Experiences of family members of drivers who violate the law against drinking and driving and its repercussions

Rev Bras Enferm. 2021;74(1): e20190466 http://dx.doi.org/10.1590/0034-7167-2019-0466 7 of ABSTRACT Objectives: to understand the experiences of family members of drivers who violate the law against drinking and driving and the post-penal repercussions. Methods: a qualitative study, with family members of drivers who violated the law against drinking and driving who participated in the Projeto Justiça e Sobriedade no Trânsito de Maringá PR (Traffic Justice and Sobriety Project in Maringá – PR). Data collection was carried through semi-structured interviews, analyzed through thematic analysis. Results: it was observed in the family members’ reports: the suffering of families due to the consumption of alcohol and other drugs; the violation of the law against drinking and driving meaning turning point, with positive and negative changes in the family context; and the meanings of the Traffic Justice and Sobriety Project. Final Considerations: the law against drinking and driving penalties triggered unemployment and financial expenses, but the positive aspects were quitting alcohol use and/or not drinking and driving anymore. The Traffic Justice and Sobriety Project was informed as solidarity and a trigger for changing the offenders’ behavior. Descriptors: Alcohol Intoxication; Family Relationships; Drive Under the Influence; Accidents, Traffic; Public Health Nursing.


INTRODUCTION
Harmful use of alcohol is responsible for approximately 3.3 million deaths every year, and 5.1% of the global disease burden is due to alcohol consumption (1)(2)(3) . Its implications are not restricted to the individual consumer, but it extends to all members of the family nucleus and society, with social and economic damage (4)(5)(6) .
Families of drug users, exposed to problematic situations, experience psychological suffering, which causes them to face daily challenges, such as guilt, depression, social abandonment, and anxiety. The suffering experience interferes with relationships and family life, causing tension by trying to resist the situation (5,(7)(8)(9) . A study on the repercussions of events related to alcoholism in the lives of these families, would assist in the understanding of this phenomenon, contributing to the prevention, users' treatment and rehabilitation, besides supporting response strategies focused on the family context (10) .
Among the several problems resulting from the harmful use of alcoholic beverages, traffic accidents fill a prominent position (11)(12)(13) . According to the World Health Organization, due to its sedativehypnotic characteristic, alcohol has a strong influence on traffic accidents, which is why it was considered an "accident factor", that is, it directly affects the skills of those who drive a motor vehicle (1,(12)(13) . Thus, studies point to a clear trend of increased risk for the occurrence of traffic accidents among drunk drivers (14)(15)(16) .
Brazil has taken actions to discourage the population from driving under the influence of alcohol or any other drugs, implementing federal legislation since the 1990s, which establishes blood alcohol surveillance and imposes penalties on drivers who drive under the influence of alcohol (15,17) .
The law against drinking and driving was an important step towards the establishment of more effective policies to fight drinking and driving, as it imposes zero alcohol intake and attention on alcohol intake by drivers (11,(17)(18) . According to this law, drivers under the influence of alcohol will get fines, suspension of the right to drive for 12 months and the vehicle's apprehension, with the risk of imprisonment if there is a traffic crime (17)(18) .
The experience with the individual who violates the law against drinking and driving, whether it is an acute/binge user or a chronic user (2) , weakens family relationships (19)(20) , because risky attitudes generate traffic violence, consequently fatal victims and physical and emotional sequelae in survivors, affect the offender's family members, who share the consequences of these attitudes, whether financial, psychological or physical (5,7,(21)(22) .
Knowing the consequences of the association of alcohol and motor vehicle driving in the family context (5,21) , this study aims to answer the following concerns: How did the family experience the violation by alcohol abuse of a family member? What are the repercussions of the penalties resulting from the violation of the law against drinking and driving on the family?

OBJECTIVES
To understand the experiences of family members of drivers who violate the law against drinking and driving and the postpenal repercussions.

Ethical aspects
The project was approved by the Research Ethics Committee Involving Human Beings of the State University of Maringá, meeting the ethical aspects according to Resolution 466/2012 of the National Health Council. The interviewed family members were identified by the letter F, followed by the ordinal number that respects the sequence of the interviews, assuring the participants' confidentiality.

Type of study
This is a descriptive, qualitative study, to understand the meaning of alcohol use and the violation of the law against drinking and driving in families of offenders, based on Minayo's technique of thematic analysis (23) .

Study setting and data source
Participants were family members of drivers who violated the law against drinking and driving, and were part of the Traffic Justice and Sobriety Project in Maringá, Paraná, and were registered in the Poison Control Center database of the Hospital Universitário Regional de Maringá -CCI/HUM as intoxicated by alcohol and other drugs.
The Traffic Justice and Sobriety Project of the First Criminal Court of Maringá was implemented in 2016. It is an educational intersectoral project, based on Law 13281/2016, that carry out activities for the offending driver who was fined for drunk driving, as an alternative penalty of the provision of services in health centers (19,24) , aimed at contributing to the change the offender's behavior and with the decrease of reoffending of alcohol in traffic.
The Project's activities are carried out in four phases: court hearing; participation in a meeting/workshop, which addresses aspects of defensive driving, with a primary focus on drunk driving and information for helping in health services; provision of services to assist victims of accidents treated in the health services/ hospitals involved in the Project, with a workload of 30 hours; and evaluation of the effectiveness on the activities performed.
The first study scenario was the CCI/HUM, for the selection of the epidemiological records of Toxicological Occurrence of Alcohol Intoxication and/or Other Drugs -OT/IA of the offending drivers, who are reported through the University Extension Project Toxicovigilância e Busca Ativa de Casos e Educação em Saúde (Toxicovigilance and Active Search of Cases and Health Education), filled in meetings/workshops of the Traffic Justice and Sobriety Project. Drivers were considered intoxicated if their alcohol intake was chacked by an alcohol meter or signs of intoxication.
The following inclusion criteria for the study were considered: drivers approached by the Military Police in cases of traffic accidents or traffic inspections of different types; participants of the Traffic Justice and Sobriety Project in 2017; and who lived in the city of Maringá -PR. Offending drivers with incomplete addresses were excluded from the CCI/HUM records.
After selection, the second scenario of the study was the home of the offender/family member, to conduct a semi-structured interview. The following inclusion criteria for family members were used: being 18 years of age or older; and living with the offending driver, playing the role of a supporter/caregiver in the life of this family member. Family members of offenders who had not completed the four phases established by the Traffic Justice and Sobriety Project were excluded.
A total of 115 records of offending drivers met the criteria for inclusion in the survey and 30 OT/IA records were randomly separated for access to families. Eight family members were interviewed effectively, using the theoretical saturation criterion for dimensioning the sample, supported by the saturation of the speeches and the research objective achieved (25) .

Data collection
Data collection was carried out from October to November 2018, using interviews through a semi-structured script, with sociodemographic questions of the offender and family members, problems related to drug use and about the violation. The interviews were conducted in full by the main author, recorded on audio and guided by the questions: Talk about what it is like for you to live with the use of alcohol in your family? What are the repercussions of the penalties of the law against drinking and driving in the life of the offending driver and his family's life?
Home visits were previously scheduled by telephone contact and access to families was through addresses recorded in the OT/ IA forms. There was no prior contact with the participants, and training to conduct the interviews was carried out in research groups. The interviews were conducted in two meetings per family, with an average of 40 minutes each, and in three interviews, in addition to the participant and interviewer, another family member was present, according to the interviewee's request.

Data organization and analysis
For the analysis of the relative's interview, the interviews were listened to, respecting the period of not exceeding three days after the meeting. The responses to the triggering questions were transcribed in full, typed into a text document using Microsoft Office Word 10.0.
The results were analyzed using Minayo's thematic analysis technique (23) , following the phases of pre-analysis, material exploration and treatment of results/inference/interpretation.
In the pre-analysis, an attempt is made to make a comprehensive reading of the selected material, exhaustively, reaching deeper levels, so the author is saturated with the material. In the second phase, the exploration of the selected material is carried out, the analysis itself, also called categorization, which comprises making the clippings of the texts in units of records and the classification and aggregation of information in thematic categories, aimed at identifying the nuclei of meanings (23) . In the third stage of treatment of the results/inference/interpretation, we seek to highlight the information provided by the analysis, through simple quantification. Thus, the inference is made at an intermediate stage, between analytical treatment and interpretation. Finally, the results obtained are interpreted using the theoretical basis (23) .

RESULTS
The offending drivers were men, half were single, with ages ranging from 23 to 53 years old and an average of 42.0 (SD±6.02) and 7.8 (SD±2.47) years of education. The time of alcohol use, reported by the offending drivers, was 19.2 (SD±6.66) years and two offenders used illicit drugs associated with alcoholic beverages. Regarding the violation, three drivers were fined by the Military Police in traffic inspections and five were involved in traffic accidents after drinking alcohol.
The family members interviewed were women: two mothers, two wives and four sisters. The age ranged from 22 to 61 years, with an average of 44.4 (SD±14.56) and education of 9.5 (SD±3.60) years.
The family members speeches were organized into three themes, emphasizing situations experienced by families and the consequences of the penalties of the law against drinking and driving: Family suffering from the use of alcohol and other drugs; Turning point: positive and negative changes arising from the violation in the life of the offending driver and the family; and Recognizing the importance of the Traffic Justice and Sobriety Project in the offender and families' lives.  The daily problems from living with the user can cause disorders in the family environment, mainly due to fights and financial expenses to buy alcohol and other drugs. In some families, the user was the primary provider of the home. Furthermore, it was observed that living with a family member who uses alcohol and/ or other drugs generates codependency in these families (Chart 1).
Whether living with occasional alcohol use or abuse, the families expressed the repercussion as always being negative. Family suffering is intense, influenced by the "high doses" ingested on weekends and by daily living with alcohol consumption (Chart 1).
Chart 1 also shows that in addition to testimonies of suffering from alcohol use, the problem of the association of drinking and driving was reported in a meaningful way by families, causing suffering due to the feeling of fear with the possibility that their family member will suffer some physical trauma, sequelae and permanent disability, besides death from a traffic accident. Moreover, the fear concerning the relative, the interviewees expressed fear that their relative would drive under the influence of alcohol and cause some harm to other people, to other families, which they called "innocent people".

Theme 2: Turning point: positive and negative changes from the violation in the offending driver and the family's lives
The law against drinking and driving was understood and supported by families as an extremely important law, which must be complied with by the offenders, even though they experience difficulties in the family context caused by the charge. These difficulties can be seen, especially, by the driver's unemployment and the financial resources spent to pay fines and other administrative measures (Chart 2).
On the other hand, although the violation was a difficult process experienced by the family, the penalties of the law against drinking and driving were understood, by some family members, as an essential measure in the offending driver's process of awareness, influencing the cessation of alcohol use. Although some offenders persisted to drink alcohol, some families expressed a feeling of relief that the family member no longer took the risks of drunk driving (Chart 2). The interviewees showed support for the Traffic Justice and Sobriety Project, understood by them not as a punishment, but as an educational awareness activity. It was recognized by families as an impacting project, directly influencing offending drivers to rethink the act of driving under the influence of alcohol (Chart 3).

Experiences of family members of drivers who violate the law against drinking and driving and its repercussions
Elvira IKS, Marcon SS, Martins EAP, Oliveira MLF.
The families experienced, with their members, the process of participation in the Project and they reproduced the knowledge on this theme, since they mentioned their experiences with the family (Chart 3).
The Project influenced the decision-making for the psychosocial treatment of the offender, although relapses were reported sometime after the end of the activities in the health units. In this way, family members expressed the desire that the activities in the Project would be carried out with a workload over 40 hours, understanding the influence of this period on the offender's rehabilitation process (Chart 3).

DISCUSSION
The II National Survey of Alcohol and Drugs estimated that 5.7% of the Brazilian population is dependent on alcohol and/ or marijuana and/or cocaine, that is, in households composed of an average of four people, one is dependent, with more than eight million drug users and 30 million people living with a drug addict (26) . These families experience fears and insecurities occurring from the dependence and risk behaviors assumed by their members (5,(6)(7)(8)(27)(28) .
Relatives of drug users have significantly more chronic physical symptoms, complaints of mental suffering and greater psychosocial difficulties than the average population (21,(27)(28) . Those who suffer most from the negative impact caused by the abuse of alcoholic beverages or illicit substances are women, who are generally responsible for the users' treatment, as a large part of them share the role of "head" of the family and care for the user and the whole family (8,22) .
The family members, in general, revealed their daily struggle and confrontation, both because of the direct contact with the user, and because of the feelings of uncertainty, shame, sadness and insecurity concerning the trajectory of their family members (5,(21)(22)28) . Family conflicts, divorces and financial problems due to the money continuously spent to buy alcohol and unemployment are consequences of harmful alcohol consumption (5,(21)(22) . With all the problems happening and experienced by the family, the fear of accidents, aggression and the driver's death is greater than all of these (29) .
The Brazilian government invests in increasingly rigorous measures for those who take up the risk of drinking and driving (14) . Violating traffic laws and taking over driving under the influence of alcohol is considered a very serious violation by the Código de Trânsito Brasileiro -CTB (Brazilian Traffic Code). And those fined for violating the law against drinking and driving are determined to pay 10 times the fine, that is, R$ 2934.70 (18,24) .
Besides the financial cost of the fine, the offending driver commits a traffic crime when he is caught driving a vehicle with a concentration equal to or greater than six decigrams of alcohol per liter of blood or equal to or greater than 0.3 milligrams of alcohol per liter of alveolar air, or if signs of intoxication are detected. The vehicle is apprehended and the driver arrested, if there is no situation of killing or serious bodily injury, the driver can pay bail of up to one hundred minimum wages (18) .
The families of the offending drivers, under study here, experienced the penalties of the law against drinking and driving in its negative and positive aspects. The measures of authoritarian are evidenced by families as a necessary attempt for the user to recognize, with greater significance, the consequences arising from drinking (22) .
The law was understood as a measure to save lives and prevent traffic accidents caused by the influence of alcohol in the direction of motor vehicles. The families supported the law, recognizing the forthcoming risk of damage to the individual and other families, since most of the charges of its members were for being involved in traffic accidents.
However, the penalties reflected in the family financial condition, considering that many drivers were the main providers. Families highlighted long-term financial consequences and unemployment after the violation, which had an impact on the families' lives, both in the financial aspect, as well as in professional and family achievement. Furthermore, they indicated the law against drinking and driving as a turning point in their family members' consumption of alcoholic beverages. A turning point is a moment when the individual becomes aware of his actions from an impactful, joyful or painful event, and starts to try to stop using the drug (30)(31) . The violation was the moment that increased the propensity or behaviors in a "transformation" of life change towards the cessation or decrease of damages from the drug use (31) .
The turning points are not only the cessation of consumption, but the tendency of individuals to move from the compulsive phase of drug use to controlled patterns (30) . However, relapses may happen if failure trying to achieve established goals and not taking over life more consciously occur (31) .
After cessation of alcohol use, that is, alcohol abstinence, the recurrence rates decrease when the individual is aware of his dependence, determined and committed to changing behavior and have a new lifestyle (31) .
Family members acknowledged that harm reduction actions, such as not drinking and driving, although the family member persisted to drink alcohol, should be encouraged, as it reduces stress and suffering in the family. Harm reduction strategies, which aim to identify the presence of a problem, stimulate behavior change and propose strategies for this change to happen (32) , have been progressively incorporated into Brazilian drug legislation. Thus, in the last two decades, health policies have recognized the care gap provided to users of alcohol and other drugs that were carried out only in cessation programs (32)(33) .
The Traffic Justice and Sobriety Project was understood as a harm reduction strategy for families and brought to the home experiences lived by offenders in health units, allowing families to perceive the impact of project activities on the offender, directly influencing awareness of the damage caused by driving under the influence of alcohol.
The desire for the Project to have a longer workload, seems to indicate that families also recognize it as a space for rehabilitation and shows that these families need educational actions and less stricto sensu punitive, so that their families cease the use of alcohol and/or other drugs and adopt healthy lifestyle habits.
In this perspective, more partnerships are required between public health networks with national traffic agencies, in raising awareness among drivers and others involved in traffic. Public 7 of Experiences of family members of drivers who violate the law against drinking and driving and its repercussions Elvira IKS, Marcon SS, Martins EAP, Oliveira MLF.
health networks are closely related to fighting violence in traffic, since harmful alcohol consumption is an important public health problem. Working to promote the health of drug users is closely related to the well-being of their families.

Study limitations
Although the analysis presented here refers to data that identify only a small part of the problems associated with alcohol intake and driving, the study shows the consequences associated with this practice related to the penalties of the law against drinking and driving, which significantly affect the lives of families living with offending drivers.
As this is a study with families of traffic violators, who participated in a specific local project, we observed limited literature for further comparisons and discussions. However, the originality of the study stands out, which may support other research in diverse contexts.

Contributions to the field of nursing, health, or public policy
The impact of risky behavior by users of alcohol and other drugs is closely related to nursing actions, recognizing the role of caring through direct contact to the patient and his family. Thus, different learning scenarios make it possible to exercise clinical judgment in their training, by linking teaching and service, to establish relationships in the different settings of the individual, family, and society.
Studying the repercussions of the law against drinking and driving in the family context allows contributing to a better understanding of the problems related to alcohol and driving, besides being able to provide subsidies for the establishment of specific policies and campaigns, highlighting the importance of the link between awareness, prevention and inspection.

FINAL CONSIDERATIONS
This study highlights the repercussions of the law against drinking and driving penalties in the family environment, reported by families, in their positive and negative aspects. Participants reveal the suffering of families and drivers who violate the law against drinking and driving due to the daily problems caused by drinking, in which we highlight fights, financial problems, prison and fear of death.
The law against drinking and driving penalties was negatively impacted by financial expenses and unemployment after the offense. However, it was also positively recognized as a turning point in the lives of these families, mainly concerning the cessation and/or harm reduction from alcohol use. Family members also reported the meaning of the Traffic Justice and Sobriety Project in their lives, as a harm reduction strategy in terms of not driving under the influence of alcohol.
This study allows reflection on the importance of the family in the process of coping with risky behaviors involving alcohol and driving, and highlights that just punitive laws are important to establish rules on human behavior in traffic, educational projects activities are crucial in making drivers aware of compliance with the law.