ALCOHOL , ALCOHOLISM AND ALCOHOL ADDICTS : CONCEPTIONS AND ATTITUDES OF NURSES FROM DISTRICT BASIC HEALTH CENTERS 1

This qualitative study aimed to learn the conceptions and attitude tendencies of nurses from public district basic health units towards alcohol, alcoholism and alcohol addicts. The sample consisted of ten nurses from three institutions in a city located in São Paulo. Data were recorded and submitted to content thematic analysis. Subjects evidenced that these nurses are permissive towards moderate alcohol use, but reject alcoholism, conceiving it as a potentially fatal disease, and tend to associate it to personal will, indicating the influence of the moral concept on their conceptions and attitudes. The participating nurses’ knowledge about the topics alcohol and alcoholism was also evidenced. Based on the results, the authors suggest training this group and preparing these professionals for the care, recognition and prevention of disorders related to alcohol use/ abuse at these health centers.


INTRODUCTION
Despite the fact that alcohol is broadly accepted and evenE socially encouraged, once its consumption gets excessive, it becomes a relevant problem and generates high costs for society.Superventions caused by alcohol exceed the ones widely announced in literature, characterizing it as a problem that involves serious social consequences and placing it among the main current public health problems.
Data collected by the II Home Survey about the use of psychoactive drugs in Brazil (1) , in 108 of the major cities in the country, indicate that 12.3% of the population from 12 to 65 years old are alcohol addicts, and 74.6% have already drunk alcoholic drinks some time in their lives.
Alcohol addicts present a series of events related to alcohol abuse before they are diagnosed as addicts and forwarded to a specific treatment.
Considering the organization of the Brazilian health system, whose guidelines consider basic health centers as the entrance door to health services, it can be inferred that these services attend several individuals with abusive consumption patterns, often due to early complications of alcoholism, such as traumas, intoxication and family violence.
In this respect, studies (2)(3) show that a substantial part (10 to 40%) of the population that seeks health care at basic health centers every year present disorders associated to the use and abuse of alcoholic drinks, which presupposes that basic care nurses have frequent contact with these patients.
Nevertheless, Brazilian research about nursing care to individuals with disorders related to psychoactive substances is poor and performed in hospitals (4)(5) , especially studies about professionals' used Content Analysis (6) as the theoretical framework and Thematic Analysis (6) as the technique for data treatment.The interviews were recorded, transcribed and exhaustively read.Thus, each statement was a source to extractthe themes emerging from the nurses' statements, which were grouped into theme categories compatible with the theoretical framework regarding the study of attitudes.Next, each theme was analyzed in order to understand how each nurse conceived the problems of alcohol and alcoholism.

RESULTS
Only one of the ten students was male and the prevalent age group was from 41 to 50 years old.
They had been developing their career between 16 and 20 years, four nurses had a master's and nine a specialization degree in nursing.

Conceptions and attitude tendencies of nurses towards alcohol and alcohol use
As nurses expressed their personal conceptions towards alcoholic drinks, the analysis of their statements showed ambivalent conceptions.
While some professionals conceive this substance as something negative, a significant part of them attribute beneficial characteristics.Despite the fact that alcoholism is conceived as a disease by most of the nurses, as previously evidenced, two nurses mention in their statements that the individual is not always seen that way, since (s)he is attributed with predicates that do not refer to the conception of a sick person, but to the stigma that still falls upon the carriers of this disease.... We generally think the alcohol addict is a bum, an irresponsible person, we give them all of these attributes and it doesn't occur to you that he is sick (E.8).... It is awkward, although it is a disease, it is not seen as one; it seems it is more considered as cheek, shameless (E.10).
Yet, regarding the conceptions of alcohol addicts, nurses seem to discredit and have little hope for the recovery of this person, because they believe that, even after being assisted and disintoxicated at the health center, the first thing the alcohol addict will do is search for a bar to get drunk again.... Sometimes they arrive here completely disoriented, and they go out physically well, we know this is something momentary, he will soon have another alcoholic drink (E.3).... I am sure the first thing they do after they get better it to cross the street, get into a bar and drink some more(E.6)....He comes here looking for care, takes some glucose and some medications, and as soon as he is discharged he goess back to the bar to drink (E.10).
The alcohol addict is someone who presents repetitive problems and, due to this recurrent pursuit of health care, he is characterized as a chronic and sometimes even as a hopeless case.... Because he feels the need and drinks, and then he comes back to the health center for care (E.3).... The first thing you notice when you take care of an alcohol addict is that it is something repeating (E.4).
...Thus, these chronic cases we see are lost cases, there is nothing else to do (E.5)....And they are those patients who are always returning (E.7) At the moment nurses manifest themselves about the alcohol addict, there seems to be a dominant conception that this individual lacks the will to interrupt the consumption, believing the person has control over the consumption of alcohol and that, if he wants he is able to quit the habit ... I think the person is able to quit this habit, it is just a matter of will, the person has to want it.(E.4) ... I think any kind of treatment for an alcohol addict is valid, but it has a lot to do with his will as well, we know that (E.6) ...Then, I think there are people who drink a lot in these cases, and they are able to stop it, but sometimes they don't feel like doing it (E.9).There are also indications of the influence of those situations lived in the family or in the social environment, making this nurse compare with personal experiences, and consequently, believe that alcohol addicts are able to stop drinking without any kind of help, as if their own will was everything they needed.... 'Because I know many people who used to drink and, that, once they decided to quit it, they managed to do it very well, without any medical help, hospitalization or the use of medications.
Just because the person wanted to do so.So why did he stop?How did he manage to do it?It is just a matter of will, indeed.(E.8).
One studied nurse, however, seems to conceive the possibility that will is not the only determinant factor of alcoholism, because there are other kinds, specific cases.This presupposes that the previous conception still falls upon most of the alcohol addicts: the will to stop, in other words, someone only drinks because he wants to.... Nowadays, we face other kinds of patients who have something else, besides the will (E.10).
These results permit inferring that the conception of alcohol addict among the studied nurses is that these persons need alcohol and, thus, drink every day.The conception of the alcohol addict as someone who cannot be without alcohol, seems to presuppose the establishment of dependence.Data analysis also evidences the presence of influence by socially determined conceptions towards the alcohol addict, for instance the conception that they are individuals who drink because they do not want to stop, they want to drink.Another conception considers the alcohol addict as a repetitive patient, who has a low probability of recovery and, thus, constitutes a hopeless case.

DISCUSSION
The nurses who participated in this study manifested more acceptance towards alcohol use in comparison with similar studies.By analyzing the attitudes and conceptions of nurses from general hospitals, some authors (5,7) evidence that these professionals presented negative attitudes towards moderate alcohol use and considered alcohol as something harmful, regardless of the consumed quantity.
Furthermore, the analysis of the interviews revealed that nurses who use alcohol were more permissive towards alcohol use, whereas those who claimed to be abstemious rejected the consumption of alcohol, regardless of the consumed quantity.This attitude was already expected, since there is a tendency for professionals to consider their own alcohol consumption as a reference for normal consumption, or to reject patients who do not know when they are supposed to stop drinking (2, 8-9) .
It is worth highlighting, as a positive aspect compared to previous studies (4,5) , that nurses express their own consumption of alcoholic drinks.A similar study (7) evidences that nurses presented some resistance to mention their own consumption of alcohol, which is an attitude that can be related to the fact that these professionals do not feel very comfortable to assume that, even being health professionals, they also consume alcoholic drinks (7) .
This situation infers that the consumption of alcohol may be seen as something shameful and immoral by this professional group.
The expression of alcohol consumption may indicate more permissive and less moralist conceptions towards the use of alcoholic drinks, since it may be possible that these opinions influence the acceptance of the alcohol abuser, as long as it does not turn into total permissiveness.On the other hand, although they manifested their own consumption of alcoholic drinks and presented positive conceptions of moderate alcohol use, the studied subjects are against excessive or uncontrolled drinking, a tendency that has been reported by Brazilian (5, 9) and international studies 10) .
The fact that nurses turned out to be permissive towards moderate alcohol use, but against excessive consumption of alcohol and alcoholism, may be supported by society, which encourages and accepts the act of drinking, but rejects it once it becomes excessive (11) .Therefore, this term is controversial, because society may establish its standard based on the personal standards of its citizens, becoming more subject to social tolerance.
According to these nurses, alcohol is conceived as something pleasant, which has antianxiety properties but, once it is consumed inappropriately, it generates addiction and, consequently, health problems.Although moderate alcohol use is accepted, they tend to reject its heavy use, believing there should be more control over the commerce of alcohol in the country.
These nurses conceive alcoholism as a disease, in line with the data literature has used to evidence this conception from the nurses' point of view (4-5, 7, 9) .In this sense, Vargas (12) states that several groups of professionals recognize alcoholism as a disease, and that it is easier, however, to accept that intellectually than emotionally.According to literature (4)(5)9) , these professionals agree to the fact that alcoholism is characterized as a disease but, when it comes to assisting this kind of patient, they manifest embarrassment and feelings of discomfort, as they see alcohol as something morally wrong.
These nurses conceive the alcohol addict as someone who needs alcohol on a daily basis, referring to the concept of dependence on alcohol.
By presenting this conception, they may indicate the understanding that the alcohol addict is someone who gets sick, depends on it and needs this substance to live.
Understanding this user, who drinks every day, indicates that nurses have poor knowledge about the evolutionary stages of dependence and about alcoholism itself.That is a fact because, according to literature (13) , the disease does not necessarily involve daily and permanent consumption in excessive quantities, since certain kinds of paroxystic alcoholism, even between longer periods of time, may lead to severe psychosomatic and social consequences.Therefore, the whole pathological use of alcohol, regardless of the frequency, should be considered as addictive behavior.
Despite the evidence of changes in the way nurses have perceived alcoholic addicts over the last decades (9, 14)   , this study data confirms that they are not always attributed with the status of sick persons.
Moreover, the professionals' statements indicate that, even being sick, they are not always seen that way, and labels like cheeky and shameless still remain.
The nursing professionals did not consider alcoholic patients as sick persons for decades; they used to see these patients as opportunistic and badtempered persons, people aware of their actions when they arrived at the emergency unit drunk (15) .
Studies (15)(16) have evidenced alcohol addicts as patients who should not be treated, who disturb the service dynamics.These scientific literature records indicate the importance of the moral character that falls upon alcoholic addicts.
Another conception present in the participants' statements refers to alcohol addicts as people who present repetitive problems and recurrently seek health care, being characterized as chronic or even hopeless cases.This conception indicates that, among the studied nurses, alcohol addicts have few chances of recovery.Maybe due to these facts, nurses see these patients are seen with certain discredit, as one of their statements shows: ... I am sure the first thing they do after they get better is to cross the street, get into a bar and drink some more..This certainty can make professionals underestimate care delivery to alcohol addicts since, contrary to other patients, they will not have their problem solved and will always return to that service drunk for a new procedure.
By assisting alcohol addicts, nurses may expect to reach their goals, mainly regarding treatment compliance and abstinence, and whenever this does not happen at the beginning, the professionals may interpret this attitude as some kind of resistance to help, distancing them from the alcohol addicts and making them experience dissatisfaction in work with those patients.
The conception that attributes alcoholism to a lack of personal will constitutes a reduced point of view.However, it is still possible to find a significant number of nurses who keep considering alcohol addicts as immoral and weak persons, with few possibilities of recovery (9,14) .Nevertheless, a secular conception cannot be easily undone because, as a social being, nurses, just like all human beings, are influenced by the environment they are placed in and that, in this case, still attributes alcohol addiction to a moral defect, character weakness and the personal will of the individual who gets sick.
The attribution of alcoholism to individual weaknesses or deficiencies allows nurses to blame these people for their own disease.Therefore, the assumption that alcohol addicts can control their drinking habit not only influences the population in general, but also health professionals, nurses in this case.
The studied nurses turned out to be favorable to moderate alcohol consumption and reject alcoholism.However, even though they conceive it as a disease, and patients as addicts, they still show a strong tendency to associate the disease to the lack of personal will.This fact is considered concerning because, according to the assumptions of the current national policies in alcohol and drugs, the nurse is part of the health care team that assists users of alcohol and other drugs (17) and, if they stick to this conception, they will probably meet difficulties to provide health care to this population.
conceptions and attitudes towards the patients.The definition of attitude, according to references found in the Health Science Descriptors of the Medical Subject Headings (MeSH) and presented by the Latin American and Caribbean Center on Health Sciences Information (LILACS), through the Latin American index, would be: an enduring, learned predisposition to behave in a consistent way toward a given class of objects, or a persistent mental and/or neural state of readiness to react to a certain class of objects, not as they are but as they are conceived to be.Therefore, considering the number of individuals facing alcohol-related disorders who are assisted at public basic health centers and the lack of studies by Brazilian nursing about the subject, this study aimed to get to know the conceptions and attitude tendencies of nurses from District Basic Health Centers (DBHC) towards alcohol, alcoholism and alcohol addicts.METHODOLOGY This is a descriptive study that aimed to get to know the conceptions and attitude tendencies of nurses from DBHC towards alcohol, alcoholism and alcohol addicts.Three District Basic Health Centers from Ribeirão Preto-SP were chosen as the study scenario.The selection of the units is explained by the fact that they are secondary referral units with greater technical capability and specialized care for individuals with chronic and/or acute complications, since the staff includes more nurses and the units function 24 per day, seven days per week.Ten nurses participated in the study.They were intentionally selected according to their work shift, with the purpose of interviewing nurses from each period (morning, afternoon and evening) at each institution.Nurses who agreed to participate in the study were asked to sign the Informed Consent.The participating nurses are referred to by the number of the interviews, so as to preserve their identification.The present study was developed between May and June 2004, and data were collected through directive and semi-structured interviews, containing three guiding questions: 1-What is your opinion about alcoholic drinks?2-What do you think of someone who consumes alcoholic drinks?3-How do you deal with patients who are alcohol addicts at work?Data analysis Data analysis revealed three subjects for presentation: a) conceptions and attitude tendencies of nurses towards alcohol and alcohol use, b) conceptions and attitude tendencies of nurses towards alcohol addicts, c) conceptions and attitude tendencies of nurses towards alcoholism, which are analyzed next.
instance eating compulsively, as the nurse's statement evidences (2).... It is like that person who cannot stop eating, he wants to lose weight, but he cannot stop eating, I believe that kind of impulsiveness is similar to what happens in alcoholism (E.2) ...In my opinion, the alcoholic drink itself should have its commerce better regulated, because the way it works, you see that people eventually get addicted and end up having several problems (E.2). ... I think alcoholic drinks here in Brazil are too accessible, mainly for adolescents.Despite the law, what really happens is that it is not respected (E.8)Individual discourse analysis evidenced that nurses who did not use alcoholic drinks presented more negative conceptions towards this consumption, and tended to consider alcohol as something harmful in any situation....I don't drink, I think alcohol is harmful regardless of the consumed quantity (E.1)....I hate alcohol; I think it damages health very badly (E.2).I believe alcoholic drinks aren't good in any situation...I don't drink (E.8)Some individuals expressed positive conceptions towards alcoholic drinks, when moderately used, emphasizing its beneficial aspect to the body as relaxing, anti-anxiety or pleasure sources ...I think it is quite good, it relaxes you, and I believe that if consumed with moderation it can even have a beneficial effect on our body (E.4) ... I think alcoholic drinks are the oldest anti-anxiety substances people know(E.7)... Alcohol was made to give us some pleasure(E.9)Statementsalsoevidencedthatnurseswho use alcohol tend to have more positive attitudes towards alcohol and its use than nurses who do not drink, as previously mentioned ... I am not against people who drink, I also drink socially (E.7).Nevertheless, the latter does not seem to apply to abusive drinkers.Negative conceptions prevail because, when it comes to heavy users, nurses claim that one has to know how to drink and the lack of self-control does not seem to cause the same acceptance....You have to know how to drink.There are people who drink and have control over it, they can behave and they know when they are supposed to stop, and there are those who have no control over their habit and don't know the time to stop drinking, and this affects their lifestyle (E.3) ... I believe alcoholic drinks can be consumed, provided that they are consumed in a way they do not harm your health and moderately, in other words, provided that the person knows how to drink (E.5)....I think people can drink when they are not alcohol addicts, but moderate people, who know when to stop drinking (E.7).... Alcoholic drinks are nice, it becomes a problem when the person crosses her limits, it is then a lack of self-control (E.10) necessary to know how to drink, which implies negative conceptions and, consequently, attitudes towards the lack of control over alcohol consumption.In other words, even those nurses who are favorable to the use of alcohol seem to reject its abuse.Yet, according to one individual in the group, there is a conception that alcoholism is a disease associated to anarchy, disorder and having fun, and then, before even knowing, individuals end up developing the disease of alcoholism....Then, one of these patients who gets here drunk, who is drinking and having fun, can really develop the disease, alcoholism (E.8)These results show that the nurses under study conceive alcoholism as a progressive disease that can be fatal unless it is treated.Besides, there is probably an association between alcoholism and disorder, inferring that it is a disease developed in situations of disorder.Even through nurses see the possibility that the alcohol dependent is someone who depends on alcohol, one individual associated alcoholism to compulsion, which is conceived as a characteristic inherent to the alcohol addict, since this compulsion for drinking is compared to other compulsive behaviors, for