curiosidad y búsqueda de diversión (93%). Consideraciones Risk factors for substance use: perception of student leaders Fatores de risco para uso de substâncias: percepção de líderes estudantis Factores de riesgo para el uso de sustancias: percepción de líderes estudiantiles

Risk factors for substance use: perception of student leaders Balthazar EB, Gaino LV, Almeida LY, Oliveira JL, Souza J.
students, attend sport and recreational competitions, parties and educational events.

OBJECTIVE
To analyze the perceptions of student leaders of the undergraduate course in Nursing about the motivations and/or risk factors for the consumption of psychoactive substances in the university environment.

METHOD Ethical aspects
The study was conducted in accordance with the guidelines contained in resolution CNS 466/12 for development of research with human beings and has been approved by the Research Ethics Committee of the unit where it was carried out.To preserve the anonymity of the participants of the study, the city where it was conducted was not included in the tables, and the interviewees were identified by numbers throughout the research.

Theoretical-methodological framework
The process of research and analysis had as theoretical framework the recommendations of the Ministry of Health on the prevention of substance use (5,(9)(10)(11) .
Type of study This is a descriptive exploratory research with qualitative character.

Study scenario
The study was carried out in a campus of the University of São Paulo, specifically in the unit for courses in Nursing.

Data source
In this unit, the student associations are responsible for organizing, guiding and encouraging the integration of students of the course in Nursing through sport, recreational, academicscientific and social activities, in addition to representing and defending their interests * .

INTRODUCTION
Admission in higher education can be considered a milestone in the transition of stages of the life cycle of young people.Such an event generally encompasses a set of new experiences and positive feelings related to adult life and the pursuit of a professional career.The adaptation to a new routine, on the other hand, is a critical moment of transformations in an individual's lifestyle, support network and autonomy.Thus, the requirements of this stage of life can lead to greater vulnerability to the adoption of harmful behaviors and to possible fluctuations in their psychological well-being (1)(2)(3)(4) .
One of the behaviors which university students are most vulnerable to is the use of psychoactive substances.That is, some researchers point out the undergraduate period as an important determining factor related to the beginning, continuity or intensification of the use of psychotropic substances (NPS) (5)(6) .
The wide acceptance of consumption and availability of these substances and susceptibility to stress in the university environment have been described as factors which favor the experimental use and/or increased frequency of use among students, contributing to the high prevalence of use of these substances in this population (6) .
The abuse of substances among university students has been associated with risky sexual behaviors, car accidents, violence, academic distractions and losses, stress, decreased cognition and health problems (5,(7)(8) .
In spite of these negative consequences, some studies have tried to identify the risk factors related to this consumption in the university context, pointing out important results and devising numerous recommendations (5,(7)(8)(9) .Nevertheless, the prevalence of consumption in this group has not been decreasing, which suggests the need for research approaches that capture with greater accuracy the reality of these subjects.
It is understood that to plan and undertake effective prevention strategies it is necessary to assimilate the students' perception on the dynamics of these risks, i.e., their understanding about how these factors operate in their daily academic life.
It is worth mentioning that the "prevention" aspect of the Brazilian drug policy has recommended the adoption of a philosophy of shared responsibility, valuing the logic of multipliers and the engagement of representative associations in the support to preventive activities.Student leaders are mentioned as one of the key elements in this proposal (9)(10)(11) .
It is understood that these subjects have an insider's view on the real risk factors of substance use and the way they operate in daily academic life, since they have greater proximity to the Thus, the study population encompassed the 30 members of these student associations.The inclusion criteria were: being regularly enrolled in any semester of the courses in Nursing and being a member of these associations.The exclusion criteria were: being under 18 years old and having any health problem that prevented their participation in the interview.All members met the criteria adopted and agreed to participate in the study, totaling 30 participants.

Data collection and organization
The data were collected by a student of the final year of the undergraduate course who had been previously trained to carry out the collection.The interviews were conducted individually, in the headquarters of these associations, outside the school period (during breaks or after the end of lessons) in agreement with the participant, so it did not interfere with the academic activities of professors or students.The data collection period was from May to August 2016, and each interview had an average duration of 30 minutes.

Study steps
Firstly, semi-structured interviews were carried out using a preestablished questionnaire.Each of the five items of the questionnaire corresponded to the description of a case related to substance use by university students, especially at parties promoted by the student associations themselves during the freshman reception or over the course.Such situations triggered the participants' report on their daily life experiences in relation to the subject.The questionnaire was discussed with two professionals with experience on the theme of alcohol and drugs and with two undergraduate Nursing students who did not belong to the population studied.
Then, a second questionnaire was applied, containing items related to the demographic aspects and six situations described by the literature as risk factors for substance use among university students (5)(6)8,12,(16)(17) : influence of peers, curiosity, entertainment, stressful situations, media influence and distancing from the family sphere. The particiants were instructed to indicate whether or not they considered such situations as risk factors.

Data analysis
For data analysis, the thematic analysis technique was used (19) , with triangulation of analysts (20) .The interviews were recorded and, after transcription, arranged in a corpus of information.Successive readings were undertaken to identify units of meaning from which a list of codes was generated.From the information's coding, it was identified that the influence of the social environment was the central element in the results.In this way, the grouping of codes into categories was performed considering the different aspects that make up an environment that is conducive to the use of substances, considering the theoretical framework adopted.Thus, the categories generated were: 1) circumstances of the academic environment, 2) conditions that promote the use of substances, and 3) expectations regarding the use.The analytical stage was undertaken by an undergraduate and a graduate student under the supervision of a professor with experience in qualitative research.The fact of the undergraduate student composing the group of researchers was an important factor because, although she did not belong to the associations researched and had no direct link with the participants (friendship or affective bond), she somehow experienced the phenomenon under study, had proximity to the thematic and involvement with the population studied (university students).This is an important factor in terms of reflexivity because, in the same way that it influenced positively the development of the research, it may also have led to some bias in the analysis.The data from the questionnaires were inserted in a Microsoft Excel 2013 spreadsheet and were analyzed using descriptive statistics.

RESULTS
The participants were, in average, 21 years old (SD = 1.52), and 15 (50%) were female.Five (17%) were in the first year of the course, six (20%) in the second, ten (33%) in third, seven (23%) in the fourth, and two (7%) in the fifth year of graduation.
As can be seen in Table 1, the influence of friends, followed by curiosity and search for fun were the risk factors mentioned by the participants.
In relation to the experiences reported by the participants, Figure 1 presents the codes corresponding to each of the categories generated.

Circunstances Conditions Expectations
Risk factors for substance use: perception of student leaders Balthazar EB, Gaino LV, Almeida LY, Oliveira JL, Souza J.
The risk factors indicated by the participants in the questionnaires converged with the experiences reported in the interviews.In relation to the first category (circumstances of the academic environment), some circumstances mentioned by the participants were: being in an environment with easy access to substances and the low cost of alcoholic beverages.In addition, the participants indicated specific stress triggers of the academic environment as circumstances that favored the use of substances such as excessive commitments, internships and extensive course load, as illustrated in the reports: In my opinion, the issue of stress, of the pressure from the course load that is too tight, making us very anxious, drinking becomes a convenient way for us to eliminate stress.(participant 6)

Because often the university pushes us to our limit, and it's too complicated thinking up other alternatives to unwind when what you have closest to you is, unfortunately, alcohol or some other drug. (participant 22)
Regarding the second category (conditions that encourage the use of substances), the participants reported that being in the first year of graduation, or in popular terms, being a freshman, is a risk condition for the consumption of substances, because obedience to the culturally defined hierarchy between freshman and seniors implies following the orders of the latter in relation to substance use.
I think it's wrong, this attitude of veterans forcing freshmen to drink.Because I think here, freshmen feel pressured into having to do things to be accepted in the college environment.Veterans put pressure on them and if they don't do it, they'll be shut off.(participant 18)   In addition, the first contact of freshmen with the academic world, generally conceived as an environment that is conducive to new experiences, including the free use of substances, can both stimulate and inhibit their use, due to excitement or fear in relation to the new conditions.

When it's a course outside your city, when you come to a new place, you're afraid of everything. You don't want to drink, you don't want to use anything different, especially when you've just met a person and still don't trust them. (participant 28)
Distance from the family was also mentioned as a condition that favors the use: Just the fact of being away from home [...] encourages substance abuse.(participant 10)

You're alone in a city you don't know, away from your family, you have no one you can turn to. (participant 22)
The participants also indicated individual characteristics such as: immaturity, personality type and being young as risk factors.
Depends on their education, and on their maturity, too.There's this issue of personality, if they haven't already, they end up being manipulated to externalize these types of behavior.In the third category (expectations regarding the use), the participants highlighted expectations such as the search for fun and for a sense of belonging.
There's the parties that have alcohol as form of leisure.(participant 6)

People come to experiment and have fun [...] most use drugs to have a good time. (participant 14)
To meet other people's standards, to be accepted.So they have to be accepted in a certain clique for example, to get along with everyone else.They do what others do so they won't be seen as a loser.(participant 1)

Ways of coping and relaxation were also identified as expectations:
A kind of relaxation.(participant 8)

Because booze, drugs, they give you a momentary pleasure, some relief. (participant 27)
It's a way to escape your problems for a little while.(participant 9) I believe booze and drugs are a refuge.(participant 16)

DISCUSSION
The student leaders mentioned social influences of the university environment as risk factors for substance use, highlighting circumstances of this environment, personal conditions and expectations related to consumption.
A previous research identified similar results to this study, that is, suggesting that the university environment can favor the increased frequency of consumption of alcoholic beverages (4) .
Previous studies indicate that environmental determinants operate in conjunction with the subjects' individual characteristics (6,12,14) , and in this study, both the age range of the group and the aspects related to maturity and personality type were perceived as risk factors by the participants.
University culture offers several moments in which psychoactive substances are not only available but part of the context, such Risk factors for substance use: perception of student leaders Balthazar EB, Gaino LV, Almeida LY, Oliveira JL, Souza J.
as in student housing or fraternity parties, during the freshmen reception activities and graduation fundraising events, as well as in the bars or restaurants near the university (1) .
A research conducted in a private university of Rio de Janeiro indicated that Nursing students typically consumed alcoholic beverages mainly at parties (4) , corroborating the results of this study.The "open bar" modality -in which purchasing the entrance ticket entitles guests to the unlimited consumption of alcoholic beverages, or events with alcoholic beverages at a very low price -represents situations of greater vulnerability to excessive consumption (4,15) .
Given the above, it becomes evident that the legislation that regulates and controls the sale of alcoholic beverages to young people needs to be put into practice, and events with forms of leisure other than the use of psychoactive substances need to be encouraged and enforced (4) .Therefore, student associations can play a key role in the development of more effective preventive actions.
For instance, student leaders could, among other activities, promote conversations and debates, using the same language as their peers to motivate them and provide a friendly environment for students to expose their opinions, feelings and proposals for confronting the problem of substance abuse.
In relation to academic demands, in this study, conditions similar to those described in previous studies were mentioned, including sleep deprivation to keep up with their studies, stress generated by assignments (16,21) , extensive course load, requirements related to the composition of reports (22) , exposure to internship activities that generate fears related to failures/errors, and high test frequency (18) , which generates excessive levels of stress.
It should be noted that, although not mentioned by the participants of this study, there is also the emotional burden generated among Nursing students caused by the close contact with different people in pain (23) .
Although some participants stated that the insecurity felt as a freshman could make them avoid consumption, studies have indicated the opposite: the university allows experimentations that could not be experienced before, and more autonomy to decide whether to use substances or not (15) .It is discussed that, in addition to other conditions, curiosity and the desire to experiment may be risk factors, identified in a prior research performed at the public university of Western Amazon with Nursing students (4) .
Thus, being a freshman in university is a risk factor that would need specific actions aimed at the control or prevention of abuse and/or involuntary use of psychoactive substances.There should be alternatives to the so-called "hazing" (mandatory actions or behaviors, mainly directed by veterans) and other conditions that are characterized as pressure for the consumption of alcoholic beverages.Some options would be charity actions or cultural and/or entertainment events that celebrated the entrance in the academic world, without the prerogative of substance use.Again, student associations could play a key role in the implementation of these actions, considering the leaders can be safe references to new students.
The search for fun, relaxation and coping were expectations related to the use, according to the perception of the participants, and these effects were also described in previous researches conducted with healthcare students, highlighting that psychoactive substances can awaken feelings of general well-being and physical and mental relaxation; their consumption has been a strategy used by students to alleviate stress and the emotional burden (1,15) , as mentioned by some participants.It is discussed that university students may choose this negative way of coping with adverse situations for believing in the possibility of this use enabling a sort of "transcendence" from the real world in which they live, allowing them to escape reality (18) .
The university experience provides students with a new opportunity to integrate themselves in a large group of friends without or with less family supervision, making them more vulnerable and prone to experiencing new sensations such as the consumption of psychoactive substances (8) .In addition, the need to establish new friendships is part of this cycle and can stimulate students to use alcohol and other drugs, as many seek a sense of belonging (1) .
Thus, the present study shows that, in addition to specific actions for the prevention of substance use, actions aimed at mitigating the stress burden generated by academic activities among Nursing students would also be relevant.As an example, the following suggestions are valid: mandatory breaks in the class schedule; spaces for discussion and listening about the anguish generated by tests and other aspects of academic life; physical spaces for relaxation between classes; and promotion of the practice of physical activities.
This last aspect is often exploited by one of the student associations that participated in this study, which is responsible for the organization of sports activities.However, in addition to this, these associations could demand and negotiate, along with formal academic councils and committees responsible for managing academic activities, the other suggestions mentioned above to alleviate the emotional burden and stress of these subjects.

Study limitations
It is considered, as limitation of this study, the use of only one qualitative technique for data collection.Other collection instruments like ecomapping and participatory observation by a researcher who is external to the universe studied could assist in the identification of relationships and locations that may constitute themselves as risk factors or motivation for substance use.Nevertheless, the data of the questionnaire somehow allowed cross-referencing the information generated.

Contributions to the field of Nursing
Nursing professionals stand in an ideal position for carrying out health promotion interventions.However, the results of this study show that some aspects related to self-responsibility in health care and to the promotion of healthy lifestyles need to be further strengthened while they are still in college, within the spaces occupied by these subjects while undergraduate students.
The early detection of drug use and the disclosure of information are actions that have already been carried out worldwide and proven useful in this approach.However, using alternatives that have closer proximity to students, in partnership with student leaders and that encompass situations of the university context itself, reducing exposure to the physical and psychological suffering of everyday life, may work as a resource to address substance abuse, expanding the range of options and strengthening prevention programs in this context.
In broader terms, it is understood that the results of this research will help to spread awareness about the mental health Risk factors for substance use: perception of student leaders Balthazar EB, Gaino LV, Almeida LY, Oliveira JL, Souza J.
of Nursing students, encouraging debates about the development of new strategies for the prevention of substance abuse and promoting a healthier school environment.

FINAL CONSIDERATIONS
The results of this study corroborate some risk factors which have been indicated by the literature such as the influence of friends, curiosity, the search for fun, living away from family and university-related stress.However, intrapersonal (personal characteristics) and social (being in an environment with substances, low-cost drinks, being influenced by the moment) aspects, the condition of being a freshman and issues inherent to the academic context were also discussed.From the results presented, important recommendations were formulated.
Some proposals include alternatives with close proximity to these subjects to reduce exposure to the physical and psychological suffering of everyday life, encompassing situations of the university context itself, which may work as resources for the prevention of the abuse of psychoactive substances.In this sense, the ability of recognition of such situations in the university environment is positive for the development of actions aimed at prevention in this space.
In addition, it is worth noting that student associations have a central role in these aspects, considering the key position of these leaders in the social network of students.Collaborative actions between formal management mechanisms and these students could be effective for the preparation and implementation of preventive strategies in this context.
In addition to these discussions, the relevance of the collaboration of the students themselves stands out both as a source of data and in the case of the participation of an undergraduate student in the analysis of the results, providing a discussion that was not only academic, but also based on her perception of this reality.

Table 1 -
Risk factors for the consumption of psychoactive substances, state of São Paulo, Brazil, 2016 Figure 1 -Summary of results by category, state of São Paulo, Brazil, 2016 Influences of the social environment When we're in a party [...] we get used to consuming alcohol, we become more vulnerable to consuming other substances.