Social determinants of alcohol use in childhood and adolescence in rural areas

Abstract

This paper analyzes the social determinants of alcohol use in childhood and adolescence in rural areas. This qualitative study was carried out in a small municipality of Rio Grande do Sul State, Brazil, with professionals from the psychosocial and intersectoral care network. Data were collected using the Empowerment Evaluation and analyzed by thematic analysis. The social determinants found show that alcohol use is a cultural aspect of the Pomeranian families and the religious rituals that mark the passage from youth to adulthood. In work-related aspects, alcohol use is a form of leisure in face of the responsibilities the youth assume in farming. Gender and violent situations also influence this factor: boys are encouraged to try alcohol, while girls are the biggest victims of physical aggression. Risk behaviors are observed in traffic accidents involving children and adolescents under alcohol the influence of alcohol. The social determinants broaden the scope of the topic, moving away from an exclusive conception of chemical and biological dependence to encompass multiple factors such as territories, cultures, work, and society.

Keywords:
Child; Adolescent; Rural Areas; Alcoholic Beverages; Mental Health

Resumo

Este artigo visa analisar os determinantes sociais que envolvem o uso de álcool na infância e adolescência em territórios rurais. Trata-se de um estudo qualitativo, desenvolvido por meio da Avaliação de Empoderamento, realizado em município de pequeno porte do Rio Grande do Sul com trabalhadores da rede de atenção psicossocial e intersetorial. Para análise dos dados, foi utilizada a análise temática. Os determinantes sociais analisados demonstram o uso de álcool como parte da cultura das famílias pomeranas e dos rituais religiosos que marcam a passagem do jovem para a vida adulta. No aspecto relacionado ao trabalho, observa-se o uso de álcool como uma forma de lazer frente às responsabilidades que o jovem assume na lavoura. Identifica-se a influência do gênero e situações de violência - os meninos são motivados a experimentarem o álcool, enquanto as meninas são as maiores vítimas das agressões físicas. Observa-se comportamentos de risco em situações de acidente de trânsito envolvendo crianças e adolescentes sob efeito de álcool. Os determinantes sociais ampliam a visão sobre o tema, afastando-se de uma concepção exclusivamente de dependência química e biológica para abranger os múltiplos fatores como os territórios, culturas, trabalho e sociedade.

Palavras-chave:
Criança; Adolescente; Zona Rural; Bebidas Alcoólicas; Saúde Mental

Introduction

Drug use and abuse experienced by children and adolescents is a public health problem that affects many families and is directly related to culture and social background. One of the main drugs used by this age group is alcohol, since it is easy to purchase and its consumption is seen as natural by society, including within family environments (Henriques; Rocha; Reinaldo, 2016; Oliveira et al., 2020).

Childhood is a phase of life during which the individual is introduced to a historical and social culture, acquiring human specificities from experiences and relationships with other children, adults and symbolic and material elements from humankind (Quinteiro, 2019). Adolescence, on the other hand, is a phase characterized by many significant biological, physical, social, and psychological changes; these are often determining, as they associate with other factors-especially environmental ones-, because they can induce the use/abuse of drugs. Therefore, childhood and adolescence are distinct phases that require qualitative family, school and health monitoring (Moura; Monteiro; Freitas, 2016).

Mental health care aimed at children and adolescents has gained prominence with the creation of law No. 8,069/1990, which provides for the Child and Adolescent Statute (ECA), the creation of the Brazilian National Health System (SUS), the Psychiatric Reform movement and the implementation of the Psychosocial Care Network (RAPS), which provides care for children, adolescents, adults and elderly people experiencing psychological suffering and in need of attention due to drug use and abuse.

These political systems enabled the creation of territorial-based care services and brought a new understanding of the concept of health, as well as the need to expand the ways of acting and caring, including the understanding of social determinants in the concept of health needs.

The primary assumption of social determinants is the understanding that the health/disease process is tied to the interdisciplinary analysis of how society is organized, involving economic and social issues, ways of life, relation networks, territories and cultures, and not only exclusively natural and biological situations that characterize a biomedical and positivist view (Garbois; Sodre; Dalbello-Araujo, 2017).

Living conditions, accessibility to public health services and actions and community resources, as well as social support in the community, gender, race, ethnicity, among other factors, are part of a complex equation that are articulated differently in urban and rural contexts and that are responsible for the differences in the health-disease-care process observed in these contexts (Belmarino et al., 2016).

In rural areas, some national and international studies show that risky alcohol consumption among adolescents is similar to, or larger than, that in urban areas, with particularities in the ways of life that reverberate in the relationship of children and adolescents with alcohol use (Donath et al., 2011; Obradors-Rial et al., 2020).

There may be different ways of experiencing the surrounding area, and in rural areas the health/disease process and drug use in childhood and adolescence have local specificities regarding the relationships created in this space of existence, which must be thought about in health care and in the construction of public care policies and the organization of local teams. Thus, this paper seeks to analyze the social determinants that involve alcohol use in childhood and adolescence in rural areas.

Methodology

We conducted a qualitative study using the methodological assumptions of Empowerment Evaluation, which is characterized as a participatory evaluation that uses concepts, principles and techniques to promote the understanding of contexts and improvements of social programs and technologies (Fetterman; Kaftarian; Wandersman, 2015).

Empowerment Evaluation aims to help people evaluating their own programs/ organizations/actions in three integrated steps: (1) construction of a mission, that is, to analyze the purpose intended by the organization with the work of the different participants; (2) knowledge of the situation in which participants evaluate the current moment of the program, the strategies carried out and the actions that must be prioritized to achieve the mission; (3) planning for the future, the moment when the objectives and the strategies to achieve the mission are set (Fetterman; Kaftarian; Wandersman, 2015).

The research field was the RAPS of a small town in Rio Grande do Sul State. It was chosen intentionally because it stands out in terms of network care from the perspective of psychosocial care, pioneering the implementation of Psychosocial Care Centers (CAPS) in the state. This town had an estimated population of 44,580 inhabitants in 2017, with approximately 50% living in the rural area. It is of German colonization, with one of the largest concentrations of Pomeranian descendants in the world. The administration of the municipality consists of eight districts, one urban central district and seven rural districts, in which there are five quilombola areas (IBGE, 2017).

The interest groups in this study include workers of the RAPS care services for drug users. For data production, we used the triangulation of qualitative methods: participant observation; semi-structured interview; and open forum.

We aimed to follow the practices of the workers of CAPS Alcohol and Other Drugs (AD) and, based on this service, to know what was produced about the operation of the network and its connections and compositions. This process involved field immersion and daily interaction by the main researcher of the study in the activities performed by the network. Thus, the researcher attended and took part in the activities of the network during the months of March to December 2017, for five days a week, from 8 am to 6 pm, to follow the internal dynamics of the service and its relations with the integrated work, in care actions in the area and daily flows.

The semi-structured interviews were applied to 42 workers from the following network branches: 18 workers from the primary health care branch (Harm Reduction, Central Health Unit, Family Health Strategy (FHS) and Family Health Support Center (NASF); nine from the Strategic Psychosocial Care (CAPS AD, CAPS I, CAPS Infantil); one from the Urgency and Emergency Care (Mobile Emergency Care service (SAMU)); one from Hospital Care (hospital ward specialized in substance addiction; one from the Psychosocial Rehabilitation Strategies (Child Care generation service) three RAPS managers (Health Management for mental health, primary care, and education research and extension), five from Social Services (Social Services Department, CRAs, CREAS, Children’s House, PIM) and four from the Intersectoral Network: (Guardianship Council, School, Judiciary and Public Prosecutor’s Office). The interviews were conducted individually, recorded and transcribed in full.

The interview was conducted to better understand aspects not clarified during the observations and that needed further investigation, and included questions about the mission of the RAPS in the attention to drug users, the current needs and potential of the network, and the strategies for the future of the network.

The criteria for inclusion of the participants were: accepting the invitation to participate in the research, being a coordinator for at least one month in the network service, and for workers, being employed for at least six months.

The Open Forum (FA) was a technique used to negotiate and validate the research data, and it had the participation of professionals who were members of the management body: three managers of RAPS (Mental Health coordinator, Primary Care coordinator, and Multiprofessional Residency coordinator) and a representative of the network branches (CAPS AD III, CAPS I, CAPS Infantil and SAMU). The FA enabled the convergence of the information obtained from the analysis of the participant observations and from the interviews, to prioritize the mission of the RAPS, the knowledge about the current situation of the network and planning strategies for the future. The FA also enabled a discussion of the research data, allowing each participant to state their position and a reflection to resume the events and produce new results, so that everyone could have the opportunity to change or ensure their credibility.

For data analysis, we used thematic analysis, through which we skimmed through and scanned all the collected material. After that, we separated excerpts and fragments that were important to the study. They were distributed into topics - identified as “information unit”- and then all similar information units were brought together, thus originating the units of meaning. Thus emerged the analytical categories that guide the study. Finally, we did an interpretative summary based on the treatment of the results obtained, which underwent complex or simple operations that allowed highlighting the research data (Minayo, 2014). Data analysis showed thematic categories related to the evaluation of the RAPS. This paper presents the category referring to the stage of current knowledge of the network, in which the following theme emerged: social determinants associated with drug use in children and adolescents in rural areas.

This research was guided by the principles and guidelines of resolution No. 466/12 of the National Health Council. The workers were identified with the letter “T” followed by the RAPS branch in which they work. Both letters were followed by Arabic numerals, according to the ascending order of the interview. The study was approved by the Ethics Committee in Research with Human Beings, under Opinion No. 72657617.7.0000.5347.

Results and discussion

The countryside, thought as a moving space, has different kinds of conditions and ways of life. Despite its many specificities, the rural context maintains historical, social, cultural and ecological particularities, which create a distinct physical and social space that reverberate in the subjective and socialization processes, and which need to be considered in the organization of public policies (Belmarino et al., 2016).

In the theme of drug use, understanding the social determinants has been a challenge, given the often reductionist explanations, not devoid of moralism and prejudice, which do not contribute to an expanded reflection on the subject (Ronzani; Costa; Paiva, 2016).

When we approach social determinants, culture is a reference associated with the health/disease process. The concept of culture refers to a map, a prescription, a code which the people of a group share and from then on create bonds and group transformations to live together, feeling part of the same totality (da Matta, 1986). In the theme of drugs, when we talk about codes, we can understand that drugs are permeated by the culture of the people and the society in which people are inserted, therefore they are related to the historical and symbolic construction of values and beliefs surrounding their use (Silva et al., 2019). In the context of this study, we identified the link between culture and alcohol use in childhood and adolescence:

[…] we have here the issue of the countryside, the rural area, alcohol use is part of the culture of the families, children grow up seeing their parents drink at the end of the day, even more on weekends, and many parties illustrate that. If you go to the countryside on the weekend, all the parties have lots of beer, of drinks, they motivate and encourage consumption in a certain way. (T34 intersectoral network branch)

[…] from an early age, parents also encourage their children a little by offering them a drink. For example, there were many soccer championships and the prize used to be a crate of alcoholic beverage. This is an early encouragement for children and teenagers. (T20 Rural Area Primary Care branch)

[…] a lot of kids are drinking from a very early age, we see a lot of alcohol being sold at school parties (T27 Primary Care branch)

We can see in the reports that the social background and relationships are crucial for the first motivations for alcohol use. Countryside families have a strong relationship with alcohol use as an aspect of Pomeranian culture. It is common for families to use alcohol in the presence of children in the home environment and in communities. At parties and championships in rural areas, there are drinks and there is often an incentive to their use.

The literature produced on the cultural theme of drug use demonstrates that alcohol is part of cultural, religious and social practices, and is perceived as a pleasure by many users. In Brazil, alcohol use dates back to before the European colonization. The indigenous peoples produced a wide variety of alcoholic beverages fermented from cassava and fruits - cashew, pineapple and jabuticaba (Brazilian grape). Their use was intended for rituals and festivals determined by indigenous culture, such as in celebrations for the birth of a child, in the rituals of coming of age or in cannibalistic orgies (Alarcon; Jorge, 2012).

A noteworthy aspect in Pomeranian culture is the relationship between the initiation to alcohol consumption in adolescence and the Rite of Confirmation:

For them, here in the countryside, it’s after Confirmation […]. From that moment on, they can drink, they can go to all parties, and they are teenagers, usually twelve to thirteen years old. […]. It is like the first communion for us […]. For them here in the countryside, it is like Confirmation, it is like turning fifteen […] it’s like becoming an adult. (T24 Rural Area Primary Care Branch)

[…] it is a thing of the past, but it’s strong, it’s still here. [ ... ] they get confirmation […], is the first communion, […] in the countryside, they are mostly evangelicals […]. And often the reward is also that, and they can party, and there is the whole cycle of drinking, of partying, you’re already allowed to drink. And they get motorcycles […]. (T20 Rural Area Primary Care branch)

[…] often they are getting drunk before they are twelve Sometimes, they don’t even wait for Confirmation. (T25 Rural Area Primary Care branch)

[…] it is like a birthday gift when you turn fifteen, or sometimes even before, they get Confirmation when they are thirteen; and it is a big celebration, it is a celebration of their debut in society, in which society means the drink. (T23 Rural Area Primary Care branch)

In the context of this study, The Rite of Confirmation happens in countryside communities as a moment of celebration for the families and the community, since they mark the end of one cycle and the beginning of another. From this “transition to adult life”, many adolescents have their first experiences with alcohol use in the eyes of the community, and they can now go to places where previously were not allowed to. In addition, some of them are given a motorcycle as a gift.

The Rite of Confirmation is part of the Protestant religion, which is considered the predominant one (49.61%) in the town (IBGE, 2017). In rural areas, Confirmation is a celebration that marks the passage from adolescence to adulthood in the community, meaning that one is allowed to go to parties and use alcoholic beverages (Dreher, 2005).

Studies with adolescents show a range of reasons for alcohol use in this phase, in association with aspects of sociability, relaxation, companionship, excitement, being able to cope more easily with unpleasant emotional states, group pressure and the drinking culture in the country and in the local community (Kloep, 2001; Martin, 2019; Silva; Menezes, 2016).

Although the pursuit of such sensations is an integral part of drinking, what is noteworthy is the need of young people to be accepted as adults within their own culture and, therefore, to develop habits similar to that of adults in various ways, including the use of alcohol. For young people, this behavior will reflect on their acceptance in society, therefore it is likely that they ignore or discard evidence that such use may pose a short-term threat, such as involvement in accidents and fights, or in the long term as health problems (kloep, 2001).

Along with Rite of Confirmation, there is a connection in the countryside between drug use and leisure, as a kind of reward for the effort made on the farm:

[… ] in the countryside people start working very early, children as young as ten have been working on the crops for a long time, and then when a teenager goes to a dance and drinks too much, “Ah, poor thing, he worked so hard, he deserved it”. They see it as a reward […]. (T28 Primary Care branch)

We note a way of living that does not allow individuals to mature and develop psychosocially as a process, and the evidence of that is that the Rite of Confirmation is performed at the age of 13. We note that the lives of children and adolescents are mixed with those of adults because there is a strong relationship with work and responsibilities with farming.

Work is a social determinant that impacts the lives of these children and adolescents. This is a violation of human rights since it deprives them of important development stages. Child labor in family farming, for example, cannot be seen as something dignified, since it is related to a complex set of economic, cultural, generational, political and educational factors.

Indicators related to child labor show a significant decrease in recent years in the exploitation of child labor in rural areas. However, this exploitation remains rooted in society. Among the main factors that promote the perpetuation of child labor in family agriculture, we find poverty and the generational reproduction of the parents themselves, as they regard child labor as something positive for the subsistence of the family (Custosio; Cabral, 2019).

In view of these determinants, the factors of child and educational development are often minimized, and children and adolescents begin to abandon school due to fatigue and the work as farm laborers (Custosio; Cabral, 2019). Another issue observed in the reports are situations of violence with children and adolescents:

[…] the head teacher called me because he [the child] told her. […] His father gives him caipirinha at home. [The father] tells him to fetch limes at ten o’clock in the evening […], he said, “My father makes me drink with him”. The nine-year-old boy. And then he said that his father takes drugs, […] he told the teachers himself, “my father beats my mother, and then makes caipirinha and makes me drink it, too”. […] He was hitting his classmates, wanting to fight and saying a lot of things to the teacher, to kick the teacher […]. (T19 Rural Area Primary Care branch)

[…] women suffer a lot from this because they really are, the wives and daughters, the biggest victims of fathers or men who use alcohol. And then the family conflicts begin; some usually come home after they have drunk a lot, bothering, assaulting, not physically, but sometimes verbally, or sometimes both. Then, […] I associate a large part of the family problems here, especially the problems of the children, with family conflicts; with the fights between the father and the mother, or the father with the children after coming home drunk. (T21 Rural Area Primary Care branch)

We identified that situations of violence are associated with drug use in the family environment, with reports of physical and psychological aggressions that compromise the psychosocial development of children and adolescents. Other studies also highlight the exacerbated use of alcohol in the Pomeranian culture, associating this practice with violence, disorders related to alcohol use and suicide (Jaeger; Spring; Silveira, 2018; Potratz; Coast; Garden, 2014).

There is a strong influence of gender, whereby sons are motivated by their parents to experience their behaviors (using alcohol, assaulting people), which constitutes psychological violence, while daughters are the biggest victims of physical aggression and the historical problem of violence against women already experienced by the mothers.

Violence against women is one of the most perverse manifestations of gender inequality, a product of power differences that represents an important social phenomenon and a violation of human rights, significantly impacting the health-disease process and womens’ life prospects (Barufaldi et al., 2017).

In rural areas, women experience several factors that impact their life contexts, considering situations of vulnerabilities and aggravations, since they face situations of gender inequalities and family devaluation (Nascimento et al., 2017).

Both the aggression experienced by women and the violence against children mentioned by the study participants were associated with the abuse of alcohol and other drugs bringing risks to all the people within the family. This corroborates a study conducted by the National Institute of Public Policies on Alcohol (INPAD) in 2013 with people over 14 years old, in which for every 10 participants, more than two reported having suffered physical violence in childhood. In addition, two in ten reported that the abuser was under the effect of alcohol (Feijó et al., 2016).

Another issue that needs attention in this structural violence is the living condition of children and adolescents, making their growth and development vulnerable. Childhood and adolescence are phases that require special care, as they are important stages of physical, psychic and mental structuring. Going through these complex processes, by itself, makes children and adolescents peculiar beings (Rozin; Zagonel, 2013).

Adolescence is also characterized by the search for autonomy and self-affirmation, social approval and the susceptibility to influences that can substantially interfere with early consumption of alcohol and tobacco, which can be the “gateway” to the use of other psychoactive substances (Pembrokeshire et al., 2019).

In this sense, the family can be considered a risk factor when it makes use of drugs and displays, in their relations of authoritarianism, conducts of violence and permissiveness, situations that increase the chances of psychoactive substances use (Valim; Simionato; Gascon, 2017). On the other hand, we draw attention to the need for healthy investment in this relationship, since the predictors of low drinking among adolescents include involvement in leisure activities with parents and parents’ concerns about drinking (Kloep, 2001).

It is also important to consider that the social violence imposed by adults in the lives of these children is connected to creative advertising campaigns that convey a sense of joy, euphoria and well-being. In this sense, alcohol use can also be incorporated by the family as a habit of strength, pleasure and abstraction. For adolescents, this perception can lead to risky behaviors, such as involvement in fights, insertion in crime, acts of violence and accidents (Moura; Monteiro; Freitas 2016; Pinho et al., 2017). One of these risk/vulnerability behaviors is identified in this research as traffic accident situations in rural areas, involving children and adolescents using alcohol:

[…] here in the colony, they give kids a car when they are 12, 13 years old. Kids get a motorcycle when they are 10, 12. So they go around, speeding, they drink, get hurt, they fall here. And when you realize, they drive tractor, they turn the tractor around, and how old are they? Ten. […] it’s a culture. (T19 Rural Area Primary Care branch)

[…] a lot of motorcycle accidents in the countryside, because they do not wear a helmet, they are not careful at all, they go to parties on their bikes and drink, and rural areas have a lot of dirt roads, so they skid on the sand and have those accidents. It happens a lot. Probably because of German culture, right? (T20 Rual Area Primary Care branch)

Vulnerability refers to the definition of fragility and dependence, after all, every human being can experience situations of vulnerability, but in the case of children and adolescents, there is a greater risk/probability of vulnerability due to their dependence on older people, submission to the physical and social environment in which they meet with families, who are responsible for their biopsychosocial well-being (Getachew, 2019).

Regarding the research data, there is a vulnerability related to cultural and social relations built with the family and the living environment. As with the violence and abuse naturalized by families, there is also the permissiveness of parents, as they do not reflect on the risks that can be caused by the experiences of drug abuse, use of vehicles and excessive work by children and adolescents in rural areas.

In the context of care, we draw attention to the many challenges that teams face when organizing actions to prevent and treat drug use in rural areas. It is important to point out that there is a lack of specific policies for rural areas. In the most recent public policy aimed at the integral care of rural and forest populations, no reference is made to mental health, whether to point out the territorial, social and cultural particularities in the ways of life of these populations, their health needs, ways of getting sick and of care, or to guide the planning of psychosocial care networks (Belmarino et al., 2016).

We believe that an approach not limited only to clinical issues and biological aspects of drug abuse is a major challenge in mental and public health. It is necessary to perceive the social determinants that take into account the constitution of health/disease problems, like health care requires a special bond and sensitivity toward the young public, needing actions that include the family and address the different lifestyles.

Such aspects should be reflected on in rural teams to help workers understand this problem in an expanded way, since they are also inserted in this culture and may not have the perception that alcohol use in adolescence is a problem:

The reality of alcohol is in their families [community agents]. Sometimes we even talk about it. They’re from the city, our agents here. […] And they themselves report that alcohol use is part of their culture there, both have pre-adolescent children and say “the friends of such-and-such are drinking beer, I do not know when such-and-such will start drinking, […] I bet he will start drinking soon”, so we are at that phase there. (T23 Rural Area Primary Care branch)

Therefore, rural workers should be the target of permanent education policies, updating and planning strategies and organization of care since these workers are on the front line in rural areas, inserted in that context and in contact with families, often reflecting community perceptions about the issues of drug use, or even experiencing feelings of fear and insecurities to carry out these approaches.

Many studies about the rural environment mainly involve the difficulties related to the access and structure of these teams, and the actions of the RAPS are often prioritized for professionals in the city.

In this study, we identify the need to develop more concrete proposals for inclusion in continuing education and qualification actions of these professionals who work in rural areas, aiming to reflect on the culture, relations and ways of life of the regions where they work. If these issues are not discussed, the population of the rural environment will remain on the margins of the health system and remain excluded from public policies.

Thus, in view of the importance of the social determinants exposed, we understand that the mental health care demands for children and adolescents should reflect critically on the culture of naturalization of drug use together with the perception of the many problems related to the theme, which require innovative actions to promote health and psychosocial rehabilitation to young people in rural areas.

Final considerations

As results, we identified some social determinants in the process of health/disease and drug use in childhood and adolescence in rural areas such as culture, family environment, substance use rituals, such as “confirmation”, leisure, childhood labor on farming, issues of vulnerability and violence in childhood and adolescence.

Mental health care in rural areas was associated to work difficulties with sociocultural issues of drug use involving the perception of the teams themselves, and the importance of strengthening strategies for permanent education, updating and qualification of professionals working in this context.

The contributions of this study reflect the importance of investing in information and mental health care based on social determinants in health, which broaden the view on the topic of drug use from an idea exclusively of chemical and biological dependence, but involving multiple factors, such as territories, cultures, work and society.

We suggest investment in qualitative research that addresses this issue in the perception of those who experience in their daily lives alcohol use related to childhood and adolescence, as a limitation of this study is the need to listen to the children and adolescents, as well as their families, for a more in-depth debate on drug use in rural areas.

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Publication Dates

• Publication in this collection
  10 June 2022
• Date of issue
  2022

History

• Received
  16 Oct 2020
• Accepted
  15 Jan 2022