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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.4 São Paulo Aug. 2011
Family Health Nurse in the Amazon: concepts and management of themes regarding alcohol use
Enfermero de Salud de la Familia en Amazonia: conceptos y manejo en la temática del alcoholismo
Rodrigo Otávio Moretti-PiresI; Sidnei Bruno Guedes FerroII; Fátima BücheleIII; Hadelândia Milon de OliveiraIV; Maria Jacirema Ferreira GonçalvesV
Professor of the Department of Public Health of the Center for Health Sciences,
Federal University of Santa Catarina. Florianopolis, SC, Brazil. firstname.lastname@example.org
IIGraduate of the Institute for Health and Biotechnology of the Federal University of Amazonas. Manaus, AM, Brazil. email@example.com
IIIPhD Professor of the Department of Public Health of the Center for Health Sciences, Federal University of Santa Catarina. Florianopolis, SC, Brazil. firstname.lastname@example.org
IVAssistant Professor of the Department of Internal Medicine Nursing of the School of Nursing of Manaus, Federal University of Amazonas. Manaus, AM, Brazil. email@example.com
VPhD Professor of the Department of Maternal Infant and Public Health Nursing of the School of Nursing of Manaus, Federal University of Amazonas. Manaus, AM, Brazil. firstname.lastname@example.org
The objective of this study is to identify the concept that nurses in the Amazon have on alcohol abuse and the forms used for management. Focal group and individual interviews were performed with all nurses of twelve family health teams from a city in the Amazon. It was observed there was a lack of university degrees, continuing education and of support/reference - counter - reference towards the dimension of alcohol use in the studied population. There is need to reform nursing courses and perform continuing education for family health team members, and provide them with the necessary support regarding this important theme and its consequences, for individuals and their families, as well as for the society as a whole.
Descriptors: Alcoholism; Family health; Public health nursing; Education, nursing
El estudio apunta a identificar la concepción de los enfermeros sobre la temática del abuso de alcohol y las formas de manejo utilizadas, en el contexto Amazónico. Se utilizó grupo focal y entrevistas individuales con todos los enfermeros de los doce equipos de salud familiar de un municipio del interior de Amazonia, Brasil. Se observó la falta de formación universitaria, de educación permanente y de soporte-referencia-contrarreferencia en la atención de la dimensión del abuso de alcohol en la población descripta. Existe necesidad de reformulación de la estructura curricular de los cursos de graduación en enfermería, así como educación permanente en Equipos de Salud Familiar y soporte para los mismos en esta importante temática y sus consecuencias, tanto individuales como familiares y para la sociedad en general.
Descriptores: Alcoholismo; Salud de la família; Enfermería en salud públic; Educación en enfermería
The Ministry of Health (MoH) has developed various strategies to modify the traditional health practices in Primary Healthcare (PHC), in order to improve the reception and the bond between the users and teams. These initiatives collide with the formation of the professional within the university(1). Changes in the undergraduate courses in the area of health have been proposed, aiming at greater involvement of the future professional with the principles of the Brazilian National Health System (SUS) during their formation, an important context for the development of the Family Health Strategy (FHS).
Despite the implementation of the Family Health Strategy, with the purpose of reorganizing the work processes and activities of the SUS, the Brazilian professional formation in health today, even when aiming at strategies such as the FHS, promotes a decontextualized vision of the Brazilian reality(2-3), with contradictions between the higher education institutions, the health services and the communities. Health professionals still maintain the focus on curative, individual care, focused on the disease, with a certain misunderstanding of the reality and the sociocultural context of the families. This means that primary healthcare should work with the health concept in all the dimensions of its bio-psycho-social approach.
The dimension of mental health is implicated in this expanded perspective of healthcare. The interventions require the planning of actions and strategies for implementation, as well as the politics of formation/training of human resources which enable the future health professionals to identify and take action in this area, including the various risk factors and situations that lead to psychological harm and to the suffering of the user of the Healthcare System, so that the demands can be diagnosed and treated in a preventive and interventive way, principally in the FHS. In this panorama, the magnitude of the societal coverage of the use of alcohol as an instrument of socialization is highlighted, with the monitoring of the use of alcohol being relevant(2). The context of the formation of health professionals, based on the model polarized between health and disease, presents a certain discrepancy when overvaluing the conditions of alcohol or other drug dependency as a public health problem. The approach advocated by the World Health Organization(2) is based on a continuum of four patterns of consumption, which can be visualized by health professionals, namely: low risk use, hazardous use, harmful use and dependence(2). For each pattern there are both preventive and curative interventions strategies available. The performance of health professionals must be based on a perspective founded on the trust and the collaboration of the patient. This focus originates from an expanded approach, distant from the reductionism of the diagnosis and purely medicinal interventions. By taking into account the context of the lives of the subjects and their involvement in the intervention process, it is shown as an important resource to be used by nurses, which must be present both in the formation and the daily work schedule, incorporating the theme of problems related to alcohol in the practices of the FHS, a necessity in order to overcome them(3).
Given the importance of this context, the specific literature on the topic of chemical dependency within the theme of alcohol use was reviewed, as well as in the manuals of the FHS, with gaps identified regarding this aspect of expanded health in the PHC, with emphasis on the development of this study. In this sense, this article aims to identify the concept of the FHS nurses regarding the theme of problematic alcohol use, in an Amazonian context, as well as how these professionals work with the theme in their quotidian, in relation to the population that makes use of psychoactive substances.
This is a qualitative study, seeking to comprehend a determined problem from the perspective of those who experience it, as well as the essential nature of the facts(4). Qualitative studies are able to incorporate the meaning and intention of the acts, with the relationships and social structures, both in the event as well as in its transformation, by immersion in significant human constructions(4). To gather the empirical information, two techniques were used - Focus Groups and Individual Semi-structured Interviews(4-5). The simultaneous use of these techniques allows different perspectives to be raised on the same theme, with the first technique referring to a collective construction, and the second to the individual perspective of the interviewees. The joint use of both allows the confirmation or otherwise of the impressions, with in-depth interpretation of the information(5). The results were discussed in an integrated way, seeking a broad perspective regarding the phenomenon under investigation(5).
The sample consisted of twelve FHS nurses of the city of Coari - Médio Rio Solimões Region (Amazonas State), representing all these professionals within the PHC service. For one of the techniques employed, the semi-structured Scripts used referred to the various aspects of how the theme of alcohol use emerges in the daily work in the FHS; coping with this issue; and the existence of individual and team actions in the management of substance use by the ascribed population. The following characteristics were used as inclusion criteria: (1) being a nurse, (2) working in the FHS. The lack of either one of the above criteria would exclude the research participant. The interviewees were recruited individually through the researchers contacting the team they worked with. All those invited accepted the proposal to participate in the study.
The focus groups were conducted on dates previously scheduled, in a room provided by the Institute of Health and Biotechnology of the Federal University of Amazonas in the municipality of Coari (AM). Two focus groups were conducted with six subjects each, with an average of one hour duration, and recorded using digital mini-recorders. The groups were conducted by a moderator, and accompanied by an observer who would record their impressions and the expressions of the participants. During the group, both summarized the notes of the participants. At the end, both the researchers crafted a consensus report, for assistance in the data analysis, conforming to procedures established in the literature(5). Prior to conducting the focus groups, both the moderator and the observer underwent training in the theme and in conducting focus groups. Two weeks after the performance of the focus groups, the nurses were again contacted and individual interviews were scheduled with all participants. On this occasion, a deepening and expansion of the data collected during the employment of the first technique was obtained.
As a form of identification for the statements selected for this study, the code FG was assigned for those originating from the Focus Groups and II to those from the Individual Interviews. The numbering, which follows the code, specifically indicates which of the Focus Groups or Individual Interviews the statement belong to.
The project was submitted to the Human Research Ethics Committee of the Federal University of Amazonas and obtained ethical approval, registered under number CEP/UFAM/Protocol114/2007. All the subjects participated after the explanation, comprehension and registration of formal acceptance to participate in the study through signing two copies (one for the researcher and the other kept by the subject) of the Terms of Free Prior Informed Consent. All ethical procedures laid down in the current legislation of the country were followed.
The nurses referred to the use of alcohol as a disease, focusing on the treatment. For the interviewees, the affected individuals have no control over their actions and deny that they are ill. By worshipping this perspective, the nurses are distinguished by their approach to the use of alcohol as a disease, not identifying the continuous risk/use patterns. Despite the reference to the phenomenon in the mental health dimension and its implications, the conceptualization of these professionals is based on the biomedical model, with even the representation of contamination by the morbidity.
It's a public health problem. Alcoholism is considered a disease (FG2).
I see alcohol as a disease that needs to be treated with people who are already chronically contaminated (FG2).
Actually, everybody knows it's a disease. Those who know understand that what is actually needed is help (FG2).
The patient does not accept that it is a disease (FG1).
Excessive consumption of alcohol was presented as the main cause of problems related to the substance, due to lack of control of the individual over their own way of drinking. The respondents believed that the gradual increase in tolerance to alcohol is a symbol that the subject is an alcoholic, not considering the continuum that exists between low risk use and dependence. Among the interviewees, the dosage itself is taken as a parameter of dependency. This concept is in inclusive disagreement with the Psychiatric clinical parameters regarding alcohol addiction, according to which, for the characterization of dependence, the existence of three or more of the associated symptoms is required: a strong desire or compulsion to drink; difficulty in controlling the use; increased tolerance; alternative interests in favor of alcohol. There is some polarization between being sober and being an alcoholic, reflecting the silence concerning other perspectives and ways of managing relationships with alcohol.
At the time they do not know the dose, the time and the quantity of alcohol that they will ingest. I think that when a person drinks, no longer socially or for a party. He drinks because he needs to, because his body demands it more. Here he is already considered an alcoholic (II5).
When it is consumed in excess, because while a person drinks only a glass, he is still not considered an alcoholic. But from the moment you drink one glass you are already, according to the breathalyzer test, drunk (II8).
The implications of alcohol use are not restricted to the individuals themselves. They affect the social relationships, the family sphere and the society, having implications of a financial or emotional nature. For the interviewees, these consequences justify approaching this topic as a public health problem, both in terms of the suffering of the exposed individual, as well as the impact on the family and society. However, they denounce the lack of support to act faced with this reality, including certain feeling of guilt.
[...] It will certainly cause repercussions as another problem for society, which also ends up being a public health responsibility. [...] usually we have to involve the family, the family nucleus, then we'll get to the root of the problem to solve it (II2).
Because it involves a whole social question, family matters also have to be included in society. Speaking specifically of pathological problems, the family issue is reached, the cultural issue as well and in reality the community would have to have a specific program for this problem. Unfortunately due to our own fault or lack of opportunities, they have not been included in this care (II7).
Among the professional interviewees, there is clear lack of knowledge regarding the national data on prevalence of alcohol use and alcohol-related problems. Interestingly, the lack of referral/counter-referral of the PHC was noted, with only a mention of the Alcoholics Anonymous Association as a potential initiative to support cases in the municipality. This information differs enormously from the perspective that PHC, both in the individual and collective sphere, constitutes a space for actions that cover promotion and protection, injury prevention, diagnosis, treatment, rehabilitation and maintenance of health, developed by democratic and participatory management and sanitary practices, guided by both in the knowledge of the epidemiological profile of the population assisted as well as in the guiding principles of referral/counter-referral and intersectorality.
Well, the alcoholic is a person that does not see the alcohol. If you go to get statistics, there are no statistics about alcohol in Brazil and also probably not in our municipality. There should be, though I don't know, an alcoholics anonymous in Coari (II1).
There is alcoholics anonymous, but in the SUS, at least as far as I know, no. If it exists I do not know of any specific work, directly aimed at alcohol. Sometimes the NGOs have more initiative related to this (II4).
Heredity has been considered a factor related to the problematic use of alcohol. However, the lack of dialogue and of contact between father and children also mediates the problem. Another family contribution refers to the reproduction of patterns of behavior in the generations, in which the children of drinkers also behave this way. Alcohol use also presents the purpose of socialization in which, through the substance, the users would facilitate interaction with others, in relational environments.
Sometimes the youths arrive at a certain age and, unfortunately, do not listen to their fathers and mothers. Because they already have friends of the street doing it and think they have to also (FG1).
It passes from father to son, because the child grows up with the drunken father in the house, sees this, and sometimes even seeks it. It is a refuge (FG2).
Because they see their father, they see their uncle, see someone in the family doing it or even because they think it is beautiful (FG2).
The school cannot be in charge of their upbringing, but it provides professional guidance. It is family education that is responsible. So, for those who use alcohol, the blame is on the parents because they do not have a family foundation (FG1).
Within the issue, the nurses identify the media as a strong influence on the pattern of alcohol consumption of the population. Advertisements are presented as bearers of the message of immediate and momentary well-being brought on by the use of the substance, based solely on relaxation and fun, showing beautiful and happy people. However, the advertisements omit/ignore the direct consequences caused by alcohol use, as well as the associated comorbidities.
And the media shows many beautiful women, perfect women. It is the logo, it is a woman. [...] the media itself is keen to make a beautiful advertisement, using artists and influencing the youth to drink (FG1).
The media does not want to lose out. For the media it does not matter that this family has no money to eat, that the family is paying the price in relation to alcohol. What the media want, what the TV, the wine, the whiskey producers want to do is sell, and make money from this. Hence the consequences, they do not care (FG2).
Table 1 presents a summary of the empirical information, identifying points of convergence between the collective product of the Focus Groups and the perspectives from the Individual Interviews.
The information gathered highlighted the issue of the training and ongoing education of the nurses working in the FHS, in the Amazon context investigated.
The conceptualization of the interviewees regarding the use of alcohol as a disease, is a perspective that, somehow, vindicates the legitimacy of the social power of the health professionals, as if the theme concerned the illness and the cure(6), and not the deep bonds between the various aspects of socialization, the significant difference between the bar drinker and the solitary drinker, or even the question of alcohol use as an emblem of status, control of behavior and of the minutiae of the power(6). In parallel, the approach of the health problems in the strictly biological aspects of alcohol use and its relationship with other morbidities, reveals the maintenance of a technicist and hospitalcentric formation, far from the integral and generalist formation(7). It is an indication of a lack of preparation for dealing with broad health dimensions, such as patterns of use prior to the dependence and their various implications. From another perspective, the traditional formation of health professionals prioritizes the biologicist protocols and referrals to specialists in the PHC(8).
An interesting finding is the stigmatization of the users of alcohol. This may originate from the difficulty to adjust the transversality of the theme to the paradigm of the explanation of the motives that lead the subject to addiction, wrongly isolating alcoholism as a purely social phenomenon, unrelated to other issues such as family, employment, general health and culture. The use of socially stigmatized terms such as alcoholic; the reference to the phenomenon as transmissible, considering the mention of contamination; and other aspects presented are very similar to the social representations of the alcoholic for the family members and for society. It is an uneven condition with the posture of professionals who present a broadened view of the health-disease process, which is a social manifestation, and individual construction. As well as the results of this study, evidence in the literature indicates that the approach of the nurses to the theme of alcohol use is still focused on the symptoms and not on the early identification and prevention of related harm(9).
It escapes them that the use of substances that alter consciousness is also related to the symbolic dimension, to the set of consumer motivations, which is an active subject when using symbols to relate and communicate with their social environment(10). Alcohol cannot be treated as a substance of commercialization the same as any other. Historically, it acquired importance nurtured by the cultural and symbolic aspects, in the majority of populations(11). To face the use only from the perspective of the pathology is to reduce the theme and, as a result of this simplification, to reduce the possibilities for intervention together with the theme(10).
An important demand identified relates to the mechanisms of referral/counter-referral for the cases. Since the SUS provides the Psycho-Social Care Centers (CAPSs), including specific methods for Alcohol and Drugs - the CAPSs-AD, the absence of this in the Médio Solimões region constitutes an important barrier for the professionals of the FHS. Referral services are critical for the performance within the theme and should be available to all the Family Health Teams(12). These reflections lead to the idealization of the actions in the integrality, because the SUS aims to meet the real needs of the Brazilian population(1). In particular, the family health nurses encounter problems to work in consonance with the previously mentioned principles of the SUS. If alcohol use is taken as an emblem for the ascribed population, as one of the dimensions of healthcare in an integral way, there are problems with the action of the FHS in the Médio Solimões region, given that alcohol is related to the etiology of 1.5% of deaths in worldwide terms(2) and the prevalence of alcohol dependence is estimated at 11.2% of the adult population of Brazil(13). Even in terms of causality and alcohol use, the heredity associated with alcohol use is a multifactorial/multicausal phenomenon, with genetic variations in the aptitude or resistance of the body for or against its manifestation(14). However, there are genetic, social, cultural and environmental interactions that underlie its development(14), there is evidence that good family relationships and religious practice are protective factors for the development of problematic alcohol use(15).
Despite the scarcity of related articles in the Brazilian literature, longitudinal epidemiological studies performed in different countries and cultural contexts, show that there is an association between exposure to commercial communications about alcohol carried by the Media and the initiation/increase in the consumption of the substance(16), corroborating the perspective raised by interviewees in this study. Despite the formation problems, the nurses interviewed showed themselves to be sensitized regarding the subject of alcohol. They refer to the difficulties in healthcare actions in this field. There is, thus, a predisposition of these professionals to implement interventions in the FHS. The multiprofessional/interdisciplinary action becomes the model of care suitable for acting against the problem. However, in addition to training, the work process in Family Health should be revised and resized, enabling not only the action, but also the monitoring and control, an example being the inadequacy and unreliability of the data of the current Health Information Systems, when it relates to alcohol and other substances(8).
The performance of the FHS professional, consistent with the dynamics of this problem, should be guided by appropriate and personalized intervention, basing this on the resources of conscientization and motivation of the patients themselves regarding the problem, where the intervention contemplates the expectations, interests and values of each user and observes their individuality(6-7). Another issue is the disregard for the collective dimension as a subject of professional action within the problem. There are consequences, such as problems at work and unemployment, abuse, domestic violence and accidents, among others, which do not just affect the community, but also the family in particular(8). Conversely, given the social character of the use of this substance and of the guiding principles of the FHS, the collectivity is an interesting field for the diagnosis and intervention favoured by the Family Health Teams.
Throughout Latin America there is a certain tradition in Nursing regarding care and prevention in the use of psychoactive drugs. Despite this context, there is a movement toward the resizing of the content in the graduation in Nursing with respect to the theme presented here, especially as it relates to Primary Healthcare. Authors(17) show that 93% of the nursing students, in a national sample of 25 institutes, received some form of education concerning the problem of alcohol and drugs during the course. Regarding the content itself, 81% corresponded to the psychiatric approach, 79% to the problems related to adults and 72% to the phenomenon as a disease. In relation to the conceptualization regarding chemical dependence the study shows that only 1% of the 485 interviewees related to the cultural, social and emotional problems, with the remainder tied to the biological character of dependence. The authors suggest a curricular reformulation, given the lack of relevant inclusion of the subject in undergraduate Nursing courses. The suggestions relate to both the transversality of the theme and the need for a focus that prioritizes the ongoing and multidisciplinary teamwork of a institutional and extra-institutional nature, highlighting the need to focus on prevention rather than treatment. The university formation is still weak in addressing the problem, since 70% of the students interviewed had received little or no information regarding the organic, family and social problems related to alcohol(18).
It is noteworthy that, from the 1990s, the scientific knowledge on the theme in Nursing has made undeniable advances, including the aspect of the formation of nurses(19). However, the formation and care, conforming to that described in the present study, did not accompany this movement. The international panorama on the formation of nurses to deal with problems related to alcohol use reveals that the difficulties are not restricted to Brazil. A study conducted in Colombia showed that, despite the theoretical knowledge provided by the graduation and the tradition of caring that supports Nursing, there were difficulties of acting in the quotidian practice of this social support, as well as in the integrated and multidisciplinary work required for interventions in a broadened perspective in health(20). This gap in primary healthcare is solvable, with strategies existing recommended by the WHO for screening and intervention in this problem in PHC. These are called Screening Strategies and Brief Interventions for the problematic use of alcohol(7). The use of brief interventions is aimed at identifying users in the continuous and varied patterns of alcohol use, in order to promote prevention before the development of the dependency syndrome, reducing the risk of harm related to psychoactive substance use(7).
The use of brief interventions is guided by the action of counseling, using empathy together with the user who needs them. To promote the gradual reduction of the risks of harm in a usercentric way, is not in the strictly biological protocols. Thus, the Family Health nurse has a routine of care available, both in the health units as well as in the community, with an approach which is not only founded in the identification of standards and fixed behavior, but also in the stimulus, sensitization and motivation of the user for their own gradual reduction of use. Given the importance raised by this issue, this work constitutes an initial approach, without the presumption of having exhausted all aspects, including the binomial 'formation/actuation' of the Family Health nurses regarding the use of the substance by the ascribed population.
Outside the scope of this investigation is how this theme is articulated to the other professions involved in the FHS, in their formation/actuation, as well as to the other sectors involved, such as the local commerce, the public power and its posture, the judiciary, and the sectors of repression of the user, among others that refer to the object under investigation, which can be taken as an emblem of intersectorality in a theme of health so present in Western civilization.
The proposal to create a model of care such as the Family Health Strategy is based on various principles and, among them, one of the most important is: the action of the team in the face of the main health problems of the population. The problem of alcohol use in the population ascribed to the FHS is not only relevant due to the epidemiological profile of the population, but also due to the consequences in the medium and long term in the health of the individuals, the family impact and the consequences for society, such as violence, among others. This panorama is presented by the interviewees, indicating that the Family Health nurses visualize the importance and relevance of the theme. However, inconsistencies in the implementation of the FHS are presented, especially with regard to the lack of training and ongoing education reported by the interviewees, that seriously undermine the actions in primary healthcare in the SUS. In this article this panorama presents itself in the sphere of alcohol use, but is not limited to this. There is an urgent need for change in the curricula, politics, and professional practice, indicating the practical employment of light technology in the quotidian of the FHS professionals. The lack of support for the professionals on the issue, in terms of referral/counter-referral, is also presented as a critical point in the context, as much as the lack of programs and services in the sphere of the Family Health Strategy.
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addressed to: Received: 07/03/2009
Rodrigo Otávio Moretti-Pires
Depto. de Saúde Pública, Centro de Ciências da Saúde
Universidade Federal de Santa Catarina - Campus Universitário Trindade
CEP 88040-970 - Florianópolis, SC, Brazil