Satisfaction of black and non-black individuals assisted at the Alcohol and Drugs Psychosocial Care Center

ABSTRACT

The paper aimed to compare the satisfaction of black and non-black individuals assisted by Psychosocial Care Centers for Alcohol and Drugs in three Brazilian states. This is a quantitative, cross-sectional and evaluative study, with inferential analysis of the data we collected through interviews. A total of 707 individuals participated in the study, mostly men, self-declared black, with an average age of 44 years. The results show that black and non-black individuals were equally satisfied with the assistance offered, especially with the competence and understanding of the professionals, embracement and help received. These results contradict the traditional literature that reveals racism in health services. We believe that the Psychosocial Care Centers on Alcohol and Drugs are powerful and differentiated services in the health system, more welcoming and inclusive of their. This result is consistent with the history of these health devices in our country, being central services in the network that is substitutive of hegemonic and asylum-centered psychiatric care.

KEYWORDS
Mental health service; Health services research; Patient satisfaction; African continental ancestry group

RESUMO

Este artigo objetivou analisar comparativamente a satisfação de indivíduos negros e não negros assistidos por Centros de Atenção Psicossocial em Álcool e Outras Drogas de três estados brasileiros. É um estudo quantitativo, transversal e avaliativo, cujos dados foram coletados por meio de entrevistas seguidas de análise inferencial. Participaram do estudo 707 indivíduos, a maioria homens, autodeclarados negros, com média de idade de 44 anos. Os resultados mostraram que indivíduos negros e não negros estavam igualmente satisfeitos com a assistência ofertada, sobretudo com a competência e compreensão dos profissionais, acolhimento e ajuda recebida, o que contradiz a literatura tradicional que desvela racismo nos serviços de saúde. A avalição é a de que os Centros de Atenção Psicossocial em Álcool e Outras Drogas são locais potentes e diferenciados do sistema de saúde, mais acolhedores e inclusivos, para o cuidado de qualquer tipo de população com necessidades decorrentes do uso de substâncias. Esse resultado é coerente com a história desses dispositivos de saúde em nosso país, sendo serviços centrais da rede substitutiva aos cuidados hegemônicos e asilares.

PALAVRAS-CHAVE
Serviços de saúde mental; Pesquisa sobre serviços de saúde; Satisfação do paciente; Grupo com ancestrais do continente africano

Introduction

The Brazilian psychiatric reform movement led to the restructuring of mental health services with the purpose of promoting humanized and integral care. Since 2002, through the implementation of the Alcohol and Drugs Psychosocial Care Centers (Caps AD), the building of a network of services for people with problems of abuse of psychoactive substances began. The logic of Caps AD is that of harm reduction and its purpose is to fulfill the needs of the users of the services in a systematic and active manner, according to the cultural and community environment they are in and following the principles of the psychiatric reform and of the Brazilian Constitution in what relates to equality and universality^1-3.

However, this universal and egalitarian access to health has bumped into several hindrances which include the existing socioeconomic differences, with the black population being subject to much of the impact for reasons relating to the long historic period of slavery in Brazil, racism, poverty, specific diseases and the fact that they are more than half of the Brazilian population (53,1%). They are self-declared black people (black and pardo race) requesting public policies with specific actions to bring balance to such differences^4,5.

From that perspective, the National Integral Health Policy for the Black Population (PNSIPN), established by the Ministry of Health in 2009, with the purpose of fighting ethnic and racial discrimination in health services, as well as to provide equity in the access of the black population to health, includes strategies for strengthening mental health care, especially regarding problems resulting from the use of alcohol and other drugs⁵.

Recent research has shown that the black population has even less access to health services than the white population. The black population reports having been discriminated at given times during the care provision process. Besides, black people, in their majority, lack health insurance (78,8%), thus depending on the services provided by the Single Health System (SUS), and representing more than half of the population to whom it provides care^6-8.

In that sense, the Caps AD service is fundamentally important for providing care for black individuals making use of alcohol and other drugs, which implies the need to have it constantly evaluated. A recent study on patterns of crack use showed that most users are black⁹. In another review study it was suggested that the selection by race is an important social marker that can provide scientific evidence and contributions to a better performance of the health services¹⁰.

Furthermore, satisfaction with these services contributes to better life quality, reduction in the number of hospitalizations and better adherence to treatment and to treatment frequency¹¹. Therefore, a study analyzing the satisfaction of the black and non-black population at the Caps AD would provide information and understanding of the subject matter. This way, the aim of this study is to comparatively analyze, within a racial perspective, the levels of satisfaction of black and non-black individuals receiving care from the Caps AD in three Brazilian states.

Material e methods

It is an evaluative, transversal and quantitative approach research. Studied population is made of 707 users at 30 Caps AD distributed along 19 cities of the three chosen states: São Paulo (SP), Minas Gerais (MG) and Amapá (AP). A draw was made of 30 names of possible research participants for each Caps AD. The loss criteria related to refusal to participate or impossibility to contact prospect after five attempts, requiring a new draw for replacement. Sample was calculated based on a pilot study. Individuals included were of ages ranging from 18 to 65 and had been participating in Caps AD activities for at least six months, having problems resulting from abusive use and addiction to alcohol and other drugs, with cognitive capacity to respond to questionnaires and who agreed to sign the Free and Clarified Term of Consent.

Data collection was performed from 2013 to 2016. In order to evaluate the degree of satisfaction with the service, the Satis-BR Mental Health Service Patient Satisfaction Evaluation Scale was used. This scale was elaborated by the Division of Mental Health of the World Health Organization and was validated for Brazil¹¹. A recent validation study states that the scale has an internal consistency rate (Cronbach’s Alpha) equal to 0.88, a value considered valid by the literature. Furthermore, the scale showed a convergent validity made evident when comparing the correlation with scale scores measuring a similar construct. The analysis of correlation of factors with the global scale demonstrates a positive and statistically significant correlation¹¹.

Satis-BR has 12 items grouped into three factors to evaluate the satisfaction degree of patients regarding: the degree of skill and understanding of the team regarding the patient’s problem (factor 1); the quality of the help received and of the team’s welcoming (factor 2); and the physical conditions and the comfort of service (factor 3).

The reply alternatives to the items were organized in a scale of the Likert type with a score of up to 5 points, where 1 means that user is deeply unhappy and 5 means he is deeply satisfied with service. The instrument was applied by making use of online Google Forms®. The collected data were tabulated, coded and processed using version 15 of Stata® programs and version 20 of IBM SPSS for Windows®.

A multiple logistic regression analysis was performed to examine the relationship between the independent variables with the fact of the user being black or not, and the analysis was controlled according to education, literacy and income levels. A multiple logistic regression was used to find the equation that could best predict the values of the dependent variables considering the values ​​of the independent variable. In this case, black or non-black¹². In other words, the analysis allows to visualize the probability of obtaining a particular value for outcomes to affect either a black or a non-black population. It was assumed that there is inequality in the way blacks are treated compared to non-blacks and this was confirmed by the literature, since international and national studies show that racism reinforces even the distribution of resources in the health area, this being an obstacle to integral, universal and equitable health^13-17.

In this inferential analysis of inequality in treatment, we controlled the variables for income, literacy and education, so that the effect of the race variable was not confused with these social determinants. Thus, when the race variable is found among the dependent variables, it can be said that this effect does not depend on the level of literacy, education and income of individuals. Values ​​of p <= 0.05 are considered statistically significant.

The study derives from a matrix research evaluating Caps AD, approved by the Research Ethics Committee of the School of Nursing at the University of Sao Paulo and by the Municipal Health Secretariat of Sao Paulo under the opinions 1001/2011 and 054/12, respectively, considering the ethical precepts of Resolution nº 196/96 and nº 466/12 of the National Council of Ethics in Research.

Results

Of the total of 707 study participants, 420 (59.4%) were of African origin, 297 (42%) of them being black and 123 (17.4%) of pardo race, whereas 287 (40.6) were non-black. Their profile is described in the frequency distribution of sociodemographic variables according to their state in the federation, sex, ethnicity, marital status, family income, literacy, education and age (table 1).

Table 1
Distribution of frequencies of sociodemographic variables of users of Caps AD. Amapá-AP, Minas Gerais-MG, São Paulo-SP, Brazil

Variables	Frequency (n)	Percentage %
State
Amapá	60	8.5
Minas Gerais	330	46.7
São Paulo	317	44.8
Sex
Female	302	42.7
Male	405	57.3
Ethnicity
Non-black	287	40.6
Black (Black/Pardo race)	420 (297/123)	59.4 (42/17.4)
Marital Status
Married	213	30.1
Divorced or separated	67	9.4
Single	417	59
Widow/Widower	10	1.4
Family Income
Up to 2 minimum wages	503	71.1
From 2 to 4 minimum wages	148	20.9
Above 4 minimum wages	56	7.9
Can read
No	40	5.7
Yes	667	94.3
Education
No education	18	2.5
Incomplete primary school	274	38.8
Complete primary school	96	13.6
Incomplete secondary school	86	12.2
Complete secondary school	134	19
Incomplete technical education	3	0.4
Complete technical education	12	1.7
Incomplete college education	37	5.2
Complete college education	31	4.4
Incomplete post-graduate education	1	0.1
Complete post-graduate education	4	0.6
Not informed	11	1.6
Age
Average	44
Median	44
Mínimum	18
Maximum	76

Source: Own elaboration.
• Caps AD: Drug and Alchohol Psychosocial Care Center.

Table 2 shows the comparative distribution of the percentage frequency of socio-demographic and economic variables of blacks and non-blacks. It is observed that the family income of most blacks (75.2%) is of up to 2 minimum wages, while for non-blacks this percentage drops to 65.2%. It is also observed that only 5.5% of blacks receive more than 4 minimum wages, whereas the percentage for non-blacks rises to 11.4%.

Table 2
Frequency distribution of of sociodemographic variables of blacks and non-blacks at Caps AD. Amapá-AP, Minas Gerais-MG, São Paulo-SP, Brazil

Variables	Non black Percentage %	Black Percentage %
Can read
No	4.2	6.7
Yes	95.8	93.3
Education
No education	18.1	33.1
Incomplete primary school	25.1	30.0
Complete primary school	16.4	12.1
Incomplete secondary school	8.0	6.0
Complete secondary school	13.2	7.1
Incomplete technical education	1.7	2.1
Complete technical education	4.5	4.5
Incomplete college education	5.6	3.1
Complete college education	5.9	1.4
Incomplete post-graduate education	0.3	0.0
Complete post-graduate education	1.0	0.2
Not informed	0.0	0.2
Family income as of last month
Up to 2 minimum wages	65.2	75.2
From 2 to 4 minimum wages	23.4	19.3
Above 4 minimum wages	11.4	5.5
Time attending service center
6 months	8.4	15.5
From 7 to 12 months	22.3	21
From 1 to 2 years	24.7	22.1
From 3 to 5 years	28.2	26.4
More than 5 years	16.4	15

Source: Own elaboration.
• Caps AD: Alcohol and Drughs Psychosocial Attention Center.

Regarding education, despite the fact that the majority of blacks (93.3%) and non-blacks (95.8%) know how to read, there is a higher level of education among non-blacks, given that they are in higher percentages when it comes to having completed both elementary education as well as medium and high education, even more so because blacks show a higher percentage of people with no education whatsoever (33.1%) compared to non-blacks (18.1%).

As for how long participants are assisted in the services, we highlight that there is a higher proportion of black individuals who have been provided services for a shorter period.

Table 3 presents the results of the descriptive analysis of the global satisfaction score and of the satisfaction score of the participants according to factors (1,2,3,4) for each item of the Satis-BR scale, in median values. The results show a positive evaluation of overall satisfaction for all items, with a median of 4.4 for blacks and non-blacks.

Table 3
Descriptive measures of Satis-Br Scale Scores regarding black and non-black users of Caps AD. Amapá-AP, Minas Gerais-MG, São Paulo-SP, Brazil

Factor	Blacks (Median)	Non Blacks (Mediaa)
Satisglobal	4.4	4.4
Factor 1: Competence (Skill) and Understanding	4.5	4.4
Factor 2: Helped received and Welcoming	4.6	4.6
Factor 3: Physical condition and comfort	4.0	4.0
Factor 4: Satis-BR x CSQ-8	4.6	4.5

Fonte: Own elaboration.
• Caps AD: Alcohol and Drug Psychosocial Center; Satis-BR: Satisfaction Scale; Satisglobal: global satisfaction; CSQ: Client Satisfaction Questionnaire.

The questions about Help received and Welcoming (factor 2) were the best evaluated, with values ​​of 4.6 points for blacks and non-blacks. The same happened with factor 1, about the team’s Skill and Understanding, which presented positive scores of 4.5 and 4.4 for blacks and non-blacks, respectively.

Despite having been given a good score, the physical conditions and comfort of Caps AD (factor 3) showed the lowest score among the scale items, with a score of 4.0 points for both groups.

Factor 4 - Satisfat4 compared the results obtained at Satis-BR with the data from the CSQ-8 (Client Satisfaction Questionnaire) – a standardized scale for evaluating satisfaction with mental health services, developed by Larsen, Attkisson, Hargreaves and Nguyen (1979). This comparison between the responses of the scales aims to constantly reassess the concomitant validity of the scale used in the study. This factor also showed a positive result, with values ​​of 4.6 for blacks and 4.5 for non-blacks.

Table 4 shows the multiple logistic regression analysis of the satisfaction evaluation among black and non-black participants. The results obtained demonstrate that there were no significant associations for this study, regarding the fact that the user is black, even when controlling the influence of literacy, education and income variables.

Table 4
Logistic regression of the satisfaction evaluation among black and non-black users of Caps AD. AP, MG, SP, Brazil

Logistic Regression	Satisglobal	Factor 1	Factor 2	Factor 3	Factor 4
Black
	-0.044	-0.013	-0.06	-0.126	-0.057
	0.038	0.042	0.043	0.067*	0.047
Literacy
	-0.135	-0.115	-0.101	-0.258	-0.089
	0.082*	0.089	0.092	0.142	0.101
Education
Incomplete Primary	-0.004	0.028	-0.059	-0.037	-0.007
	0.05	0.055	0.057	0.087	0.062
Complete primary	-0.064	-0.034	-0.035	-0.215	-0.025
	0.062	0.068	0.07	0.108**	0.077
Incomplete secondary	-0.001	0.088	-0.105	-0.158	0.003
	0.081	0.088	0.091	0.14	0.099
Complete secondary	0.125	0.115	0.03	0.302	0.043
	0.071	0.077	0.08	0.123**	0.087
Incomplete technical	-0.096	-0.01	-0.212	-0.221	-0.092
	0.135	0.147	0.153	0.235	0.167
Complete technical	-0.235	-0.179	-0.297	-0.338	-0.168
	0.094**	0.102	0.106***	0.163**	0.116
College	-0.135	-0.048	-0.241	-0.283	-0.137
	0.083	0.09	0.093**	0.144**	0.102
Family income
2 to 4 minimum wages	0.134	0.109	0.157	0.185	0.161
	0.047**	0.051**	0.053***	0.082**	0.058***
Above 4 minimum wages	-0.007	0,02	-0.023	-0.078	0.016
	0.075	0.082	0.085	0.131	0.093
-cons	4.493	4.476	4.7	4.24	4.538
	0.083***	0.091***	0.094***	0.145***	0.103***
F statistic	2.6	1.4	2.5	3.4	1.3
Adjusted R-squared	0.02	0.01	0.02	0.04	0
N	707	707	707	707	707

Source: Own elaboration.
• Caps AD: Alchohol and Drug Psychosocial Care Center; AP=Amapá; MG=Minas Gerais; SP=São Paulo;
• ^*
  p<0,1,
• ^**
  p<0,05,
• ^***
  p<0,01.

Discussion

The 707 individuals who took part in this study were from the AD Caps of three Brazilian states: SP, MG and AP. Sociodemographic characteristics were as follows: the majority were men (57.3%), single (59.0%) and with an average age of 44 years. These data are similar with data of other studies in the area⁹.

Of this total, 420 were of African origin (297 black and 123 of pardo race) and 287 (40.6) were non-black. Comparatively, the number of blacks (75.2%) with family income of up to 2 minimum wages is higher than that of non-blacks (65.2%). And, in spite of the fact that the majority of blacks and non-blacks know how to read, there was a higher level of education among non-blacks. Such differences in sociodemographic variables have been associated in the international literature to a racial belonging that leads to inadequacies in terms of life condition, lifestyle, employability, and access to food and health services^18,19.

Satisfaction was then assessed in relation to the assistance received by applying the Satis-BR Scale with a racial profile, considering literacy, education and income variables. It was assumed that there is a difference in the assistance provided to blacks and non-blacks, with a consequent impact on the referred satisfaction.

In this case, the multiple logistic regression analysis showed that there were no differences in overall satisfaction between the two population groups, providing a good general assessment regarding the assistance provided by the studied AD Caps, this effect being independent of the literacy, education and income of these individuals.

Studies have reaffirmed that, although the black population presents the same diseases as the population in general, comparatively, there are differences in the account they make of them and in the care provided. Such differences are related to situations of prejudice, stigmatization, social exclusion, and inequalities, with consequent restricted access to health services. In the latter, they refer to interferences regarding the professional relationship in the services^20,21.

It is important to consider the singularities of the black population in different scenarios and contexts²², and it is necessary to reflect on how the results of this study are justified in view of the similar levels of satisfaction analyzed for the groups of blacks and non-blacks conferred to the services of Caps AD, from the racial perspective.

The progress made by the Brazilian psychiatric reform led to an important expansion in the number of Caps AD throughout the national territory. Although this number is still insufficient to meet the demands of the population, literature has shown that such devices play a fundamental role in the psychosocial care network as protagonists in the process of providing care to people with needs resulting from the use of alcohol and other drugs²³.

In addition to this, and although incipient, there has been an increase in the last few years in the Brazilian research addressing ethnic-racial issues, which contributes to a better understanding and better access to health actions and services, as well as to specific public policies²², including public policies for the health of the black population, evaluation of the service network and of work processes, among others.

The national and international literature on the evaluation process in mental health has identified that the user’s positive satisfaction with the service is related to the bonds they make with the health team, to how they are welcomed to the appointments, to quality of services, to the monitoring during and after treatment and to guaranteed access^17,23-26, a data that can be reinforced in this study, as we did not see differences related to race or color.

On the other hand, this positive satisfaction with the service has also been related to a certain fear participants have of possible loss of the right to access care, often expressed in negative evaluations but not necessarily expressed in opinions, a situation known as gratitude bias²⁷. It is necessary to consider that Caps meet the demands of a population much fragilized from the physical, emotional and social points of view, and that this can be worsened by the stigmatization, discrimination and prejudice that involves substance use, which can be intensified by racial issues. It is therefore essential to welcome all who access the services^6,28. Relevant factors that could influence the findings of this study.

The satisfaction expressed by individuals assisted by mental health services involves the need for fundamental change in the context of the user’s relationship with health professionals to facilitate the engagement in the care offered²⁵, together with an offering of an assistance free of judgment and regardless of race or color^29,30, as also demonstrated by this study.

As for the factors on the Satis-BR scale assessed in this research, it was found that factor 1, about Team Competence and Understanding, and factor 2, about Help and Welcoming, received the best assessment scores, corroborating other studies in this area^17,31.

A recent study obtained a similar result, showing good evaluation of Caps AD by 88.3% of the individuals, mostly black, who reported that the service could be improved in terms of physical structure, indicating that this may be the greatest weakness found¹⁷, a weakness also revealed in other studies^32,33.

We evaluated that the positive results observed by the individuals assisted in the services, regardless of their race or color, indicate that Caps AD are services that surpass the rigid and segregationist construction of other models of health care found in Brazil and in the world^13-16, lying on their progressive nature ever since their implementation.

Caps are seen in the literature as services that provide space to diversity, citizenship, cultural appreciation, with a focus on the rights and protagonism of the assisted individuals³⁴. We understand that the role Caps AD play in the Psychiatric Reform, along with their history and their central service for an integral health system, are all responsible for the results found here.

Unfortunately, the scenario of comprehensive mental health care has been threatened in recent years by practices and services that bring back the conservative and asylum centered mentality. Some services, such as therapeutic communities, use labor therapy and offer healing through religion, departing completely from evidence-based practices³⁵. This approach hampers the progress that came along with the Brazilian psychiatric reform and there is literature we support confirming this. Such setback may soon threaten the existence of the psychosocial care network, making prevail again the psychiatric hospital and asylum centered perspectives³⁵.

However, we are faced with the dialectic relation between conservative and progressive practices, which brings tension to the care provided by the psychosocial field valued by the Brazilian psychiatric reform taken place between the 1980s and the year 2016, when a clear conservative wave took hold of Brazil^36,37, with its effects being seen in the system as a whole. The clashes between asylum and other forms of care in the community, the psychiatric field versus the psychosocial field, the goal of total abstinence as a norm versus harm reduction as an option of choice and, last but not least, the war on drugs policy – historically instituted as a war against the poor, black and peripheral population – are elements that challenge mental health and alcohol and drug practices and impose constant barriers to be overcome. It is necessary to rely on scientific evidence and on humanized, inclusive and comprehensive care, such as that provided by the Caps AD, so as to resist to this setback scenario and think over public policies that support the subject’s decriminalization model³⁵.

The assistance provided by Caps AD in the states of São Paulo, Minas Gerais and Amapá is satisfactory, regardless of the race and color variable, with emphasis on the competence and welcoming of the health team, given that it highlights the potential of community mental health services to provide care to the entire population with needs arising from substance use, without reinforcing the place of difference related both to drug use and ethnic-racial issues.

Limitations to study

Given that it is transversal, this study did not evaluate cause and effect relations. Besides, the small amount of papers on the theme found in the literature restrained the discussion to a few findings.

Contributions of the study to the practice

Caps AD are considered satisfactory among users of alcohol and other drugs, regardless of race or color. Evaluating satisfaction with the service through a racial approach allows giving a voice to participants, especially those from the black population, reflecting on the role and quality of the assistance provided. Such an attitude provides for the continuous understanding, elucidation and co-responsibility of the actors involved, i.e., professionals, managers, broader society and those assisted by the service, towards an assistance that may be increasingly equitable, integral, effective, participatory, non-judgmental or stigmatizing.

Conclusions

The findings of this study showed, in general, good satisfaction of users regarding the service offered in the analyzed Caps ADs, creating the possibility of larger access to treatment, as well as a positive image of these venues, seen as powerful places for care in the network. Although there was no difference in the level of satisfaction reported between blacks and non-blacks, such similarity can be an indication of quality of care.

It is true that more research evaluating these services is necessary as it allows reflections on the role and quality of the assistance provided, in addition to giving voice to the service users about the experiences lived in these places. In addition, the evaluation through the racial cut contributes to strengthening the National Policy of Integral Health of the Black Population (PNSIPN) focused on the attention to mental health, allowing, thus, a greater understanding towards an increasingly equitable and integral assistance.

The best scores, obtained by both blacks and non-blacks, were related to factors Help, Welcoming and Understanding, all of them related to the bond between the professional and the user. These factors indicate, respectively, the fulfillment of the objectives of the service and its importance, representing an important advance in the Brazilian psychiatric reform from the perspective of care and reception for all types of population, despite difficulties faced in terms of comfort and physical structure, a factor with a lower satisfaction score compared to other factors.

In view of the small amount of publications that address this issue from a racial perspective, this study represents an important estimate of the evaluation of the black population in these three states, requiring an expansion of the evaluation to other regions of the country. In this way, it is expected that the results will contribute to local policies in the improvement of actions that expand comprehensive care, generating greater evidence with a racial profile.

• Financial support: non-existent

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Publication Dates

• Publication in this collection
  31 Mar 2021
• Date of issue
  Oct-Dec 2020

History

• Received
  14 Jan 2020
• Accepted
  15 Aug 2020