versión impresa ISSN 0080-6234
Rev. esc. enferm. USP vol.44 no.3 São Paulo sept. 2010
Representaciones sociales de agentes comunitarios de salud respecto del consumo de drogas
Jeane Freitas de OliveiraI; Cecília Anne McCallumII; Heloniza Oliveira Gonçalves CostaIII
in Public Health. Professor of the Nursing School of the Federal University
of Bahia. Member of the Study Group about Women's Health, Federal University
of Bahia. FAPESB Scholar. Salvador, BA, Brazil. email@example.com
IIPhD. in Anthropology. Visiting Professor of the Public Health Institute of the Federal University of Bahia. Salvador, BA, Brazil. firstname.lastname@example.org
IIIPhD. in Administration. Professor of the Nursing School of the Federal University of Bahia. Member of the Study Group about Management, Work and Policies in Nursing and Public Health and the Group about Decentralization, Management and Public Policies of the Federal University of Bahia. Salvador, BA, Brazil. email@example.com
This paper discusses on the social representations of community health agents (CHAs) about drug use as part of a qualitative, ethnographic study with data collected by means of a set of research techniques among health professionals including 22 CHAs in a basic health unit in Salvador, Bahia (Brazil) from January, 2006 to January, 2007. The Theory of Social Representations was adopted as the theoretical framework whereas gender was the chosen analytical category. CHAs were found to recognize the women's proximity and participation in the drug phenomenon in the community where they live and act, although they take no professional measures towards such an issue. Their social representations were shown to reproduce stereotypes and prejudices towards drug users and drug use, especially gender- and social class-related, while highlighting the invisibility of drug use as a health problem for the population under study.
Key Words: Health personnel. Community Health Aides. Substance-Related Disorders Gender identity. Health services.
Este artículo discute las representaciones sociales de Agentes Comunitarios de Salud (ACS) respecto del consumo de drogas, como elemento integrante de un estudio cualitativo, de cuño etnográfico, cuyos datos fueron recogidos en el período de enero 2006 - enero 2007. Se aplicó un conjunto de técnicas en profesionales con actuación en una Unidad Básica de Salud de Salvador, BA, Brasil, de los cuales 22 eran ACS. La Teoría de las Representaciones Sociales fue adoptada como eje teórico y el género como categoría de análisis. Los ACS reconocen la proximidad y el grado de compromiso de las mujeres con el fenómeno de las drogas en la comunidad en donde viven y actúan; no obstante no adopten en su trabajo ninguna acción direccionada hacia tal problemática. Las representaciones sociales aprehendidas reproducen estereotipos y preconceptos en relación a las drogas y a las personas usuarias vinculadas, sobre todo al sexo y clase social y señalan la invisibilidad del consumo de drogas como un problema de salud para el grupo estudiado.
Descriptores: Personal de salud. Auxiliares de Salud Comunitaria. Transtornos relacionados con substancias. Identidad de género. Servicios de salud.
The consumption of drugs, comprehended as the use and/or abuse of psychoactive substances, is seen as a world social and health problem since the beginning of the century XIX. The frontiers between use and abuse are not clear, and at a certain point the mere use may become abuse and continue indefinitely, causing a series of personal and social disorders. The types and meanings attributed to the use of drugs also differ from individual to individual and from group to group inside the same culture and, especially, in contrasting cultures(1).
In Brazil, the Ministry of Health recognizes the dimension, transversality and heterogeneity of the problem of drug consumption; the need for new strategies of contact and bond to drug users and their family members, as well as the lack of prepare of the professionals to deal with the abusive use of alcohol and other drugs(2). The insufficient teaching in nursing graduation courses related to drugs is pointed out by an author(3); in a study developed with nursing undergraduates, in which most of the students referred to feel unprepared to act professionally in this area.
The proved lack of ability and sensitiveness of the health professionals to handle problems related to the abuse and dependence of drugs indicates that the traditional tools and actions aimed at the promotion, prevention and treatment, mainly in the basic care scope, have not been enough to handle the problem, which requires changes in the education and qualification of the professionals, as well as in the action strategies.
The change perspective in the health care model is not a recent concern. In 1991, the Ministry of Health/National Health Foundation, in the search for the consolidation of the Unified Health System, created the Program of Community Health Agents (PCHA), which establishes the inclusion of the Community Health Agent (CHA) in the multi-professional team that develops activities in basic health units(4). The incorporation of Community Health Agents to these health teams aimed to guarantee a closer relation between the health services and the community in order to allow interventions, mainly those of preventive character that would consider the specificities of each location. This program innovates with the possibility of operationalization of the enlarged view of health and the development of actions that are not centered only in the medical intervention(5).
Among the attributions of the CHA, those that stand out are: the orientation of the families for the appropriate use of the health services and the transmission of information to the other members of the health team regarding the social dynamics of the community, its availabilities and needs(4). Under the condition of living in the region where he works, the Community Health Agent lives both with the problems that affect the users of the community, and the local health practices. These conditions, associated to their education that is based on biomedical referentials, attributes to the professionals a "hybrid and polyphonic" character that contributes to the strengthening of their performance as mediator between the community and the health services, in the implementation and consolidation of the new care model(6). Therefore, the Community Agent is considered the key for the development of basic actions, especially for educational and preventive actions aimed at the most varied health social problems of the population, for instance the consumption of drugs.
In face of the amplitude of the actions required to Community Health Agents, who can rely almost exclusively on their life experience as they have a short specific education, it is possible to state that their social representations will be the fundamental substrate to guide their actions. The multiple and complex character of the social representations allows to comprehend the subjective and the social, the thought and the action, the history and the culture, making them an important tool for the investigation of culturally naturalized and social questions that define inequalities(7). Thus, learning the social representations of the CHA regarding the consumption of drugs may contribute to the elaboration and implementation of actions to face this problem in a humanized way, not prejudiced, respecting the differences, including those of gender.
According to Moscovici, representing something, a state, does not consist on simply unfolding, repeating and reproducing it, but especially on reconstituting, correcting and changing it(8). The potentiality to create and transform the social reality and the creative process of cognitive and symbolic elaboration, that serves as guidance to the human behavior, gives a dynamics to the social representations that differ them, according to the social groups that elaborate and use them(7).
The dimension of the representation field implicates images, social models and hierarchies that comprise the representation spectrum with values that instruct it. The attitude expresses the position, the affection and the decision-making towards the represented object, in other words, people are instructed and represent something only once they have taken a position and according to this taken position(9).
In face of the considerations presented and the lack of studies in the Brazilian literature about the way health professionals face the problem of drug consumption, this study was developed aimed at analyzing the practices and social representations of the various professional categories, including the Community Health Agents (CHA) from a basic health unit of Salvador-BA, regarding the consumption of drugs. The data here presented constitute an extract of this study, aimed at discussing, from the perspective of gender, the social representations of the CHA about the consumption of drugs.
This is a qualitative descriptive study, with ethnographic character, developed at a basic health unit located in a central community in the city of Salvador-BA, which is characterized as violent due to the heavy consumption and traffic of drugs. The anthropological approach in the public health scope offers contributions of political and epistemological aspect, which enable the planning and implementation of transforming actions that transcend the limited field of health(10).
The study project was submitted to the Committee of Ethics in Research of the Institute of Public Health from the UFBA, under the record 045-06/CEP-ISC. The ethical questions were considered at all stages of the study according to the determinations of the Resolution 196/96 of the National Council of Health. All participants signed the Term of Free and Clarified Consent, being identified only by their professional category and followed by the ordering number of the interviews, in order to keep their anonymity. The unit and the community were identified, respectively by the names CAMUDE and Nova Vida.
The production of empirical data adopted three different techniques, however complementary, which allow to reproduce the reality experienced by the professionals who work in this unit, for instance the group of twenty two Community Health Agents (CHA), focused on indentifying the practices adopted in the daily life and apprehending their social representations regarding the consumption of drugs. The techniques used were: a) participating observation during the period from January, 2006 to January, 2007; b) application of the test of free association of words to the twenty two Community Agents who work in the unit; c) semi-structured interview with five CHA.
During the participating observation period, there was the registration of data regarding the social actors, the community and the clients into the field journal. Each CHA was monitored, individually, in their daily activities in the community and, collectively, in activities developed in the institutional center with the clients and/or supervising nurse.
The Test of Free Association of Words (TFAW) comprised five inducing stimulus: drugs (S1), consumption of drugs (S2), male drug user (S3), female drug user (S4) and care to the drug user (S5). The data produced by this instrument were submitted to factorial correspondence analysis (FCA) through the software Tri-Deux-Most, version 2.2. The result of this analysis revealed the variables of opinion that presented statistical significance, according to the criteria established by the software for each inducing stimulus. According to experts, the free association of words is a technique that allows to study social stereotypes, which are spontaneously shared in the studied social group, besides visualizing the structuring dimensions of the semantic universe specific of the SR and their unification, in face of the inducing stimulus used in the study (11).
Interviews were guided through a script with guiding questions about the education and insertion in the unit, professional practice, ideas, opinions and situations they face regarding the drug problem in the community. The number of interviews was defined through the repetition of ideas associated to the data produced by the other techniques used. All interviews were carried out in the unit at a previously scheduled time, recorded and fully transcribed, being its content submitted to exhausting readings and grouping the evoked ideas according to the stages of content thematic analysis(12).
Based on the variables of opinion identified at the FCA, the triangulation of the data produced by the other techniques was performed to obtain the identification of the empiric categories of analysis. Two empiric categories emerged from the data organization, which express the social representations of the Community Health Agents regarding the consumption of drugs: 1) Drugs: cause and consequence of inequalities; 2) The image of the drug user.
However, before presenting the two categories of analysis, a brief characterization of the community, the unit and the study subjects will be presented. This characterization complies with the Theory of Social Representations and the ethnographic character adopted in this study.
THE COMUNITY, THE UNIT AND THE PARTICIPANTS
The district Nova Vida is considered one of the oldest regions of Salvador, located in a privileged geographic area of the city. It presents a very irregular topography, characterized by hills, valleys and hillsides, of irregular conformation, being in the center of average and average-high class districts. It currently has the total area of 203ha with a population of 82,976 inhabitants, distributed among four districts with a population density of 408 inhab/ha(13).
The population living in the community Nova Vida consists of young people, (40% are under 25 years old), predominantly dark-skinned (88%) and female (53.1%); most of them are catholic (54%), with low level of education, high level of unemployment and/or underemployment. Over half of the people responsible for the permanent private homes (60%) earn less than three minimum salaries and 40% of the families are administrated by women(14).
The violence and the drug traffic are highlighted as the main problems in the district Nova Vida, both in institutional documents(13) and in articles from local newspapers.
CAMUDE is among the public health services available to the population of the district Nova Vida. The unit offers basic care as preconized by the Ministry of Health, which characterizes it as a Basic Health Unit (BHU), from the Unified Health System (UHS). The activities are developed by a multi-professional team that acts, distinctly, in the institutional center and in the community with actions focused on children, women and adults, aimed at the promotion, prevention, treatment and rehabilitation of health(4). The actions developed at the community are executed, mainly, by the twenty two CHA, who constitute the subjects of this study.
The CHA group has twenty two professionals, mainly female (19 women and 03 men), aged between 27 and 45 years old, but predominantly between 30 and 39 years old. Among the twenty two studied professionals, five defined themselves as mulatto, two as dark-skinned and the others stated they were black. The single status was prevalent among the participants, even though some revealed, in informal conversations, the existence of a fixed partner with stable relationship for several years. Among the nineteen women, only one stated she did not have children, but she took care of her sister's children, who lived in their house.
The CHA had worked in the unit for 7 to 9 years and, lived in the community for 10 to 45 years. All members of the group could read and write; some of them were still studying in order to get into university. For most of the participant in this group, the only source of income consists of the salary they receive as Community Agents. Frequent payment delays constituted a reason of dissatisfaction for the execution of the activities and concern regarding the family survival. According to the statements of the group, the profession of the Community Health Agent did not constitute a choice. Being a Community Agent was one of the few options of source of income, due to their level of education and the social and economical circumstances in which they live.
By the time I took up the PCHA I had been unemployed for five years. One day I was passing by the oral health unit, from Dique, when I saw a subscription ad for community agents, and I did not know what that was about. [...] at the time I volunteered as a minor commissioner (CHA 4).
Today I can say I like what I do, but when I started I did not even know what I was going to do. [...] I was unemployed, I used to sell acarajé with my aunt, but it was just beginning and the place was not mine. Then this health agent story came up, I registered and I passed (CHA 1).
The work of the CHA takes place mainly at the community, through home visits, which are scheduled from Mondays to Fridays during the working hours of the health unit. The group work at the institutional center is limited to the participation in monthly administrative meetings with the supervising nurse, and weekly educational activities with groups of children and old people.
RESULTS AND DISCUSSIONS
Drugs: cause and consequence of suffering and inequalities
At the factorial correspondence analysis, the drugs (S1) and the consumption of drugs (S2) are represented by the CHA through the opinion variables: sadness, depression, suffering and violence. According to the speech of the interviewees, the sales and the consumption of drugs are part of the community's routine. For this group of professionals, the consumption of drugs is represented as a behavior in expansion that affects young people more directly and, indirectly, their families and the other inhabitants of the community. The drugs represent the cause and, at the same time, the consequence of the poverty condition and the lack of family structure faced by a great part of the population living in the same place where the CHA live and work:
What I see in my context about the consumption of drugs is an explosion happening mainly among young people. They use it because of the lack of communication and dialogue in the family. Those are families with many children and unemployed parents who have many needs; sometimes they do not even have what to eat (CHA 2).
Drugs cause a lot of suffering, but it seems that it is a way of facing the suffering caused by the hunger; the parents' unemployment; the arguments at home; the mother or father's need for some medication; the violence in the neighborhood and in the family. [...] Once you get involved with drugs, there is sadness every day, it starts with robberies at home, then on the streets, and when the mother sees that, she gets sick and things only get worse every day, and then there is depression. It is a lot of sadness and suffering (CHA 3).
Among the reasons that lead to the use of drugs, mainly by adolescents, they mentioned: the curiosity, considered as a characteristic of the adolescence; the friendship with drug users, seen as bad influence; the lack of love, mainly, from their parents and, still, situations of suffering represented by the hunger and the occurrence of violence in several ways experienced in the family.
Disorder caused by family problems, divorce of the parents, a husband who drinks too much and hits or attacks his wife, a mother who has to work all day to support her family and, when she gets home, she is attacked by her husband who is unemployed and drunk. Then, somehow, this takes the structure of the child, and, in some cases, causes rebellion and affects the adolescence, or in the adulthood, many of them end up getting involved with drugs due to the lack of opportunities in life, in order to bear the situation or earn money to change it (CHA 4).
In the social representations of the CHA regarding the consumption of drugs, there is the idea that the type and objectives for the use of drugs differ, especially, according to the social class. In this context, they highlight that people who are characterized as poor get involved with drugs through the traffic, whereas people who are classified as rich use drugs for their own consumption. This conception reproduces social and power inequalities that permeate the daily relationships experienced in the institutional scope and in society.
People who live here in the community use mostly marijuana and crack, because I heard they are cheaper, but rich people use cocaine (CHA 2).
Rich and poor people use drugs, but the great difference is that rich people have money to buy it and they do not get involved in the marginalization. Poor people cannot afford, but they want to use it and have reasons to do so, so many of them end up getting involved in the traffic to get money, to buy drugs and, also, to buy food, clothes and medicine (CHA 1).
In a general way, the group manifests the idea that the drug acts in the organism with the power to transform people, making them violent and capable of violent acts. This idea, besides emphasizing the action of drugs over people, associates the drug problem with violence, attributing to the drugs a relevant factor for the maintenance and dissemination of violence in its various modalities.
According to the speech of the interviewees, violence is presented as: motivation for the involvement of people with drugs, the effect of drugs over people and the consequence of its use and, especially, the involvement with the traffic of drugs.
The person is a user but also deals the drug, participates in a group, and then the violence problem comes, due to the competition between groups that sell drugs over the point of sales. Besides, the police action against the drugs ends up causing a lot of violence, killing people who are not even involved with the matter. [...] There are people who use drugs to escape from the violence at home, from the parents, from the father towards the mother... [...] I know people who are transformed by the drugs, they get nervous and impatient when they do not use it for a long time or when they use it in great quantity. I think drugs are not good to anyone (CHA 5).
The variables of opinion evoked by the Community Health Agents for the stimulus 'drugs' and 'drug consumption' and the situations experienced in the routine of their activities, presented in extracts of the interviews, show that the problem is complex and has several repercussions for the entire population. The complexity of the problem seems to be centered exactly in the need to contemplate reasons that lead to the consumption and/or involvement with drugs, as well as specificities of drug users and groups of drug users in their different social contexts.
The image of the drug user
The variables of opinion young, violent and abandoned, influenced showed statistical significance to the stimulus male drug user (S3) and female drug user (S4), respectively. In the speech of the interviewees, the semantic field of these variables reveals the reproduction of social-cultural constructs that characterize men as strong and violent and women as submissive and socially excluded.
All participants corroborated the information that the consumption of drugs is an eminently masculine behavior. Epidemiological studies of national(15) and international(16) scope show that the consumption rates of psychoactive substances, especially those characterized as illicit, are still higher among men. However, the data in these studies point out to a decrease in the proportion of consumption of these drugs between the genders, and a higher consumption of substances characterized as medication among women.
In the context experienced in the community, the CHA built the image of the drug user as being male, young, black, poor, with low level of education, unemployed, violent and marginalized. Due to the involvement with drugs, the male drug user becomes a bad influence and a threat to his family, friends and neighbors, being destined to die early, either as a result of the police action against the drug traffic, or because of the conflicts among the groups that sell and use illicit psychoactive substances.
From what I see here, the consumption of drugs is prevalent among men. They have low education, many of them cannot write their own name. They are people with low self-esteem who give in due to the substandard life conditions and poverty. They are adolescents, young, and some start at the age of 12 years old or less. They kill, steal and do anything for the drugs (CHA 1).
The male drug user sells the drug, participates in a group. Then, the violence issues come and many of them end up dying early due to the competition among the groups over the point of sales. There is also the police action that, unfortunately, results in the death of many of them before they are 20, 25 years old, most of them die in this age group (CHA 4).
Despite of the fact that the consumption of drugs among women is considered a condemned, inadequate behavior that eliminates the family structure, the group points out that in the community women are involved directly and indirectly with drugs and, in Bahia, there is an expansion in the consumption of drugs by women. As indicated in the specialized literature, the CHA believe that this expansion in the consumption of drugs by women is motivated by the changes in the life style of the female population over the last decades, and by the tendency that several women have to adopt behaviors that are socially and culturally characterized as masculine(17).
Furthermore, the group recognizes that the functions and roles socially and culturally established for female people, such as mother, wife and caregiver, lead to countless responsibilities and adversities in the social relations of their daily lives, which cause disorders and overloads that may contribute to the consumption of drugs.
I think it is the worst thing for a woman to use drugs, because we are used to seeing her as the caregiver, someone who raises and brings up their children, instead of someone who does wrong things, like using drugs. But giving a second thought, women face a lot of family problems, sometimes they have to work in order to raise her children on her own, or she has a husband who is an alcoholic and hits her, so if you think well, women has even more reasons than men to use drugs, but society does not accept it. It is very hard. I know I have prejudice regarding a woman using drugs, but I had never thought about it this way. I guess people never think, they just condemn and criticize (CHA 5).
For the CHA, the involvement of women with drugs happens in two ways: directly and indirectly. The direct involvement is that in which the woman lives with someone who is a user and/or drug dealer. This type of involvement is more directly associated to the woman in the condition of a mother, but may also occur to those in the condition of partner/wife. In this last condition, alcohol is the most frequently used drug, whereas in the condition of mother, the drugs used are those classified as illicit. Either in the condition of a mother or a wife, the woman is seen as someone who suffers, a victim of the situation, someone who faces difficulties in an attempt to help her children and/or partner.
I see the suffering of many mothers here because their children are involved with drugs. There is one who has already sold her house to send her son to São Paulo for treatment, but some time later he came back and started using again. There is another mother who always finds a way to pay the lawyer when her son is arrested, she pays 4, 5 thousand and he gets out soon, keeps using, dealing, and gets arrested again. She walks with her head down like an ostrich, working hard, and they do it all again (CHA 1).
In the direct involvement, the woman is conceived as a drug user. In this case, she is also considered as the partner of a drug user or a drug dealer. In order to justify this type of involvement, the speeches of the different groups of professionals reproduce the idea of submission of the woman towards the man, since they defend the idea that she is influenced by her partner into the initiation and maintenance of the consumption of drugs. In this context, the male drug user is considered a bad influence and the woman as someone who is influenced, who does not have her own decision.
They use cocaine because their partner also does so. It is hard to have an addict husband and do not use, I think it is very difficult. Here, most of them use drugs because most of them have a partner who is either a drug user or a drug dealer (CHA 4).
The idea that the woman is influenced by a man who uses drugs, both to start using and to keep the consumption, is presented in the specialized literature both in the national(17); and in the international(18) scope. Female drug users, from peripheral communities in Salvador-BA, also reproduce the speech of the partner's influence as a way to justify their use of illicit psychoactive substances(19).
Another aspect that defines a difference in the direct and indirect involvement of women with drugs is their age. For most of the CHA, young women tend to get directly involved with drugs, whereas older women have an indirect involvement. This statement, which is supported by data from the reality experienced by the CHA, was not found in the literature. The speech of the interviewees indicates that young women who use drugs are also characterized as violent, as aggressive as men, but also adds qualities such as the adjective abandoned and responsible for family disagreements.
Most of the girls around here have partners who are thieves, drug dealers, drug users and they also participate, they are also users, most of them [...] These women are dangerous, we have to keep distance from them because these men are capable of killing, hitting (CHA 3).
According to the content of the speech of the CHA, the female drug user has similar sociodemographic characteristics to those of male drug users, in other words, she is young, black, poor, with low level of education. Besides, the group points out that women who use drugs, especially those classified as illicit, are women who cause the loss of structure in the family, who were abandoned by their partners, and abandoned by their family. For the group, female drug users are identified by aggressive actions and by the use of short and tight clothes in order to show their bodies, which characterize them as vulgar women.
The female drug user is generally black. It is not common to see a white woman. They are between 25 and 30 years old (CHA 5).
I see young women around here, who do not study and do not have a job, using drugs. They are all black, because everyone here is. [...] First, they get involved with male users and then they start using too, they become aggressive and violent like men (CHA 4).
The sociodemographic characteristics presented by the CHA for the drug user match the profile of the population who live in the community. However, the effects of the drug in the organism give the drug user a stereotype that characterizes him as a person who practices violent actions and who is responsible for situations of sadness, suffering and depression that strike family members, friends, neighbors, and even people who live in other districts of the city. This stereotype excludes the consideration of the personality and the context in which the drug user lives as elements that interfere in the process of drug consumption.
The present study shows that the situations experienced by the Community Health Agents in the routine of their social and professional relations lead them to represent the consumption and the traffic of drugs as problems that affect all the inhabitants of the community and that cause sadness, violence, suffering and depression. Nevertheless, the consumption of drugs is not assumed as a health problem in the care context in which they act. This allows to state that there is a distance to be overcome so that this problem gets out of the invisibility in which health professionals place it. Besides, this distance is not limited to the proximity to the problem, it has deeper roots that require the reformulation of the knowledge and the concepts that pass from generation to generation and that establish specific functions and roles for people from different genders, associated to the age, social class, race/skin color and level of education. In this context, the authors believe the study of the social representations constitutes a useful tool to reveal stereotypes and to understand psychosocial aspects regarding the drug phenomenon and, consequently, to favor its visibility as a public health problem.
Even though Community Health Agents point out that the women in the community are either directly or indirectly involved with the problem of the drugs, there is a prevalent idea among them that the representation of the drug consumption is an eminently masculine behavior and that the use of drugs by women results from the influence of male drug users, with whom the women keep a sexual and/or emotional relationship. These representations reproduce social-cultural constructs that characterize men as strong and violent and women as submissive and socially excluded, besides interfering the comprehension of other aspects from the social dynamics that are leading to the increase in the consumption of drugs by women.
The findings presented in this study allow to state that: living and belonging to the community do not assure the recognition of the social dynamics, neither brings tools to recognize a problem that requires the deconstruction of paradigms, both in the scope of the society and in the institutional scope, in order to promote the awareness and to implement actions that meet the specificities of people and/or groups of people who use drugs and health professionals in the various social contexts.
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