Assessment of stigma and prejudice in the organization of care networks for drug users

Rev Bras Enferm. 2022;75(1): e20210135 https://doi.org/10.1590/0034-7167-2021-0135 8 of ABSTRACT Objective: To assess stigma and prejudice in the organization of the Psychosocial Care Network for drug users. Methods: this is a qualitative study, developed through Empowerment Assessment. The survey was conducted in a municipality in Rio Grande do Sul, with 42 network workers. For data collection, participant observation, semi-structured interviews and open forum were used. For data analysis, thematic analysis was used. Results: the network’s mission involved a proposal for care without prejudice and judgments for drug users. It was identified that the composition of the network with training in multidisciplinary residency and psychiatry facilitates achieving the mission, and among the difficulties, the challenges to overcome prejudice were analyzed. Strategies for continuing education, seminars, and user empowerment in the community are suggested. Final considerations: stigma and prejudice need to be problematized in the networks for the organization of more inclusive and rehabilitating psychosocial care. Descriptors: Drug Users; Social Stigma; Prejudice; Health Evaluation; Comprehensive Health Care.


INTRODUCTION
Drug abuse is a complex flagship with challenges for global mental health. In Brazil, the policy of confronting drugs in its propositions gives rise to the clash between the Brazilian National Anti-Drug Policy, in the scope of public security, which follows the logic of prohibition, and the Policy of Comprehensive Care to Drug Users, guided by the logic of reducing damage. Both the Ministry of Health and the Ministry of Justice focus on the theme, resulting in a set of contradictions that mark the ambiguities of this problem in contemporary times (1) .
Based on the Policy of Comprehensive Care for Users of Alcohol and Other Drugs, presented in 2003, the intention was to reverse the directionality of actions centered on repressive approaches, for a care organization based on the Psychosocial Care Network (RAPS -Rede de Atenção Psicossocial), which characterized by the integration of various services and devices that must establish communication and co-responsibility for care from primary to tertiary care (2) .
The main objectives of RAPS are humanization, a focus on the subject and not only on the disease, social inclusion and the deconstruction of stigmas and prejudices linked to people with psychiatric disorders and drug users. Despite its objectives focused on comprehensive care, RAPS has its implementation strongly challenged by anti-drug guidelines, still based on prohibition and the only negative image of subjects who use drugs, criminalizing its use and promoting a stigmatizing and prejudiced culture in society (3) .
As central concepts, prejudice is approached as a inadequate judgment to define something or someone, building an idea without previous knowledge. Prejudice is characterized by the affirmation of own identity as superior/dominant, and likewise, by the denial of the other who is different (4) . Stigma, on the other hand, is a derogatory attribute that is attributed to an individual, which is part of a characteristic and becomes something totalizing (5) . The stigma extrapolates an attitude of prejudgment, and shows something like a infamous signal, unworthy and dishonorable, considered a stain on someone's reputation, undignified and dishonorable sign, a stain on someone's reputation (6) .
Stigma and prejudice towards drug users are related to a number of factors, such as the perception that drug use leads to people committing irrational acts, racist historical associations between certain drugs and certain populations, religious objections, and perceived interference in the neoliberal values that blame individuals and exempt the state from responsibility, with the exception of actions aimed at people who abuse psychoactive substances (7)(8)(9) .
Stigma and prejudice highlight a one-way view of drug use that is disseminated by the media vehicles of communication.
There is an idea that all individuals who use the drug are chemical dependents, involved in drug trafficking and criminality. This social imaginary contributes to the social marginalization of users, obscuring the analysis of these people's lives and the social dimension of their determinants (10) . In the logic of social relationships, stigma and prejudice have been analyzed as part of the organizational dynamics that reflect the experiences of drug users in poor access to health services, as, because they feel ashamed and ignored, they find it difficult to seek help and/or complete care plans (11)(12) .
Among the strategies that users use to avoid stigma is the delay in seeking treatment, not disclosing drug use and seeking care in other community resources not linked to health services (13) . In this sense, studies on this theme are necessary to analyze and understand how stigma and prejudice reflect in the context of networking, in order to promote that these people receive shelter in the health services of RAPS and feel encouraged to seek treatments and healthcare.
It is identified that qualitative evaluative research can favor, in contact with these complex issues, not only subjects' perspectives, feelings and values, but also the institutional structural processes such as the construction of healthcare networks. Thus, considering that RAPS organization must address issues related to the stigma and prejudice experienced by drug users and provide direct, comprehensive answers supported by different network arrangements, this study presents the following research question: how is stigma and is prejudice evaluated in the organization of RAPS for drug users?

OBJECTIVE
To assess stigma and prejudice in the organization of the Psychosocial Care Network for drug users.

Ethical aspects
This study was approved by the Institutional Review Board of Universidade Federal do Rio Grande do Sul in 2017. Ethical aspects were ensured in accordance with Resolution 466/12 of the Brazilian National Health Council (Conselho Nacional de Saúde). To guarantee participants' anonymity, the statements were identified with the letter W for worker, accompanied by the name of RAPS component that works, followed by Arabic numerals, according to the ascending order of interviews.

Type of study
This is an evaluative study, of a qualitative nature, using the methodological assumptions of Empowerment Assessment, a participatory assessment built collectively between researcher and research participants with the aim of qualifying social practices and technologies. This assessment is carried out through three steps: 1) Mission construction -aims to build the purpose of networking and unify efforts among participants to achieve the objectives of work; 2) Knowledge of current situation -seeks to identify the main facilities and difficulties of the network to achieve the mission; 3) Planning for the future -involves the elaboration and prioritization of strategies to achieve the mission (14) . 8 of Assessment of stigma and prejudice in the organization of care networks for drug users Santos EO, Pinho LB, Silva AB, Eslabão AD.

Study setting
The research field was the RAPS of a small municipality in Rio Grande do Sul, Brazil, which was intentionally selected for being a reference in terms of network care from the perspective of psychosocial care, being a pioneer in the implementation of CAPS in the state. The municipality had an estimated population of 44,580 inhabitants in 2017, with approximately 50% residing in the rural area (10) . It is a municipality of German colonization with one of the highest concentrations of Pomeranian descendants in the world (15) .

Data source
In this study, RAPS managers and workers participated. The inclusion criteria for the participants were: being a coordinator for at least one month in the network service and, for workers, having at least six months of employment.
For the production of data, the triangulation of qualitative methods was used: semi-structured interview, participant observation and open forum (14) . Semi-structured interviews were applied to 42 workers from the following network components: 18 workers from the Primary Healthcare component (harm reduction, central health unit, Family Health Strategy (FHS), and Family Health Support Center); 9 from strategic psychosocial care (Alcohol and Drugs Psychosocial Care Center -CAPS (Centro de Atenção Psicossocial) AD, CAPS I, Children CAPS); 1 from emergency care (Mobile Emergency Care Service); 1 from hospital care (specialized ward in chemical dependency; 1 from psychosocial rehabilitation strategies (service of job and income generation); 3 RAPS managers (coordination of mental health, primary care and teaching, research and extension); 5 of social assistance (Department of Social Assistance, Social Assistance Reference Center, Specialized Social Assistance Reference Center, Children's Home, Beat Early Childhood); 4 from the intersectoral network: (custodial council, school, judiciary and Public Ministry). The interviews were carried out individually during the work shift in a reserved room of the service in order to guarantee privacy, later they were recorded and transcribed in full. The interviews lasted approximately 35 minutes.
Another technique used was participant observation, which is characterized as an instrument that enables approximation with participants and the research context (16) . Participant observation took place for a period of nine months in the morning and afternoon shifts at RAPS services. The records of this observation were carried out in a field diary.
Finally, Open Forum was a technique used to negotiate the research data, prioritize RAPS' mission and planning strategies for the future, and included the participation of professionals who are part of the management collegiate: 3 RAPS managers (Mental Health Coordinator, Primary Care Coordinator, and Multidisciplinary Residency Coordinator) and representative of the network components (CAPS AD III, CAPS I, Child CAPS and SAMU).

Data collection and organization
Data collection was carried out between March and December 2017. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was used as a criterion for data organization.

Work steps
As this was a qualitative evaluative research of a constructivist character, at first there was the construction of a bond with the community to gain the right of entry, which is about raising participants' awareness for involvement with the research proposal. In this sense, participant observations began, mainly in CAPS AD activities, in its internal dynamics and in the spaces and connections with RAPS and the intersectoral network. The observations' focus sought to meet the actors in order to understand how the network was organized and operated, identifying what the local RAPS' mission would be, the aspects that facilitated and hindered the work, and the improvements that could be invested for qualification of this network. All these questions were also addressed in semi-structured interviews, in order to hear the perception and experience of research participants.
Finally, the open forum was held, the differential of this research in the light of Empowerment Assessment. In the open forum, the main researcher facilitated a data negotiation process through the presentation of the summary of empirical material, encouraging participants to reflect and participate in decisions on the points that would need to be prioritized and invested in the local network, such as the local network's mission, current situation, and strategies to be invested for the network's future, taking into account current priorities, local possibilities, and what could actually be invested. In these spaces, stigma and prejudice in RAPS emerged as a unit of analysis for the construction of the local network.

Data analysis
Thematic analysis was used, carried out through three steps: data ordering, data classification and final analysis. In the first, text skimming and exhaustive reading of the collected material is made. In the second, excerpts and fragments were separated, which were distributed into topics, identified as information units, and then approximated by similarity, originating the units of meaning. Finally, the final analysis with a view to interpreting the results obtained (16) . In this article, stigma and prejudice is addressed in the light of Empowerment Assessment in its three stages: Psychosocial Care Network's mission; Knowledge of current situation; Planning for the future.

RESULTS
Among the 42 workers participating in the study, 18 are nurses, eight psychologists, six social assistants, three psychiatrists, two harm reducers, an educator, a prosecutor, a judge, a physical educator and an occupational therapist. Of these workers, 36 are female. Regarding time working in the network, 11 workers have been working with RAPS for over ten years; 11 workers have an employment relationship between 2 and 9 years; 10 workers for a period equal to or less than one year. The results of this study and its respective stages will be presented below.:

Psychosocial Care Network' mission
For participants, RAPS' mission in the city involves a proposal for care without prejudice and judgment regarding drug users.

Knowledge of current situation
At this stage, the aspects that facilitate and hinder the achievement of RAPS' mission in the construction of care without prejudice and judgment in the attention to drug users were evaluated.
According to participants, the facilitating aspects are the configuration of RAPS in constituting itself as a training field in the modality of psychiatric residency and multidisciplinary residency, as it promotes greater contact between professionals with the debate on current public policies based on harm reduction and in extended care to drug users. [ Among the aspects that make it difficult to achieve RAPS' mission, professionals highlight the practices of prejudice carried out in the network, which reinforces the stigma related to drug users present in the social imagination. In the case of the network under study, professionals demonstrate that the stereotype of drug users, as people without commitment and incapable, made it difficult for the network to "see" users' roles played in society.
[...] there was already a case that because the mother drank she was bad for her daughter, and she was always an extremely careful mother, at that time she was confused, but from the moment she resumed treatment it flowed, today she is a super mother, she lives in a context very complicated, but she treated that daughter well and [ According to participants, the prejudice of professionals often makes it difficult to link service users and proposed therapies as well as to network care: W3 reports the prejudice of professionals when assisting user C. She says that during hospitalization, the colleagues who made the reception were judging: I had to say, "imagine how difficult it must be for her, put herself in her place". (Field Diary) Psychoactive substance users who are very labeled by society, very stigmatized, and in this logic ends up being labeled and stigmatized by the services themselves, for example, until a while ago [...] the person mentioned that they used alcohol or that they used some substance, they were not even attended to, they were already referred to CAPS and today we know that CAPS is to attend to the crisis and when the person comes out of the crisis, they have to be assisted in their territory, but for that we  Prejudice towards drug users also interferes in the conception of services that serve this public, so that CAPS AD is often considered by the community as a service for "nuts people".

DISCUSSION
In the focus of Empowerment Assessment framework, the organization of care in attention to drug users is composed of an active participation of professionals in the construction of networks. To this end, their ideas and reflections on RAPS' mission, the current situation and perspectives for the future, bring a problematic analysis in relation to prejudice and stigma as aspects that need to be considered for the promotion of networked care for drug users.
In the first category, RAPS' mission is evaluated, in which W1, W37 and W5 highlight a care proposal in a network aimed at welcoming without prejudice, value judgment and judgment.
Participants emphasize that it is necessary to demystify the social stigmas of drug users. These ideas are exemplified by W1, which addresses the association of drug use with crime, violence, trickery, and this reflects in the practices of health professionals and in the work process, generating situations of prejudice.
For users, there is also the constitution of a self-stigma that occurs due to the internalization of beliefs associated with drug use, starting to believe that they have less value due to their "condition" (17) . These aspects are experienced by users in the network under study and have affected access and treatment in health services. Thus, the fight against stigma and prejudice are considered priorities of the network, constituting the collective mission listed.
The mission constructed by participants demonstrates the need to change the culture of marginalization of drug users, based on the problematization of the processes of social exclusion, negligence practices, absence of specific policies and inequality in the conditions of citizenship. The inclusion of this agenda in networking can contribute to paradigm shifts and the construction of a new form of care that brings the perspective of living with differences and guaranteeing rights in care practices (18) . Combating stigma and prejudice is a political guideline for the functioning of RAPS according to Decree 3.088 of 2011 that institutes RAPS within the scope of the Brazilian Unified Health System (Sistema Único de Saúde -SUS). However, managers face the challenge of operationalizing them in the territory considering the local potentials and challenges, as well as the municipality's cultural issues and needs.
In the knowledge of current situation of RAPS, one of the aspects identified as a facilitator for achieving the mission is the network configuration as a training field in the modality of psychiatric residency and multidisciplinary residency. This composition promotes greater contact between professionals and the debate on current public policies based on harm reduction and expanded care. This is pointed out mainly in the testimonies of W1 and W4, which highlight the exchange of experiences with other professionals as a possibility of continuing education and awareness of the teams that can generate knowledge and reflection on the theme of stigma and prejudice within the clinic, policy, theory and practice of care.
These data are related to a study that analyzes Multidisciplinary Residencies as tools for the construction of other ways of looking at healthcare, reflecting the frequent need to revisit the ethical behavior according to the principles of SUS and the expanded clinic. The worker-resident meeting manifests processes of change that can be powerful for mental health care and for the advancement of Psychiatric Reform (19) .
Although there are challenges in the articulation between residency and services, such as the stressful conditions generated in this process (20) , residency presents itself as a potential for both the training of residents and the permanent training of health workers. In addition, it is a strategy that to building new ways to involve and articulate professionals for humanized practices, and, in this way, to overcome the fragmentation of care. This reality produces innovative perspectives and consonant to the premises of psychosocial care that provide subsidies for qualification of RAPS and the reach of their proposals.

Assessment of stigma and prejudice in the organization of care networks for drug users
Santos EO, Pinho LB, Silva AB, Eslabão AD.
Among the aspects that make it difficult to achieve RAS' mission-in its proposal of care without prejudice and judgments regarding drug users, W6, W4 and W35 highlight the challenges of overcoming the prejudice practices present in RAPS, i.e., of not to reproduce prejudiced practices in environments destined to care.
In the work of the network professional, there is often an evaluation accompanied by a judgment and not based on users' needs. A factor that influences this assessment is the fact that the municipality is small, where professionals and users know each other from other spaces and have proximity between their networks of relationships, with the even greater challenge of restituting the roles occupied in the network and conducting an assessment ethics based on needs. This is exemplified in the speech of W4, in which it is clear that prejudice is linked to a negative image, the fact, for example, of seeing only the use of alcohol in the relationship between mother and daughter, disregarding that in this relationship there was also care and attention to the daughter.
Studies confirm that the professional approach regulated by prejudice negatively interferes with citizenship opportunities and the search for access to health services (21)(22)(23) . Teams often view drug users as violent, manipulative, noncommittal, and resistant to treatment. For some professionals, substance use provokes aggressive and delinquent behavior, such as robberies, assaults and homicides. This perception, associated with the weaknesses of infrastructure, training and qualification of the teams, generates feelings of fear and insecurity in professionals, perpetuating repressive, authoritarian and abstinence-oriented asylum practices (21)(22)(23) .
In the case of this research, this is also identified, in which prejudiced practices on the part of professionals can interfere in the way a given case will be conducted in the network and in the actions offered, which can be a barrier for users to link to teams and adhere to therapy. An assessment based on prejudice can reinforce isolated and punctual practices without seeking, in the network, articulation strategies to contribute to solving problems and acting on needs. For example, we can mention the stories brought by W3 and W1 that mention the poor service provided by professionals from some services in the network.
It is understood that a relationship between professional and user based on stigma and prejudice can generate negative consequences due to the fact that many people do not seek help in services in order not to be "labeled". This reduced access to the service can increase drug abuse problems, generating other psychic comorbidities and making the complexity of life and people invisible to the health and social system. Furthermore, it can result in poorer and less organized services and in the devaluation of professionals involved (17) .
From the perspective of networking, attention is drawn to the articulation between RAPS services and the development of an integrated work proposal. It is observed as a result of research that there is still a demand for drug care focused exclusively on CAPS. This centrality can reinforce stigmatization and put at risk the RAPS' proposal, since treatment and social reintegration depend on this continuity of care and to maintain the bond in RAPS, it is necessary that all teams are welcoming.
In this sense, prejudice must be worked in the network, without attributing the problem to a specific service or professional. It is about recognizing prejudice as a barrier to network care, seeking joint strategies without a rupture between services. One of these strategies is the clarification between professionals and users about the work of each service, its objectives and missions, also seeking to demystify stigmas about madness and mental health and the image that CAPS is the only service to assist drug users.
In the speech of W4, it is also possible to see the importance of the professional's self-reflection on the practices he develops, demystifying the idea that prejudice is something done "by the other". This analysis repositions prejudice to the scope of mental health care and can contribute to the construction of practices based on ethics and the qualification of network care, in addition to enabling the vision of the roles of users in society, including their socio-cultural issues.
In the field of drug use, there is a conception based on common sense, in which the complexity of people's lives is not observed. In this regard, the teams face the challenge of giving new meaning to their practices, avoiding the perpetuation of simplistic conceptions that lead to prejudiced and excluding approaches, such as referring all drug users who access the network to specialized services. This conduct reinforces CAPS image as the only place of care for drug use and distances users from comprehensive care and inserted in society.
Studies in South American countries also point out the referral of professionals to specialized services due to prejudice in drug user care (22,24) . In the case of FHS, these teams commonly report little skill and competence for the approaches. The professionals' discourse is still linked to dangerousness, which has led the teams to deny the reception and have as main answer the referral to the specialized service (25) .
W28 also points out prejudice as a barrier to access and treatment in specialized services, being a characteristic of social vision and discrimination. Users are often afraid to attend CAPS AD or any health service, fearing they will be labeled as people with mental problems in their communities. This is observed in the literature, which points out that stigma and prejudice can lead people to seek treatment in protected environments, such as clinics and places far from interactions with family and friends (26) .
As perspective strategies for the future of the network, W16, W2, W36 suggest investment in permanent education, involving dialogue between CAPS AD and FHS with a view to qualifying primary care for the care of drug users. The frequent presence of CAPS AD professionals in FHS is a strategy that can contribute to the discussion of cases and shared care, being considered a necessary tie to reach the RAPS' proposals.
Another suggestion for RAPS is professional qualification with courses, seminars, reflections on practices and motivation for teams. Workers emphasize that professional qualification is often seen as an individual responsibility. However, it is necessary to implement training as part of the network's actions to broaden collective understanding of policies and connect workers to the same efforts.
Health professionals' training needs to be permanent based on experiences and reflections as a possibility for new knowhow, linking management, care and social participation for the construction of a strengthened network (27) . These ideas meet the research participants who are interested in social change in the 8 of Assessment of stigma and prejudice in the organization of care networks for drug users Santos EO, Pinho LB, Silva AB, Eslabão AD.
care of drug users. From their testimonies W5, W9 and W7, they reflect on the importance of empowering users through social reintegration in the territory and in the job market, workshops in the neighborhoods and the search for other possibilities in the community, strengthening this relationship. This is also evidenced in other studies (28)(29) that point out as great challenges users' access to a productive life that can legitimize socially, providing greater self-esteem and quality of life. Finally, although it is a slow and gradual process, it is essential to deconstruct the social imaginary that frames drug users in some abnormal status within society's standards. This permeates intersectoral work, such as the economy, the labor market, education and social assistance, i.e., organizations beyond RAPS' work, linked only to health, but which are connected with the development of integration strategies between service and society.

Study limitations
The study is characterized by the assessment of RAPS professionals and managers. We suggest other evaluative studies with users and family members of the network, contemplating their participation in the construction of local networks, in order to broaden the understanding of the problems and their resolutions collectively and identify ways to qualify the network in the light of the psychosocial paradigm.

Contributions to health and public policies
Contributions are identified as the proposal for a participatory evaluative process, which reveals qualitative research, in addition to collecting data and information, but also as a proposal for meeting, dialogue, professional training, discussion about potential, difficulties and contributions to the advancement of comprehensive care practices for drug users at the local level.
Another relevant issue is to bring up the debate on prejudice and stigma that is often overlooked in the demands of services, routines and techniques in the field of mental health. Discussing and demystifying stigmas and prejudices contributes to the advancement of public policies on mental health for drug users, expanding their access to comprehensive, humanized and ethical care.

FINAL CONSIDERATIONS
The local RAPS mission demonstrates the need to transform a culture that marginalizes drug users, through an image and stereotype that produces social stigmas both in society, health professionals and users. To build a welcoming network, it is essential to face this stigmatization process.
Regarding analysis of current situation, the work of professionals in training spaces with psychiatric residency and multidisciplinary residency, where students and front-line professionals can discuss, learn and demystify practices based on prejudices and stigmas. The complicating factors of this process, on the other hand, are related to the production of prejudiced practices in environments that should be of care, producing barriers for users' adherence to therapy, in addition to users' fear of labeling services both by health professionals and by society, which makes it difficult access to and continuity of care in RAPS.
It addresses as a perspective for the future the need for greater investments in education and permanent professional training, the integration between primary care and CAPS AD as well as strategies aimed at reinserting users into society for income generation and visualization as citizens. These results contribute to the construction of networked psychosocial care in tackling drug abuse, integrating services and society with a broad fight against moralism and stigmatization, promoting participatory and inclusive care spaces.

SUPPLEMENTARY MATERIAL
The article is the result of a PhD. thesis at the Federal University of Rio Grande do Sul (UFRGS), therefore, published in the repository lume.ufrgs.br. The thesis can be found at the following link: https://lume.ufrgs.br/bitstream/handle/10183/201252/001105181. pdf?sequence=1&isAllowed=y

ACKNOWLEDGMENT
To the Coordination for the Improvement of Higher Education Personnel (CAPES -Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) for granting a Graduate Scholarship to the first author. 8 of