Evaluation of intersectoral resources in the composition of care networks for crack users

Evaluación de recursos intersectoriales en la composición de redes para el cuidado al consumidor de crack

Abstract

Objective:

To evaluate the intersectoral resources in the composition of care networks for crack users.

Method:

Evaluative, qualitative study based on the Fourth Generation Evaluation. The participants were 10 users, 11 family members, eight workers, and seven managers from a municipality in the metropolitan region of Porto Alegre/Rio Grande do Sul, Brazil. Data were collected in 2014 through observation and semi-structured interviews. The analysis occurred by the constant comparative method.

Results:

Stakeholders have discussed how the Public Prosecutor's Office and the Military Brigade are inserted in the network, since they carry out actions that often are not compatible with the psychosocial care proposal. The need for expansion and maintenance of liaisons with community resources was identified.

Conclusion:

It is noted the need for sector integration and participation of all social agents from different spheres in order to promote and evaluate the practices and policies of care for crack users.

Keywords:
Intersectorial action; Drug users; Public Prosecutor's Office; Health assessment; Nursing care

Resumen

Objetivo:

Evaluar los recursos intersectoriales en la composición de redes para el cuidado al usuario de crack.

Método:

Estudio evaluativo, cualitativo, basado en Evaluación de Cuarta Generación. Los participantes fueron diez usuarios, 11 familiares, ocho trabajadores y siete gestores de un municipio de la región metropolitana de Porto Alegre/Rio Grande do Sul. Los datos fueron recolectados en 2014 por medio de observación y entrevistas semiestructuradas. El análisis se realizó por el Método Comparativo Constante.

Resultados:

Los grupos de interés problematizaron la inserción del Ministerio Público y de la Brigada Militar en la red, pues desarrollan acciones que frecuentemente no concuerdan con la propuesta de atención psicosocial. Se identificó necesidad de ampliar y mantener articulaciones con los recursos comunitarios.

Conclusión:

Necesidad de integración de sectores y la participación de todos los agentes sociales de diferentes esferas para fomentar y evaluar prácticas y políticas de atención a usuarios de crack.

Palabras clave:
Acción Intersectorial; Consumidores de Drogas; Ministerio Público; Evaluación en Salud; Atención de Enfermería

Resumo

Objetivo:

Avaliar os recursos intersetoriais na composição de redes para o cuidado ao usuário de crack.

Método:

Estudo avaliativo, qualitativo, baseado na Avaliação de Quarta Geração. Os participantes foram 10 usuários, 11 familiares, oito trabalhadores e sete gestores de um município da região metropolitana de Porto Alegre/Rio grande do Sul. Os dados foram coletados em 2014 por meio de observação e entrevistas semiestruturadas. A análise ocorreu pelo Método Comparativo Constante.

Resultados:

Os grupos de interesse problematizaram a forma como Ministério Público e a Brigada Militar estão inseridos na rede, pois desenvolvem ações que, muitas vezes, não condizem com a proposta da atenção psicossocial. Identificou-se a necessidade de ampliação e manutenção das articulações com os recursos comunitários.

Conclusão:

Constata-se a necessidade de integração dos setores e participação de todos os agentes sociais de diferentes esferas para fomentar, avaliar as práticas e políticas de atenção aos usuários de crack.

Palavras-chave:
Ação Intersetorial; Usuários de Drogas; Ministério Público; Avaliação em Saúde; Cuidados de Enfermagem

INTRODUCTION

In recent years, several countries have been seeking answers to the growing social, cognitive, cultural, and political impacts on the challenging drug use. The cost of treating alcohol-related disabilities accounts for almost 1% of the gross domestic product (GDP) of several nations, although in countries such as Canada and the United States, such number exceeds 2%. Regarding injectable drugs, it is expected that five million users worldwide carry other associated risks, such as human immunodeficiency virus (HIV) and hepatitis.¹

In relation to crack, the wide social impact is noticeable. The user is perceived as a person who does not fit the ideals of society, because he or she has weak social ties and is little linked to health services.² The difficult link and access to health services is related to the experience of stigma and prejudice that drug users suffer in the care network, in the need for better coverage of services^3,4 and in the lack of preparation of health professionals for care of alcohol, crack and other drug users.⁵

However, analysis on drug user profile says a lot about something that goes beyond disease and substance. There is a need to rethink our constitution as a society to deal with differences, since the advance of drug use has evidenced that many users suffer from poor social perspectives, with any opportunities for housing, health, employment and personal/professional development, with suffered realities, permeated by violence, family disruption and family histories of first degree with drug abuse.^6-8 Thus, it is possible to understand the importance of health services interacting with other sectors of civil society in order to build proposals together that contemplate this diversity of social needs.

Intersectoriality seems to be a fundamental prerogative that involves care for drug users, since it acts on social determinants that do not depend only on the health sector. It is a form of management that must be performed through liason, cooperation and planning among the different sectors of society and the different public policies.⁹ Acting on the social determinants is to provide better living conditions.

It can be affirmed that intersectoriality is a guideline of the National Health System resulting from the conception of health adopted by the Constitution of 1988, whose conditioning factors include food, housing, environment, work, income, education, transportation, leisure, and access to essential goods and services. Besides expanding the health/disease concept, other spaces and scenarios are incorporated in this composition.¹⁰

This article aims to present the evaluation result of intersectoral resources in the construction of care networks for crack users. This is a review of the qualitative evaluation of the network of mental health services for crack users (ViaREDE), which was funded by the National Council for Scientific and Technological Development (CNPq) and by the Ministry of Health (Notice MCT/CNPq 041/2010).¹¹

METHODOLOGY

The study used an evaluative and qualitative approach, according to the theoretical and methodological reference from Fourth Generation Evaluation. It is characterized as a constructivist/responsive evaluation, in which the focus is the needs from stakeholders. The evaluation process is based on the constructions of subjects who propose to the evaluation, in a hermeneutic-dialectic process of interaction and negotiation between researchers and stakeholders. These groups, as a general rule, represent people involved or potentially affected by the evaluation process.^12,13

The study scenario was a municipality in the metropolitan region of Porto Alegre, in the state of Rio Grande do Sul (RS), Brazil. The choice of the municipality was intentional and is because the municipal management has a peculiar configuration in terms of mental health services network, being considered as a successful model of health services provision.

In total, 36 individuals participated of the study, distributed in the following groups of interest: team, managers, users, and family. Ten users who were followed up at the psychosocial care center for alcohol and other drugs (CAPS AD) or who have attended another mental health service due to crack use. Regarding family members, 11 relatives of users who were being followed up at the service or at another point in the mental health network participated of the study.

There were also eight workers from CAPS AD (two psychologists, one psychiatrist, one occupational therapist, one helper, one nurse, one nurse technician, and one administrative assistant). In the management group, seven were members of the Municipal Board of Mental Health, the municipality's managing agency responsible for follow-up and monitoring of mental health actions and policies (three psychologists, one social work assistant, one occupational therapist, and two nurses).

Professionals and managers had to have at least six months of experience in the CAPS AD or network of mental health services to be included in the study, as well as not on leave during the survey data collection. Data were collected in the first quarter of 2014.

The evaluation process was developed according to the following steps: (1) contact with the field, presenting and discussing the research proposal; (2) organization of the evaluation process, when the researchers obtained the entry right and performed the free observation, with the purpose of understanding the reality and the context of the service, without being engaged in the evaluation activities; (3) identification of stakeholders - defined after the initial stages; (4) development and joint constructions, in which the interviews were carried out through the hermeneutic-dialectic circle; (5) expansion of joint constructions, introducing other information and materials that could contribute to the evaluation process; (6) preparation of the negotiating agenda that organized the information and constructions of groups so that they could be presented to the participants; (7) execution of the negotiation, in which the interviewees accessed the information obtained in the data collection for discussion, debate and clarification on the constructions, having the opportunity to modify them in order to reach a possible consensus.^12,13

The interviews were guided by the application of the hermeneutic-dialectic circle. The circle functioning is based on the choice of people considered as iconic, who can contribute with detailed information about the service in the network. A first interviewee was subjected to an open question (talk about the functioning of the network care for crack user in the municipality). The researcher had to pay attention to the central themes highlighted by the participant, their conceptions, values, ideas, concerns, and finally the positive and negative aspects formulated in the response. Soon after, the interview followed with a second participant that, after asking his or her questions, was invited to comment on themes arising from the analysis of the first interview. Based on the analysis of the second interview, information emerged not only about their considerations, but also on demands and constructions from the previous interview. The process was repeated with the addition of new informants, allowing each participant to talk about their issues and comment on those that emerged in previous interviews.^12,13

The data analysis was based on the constant comparative method, in which analysis and data collection are parallel processes, one directing the other.¹² As it is a participatory evaluation proposal, the study subjects interfere in both processes. Because of the whole process, it was possible to carry out an evaluation of care network for crack users of the municipality in a participatory and inclusive way. Intersectoriality was one of the challenges pointed out by stakeholders and the issues that emerged related to this theme will be presented in this article.

The ethical aspects were assured to the participants according to Resolution no. 466/2012 of the National health council. ViaREDE survey was approved by the Ethics Committee of the Federal University of Rio Grande do Sul, under No. 16,740, and all participants signed the free and clarified consent term. Respecting anonymity and confidentiality, the participants were identified by letters, according to each group and followed by the order of interviews: "S" staff, "U" users, "F" family members, and "M" managers.

RESULTS AND DISCUSSION

The stakeholders evaluated the participation of the Public Prosecutor's Office (MP), the Military Brigade and the community resources as important in their interface with the mental health network, and should be reinforced and strengthened in the context of public policies.

MP is the body that inspects and controls the conformity and applicability of public policies, transforming social reality and creating a scenario free of poverty, exclusion and social inequality, although the reality experienced in Brazil is still lacking in basic social rights, such as health, housing, employment, and social assistance.¹⁴

In turn, the State is responsible for public security and must ensure the protection of population and preservation of public order, including the action of the Military Brigade. In the context of dealing with issues related to drug use, this corporation acts together with social assistance services in order to recognize areas of greatest vulnerability, crimes, and violence, besides being constantly activated to follow up cases of compulsory internment.¹⁵

Community resources are fundamental for the promotion, prevention, and social reintegration of drug users, being places and spaces where life is as it is, where relationships and links are unveiled and social issues happen. Schools, churches, non-governmental organizations, health units, leisure spaces, sports and coexistence, among others, are relevant because they constitute as resources that contemplate this diversification of opportunities in order to promote the care for the user in his or her community.

Public Prosecutor's Office (MP)

MP emerged as a means of access to the care network of the municipality. However, during the evaluation process, criticisms were expressed about the way MPs interfere in team's decision-making, since they often act as a gateway in the network:

Sometimes, the first contact with the user is through the Public Prosecutor's Office. This is not cool for us, the [CAPS] service should be recognized by all sectors and be the first contact with the user, and not judicial. (E6)

It is considered that, in the modeling of the psychosocial network, there would be no "gateways", since there are access points that interfere in the joint work when connected. In this sense, user admission via MP is not seen as isolated or harmful, on the contrary, it should be part of this network because this composition qualifies and enhances the gateways to the health system when there is partnership and interaction.

Thus, intersectoral network professionals are invited to build communication bridges that can be efficient in the care process. In relation to health care, it is necessary to be clear that all services play an important role and each service has a function in the care process of the intersectoral network, respecting the specificities and responsibilities of each point of attention.

However, some workers added that MP, despite the necessary and performed tensions, it is still acting as an ordering of the network and becomes, in some cases, the first contact of the user and the family, because several times the MP appeals to CAPS with ready decisions, not discussed with the team:

Very easily, the Public Prosecutor's Office rules what we have to do, and we want to seek the contrary of this, we will say what has to be done, we are the regulators, the CAPS needs to think about the care, not the Public Prosecutor's Office. (E7)

We [...] are no longer saying amen for everything that the Public Prosecutor's Office delegates to us, we stand, positioning ourselves, making well-informed reports about that user, the management has been done a very difficult job with the Public Prosecutor's Office. (E2)

What also happens is that a lot of people, I think due to the very difficulty of network, structure [...] these people end up appealing to justice, Public Prosecutor's Office and others in order to have a quick response [...]. (E8)

This relationship with the Public Prosecutor's Office, according to the workers, worsened with the proceeding of draft law 7,663/2010. This draft law seeks to add and amend Law 11,343/2006, emphasizing voluntary and compulsory internment when the focus should be on expanding user access to community services. With the proceeding and recurrent exposure in the media about degrading situations of substance use, the political agenda focuses on internment and reinforces the institutionalization culture.

In this sense, the legal and political apparatus needs to be questioned and transformed, since it is responsible for establishing rules and laws aimed at monitoring and treating the user. It is necessary to combat the biases and distortions that block the network operation, including all the legal apparatus that supports the care.¹⁶

The management of mental health in the municipality under study strives to ensure that CAPS be the regulator and responsible for involuntary or compulsory internment requests, understanding that this is its function and that it has a technical team to request such therapy, even with the large demand and lack of human resources in the service. Thus, all cases from MP should be directed to the technical staff of CAPS in order to evaluate, and if necessary, to activate the general hospital, using the state beds in the absence of hospital beds in the municipality.

The need for compulsory internment demanded by the Public Prosecutor's Office is evaluated by the CAPS team. (G2)

We do what is possible, as you see, we do not have staff to care for people. It is a lot of demand, it is the demand from Public Prosecutor's Office to do home visit, to do home visit in clinics. (E3)

In a survey conducted in the same municipality, advances were identified in the mental health network in relation to dialogue and liaison with MP. The municipality has a large number of legal actions in the mental health area, which led the mental health management to create the Mental Health Itinerant Team in 2014, responsible for receiving all the demands from MP and giving the necessary referrals of each case.¹⁷

The strategy of creating the itinerant team in the municipality demonstrates the commitment of the management and mental health professionals in the elaboration of an attentive and negotiating planning, guaranteeing the evaluation of people with issues related to drug use in the reference services in mental health. This composition seems to be pioneering and represents a breakthrough in local public policies that need articulated and collaborated care networks to conduct negotiations and conversations.

It is observed that the demand for treatment, often on the part of the family, falls on the judicial sector, seeking a certain urgency of resolubility. The conformation of the psychosocial care network, in this sense, suffers interference inasmuch as several sectors - many with interfaces, but not members of the health sector - generate crossings that may hinder the conduct of public policies. Therefore, intersectoral dialogue is fundamental to find solutions for complex issues, such as those involving the care for crack user.

Military Brigade

The Military Brigade is a public security body responsible for ostensible policing in order to ensure compliance with the law, the preservation of public order, and the exercise of constituted powers, among others.¹⁸

According to the program "Crack Winning is Possible", the police action guidelines are: liaison with health and social assistance areas, partnerships with states and municipalities in order to promote safe urban spaces, strengthening of intelligence and research activities in integration with state forces and confronting drug trafficking and organized crime.¹⁹ According to the program, the role of the military police is widened and it is called upon to collaborate with the liaison of network points with other sectors to fulfill its role in protecting and maintaining public order.

However, in the evaluation of stakeholders, especially among family members and users, the Military Brigade is one of the bodies that either exempt from the responsibility of fulfilling the role of promoting public order, not meeting the demands of the family member or, when enforces it, acts in a truculent and harmful way with the user, disregarding the health problem. In the following reports, it is clear that the Military Brigade acts focused on repression, emphasizing the so debated and criticized prohibitionist model:

The police is drug repression [...]. (U6)

The Brigadians already know the [username]. Nowadays, if they see the [username] using something, they beat you up. They put pepper spray in his eyes. They have already done whatever they like with [username]. They just did not kill because they knew we would know it was them, they already beat him up a lot. (F5)

The brigade once attacked [I called] in the middle of the street because he [username] beat his grandmother and me. Then, a brigade passed by, I beat him and said that he drinks and he was trying to kill himself. Then Brigadian said: "Does he drink?". I said: "He drinks". So drunk who bothers has to let die, this way, and he did not give me assistance [...]. Then I had to pull him, get him out of the middle of street hammered, falling down not to kill himself [...]. (F6)

The increase in the rate of illicit drug use in Brazil and the dependence on the use of these substances over the last decades indicates the inadequacy of repressive measures, reinforcing the need for integrated and coherent policies that consider the diversity and different needs of the target communities.²⁰ Repressive logic strengthens the maintenance of domination relationships, intensifying the process of social exclusion.²¹

It is also emphasized that police, political and media discourses bring negative aspects that help in the construction of prejudice against the drug user, in which images and situations of violence are linked to drug use, which produces feelings of fear and indignation in the population. The idea is that all users are involved in trafficking and crime, and that discontinuation of use is related simply to the user's willpower.^11,21

There is another important factor that contributes to the social imaginary of drug user exclusion. Despite the progress made in the latest regulations, such as Law 11.343/2006, which separates drug possession for the own use from the trafficking. In this sense, it is necessary to invest on the debate that removes the confusion between the role of public security and health regarding the drug use. The two sectors are indispensable and need to be better articulated, since the sectors of public security are activated to deal with critical situations involving the social order, often acting as a gateway for care. Thus, the way in which they will understand the social needs, health, and following referrals will determine the changes in the imaginary or the reproduction of institutionalized prohibitionist strands.

The discussion herein is a model, i.e., a model of care that wants or has in relation to the drug user and how this user is seen in the context of public policies. In previous testimonies, the drug used is less important, whether lawful or illicit, but the operation mode of certain social bodies. However partnership with public security services be emphasized in order to strengthen intersectoral policies, there still seems to be some confusion of principles regarding drug repression - combating trafficking and crime, and the education of society - it reverts to the user's repression - with labeling and stigmatization of the subject.

In this sense, we understand that social withdrawal and the marginalization of the drug user, typical from interventionist and prohibitionist models, have been resumed with severe repression policies on crack use, especially in large urban centers, such as São Paulo. This hygienist and exclusionary view, executed by the police and endorsed by the public power, only brings another indication that the model is insufficient, such that the complexity of the drug phenomenon, generating more and more exclusion and less discussion about the issue.

In an intersectoral discussion space on drug user service, in the Attention Network Forums, these discussions were held frequently. Then, G7 problematizes the role of the Military Brigade, pointing out the need for understanding and dialogue for actions performed in the management with the drug user. In a way, it is a criticism that falls on the group of managers and the forum, when they realize that they do not understand in depth the orientation needs of the Military Brigade and its involvement in attendance of cases with drug users, especially crack.

We complain: "oh, they [Military Brigade] have no management, they do not know how to approach the patient [...]" and we never asked them how that is, if they have some kind of training, then often they questioned in the [Intersector Network Forum] forum, really relevant questions, which made us thinking "wow, that is true, how is it happening this way." And how much that came in speech for them and how much it was important for them. (G7)

Qualification and partnership among intersectoral network professionals are necessary to strengthen and improve care in the area. The provision of permanent education and the promotion of spaces for dialogues and discussions between the team and management can help in the approximation among services, in understanding the network dynamics, and in the served cases,⁵ in order to reverse the current situation pointed out by G7.

In this perspective, some municipalities have been implementing Regional Reference Centers (RRCs) for crack, alcohol and other drugs, which develop training and liaison actions based on the partnership between universities and territory, in an intersectoral perspective of permanent education on network care, prevention, treatment, and harm reduction.²²

Professionals of the health services, social assistance, public security, Public Prosecutor's Office, Judiciary and institutions that serve adolescents in compliance with socio-educational measures are targets for RRCs. In this integration, the issues related to drug abuse in a contextual, integrated and multifactorial way are also considered, reinforcing the need for network acting.²² RRCs are sponsored by the National Secretariat for Drug Policy (SENAD).

Given these dialogue strategies among sectors, professionals will be able to know the difficulties of acting and the doubts that the teams from each sector face and that often contribute to an isolated and decontextualized action, besides agreeing with care actions for user and their families. It is evident the importance of public security in repressing drug trafficking, however, it is necessary to discuss and deepen their relationship with the user and their families in order to reinstate the importance of offering help when necessary and fill gaps in this intersectoral composition, still fragmented in this local context.

Social reinsertion activities in the community

Social insertion activities were evaluated by the stakeholders within the components of the user's access network. The municipality has important partnerships, such as the development of educational projects with the School, the Community Preventive Health Program (SPCom), the National Service for Industrial Training (SENAI) and the National Service for Commercial Apprenticeship (SENAC). There is also the offer of community activities and solidarity economy with a Community Association:

We have partnerships, like the [name of the school], so we have some posts and some activities that in the past had a course of beautification, which a group of women went there. There are some courses like SENAI or SENAC, the Community Association of Vila Isabel [...] and we made it available to someone interested. (E2)

Drug abuse results in a weakening and rupture in the links from individuals with their social networks, in the family, at work, and in community spaces.^22,23 Thus, the care to be developed needs to include the territory as a social existence project, promoter of (re)encounters and daily actions involving the community in playful, sports, work, and learning activities.²²

Promoting the social reintegration of drug users requires the proposal of integrated and interdisciplinary actions, through discoveries and skills improvement, ability to solve problems, experimentation and exercise of citizenship, recovery of autonomy, self-esteem and their roles within the family and the community, seeking to respond to the reconstruction expectations of their life histories.²³

These community spaces are necessary to operationalize and think about networks, understanding that this construction is complex and formed by people with different points of encounter and the simultaneity of initiatives of the social actors involved. Therefore, the network must develop strategies that guarantee the construction and permanence of diverse spaces and primarily encourage the protagonism of users in these spaces with a view to strengthening their identities in the territory.

However, it constitutes a challenge, and in this research it was identified that these spaces were "lost" and have to be restored:

I do not even know if I had a partnership, if it will have. However, I see that it has not and is an extremely necessary thing. (E8)

I think [Community Association] stopped a little, [...] because it changed, it was with the UFRGS residence, and then stopped with their exit. It was also related to street practice. So, with the break of these periods and the completion of the street practice for the entrance of another team, and the residents leave and enter another colleague for the group, maybe has broken that link [...]. (E6)

There was SPCom, once a month, we went to a Municipal school, it never worked, since I got there, I had a couple, but then one could not get the meeting and then in the end, we ended up not going anymore. (E4)

Although they understand the importance of these partnership initiatives with teaching and social inclusion activities, daily impasses hindered to maintain them and can be interpreted by stakeholders as not being a priority for municipal management. In this sense, it is necessary to advance in the negotiation and attributions with shared responsibilities, with agreed goals, monitoring and with periodicity of evaluation.

The creation and resumption of community spaces could help in reducing the concentration of therapeutic activities restricted to the interior of CAPS, thus avoiding the "encapsulation" of users and professionals. This is pointed out by G1, when it recognizes the need to be more outside its walls, expanding actions for the geographic territory of the service, without disregarding the people's existential territory:

We also have to invest so that we can also be more out of CAPS, with interactions in different spaces of the city, I think that if you build a strategy, but I always say that it is not a crack user strategy, it is a mental health strategy. (G1)

Another study pointed to the constant need for a new organization, capable of provoking "outflows" of CAPS in mental health care. In these outlets, initiatives such as projects in the community, participation in events, tours, parties, trips and exhibitions of users' work have been fundamental to provoke movements with the purpose of reinforcing the linkage of professionals and users with the territory.²⁴

In the territory, the study object is extended, the user is seen in his or her social environment with his or her interpersonal relationships, forcing the worker to seek new ways of care that are not only in the health network. Thus, care in the territory brings new goals, since health needs widen in the living space and the staff perceive other issues, such as housing, employment, sanitation, social inclusion spaces available in the region, and the delicate family relationships.

The complex demands of crack users, which also involve attempts to re-signify their relationship with the drug, go through a new relationship with their life reality. CAPS, as a network component, can rediscover the user context based on what the territory offers. Moving through the scenarios and forming partnerships become effective and necessary strategies in order to place service relationships with the user and their environment.

FINAL CONSIDERATIONS

In the studied context, it was possible to identify movements in favor of an intersectoral network composition with the participation of the Public Prosecutor's Office, the Military Brigade and the community in the care for crack users, as well as the challenges to the obstacles imposed in the daily work process in network. With the expansion and diversification of needs and demands of the users, the network becomes more complex, and their bottlenecks are also appearing demanding more and more conversations and negotiation skills.

In the evaluation process, stakeholders have questioned how the Public Prosecutor's Office and the Military Brigade are inserted in the network, because it develops actions that often do not correspond to the psychosocial care network, such as isolated and hierarchical conducts, placing at stake the need for a rapprochement with these sectors in terms of integrated discussions and actions.

The Public Prosecutor's Office and the Military Brigade need to be involved in the elaboration of an intersectorial agenda with planning and actions that involves overcoming stigma and prejudice in the service of drug users. In this sense, it is necessary to clarify the citizen's rights, to the presuppositions of the psychiatric and sanitary reform that indicate intersectoriality as guideline for care.

It is considered that, in a network concept, partnerships with social bodies in the territory have been essential for care of users, implying an intersectoral practice on health needs, thus expanding the range of actions, involving education, work and leisure. However, these resources are little explored, requiring greater involvement of professionals, including partnerships, funds and interests in the implementation and maintenance of community spaces.

Thus, it is not possible to conduct isolated, decontextualized behaviors, discourses and actions based on labels and stigma. There are delicate moments of changes in public policies and it is necessary to integrate the sectors and participation of all the social agents from different spheres in order to foment and evaluate the public policies.

The participatory evaluation process gave voice to users, families, professionals and managers, and promoted reflections and strengthening of the study process on intersectoral network in mental health. Because it was a process that counted on the substantive collaboration of stakeholders from the beginning, both in the negotiation stages and in the final stages of the evaluation process, we understand that the research product was collectively constructed. Although the negotiation process does not always generate consensus, we considered only the information deemed necessary by the stakeholders to deepen the technical and political debate. Thus, we respect the conflicts arising from this stage - natural in such diverse and heterogeneous stakeholders - and ensure that only the data negotiated and accepted by the groups as relevant were discussed in this study, which are fundamental procedures in evaluations with participatory approaches.

In the intersectoral theme, we point as limits to the non-inclusion of members from other sectors in the theme discussion. We recommend future studies that can give voice to these stakeholders, considering the importance of being included in a participatory evaluation proposal. Finally, the results of this research can give a dimension on the complexity of intersectoral network study, contributing to the strengthening and advancement of intersectoral actions in drug user service.

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Publication Dates

• Publication in this collection
  2017

History

• Received
  07 June 2017
• Accepted
  31 July 2017