ORIGINAL ARTICLE
DOI:10.11606/issn.1806-6976.v12i1p22-29

 

Barriers and amenities for seeking specialized treatment encountered by women who use psychoactive substances

 

Barreras y facilidades encontradas por mujeres usuarias de substancias psicoactivas en la busca por tratamiento especializado

 

 

Caroline de Souza Albuquerque^I; Maria do Perpétuo Socorro Sousa Nóbrega^II

^IRN, Secretaria Municipal de Saúde de Santa Filomena, Santa Filomena, Pernambuco, PE, Brazil
^IIPhD, Professor, Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil

 

 

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ABSTRACT

Identify barriers and amenities encountered by women when seeking treatment for chemical dependence. Quantitative study performed in three Psychosocial Care Centers in the state of São Paulo. The study was performed based on information obtained from a sample with 44 women, of whom 52.3% were single, 43.2% were Caucasian, and 95.4% were unemployed. The rates obtained in accordance with the sample were: 77.2% used psychoactive substances in the age group from 5 to 20 years, 34.9% used psychoactive substances in the streets with friends, 45.5% were seeking treatment for the first time due to alcohol, and 65.9% were motivated to go to treatment. The following items predominated as external barriers: 81.8% did not know there was a specialized service, 79.5% did not know that there was treatment specifically for women, 79.5% had families that did not consider it important or were ashamed of them, and 79.5% had never been referred to a specialized service. However, the most relevant amenity index in the search for treatment is the support of family and/or friends, reported by 70.5% of the women. The study reflects fragilities in the early detection of the consumption of psychoactive substances in women and in the disclosure of and referral to specialized treatment services.

Descriptors: Women; Street Drugs; Therapeutics.

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RESUMEN

Identificar barreras y facilidades encontradas por mujeres en la busca de tratamiento en dependencia química. Investigación cuantitativa realizada en tres Centros de Atención Psicossocial del estado de São Paulo. La Investigación fue realizada desde informaciones logradas por muestras con 44 mujeres, siendo: solteras (52,3%), blancas (43,2%), sin trabajo (95,4%). De acuerdo con el muestreo, los índices logrados fueron: el uso de substancia psicoactiva identificada en la banda etaria entre 5 y 20 años (77,2%), el uso de substancia psicoactiva en la calle con amigos (34,9%), buscaron tratamiento por la primera vez debido al alcohol (45,5%) y (65,9%) quedaron motivadas al llegar al tratamiento. Como barreras externas predominaron los siguientes ítems: (81,8%), no sabían que existía servicio especializado, (79,5%) no sabía que existía tratamiento específico para mujeres, (79,5%) que la familia no consideraba importante o tenia vergüenza de la mujer usuaria, y (79,5%) nunca había sido encaminadas para un servicio especializado. Mientras, el índice más relevante como facilidad en la busca por tratamiento es el apoyo de la familia y/o amigos, apuntado por 70,5% de las mujeres. La investigación refleja fragilidades en la detección precoz del consumo de substancias psicoactivas en mujeres y en la divulgación y encaminamiento para los servicios de tratamiento especializados.

Descriptores: Mujer; Drogas Ilícitas; Terapéutica.

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Introduction

Over the course of four years, alcohol dependence in women aged between 12 and 65 years has grown from 5.7% to 6.9%; the use of marijuana rose from 3.4% to 5.1%; the use of cocaine rose from 0.9% to 1.2%; the use of stimulants rose from 2.2% to 4.5%; and the use of benzodiazepines rose from 4.3% to 6.9%^(1,2).Despite the increase in the prevalence of the consumption of legal and illegal drugs, the percentage of women that received some type of specialized treatment fell from 2.5% in 2001 to 1.6% in 2005. A recent study with 370 thousand crack users in the capital cities and metropolitan regions of Brazil showed that only 21.3% of users are women⁽³⁾.

The National Women’s Policy Plan between 2013 and 2015⁽⁴⁾ incorporates the commitment to insert women who use psychoactive substances (PS) in the network of health services, through measures taken by the Ministry of Health. Despite the progress made with the definition of the National Drug Policy – NDP of 2010⁽⁵⁾, the country did not improve in proper attention to the specific needs of women who use drugs, not having established directives regarding the reception and retention of this clientele in the treatment centers.

According to the world consensus on the treatment of women who use drugs, developed by the United Nations Office on Drugs and Crime – UNODC, women generally have more severe problems when they begin treatment and are faced with more obstacles than men to access it, and their apprehension towards seeking help reaches 2%, compared to men, where it is 8%⁽⁶⁾.

Many barriers are involved, such as stigma; preconceptions of society, of the women themselves, and of the health professionals (and their lack of training); resistance in approaching the subject; and the lack of planning and implementation of specific attractive services that consider the patients’ physiological, psychological, and social needs⁽⁶⁾.

The barriers to treatment faced by women can be internal, such as: denial regarding the severity of the drinking problem, the notion that treatment is ineffective, the fear of stigmatization by family members and professionals, the fear of losing custody of their children because they are in treatment, and guilt, shame, and fear of upsetting their family and being accosted by their companions who also use drugs.

The external barriers are related to interpersonal subjects, such as: the opposition of family members and friends; social disapproval; the social cost of cutting ties with family members; discouragement by partners/husbands/family; inadequate training of most health professionals in detecting drug and alcohol problems; failure to be sent to a specialized service; the lack of treatment services exclusively for women that need care with their children; and the lack of financial resources^(7,8).

In light of the above, the objective here is to identify the barriers and amenities faced by women who use psychoactive substances (PS) in seeking specialized treatment for chemical dependence at a Psychosocial Care Center. It can be stated that, by identifying barriers and amenities in access to treatment, coping measures can be reconsidered. It is important to highlight that the literature on the study subject investigated is still incipient in the country.

 

Methods

Quantitative study where the participants were 44 women who use PS and are being treated at the Psychosocial Care Center for Alcohol and Drugs (CAPSad, by its initials in Portuguese), which is an open service based on territory in the cities of São Bernardo do Campo, São Caetano do Sul, and Mauá, in the state of São Paulo, Brazil.

Access to the participants of this study occurred during the activities held at the treatment service ("women’s group", "craftwork group", and "psychotherapy group"). The data were collected through a self-administered questionnaire with 19 closed multiple-choice questions adapted from the UNODC report⁽⁶⁾ in the period between April and August 2013. All options in the questionnaire were presented to the participants of the study and more than one option could be selected.

The EPI-Info program (version 3.5.2) was used to store and analyze the data, and for the descriptive statistics on the continuous variables through the average and median. The study was approved by the Ethics Committee under the protocol number 281.057/2013. All participants signed the Term of Free and Informed Consent (TFIC).

 

Results

Of the 44 women, their ages varied from 15 to 65 years, with an average age of 22.5 years. They were mostly single (52.3%), catholic (40.9%), and evangelical/protestant (34.1%), Caucasian (43.2%), black and mixed (54.6%), with children (68.3%), with an average of 2.29 children, had incomplete basic education (54.5%), resided with companions and/or children (45.5%), parents (34.5%), and resided in Therapeutic Residences (TR) (9.1%). They frequented the CAPSad units at São Bernardo do Campo (47.7%), Mauá (34.1%), and São Caetano do Sul (18.2%). Most of the subjects did not work outside the home or have paying jobs (54.5%), had never worked (4.5%), and did not have an income (40.9%).

For 77.2% of the women, the use of PS began between the ages of 5 and 20, and for 22.8% of them, use began in adulthood (21 to 37 years). Alcohol represents the legal PS that motivated the pursuit of treatment for 66% of the women, followed by cocaine (34.11%), crack (27.2%), and marijuana (18.1%). For 34.9%, the first contact with alcohol was in the streets with friends, and for 25.5%, at clubs/bars/family parties. On the occasion of the study, 35.5% of the women were trying treatment for the first time, and 64.5% had tried more than once.

Motivation to seek treatment came from the women’s children (38.7%), parents (27.2%), companions (20.4%), and friends (27.3%). However, most women sought treatment alone (29.5%). Regarding the pursuit of treatment, the women: felt that they want to improve the clinical conditions they were in (66%), were anxious with the process (65.7%), were not concerned (72.2%), and were optimistic (66.0%).

Regarding the treatment, 61.3% of the women considered that it helped them, 50.0% percent were satisfied with the treatment, and 6.8% were unsatisfied. There were changes after treatment for 63.7% of the women: 11.4% reported changes in relation to family; 9% in relation to self-esteem; 13.8% for health, quality of life, and behavior; and, for 29.5%, little changed. For 11.4%, absolutely nothing changed, 4.6% of the women felt well treated by the professionals, and 2.3% felt like test subjects.

In relation to the opinion on treatment, the women reported that they would have liked to have more appointments with the psychologist (50%), more appointments with the doctor (45.5%), with the nurse (18.2%), and with the social worker (40.9%). They would have liked to have daycare for their children (11.4%), transportation (2.3%) and a more motivational approach for their families (2.3%).

The problems caused by drug use/abuse generate specific needs that are not always recognized and satisfied by the specialized services, and that can generate internal and external barriers to access to treatment. Despite the barriers encountered, the women recognized some amenities for access to treatment (Table 1).

 

Discussion

To understand the complexity of the experiences of women who use PS seeking specialized treatment, it is necessary to question various aspects of social life. This study revealed a sample of women who are single adults with low schooling levels and cultural, social, and financial precarity⁽⁹⁾.

An early start to the use of psychoactive substances by the women in this study is a reality shown in the literature. It has number of influences, such as friends, pressure of social groups, domestic violence, personal conflicts, escape from problems, pleasure, and search for a life alternative, as well as social learning, family interaction, personality traits, and genetic factors⁽¹⁰⁾.

Alcohol represents the most widely used substance and the main reason for seeking aid at CAPSad, corroborating the Brazilian Drug Report in 2006, which showed that alcohol use rose from 60.6% to 68.3% and dependence evolved from 5.7% to 6.9% in an interval of four years⁽¹¹⁾. In most cultures, women have a lower tendency to ingest alcohol or drink large quantities than men. However, this consumption pattern has considerably changed among women, as found in the Second National Survey on Alcohol and Drugs, where binge drinking (five or more doses per occasion) evolved from 36% to 49%, representing an increase of 36% in the female population⁽¹²⁾.

From a biological point of view, women are metabolically less tolerant to alcohol than men, due to the smaller quantity of body water and metabolizing enzymes. Thus, they are more vulnerable to developing clinical complications such as hepatic diseases and neuropathies, with an elevated risk of mortality. Despite the increase in the consumption of substances and approximation with the male consumption pattern, women still drink less, but become ill sooner and in a more severe manner – a phenomenon known as the telescope effect⁽¹³⁾.

The use of cocaine/crack also justified the search for treatment, evidencing a clientele that requires a lot of care and that, compared to men, consumes more crack rocks per day, at a ratio of 21:13­⁽³⁾. Most women studied were not seeking treatment for the first time; in other words, they were recurring patients, which reveals the ambivalence regarding the cessation of consumption, relapses, and/or abandonment and low resoluteness during the process.

In general, problematic PS users encounter difficulties in recognizing that they need help, since they do not consider their consumption severe enough to require treatment, believe that they can overcome their addictive behavior alone, and justify their attitudes by criticizing the low disposition of health professionals for meeting their needs, a phenomenon common among younger women⁽¹⁴⁾.

The women revealed the influence of companions in sharing and offering PS, as well as the lack of motivation and/or monitoring of these partners in treatment, which was also found in other studies^(15-17). When pointing out that they were not pressured by their families to access treatment, they disregarded the possibility of negligence by their family members in the lack of stimulation, aid, and support – also representing a protagonist of the treatment process.

To fulfill the objectives of the study, the internal barriers were identified in some women. The fear of not being well received and fear of health professionals demonstrate a preoccupation that may be subjacent with shame and fear of being criticized. There is stigma placed on women who use psychoactive substances, and despite the confrontation and changes in the social roles of women, attitudes that are not very accommodating and moral contexts in the treatment centers are common. It is fundamental that health professionals, when approaching this clientele, abstain from judgmental attitudes.

The fear of losing custody of children to the family or for adoption still represents a negative aspect in women’s search for treatment. This point reflects the negligence in the lack of specific public policies regarding their rights. Diverging from common sense, the women value maternity and worry about the risks drugs can present for their children. Experience has shown that motivation for seeking treatment lies in recommencing childcare, and when they are violently separated from their children, women tend to increase their consumption pattern⁽¹⁶⁾.

With regard to external barriers, the lack of money for transportation and the difficult location of the service coincide with the socioeconomic profile shown in this sample. The women are in fact being treated, demonstrating that they somehow deal with these obstacles, but the geographic and financial difficulties can compromise access to health services and the right as a citizen to access them quickly.

The non-recognition of the problem with alcohol and drugs by the individual is a condition inherent to chemical dependence. Although they do not recognize the problems, the women know what they need and the services should be structured so as to attract them. They require encouragement to seek help appropriate to their needs. In this regard, the lack of knowledge about specialized services and specific programs for women is due to the lack of disclosure of these resources.

Stigmatization, impoverishment of the social support network, negative attitudes of health professionals, inefficiency of the service network, lack of direct transportation to the service, childcare, and inflexible hours are all recognized as important barriers. Among the measures to reduce them, we highlight the full-time availability of the specialized services, accommodation of the professionals, technical training of teams, and programs to deal with complex social problems, the most varied violent situations, and physical and psychological comorbities^(18-19).

The treatment scenarios in this investigation are not specific to women: to find them, the authors had to invest, detecting little presence of this clientele – an aspect that, in itself, reflects the deficit of treatment seekers, despite the increase in prevalence. In this regard, it is a concerning observation that women are navigating health services invisible to the eyes of the professionals, maintaining the use of substances in hiding, concealed in the private space of their homes, and neglected, along with their children, in public areas, in the famous "crack lands".

The low prevalence of women in specialized services is connected to the perception that they have of their health problems – when they seek help, they initially tend to seek nonspecific clinical and psychiatric services to treat drug dependency⁽⁶⁾. There is an opportunity to investigate the use of psychoactive substances in these contexts. This requires commitment, sensibility, and qualification of the professionals to intervene and refer them to treatment. These behaviors will contribute to saving women from anonymity and exclusion in the health and social systems that be, as well as deconstructing stigma and prejudice.

Despite the significant improvement of access to health services in Brazil in the last ten years⁽²⁰⁾, women do not encounter many amenities to access them, and do not believe in the effectiveness of the treatment. Thus, critics demand what really makes a difference for accessing specialized services: economic conditions, proximity, family support, valorization, and respect of rights. In this regard, we hope that the information presented in this study offers a window to the complex and impactful reality in the lives of women who use alcohol and other drugs.

The barriers for PS users to arrive at a treatment center are numerous, and, in developing countries, the non-universalization of the care offered by the public health system is the main barrier⁽⁶⁾. In this study, the directives of the National Drug Policy – NDP⁽⁵⁾ point towards treatment, recuperation, and social reinsertion, which are characteristics specific to the different groups. Among these, women (including pregnant women) must be recognized, since they require different care and special treatment in the services.

The theme "barriers and amenities in the access to treatment by chemically dependent women" deserves to be further explored in our country. Lastly, we suggest the advancement of studies with a larger number of women to amplify the analysis of this phenomenon, since a small sample size is a limiting factor.

 

Conclusion

This study sought to identify internal and external barriers and amenities for women to access treatment for dependence on psychoactive substances. The results offer important information on the circumstances of the process of recognizing the need for professional help. They also reflect fragilities in the disclosure of mental health services and those specifically for alcohol and drugs, early problem detection, and referral by non-specialized services, corroborating the findings of the literature.

By pointing out the barriers against access to treatment by women, it is also necessary to think of strategies to keep them engaged. Knowing the needs and specificities of women leads to the planning of individualized actions that potentiate their permanence.

Among the actions, the women require approaches to work on self-esteem, issues related to violence (common in this population), the female role, maternity, childcare, stigmas, feelings of guilt and shame, and psychosocial losses – comorbidities that can produce better results when offered in a single treatment scenario or with articulation between services.

Considering the increase in the prevalence of women who use psychoactive substances in Brazil, the preventative and healthcare policies for this population must progress greatly. They should have as a premise the plurality and investment capable of sustaining the heterogeneity of women. In this light, we believe in the capacity of professional nurses to offer qualified assistance to this population; however, they must know and be interested in its demands.

 

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Received: 10.09.2014
Accepted: 22.10. 2015

Corresponding Author:
Maria do Perpétuo Socorro Sousa Nóbrega
Escola de Enfermagem da Universidade de São Paulo
Departamento de Enfermagem Materno-Infantil e Psiquiátrica
Av. Dr. Enéas de Carvalho Aguiar, 419
CEP: 05.403-000, São Paulo, SP
E-mail: perpetua.nobrega@usp.br