Assessment of health promotion and drug use prevention strategies in the psychosocial network^a

Abstract

Objective

to assess health promotion and drug use prevention strategies in the Psychosocial Care Network.

Method

this is a qualitative study based on empowerment evaluation, developed in 2017 in the Psychosocial Care Network of a municipality in Rio Grande do Sul, Brazil. The interest groups were 42 workers and managers representing the municipal RAPS components. Participant observation techniques, interviews and Open Forum were used.

Results

it was assessed that health promotion and drug use prevention actions are precarious and require investments, constituting the mission of workers and managers. Primary care was identified as a difficulty due to weaknesses in public policies and lack of support from specialized services. As a potentiality, matrix support in mental health was listed. Investment in Primary Care is suggested through training and support for these teams.

Conclusion and implications for practice

health promotion and drug abuse prevention agenda are urgent and must be included in the structuring of public policies and practices within the networks.

Keywords:
Drug Users; Disease Prevention; Health Promotion; Primary Health Care; Rural Areas

Resumo

Objetivo

avaliar as estratégias de promoção da saúde e prevenção ao uso de drogas na Rede de Atenção Psicossocial.

Método

estudo qualitativo, fundamentado na avaliação de empoderamento, desenvolvido em 2017 na Rede de Atenção Psicossocial (RAPS) de um município do Rio Grande do Sul, Brasil. Os grupos de interesse foram 42 trabalhadores e gestores representativos dos componentes da RAPS municipal. Foram utilizadas técnicas de observação participante, entrevistas e Fórum Aberto.

Resultado

avaliou-se que as ações de promoção da saúde e prevenção ao uso de drogas são precárias e necessitam de investimentos, constituindo-se a missão dos trabalhadores e gestores. Identificou-se como dificuldade a atuação da atenção primária, devido às fragilidades nas políticas públicas e à falta de apoio dos serviços especializados. Como potencialidade, elencou-se o matriciamento em saúde mental. Sugere-se investimento na Atenção Primária por meio de treinamento e suporte a essas equipes.

Conclusão e implicações para a prática

a pauta da promoção da saúde e prevenção ao uso abusivo de drogas é urgente e deve ser incluída na estruturação de políticas públicas e práticas no âmbito das redes.

Palavras-chave:
Atenção Primária à Saúde; Prevenção de Doenças; Promoção da Saúde; Usuários de Drogas; Zona Rural

Resumen

Objetivo

evaluar las estrategias de promoción de la salud y prevención de drogas en la Red de Atención Psicosocial.

Método

estudio cualitativo, basado en la evaluación de empoderamiento, desarrollado en 2017 en la Red de Atención Psicosocial (RAPS) de un municipio de Rio Grande do Sul, Brasil. Los grupos de interés fueron 42 trabajadores y directivos representantes de los componentes de la RAPS municipal. Se utilizaron técnicas de observación participante, entrevistas y Foro Abierto.

Resultado

se evaluó que las acciones de promoción de la salud y prevención del uso de drogas son precarias y requieren inversiones, constituyendo la misión de trabajadores y gestores. La actuación de la atención primaria fue identificada como una dificultad, debido a las debilidades de las políticas públicas y la falta de apoyo de los servicios especializados. Como potencialidad, se enumeró el apoyo matricial en salud mental. Se sugiere invertir en Atención Primaria a través de la formación y el apoyo a estos equipos.

Conclusión e implicaciones para la práctica

la agenda de promoción de la salud y prevención del abuso de drogas es urgente y debe ser incluida en la estructuración de políticas públicas y prácticas en redes.

Palabras clave:
Atención Primaria de Salud; Prevención de Enfermedades; Promoción de la Salud; Consumidores de Drogas; Medio Rural

INTRODUCTION

Drugs are a sociocultural and public health phenomenon with an impact on the world. The world drug report points out that in 2021, more than 36 million people suffered from disorders associated with drug use. Current projections reflect that by 2030 there could be an 11% global increase in the number of people using drugs. Against this background, the campaign entitled “Partilhe Fatos Sobre Drogas-Salve Vidas” began with the aim of strengthening scientific evidence and informing governments, institutions, civil society, families and young people in decision-making and efforts to prevent, treat drug use and protect public health.¹

Currently, in Brazil, the drug care policy is based on the Psychosocial Care Network (RAPS - Rede de Atenção Psicossocial), which assists people with mental distress and/or drug abuse. This network has among its objectives the articulation and integration of different points and services, such as Primary Health Care (PHC), Psychosocial Care Centers (CAPS), general hospitals, harm reduction strategies, among others, aiming at prevention and health promotion.²

Historically, the Drug User Care Network implementation was based on anti-drug guidelines, whose prohibitionist paradigm sees drug use as a public safety problem and not as a collective health issue. An example of this is the Brazilian National Anti-drug Policy, in which actions are focused on abstinence guidance, repression of trafficking and little information on the subject. More recently, the 2003 Drug Policy began to address the prevention of misuse, social reintegration and articulation of intersectoral care actions.³

Within the scope of networking, prevention is understood to be carrying out interventions aimed at preventing drug use by susceptible individuals and groups, with a focus on changing behavior based on awareness and information on the subject in schools and communities. Health promotion, more broadly, refers to strategies that emphasize the transformation of living conditions, which make up the basic structure of health problems, in addition to working with the strengthening of individual and collective capacity to participate in the social, economic and cultural environment and deal with health conditions.⁴ This conception opposes the simplistic view disseminated in the media that protection against drug use depends solely on the individual’s responsibility to have “information + willingness”.

In the Brazilian context, drug use prevention is insufficient, as it is characterized by the fear of young people, by the weaknesses in the articulation between health and school, and by the lack of training of teachers who deal with the subject in the classroom, demonstrating that drug prevention is not integrated and welcoming, avoiding listening and knowing the population’s doubts and anxieties.⁵ Moreover, preventive actions and health promotion must be articulated, which involve information and guidance as well as the creation of actions and policies that provide living conditions for the vulnerable population in order to avoid drug abuse.²

In this sense, considering the relevance of this topic on the agenda of Health Care Network organization as well as public policies for prevention and health promotion, essential for transforming exclusionary practices focused on drugs into expanded models aimed at the population’s biopsychosocial needs, the article aims to assess health promotion and drug use prevention strategies in the RAPS.

METHODOLOGY

This is qualitative research with an evaluative approach using the theoretical methodological framework of empowerment evaluation, which is a participatory assessment involving stakeholders in the planning and intervention of the services themselves.⁶ The choice for this assessment was due to its possible contributions to the local network, since network professionals participate in the assessment process by expressing their perceptions, needs, and improvement strategies.

This assessment was carried out in three stages: 1) Mission construction - aims to build the purpose of networking and unify efforts among participants to achieve the work objectives; 2) Knowledge of current situation - seeks to identify the network’s main facilities and difficulties to achieve the mission; 3) Planning for the future - involves developing and prioritizing strategies to achieve the mission.⁶

The research field was the RAPS of a municipality in Rio Grande do Sul, Brazil, intentionally selected for being a pioneer in the implementation of CAPS in the state. In 2017, the estimated population was 44,580 inhabitants, of which approximately 50% are rural residents. The municipality is of German colonization with one of the largest concentrations of Pomeranian descendants in the world.⁷

In this study, RAPS managers and workers participated. Inclusion criteria of participants were: 1) for managers: being a coordinator for at least one month in the network service, considering that there were many new managers in the services, but all of them were previously inserted in the network as workers; 2) for workers: have at least six months of work in the network. For the production of data, the triangulation of qualitative methods was used: semi-structured interview, participant observation and open forum.⁶

Semi-structured interviews were applied to 42 workers from all RAPS components. The Chart 1 shows the list of professionals interviewed.

Chart 1
List of the number of workers interviewed and the respective service and component of action in the Psychosocial Care Network.

Care component	Service	Number of respondents
Primary Health Care Component	Damage Reduction (DR)	2
	Family Health Support Center (NASF - Núcleo de Apoio à Saúde da Família)	2
	Family Health Strategy (FHS)	14
Strategic Psychosocial Care Component	CAPS AD	7
	CAPS I	1
	Child CAPS	1
Emergency Care Component	Emergency Mobile Care Service (SAMU - Serviço de Atendimento Móvel de Urgência)	1
Hospital Care Component	Ward specialized in chemical dependency	1
Psychosocial Rehabilitation Strategy Component	Job and income generation service	1
RAPS managers	Mental health coordination	1
	Primary Health Care Coordination	1
	Teaching, research and extension coordination	1
Intersectoral network	Department of Social Assistance	1
	Social Assistance Reference Center	1
	Specialized Reference Center for Social Assistance	2
	Casa da Criança	1
	Programa Primeira Infância Melhor	1
	Tutelary Council	1
	School	1
	Public Ministry	1

• Source: prepared by the authors.

Participant observation, characterized as an instrument that enables approximation with participants and understanding of the research context,⁸ took place between March and December 2017, in the morning and afternoon shifts at RAPS services. Records were made in a field diary. Finally, the Open Forum was a technique used to present and negotiate research data, prioritize the RAPS mission and planning strategies for the future, with the participation of professionals who are part of the management collegiate: 3 RAPS managers (Coordinator of Mental Health, PHC and Multidisciplinary Residency Coordinator) and representative of the network components (CAPS AD III, CAPS I, Child CAPS and SAMU).

Data collection started with participant observation, followed by semi-structured interviews and the Open Forum. Participant observation started at CAPS AD, observing its spaces, internal dynamics, and its connections with RAPS and the intersectoral network. In these observations, we sought to understand the CAPS AD organization and functioning in the network and to identify what would be the local RAPS’ mission, the aspects that facilitate and hinder work and the improvements that could be invested in the qualification of this network. These questions were also addressed in the semi-structured interviews. Finally, the Open Forum was held, in the light of empowerment evaluation, in which there is a presentation of research empirical material synthesis by the main researcher encouraging participants to reflect and participate in decisions and suggestions for improvements in care for the local network, considering local priorities and possibilities and what could be modified. In these spaces, prevention and health promotion in the care of drug users emerged as unit of analysis.

For data analysis, thematic analysis was used, carried out through three stages: in the first, an exhaustive text skimming of the collected material was carried out; in the second, excerpts and fragments were separated, which were distributed into topics, identified as an information unit, and then they were approximated by similarity, originating the units of meaning; in the third stage, the final analysis was developed with the objective of interpreting the results obtained.⁸ In this article, prevention and health promotion in RAPS are addressed in the light of empowerment evaluation, in its three stages: Psychosocial Care Network’s mission; Knowledge of current situation; Planning for the future.

Ethical aspects were ensured in accordance with Resolution 466/12 of the Brazilian National Health Council. To guarantee participant anonymity, statements were identified with the letter “W” for worker, “M” for manager, followed by the name of the RAPS component that works, followed by Arabic numerals, according to the ascending order of the interviews. This study was approved by the Research Ethics Committee of the Universidade Federal do Rio Grande do Sul in 2017, under Opinion 72657617.7.0000.5347.

RESULTS

Psychosocial Care Network’s mission

In this category, participants list the mission that represents one of the purposes of networking in the care of drug users. Participants’ perceptions, values and opinions are considered in order to unify efforts and achieve the purpose of this work.

Participants chose health promotion and drug use prevention as RAPS’ mission, since this strategy is assessed as precarious and that it needs investments:

[...] we are very precarious with prevention. [...] we cannot work on preventing alcohol, drugs, and especially with children and adolescents; [...] most of the time, it arrives at the CAPS and the bomb is already exploding. So, I think it should be more preventive (W9 - Strategic Psychosocial Care Component).

[...] there is a lack of prevention, health promotion [...] the number of users in the municipality has been growing and we no longer believe in prevention (Open Forum).

Professionals criticize a network care model focused on the individual and treatment:

[...] we do not see other actions to prevent drug use, or health promotion [...]. Because in the network it has to be all linked, so we don’t see other actions to insert in society again [...] in the job market [...] it’s no use treating that patient for addiction, and he lives there in the neighborhood where they sell drugs everywhere. It’s no use doing the action just on that patient, you have to develop more public health actions, you have to be treated not only with health, you have education, safety, everyone together, because it’s no use just for our network to want to treat, [...] then he goes back to his house, his friends consume drugs, the family sells them, and it turns out that we have no way of preventing this patient from having a relapse or a resumption of addiction, because in the community, in the locality, that was not worked on there [...] (W25 - Primary Health Care Component).

For participants, prevention must be connected to RAPS based on the work developed in Primary Care, through strategies to approach the territory:

[...] the network must be connected all the time, it goes back and forth or vice versa, and being able to perceive, trace this diagnosis of the location [...] perceive this set. [...] it’s being able to deal with it, knowing who lives there, what kind of life they lead, what it’s like, the reality of each one, you being able to have this previous history because that says a lot about use, because sometimes family history passes from grandfather to father, from parents to son, from son to grandson [...], that the beginning of this service has to be in the basic unit. [...] today our commitment is this: we being here, but here we are providing care for the most intensive cases, that the person can be walking in their territory with follow-up [...] (W6 - Strategic Psychosocial Care Component).

Knowledge of current situation

In this category, participants assess the network’s current situation, main difficulties and potential to achieve the mission.

Regarding the difficulties, workers problematize the need to invest in Primary Care as a space for promotion, prevention and treatment in mental health:

[...] and the strategy teams are also sometimes unable to handle it, and also this issue of mental health with alcohol and drugs, they also direct more to the CAPS and end up not appropriating as much. [...] a lot of things improved this care at the unit, in the past we didn’t have that: it was just AD and hospital, [...] not now, the unit is appropriating more, but there is still that it is only the CAPS that knows how to treat, the idea. Then some cases that could be being monitored by the unit, in a little while forward [...] (W3 - Primary Health Care Component).

[...] I see that people, including the primary care network, the staff still have this, which has to be provided by the CAPS, which has to go to the CAPS (W10 - Psychosocial Rehabilitation Strategies Component).

It is identified that PHC services have weaknesses in mental health care:

I believe that the network has good specialized care, [...] but there are other points that need to be developed a lot, such as Primary Care, there are no clear care devices to meet this demand, to carry out the reception, the assessment, it is much still in the clinical question, of the traditional question. [...] for various reasons, even prejudice against drug use, the issue of professional training, not knowing how to deal with it, the issue of not having actions, specific tools for this policy, due to the numerous programs that exist in a FHS. There are 14 health units and 12 family health teams. Of these 12 teams, four have a slightly more advanced work, either because they have more continuous matrix support, or because they have the mental health residency, which provides support, but, for example, in the rural area there is no residency, there is only the NASF support and some trips from CAPS. So, you end up not having very continuous service. Of course, it welcomes, sees these issues, monitors, it could improve and a lot (M33 - Primary Health Care Component).

At the residents’ event, one of the professionals in the network talks about the difficulty of discharges, because there is still that logic, the patient is mine, the patient is yours, in fact, the patient belongs to the network, just because he is going to be discharged from the CAPS that he now Is it just basic care? If primary care is unable to take care of this user, that is our problem, because we are the ones who have to provide support (Field Diary).

Moreover, prevention and health promotion actions are hampered due to professional turnover in PHC and the lack of knowledge of RAPS functioning:

[...] I think there is still a lack of knowledge, I don’t know, why sometimes there are young nurses who have been there for a short time and maybe they still don’t know how it works, but I believe that sometimes they think that we have to be the ones to solve it (W3 - Psychosocial Rehabilitation Strategies Component).

[...] there are times when I see the following: the specialty is there, so some people, I don’t know if this is because the turnover of people in the basic units, in the service is high, it seems that when things are at an X level that everyone is getting to know the network, knows how it works and everything, someone new comes in, and says, no, that user has to go there to the AD, in reality the user is not from the AD, he is from the whole network, so why would he have to go to the AD if he hasn’t even gotten there yet [...] (W4 - Psychosocial Rehabilitation Strategy Component).

Despite the difficulties in caring for drug users, the matrix support policy is listed as a powerful strategy:

[...] with the matrix support policy, we realize that many cases, I’m not saying the majority, but many cases can be worked on and helped by Primary Care, [...] together with the NASF, CHW I think they end up helping us a lot in this regard. [...]. This simple change in the CHW has already helped a lot for this Psychosocial Care Network to come together more and more and more to help each other, because the CAPS alone cannot be in the territory, the CAPS cannot enter the houses, know how that family’s life is, and this with the help of CHW teams is happening (W10 - Primary Health Care Component).

In a CAPS AD team meeting, professional X says that sometimes he does not go to FHS meetings [...] and that even not many things are passed on over the phone. Residents of psychiatry present at the meeting reinforce that transfers over the telephone have a different configuration from matrix support. They argue that the matrix support generates a new construction, each one brings their perception and the case referrals are agreed, it is also a learning space. Over the phone, it’s one more transfer of information, it’s different. Another resident complements by saying that he often only gets involved in certain cases, especially in the most delicate ones, because he has support in the matrix support [...] (Field Diary).

Perspectives for the future

This category addresses the perspectives for the network’s future, prioritizing the strategies that professionals can invest in to achieve the mission.

Professionals suggest strengthening PHC in mental health care:

I think the unit has to take more ownership of its function [...], what the unit can do, [...] I think the CAPS AD can also think about it, how we can provide this support [...] (W4 - Psychosocial Rehabilitation Strategies Component).

[...] we always think the participation of CAPS is very good, because you can discuss cases with them. Like I told you, over the phone it’s one thing, in person it’s quite another. And there’s the whole team [...] (W21- Primary Care Component).

[...] there are things that are free, such as training, awareness raising, reading about the difficulties. [...] on the issue of Primary Care, if they are not so trained, it’s the fault of mental health, because we can’t demand that they know about mental health, just like there’s a lot of basic care stuff that I don’t know, but who I’m going to turn to? To them, if we have, their reference [...] if we have closed or they don’t feel comfortable asking us, calling us at any time, or us going there, it won’t get better, [...] but we’ll try to be more present. [...] is to listen to them in the first place, what do they know, if they feel comfortable, [...] (Open Forum).

DISCUSSION

In approaching the empowerment evaluation theoretical framework carried out in this study, assessment took place through the participation of professionals and managers involved in care production in the RAPS. These professionals believe that the local RAPS’ mission should be directed towards prevention and health promotion in the care of drug users, considering that this is a fragile point that needs greater investments.

It was identified that in RAPS, preventive work is precarious, and little developed in communities together with PHC, which leads users to access the network in acute situations with the need for specialized treatment. Such fragility is not specific to the network under study, as in general, there is little appreciation of preventive strategies in the direction of public policies and in the distribution of resources for this purpose.⁹-¹¹ Although promotion and prevention are considered appropriate, effective and cost-effective strategies for reducing drug consumption and its consequences, investments in them are precarious.⁹-¹²

The perspective that drugs are harmful stigmatizes users as dangerous, criminal and potentially violent. This association between drugs and violence is one of the central components of programs aimed at drug users. An example of this is the data from the national drug control budget in the United States, in which of the approximately 27 billion dollars spent in this sector each year from 2016 to 2018, on average 56.7% were allocated to the repression of production and drug trafficking. Taken together, only an average of 5% were assigned to drug abuse prevention programs.¹² In this regard, the budget falls on actions that do not effectively help to reduce the problem.

In Brazil, approaches to care for drug users have been less based on scientific evidence, and more on ideological issues, which has been considerably harming RAPS actions related to prevention. It is estimated that there was a reduction in investment in harm reduction actions and setbacks with the new anti-drug policy (Decree 9761 of 2019), which proposes that treatment be based on health promotion and abstinence maintenance, and among its guidelines is the financial investment in therapeutic communities.¹³,¹⁴

Currently, Brazil faces several challenges for mental health care. Setbacks in public policies are pointed out, such as Amendment 95 known, as the death PEC, in 2016, which weakens and limits social spending, stagnating investment in intersectoral public policies. In mental health, since 2017, with Ordinances such as 3,588, which includes the financing of asylums and therapeutic communities as network points as well as changes in the Brazilian National Policy of Primary Care that allow different organizations of teams. There may be a reduction in human resources, and flexibility in the coverage of community health workers (CHW) for areas not characterized as socially vulnerable and withdrawing funding from the NASF.¹⁵ These political changes undermine access to inclusive, networked care focused on the Psychiatric Reform concepts.

Another challenge for the scope of PHC is its new funding established by Ordinance 2979 of 2019 through the Previne Brasil Program. This program requires that the entire population of the municipality be registered and linked to health teams, with a view to achieving goals, number of visits through health indicators, which becomes unfeasible for many municipalities due to the lack of professionals such as CHW and physicians. Moreover, there is a fragile cost for the maintenance of complete teams, the precarious computerization and maintenance of services.

It should also be noted that the Brazilian context is marked by social inequality and social determinants, such as poverty, misery, low access to the labor market, leisure, culture, education, which has increased considerably in recent years, with factors directly related to mental health and substance abuse.¹⁶-¹⁸

This context exposed above influences the reality of health services. In the present research, workers problematize the devaluation of prevention as well as the fragmented performance of the health sector, since it is not enough just to treat the person in the health network and believe that he will be free of dependence. The abusive use of drugs requires an integrated action between the different sectors within the communities, in order to promote health and, after returning from hospitalization, provide support in the territory by offering dignified living conditions that can break the frequent cycle of “drug abuse-hospitalization-relapse”.

This point brought up by participants refers to health promotion in the care of drug users and not just to preventive work. Although the importance of prevention is recognized in its anticipated strategies, such as information and awareness actions in schools and communities, it is known that its benefits are limited, because it focuses on the drug on the consequences of its use and on the behaviors expected to avoid or reduce the use of drugs in specific groups, such as young people and adolescents.¹⁹

In this regard, study workers draw attention to the need for an expanded work of health promotion with strategies that emphasize the transformation of living conditions, which shape the structure of health problems. From this understanding, promoting health involves actions at the global level of a State and processes of subjects’ autonomy.⁴ Although health promotion is a challenge, it is believed that possibilities can be seen from it to change the scenario of drug abuse in communities.

Professionals also point out that there must be a strengthening of PHC, mainly due to its strategic role of proximity to the communities, and its work instruments such as the community diagnosis, which can help in understanding the needs and prioritizing actions. The community diagnosis allows us to understand that the territory is not just the place where the services of a network are located, as it is necessary to consider the space lived by people and their relationships.²⁰ In attention to drug abuse, if we do not consider the territory, there is a risk of segregating, separating by specialty area and treating instead of caring. Thus, investment is needed in preventive and health-promoting networks with intersectoral approaches aimed at the social aspect of families. This is the mission that the study participants want to achieve with the work developed by RAPS.

In the current situation of the RAPS under study, the difficulties and potential of the network for the advancement of preventive actions and health promotion are analyzed. About the difficulties, there are challenges in the care of drug users at the gateway to the network, PHC. As a potentiality, they list the matrix support policy that has been developed in the municipality.

Regarding the difficulties, it is estimated that FHS is still not recognized as a service capable of providing care to drug users. The challenges faced are attributed to the lack of defined care instruments, professional training for a psychosocial approach, prejudice, lack of public policies to guide the teams, demand from other programs and lack of institutional support such as matrix support and specialized support from other services.

According to the results of this study, FHS develops care focused on traditional clinical assessment and with little systematization of actions for this care. It is identified that FHS could take more ownership of its role in the RAPS and articulate with the other points of the network to avoid unnecessary referrals to the specialized service. This difficulty is also observed in other studies, in which FHS are little perceived as places for health promotion and disease prevention for people who use drugs. The absence of drug users monitored by these services can be explained by the lack of acceptance and bond. The need to overcome the pathologizing view of drug users characterized as violent, aggressive and resistant to treatment is highlighted, valuing their expanded knowledge about health and the territory and their ability to contribute to care planning.²¹,²²

A study demonstrates that actions focused on attention to the biological body are more easily perceived as health needs by PHC professionals. These professionals point out difficulties in intervening in complex health situations, either due to lack of preparation or lack of resources.²³ It is understood that, from a Psychiatric Reform perspective, the construction of a psychosocial mode is based on networking. Primary care is a service that orders this care, as it is close to the territories, in addition to mapping, knowing and creating links with the population, identifying mental health situations. However, care based on a biomedical model, focused exclusively on signs and symptoms, is limited to carrying out the psychosocial mode, which requires health promotion and prevention, the development of care focused on the subjects, their needs and social determinants.²⁴

The challenges of PHC in mental health care are numerous, both linked to the scrapping of SUS and the context of setbacks in social policies, which undermine professionals’ work and promote the biomedical model maintenance. It is necessary to rethink and deconstruct the biomedical model’s predominant status in Brazil, which is rooted in health interventions, in the training of professionals, in the network organization and in the way of conceiving the concept of what health is. This ideal promotes reductionist strategies, which are translated as forms of subject control, positioning health professionals as holders of treatment techniques and standards, to the detriment of an expanded conception of how illness and drug use is produced in society.²⁴ As with drug use, this can have an impact on professionals’ view as a problem of behavior and abstinence treatment, little considering the importance of prevention and health promotion as well as sociocultural issues in mental health.

Still related to the difficulties in mental health care at PHC, there is a study that points to the absence of guidelines that guide the actions of professionals, contributing to them considering themselves technically unprepared.²⁵ Moreover, there are other challenges such as intervention planning in the territory, support in situations of psychiatric crisis, follow-up for the rational use of medication, prevention of unnecessary admissions to psychiatric hospitals, elaboration of continuity of care plans, encouragement of the active participation of user and family in the care and articulation with the specialized network of mental health.²⁵

In the context of this study, participants also highlighted the lack of knowledge about the RAPS and its operation as difficulties, due to professional turnover in FHS teams, which impacts the actions of promotion, prevention, care and treatment of drug users at PHC. This turnover slows down the processes of continuity and advancement in the organization of network care. Professional turnover in FHS reflects the precariousness of employment relationships. In three decades of SUS, it is possible to observe a precariousness of work, growth in the informality of work contracts and salary deterioration. In that regard, one of the strategies available to managers is to strengthen the RAPS by valuing and retaining professionals such as: job, career and salary plan; work ties with social protection; spaces for discussion and negotiation of work; institutionalize permanent education practices; and humanization of quality of work.²⁶

Network construction highlights PHC’s peculiar attribution, which has as its prerogative the coordination of care and the ordering of the different networks in its territory, in which all health care points are important and are horizontally related.²⁷ In this work logic, it is understood that PHC’s weaknesses in constituting itself as a point of care in mental health should not be attributed to this specific service, but rather the logic of work organized in a network, whose difficulties must be shared with other services, especially with those that have specialized professionals to provide this support. In the context of the study, professionals realize that there have been advances. However, FHS still needs to be connected to other points in the network, receiving support and qualification to fulfill its role, especially in preventive and health promotion actions.

As potentialities of RAPS in a perspective of promising actions, the matrix support with the participation of NASF and CAPS stood out. Although matrix support does not occur in all FHS, benefits are visualized in the actions developed such as support for CHW’s work, improvement in the understanding of the territories and possibilities for building joint actions and supported in the care in the attention to drug users.

A study demonstrates that matrix support has contributed to making FHS professionals feel part of a collective construction of care and appropriate to provide qualified listening, reducing the anguish and suffering of these professionals.²⁸ In addition to this, it is a strategy that has potential in the prevention and assessment of cases, and can help to avoid unnecessary referrals to specialized services or even improve the shared care of users who are unable or unwilling to attend CAPS AD.

In the network under study, it can be seen that the matrix support expanded the understanding of CHW about the role they develop in communities and inserted in the RAPS. With support, these professionals make it possible to access families, life situations, and connect with services. Field diary records also emphasize matrix support as a learning practice among teams and support that encourages professionals to engage with complex cases, as they feel supported, as was also observed in other studies.¹⁸,²⁸

In this sense, it would be important to extend the matrix work to other FHS teams in the municipality, readjusting the logistical needs that would involve this expansion, such as the adequacy of human resources, transport structure, mainly involving the rural environment and the city, and strategies for systematizing this work at RAPS as a way of qualifying its entry point and guaranteeing the continuity of treatments and therapeutic projects.

In the perspectives for the future of RAPS, professionals suggest strengthening FHS in prevention, promotion and mental health care actions, through understanding the difficulties faced by these teams, training, and articulation with CAPS AD. This investment is necessary, as FHS is a major reference for the RAPS and these professionals need to be prepared to manage mental health demands and establish effective primary care.²⁹

In this way, the importance of managers investing in permanent education processes is understood. In addition to the need for federal resources to maintain the Brazilian National Policy on Permanent Education, municipalities must be proactive in creating and maintaining the Municipal Nucleus of Education in Collective Health and the constant improvement of professionals working in RAPS. Moreover, training focused on a process of health promotion and prevention of drug abuse also permeates the sphere of education at primary and secondary levels as well as in the formation of higher education courses in the area of health and the like, requiring a review of curricular proposals that, for the most part, do not include the theme of promotion and prevention of drug abuse.³⁰

Still in the improvements for the future of RAPS, professionals problematize the contributions of CAPS AD to RAPS, emphasizing the need for this service to be present in FHS and contribute to the qualification of these teams. This priority presented is also observed in other studies, since the articulation between specialized mental health services and PHC is still precarious, especially involving CAPS AD professionals.²⁸

The present study shows possibilities of connection between these services that involve the organization of spaces between the teams to understand the difficulties of mental health care, awareness and availability for networking, i.e., strategies that are not restricted to contact telephone or punctual only for resolution of acute situations. Punctual contact is presented as an easier strategy if we consider the overload of professionals, and the organization of a work focused on the disease and symptoms, as are the teams’ challenges.²¹-²² However, such a way of working makes it difficult to share knowledge and practices, moving away from the possibilities of effective questioning for the construction of supportive relationships between these teams and viable alternatives for solving problems.

It was also observed that workers assess the need to change the logic of care fragmentation, in which the responsibility for the user falls on a given service through narratives such as the user is “yours”, the user is “mine”. In the proposal of a network work, the user does not belong to a specific service, team or professional, the user belongs to the network, to its territory in a way that expands the opportunity for the work that involves the “us”. However, care must be taken so that, in front of this network, the user is not lost, without points of reference or even that the teams do not take responsibility, due to the fact that there are other actors involved. In this regard, the proposal suggested by the participants is related to shared care between teams, mainly in the articulation between CAPS AD and FHS, who recognize themselves as responsible for this work and who seek a strengthened network at their gateway and connected to services and to the life territory.

Within the scope of shared care, it is worth highlighting the important role of nursing in promoting health and preventing drug use, developing joint actions between teams, fostering permanent education processes that support daily practice as well as the systematization of actions in the territory that seek to recognize and act on the determinants, risks and factors associated with drug use.

CONCLUSION

In the present study, it was identified that the RAPS mission is based on the qualification of one of the main difficulties in the care of drug users, which is prevention and health promotion. Such a perspective seeks a change in the actions developed, until then, predominantly focused on individuals and on treatment, which results in cycles of hospitalization-discharge and relapse for expanded strategies that consider the social scope, territories of residence, intersectoral and social insertion actions that strengthen prevention and health promotion in RAPS.

In knowing the network’s current situation, the weaknesses of PHC in the actions of promotion, prevention and care for drug users were highlighted as difficulties due to the maintenance of practices aimed at traditional clinics focused on the disease and symptoms, the few care instruments defined for the needs of this public, the demand for other health programs, prejudice, in addition to the rotation of professionals in the teams, which makes it difficult to know about network functioning and continuity of long-term actions. As potentialities of RAPS to achieve the mission, matrix support in mental health was identified, considered a powerful strategy for strengthening prevention and health promotion actions in Primary Care.

Regarding planning for the future of RAPS, professionals suggest investing in strengthening FHS in prevention, promotion and mental health care actions, through actions that bring the network closer to the needs of these teams, training and improvement of the relationship between FHS with specialized services for backup and support in mental health work.

It is evident that although prevention and health promotion actions are considered important, they are still not implemented in a planned and organized manner in the context of RAPS. In this regard, the study presents contributions for managers and professionals, pointing out that the agenda of health promotion and prevention of drug abuse is urgent and must be included in the structuring of public policies and practices within the networks. Furthermore, the study also presents contributions to the structuring of public policies aimed at social and health vulnerabilities that can actually improve the population’s living conditions and thus make substantial contributions to health promotion, avoiding involvement with the abusive use of drugs, and in cases of dependence, conditions of permanence in health treatments in the network.

As limitations of this study, we include the fact that it does not contemplate the participation and conception of users, family members and other FHS workers, such as nursing technicians, physicians and CHW, on the topic addressed. In this regard, other evaluative studies are suggested that consider the perception of other interest groups that can complement and direct different needs for the construction of RAPS.

• a
  Article extracted from the doctoral thesis “Empowerment evaluation of the psychosocial care network in the drug user care”, by Elitiele Ortiz dos Santos. Directed by Leandro Barbosa de Pinho. Defended in 2019. Graduate Program in Nursing, Universidade Federal do Rio Grande do Sul.

• FINANCIAL SUPPORT

  This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) in granting a doctoral scholarship to the first author Elitiele Ortiz dos Santos.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  15 May 2023
• Date of issue
  2023

History

• Received
  01 Aug 2022
• Accepted
  09 Mar 2023