ORIGINAL ARTICLE

 

Harm reduction policy and caring for the homeless

 

 

Lorenna Saraiva Viana^I; Eliany Nazaré Oliveira^II; Maria Suely Alves Costa^I; Claudine Carneiro Aguiar^III; Roberta Magda Martins Moreira^I,IV; Andriny Albuquerque Cunha^I

^IUniversidade Federal do Ceará, Sobral, CE, Brazil
^IIUniversidade Estadual Vale do Acaraú, Sobral, CE, Brazil
^IIIPrefeitura Municipal de Sobral, Sobral, CE, Brazil
^IVBolsista da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil

Corresponding Author

 

 

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ABSTRACT

OBJECTIVE: describe about workshops held with professionals involved in the care of the homeless on the Harm Reduction Policy, having as reference, the Arco de Maguerez.
METHOD: intervention research developed with 12 professionals of homeless person Specialized Reference Center and Psychosocial Care Center Alcohol and other Drugs, having Maguerez Arc as reference.
RESULTS: challenges related with stigma appeared; autonomy strengthening and intersectoral articulation fragility. We also mentioned the partnership with specialized service, Mental Health Interdisciplinary League and Residency. We also promoted theoretical-reflexive moments and a care flux construction.
CONCLUSION: we understand the importance of critical conscience activities with professionals aiming to improve care related to Harm Reduction.

Descriptors: Education; Harm Reduction; Care; Homeless People.

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Introduction

In the context of the use of Psychoactive Substances (PAS), some specific groups are inserted, such as Street People (SP) characterized as a heterogeneous population composed of individuals with different realities, but who have in common the condition of poverty and lack of belonging to life. The use of PAS emerges as a tool to "mitigate" the consequences of a symptom of social insanity that excludes citizens from their civil, political, social, and economic rights⁽¹⁾.

In that respect, this practice is immersed in several obstacles that challenge the principles of universality, equity, and integrality of the Brazilian Unified Health System (Sistema Único de Saúde, SUS). In this sense, many are on the margins of the Health Care Networks (Redes de Atenção à Saúde, RAS) and social protection, being the target of assistance, compensatory, and focalizing policies⁽²⁾.

Therefore, motivated by the culture of prejudice and exclusion of people in this situation, the following barriers can be observed: the bureaucratization of the service and prejudice on the part of some professionals motivated by the appearance of the individuals (lack of clothes and proper hygiene), the absence of identification documents and a fixed address, and/or the frequent condition of abusive or excessive use of alcohol, crack, and other drugs⁽²⁾. Thus, it is clear that the stigma, as a segregating stereotype, built around people who live on the streets and use PAS, results in the moral judgment of the individuals' conduct from these points⁽³⁾.

For this, we have the Harm Reduction Policy (Política de Redução de Danos, PRD), from the perspective of the psychosocial model, considered the main pillar of care for PAS users. It is characterized as a set of public health actions aimed at minimizing the adverse consequences caused by the abusive use of psychoactive drugs. It is guided by the search for improving the quality of life of the individuals, with the strengthening of autonomy, contextualized and shared notions of care and self-care⁽⁴⁾.

In this scenario, the objective of the study was to describe the workshops held on the PRD with the professionals involved in the care of SP, having the Charles Maguerez Arc as reference.

 

Method

With a qualitative approach, the study was built from the theoretical foundations of Research-Intervention, which is characterized as a tendency of participatory research, which seeks to investigate the lives of collectivities within their qualitative diversity, in order to develop proposals, in the face of social experiences of micro-political interventions⁽⁵⁾.

The interventions took place from August to December 2018, at the Reference Center for Street People (CENTRO POP) and at the Psychosocial Care Center for Alcohol and Other Drugs (CAPS AD) in the municipality of Sobral-Ceara. It is noteworthy that the two devices develop their activities in different spaces.

The study involved a total of twelve participants, which corresponds to about 80% of the professionals in each service, six from CENTRO POP, including a lawyer, two psychologists, and three social workers; and six from CAPS-AD (a nurse, two social workers, two psychologists, and a physical education professional).

Six workshops were developed (three in each service), held at different times according to the organization and availability of the devices. Therefore, the interventions with the professionals from CENTRO POP took place at the end of the working day and the workshops with those from CAPS AD took place along the sector's service journey, meetings designed to organize the work process, discuss the most complex cases and to moments of Permanent Health Education (PHE).

The inclusion criteria were the following: professionals with a higher education diploma who had been working in the care devices for at least one year and who accepted to participate voluntarily in the intervention. The exclusion criteria included those who did not hold a higher education diploma, who had not been in the services for at least a year, those who were on leave (prize, maternity, or medical certificate), those who were on vacation, as well as those who chose not to participate in the intervention.

The planning and implementation of the interventions were based on the Problematization Methodology using the Charles Maguerez Arc as the theoretical framework, which proposes an approach to reality by means of five stages: observation of reality; key points; theorization; possible solutions; and application to reality⁽⁶⁾.

The Problematization Methodology is configured as a teaching strategy that stimulates critical and reflective thinking, articulating theory with practice. Therefore, the search for decision making is focused on group discussion and on reflection about problems (according to the reality of the context in which the participants are inserted)⁽⁷⁾.

For a better systematization of the information, work was organized in three stages: observation and problematization of the reality found in the process of caring for SP (first workshop of each service), theoretical/practical workshop on harm reduction (second workshop of each service) and reflections on the articulation of care through the Talking Map (third workshop of each service).

The study followed the principles of Resolution 466/12 of the National Health Council (Conselho Nacional de Saúde, CNS), on research involving human beings (autonomy, beneficence, non-maleficence. and justice)⁽⁸⁾. It constitutes part of a final research project of a Multi-professional Residence in Mental Health and was approved by the Ethics and Research Committee of the Vale do Acarau State University (UVA), under opinion No. 3,002,885.

In addition, so that the names of the participants were protected, the professionals were identified through a feeling associated with the device in which they work.

 

Results and Discussion

To start the application of the Charles Maguerez Arc, there was the observation of reality in the process of caring for street people, which consisted of the active participation of the subjects, for an attentive and sensitive look at reality, thus making a first reading in which the theme was inserted. Therefore, in each of the first workshops of each service, an experiential moment was held with the professionals in order to visualize the different contexts in which the SP live.

After the initial reflections, the second stage of Charles Maguerez Arc began in the first workshop, where we tried to identify the key points about the reality of the work of the service professionals. The following guiding questions were used: What are the main challenges faced? What are the main factors that can contribute to this care? How does the flow of care take place within the scope of comprehensive care on alcohol and other drugs?

In view of this, some fundamental points were identified to be worked on in later workshops. From the speeches, the following difficulties were pointed out in the care of street people: particularities of the target population; stigma and prejudice, and strengthening of the individuals' autonomy.

Regarding the care problems, most of the professionals pointed out that the development of work with SP is challenging due to the characteristics and particularities of this population, such as nomadism. This can be understood as a permanent situation of itinerant circulation of street people throughout different regions, which hinders continuity of care⁽⁹⁾. From the professional's speech, we perceive this issue: Adapting care strategies to their way of life is a little complicated, it's difficult because they are on the street. Being on the street is a challenge in itself. (Mansidão POP).

Still related to nomadism, considered as a particular feature of SP, the absence of a reference was evidenced in the statements, especially among the professionals from the CAPS AD. In this case, the reference is related to the presence of a fixed home, a family member, and/or someone responsible for following up care at home⁽¹⁰⁾, as noted in the following sentence: The main focus here is the family member, is to seek the family member to be able to support this person, to be able to help in the care (Alegria AD).

Another aspect portrayed by all the professionals, especially those working at CENTRO POP, concerns prejudice and stigma, very present in relation to SP, making it difficult to guarantee rights in several perspectives. We also see the issue of prejudice that we know exists, prejudice and a very big stigma (Parceria POP).

On this issue, it is pointed out that both the stigmatized person and the practice can develop protection mechanisms that are manifested through distancing conducts or behaviors⁽¹¹⁾. Given this, it is identified that SP are vulnerable to prejudice due to their social condition, i.e., because of the way they live, as related to the fact of acquiring certain illnesses specific to this condition of life. Thus, many SP are often unable to access a health, social, emotional, affective, or practical support network⁽¹⁰⁾.

This perspective was prevalent among the CENTRO POP professionals in view of the difficulty they see of the people who are accompanied by the service when they need some assistance in the health sector, mainly linked to the stigma and prejudice to this subjects. They think that if they go to a health center, if they aren't accompanied by the team, the staff will treat them badly (Maturidade POP).

Therefore, it is necessary to implement public policies for access to health care for the population, especially SP. Thus, it is necessary to value the particularities and subjectivity of each individual and understand them as citizens, who have the same citizenship rights; to promote questions about the most prevalent problems, showing the difficulties in interrelationships, between care processes and ways of life on the street; to have technical and human competence in addition to having sensitivity on the part of professionals working with these subjects⁽¹²⁾.

Despite this difficulty in accessing the other services, the professionals interviewed seek to work on the individuals' autonomy within the perspective of a possible resolution of the problems mentioned and trying to minimize their demands, as mentioned by one of the interviewees: Sometimes there's the "guardianship" that they want us to go to the consultation, especially for older users, to take them to the CAPS or take them somewhere. We try to explain, we are here with the intention of achieving this autonomy. So, here, in social care there's always this predominance and this rigor of creating autonomy (Felicidade POP).

From the discussions, in this second stage, some potentialities related to the care of SP are also identified, both in general aspects and referring to the users, who make use of some psychoactive substance. All the services signaled the importance of the physical space itself and of the internal activities that take place in each of the locations, which articulate care; the partnership with the Multi-professional Residence in Mental Health (Residência Multiprofissional em Saúde Mental, RMSM) and with the Interdisciplinary League in Mental Health (Liga Interdisciplinar em Saúde Mental, LISAM) which support and reinforce specialized care for this population.

With regard to the internal activities, which are carried out in the two services within the scope of SP, the following report is pointed out: We observe the service itself for them, safety, hygiene that we offer them, this support that we have in relation to their referral in health (Felicidade POP).

Regarding the CAPS AD, the inter-sectoriality and support of the groups in the care for SP was discussed about the support of the service by means of the multi-professional team. We have the support of the multi-team; inter-sectoral support, the issue of groups, we have a lot of diversity in relation to the groups (Responsabilidade AD).

In this context, the importance of the CAPS AD is reflected, which, according to the new national policy on alcohol and other drugs, should preferably be inspired by the approach aimed at harm reduction. In this case, the individual, previously passive, becomes the protagonist of his condition of life and care with an antagonistic policy to the abstinence model (high demand) of psychiatric hospitals and therapeutic communities. Therefore, it is necessary to work on the logic of inter-sectoriality, multi-disciplinarity, group follow-up, territorial perspective, interventions, and approaches to issues related to stigma⁽¹³⁾.

In addition, it is necessary to obtain information about the clientele that demands care at the CAPS AD. The aforementioned following the logic of singularized care and in the search for a better understanding about the role that the device plays with the population and the care network⁽¹⁴⁾.

In most of the reports, the importance of the actions of RMSM and LISAM in the two services was perceived, by means systematic activities, which involve various perspectives of care for people marginalized within the scope of comprehensive care policy on alcohol and other drugs. We have the HarmReduction group there at the CENTROPOP and we can also bring cases through the medical internship (Leveza AD).

Still in the first workshop of each device, with regard to the flow of care to homeless people, it can be identified that the way in which care is organized is interrelated to the challenges encountered. At first, the work process and function of each device in relation to street people were discussed. This complaint was made mainly by the professionals from CENTRO POP, as can be seen in the following statement: We wanted the teams to understand the work of CENTROPOP, we are not a charity, we work on policies (Cumplicidade POP).

It is argued that health and social assistance services reinforce, in their speeches, performance limits, reflecting a strong sectorialization and hierarchy, configuring a compartmentalized work. Thus, the teams working in these services have different understandings about the relation of both work processes. Thus, promoting possible doubts and disagreements between the concept of performance and the duties of each sector⁽¹⁵⁾.

Many difficulties can be identified for the professionals from the CAPS AD to organize care in this device. Firstly, it is clear that there is no specific line of care for street people; therefore, there is a tendency for different disagreements within the service team. There's no specific line of care, there was even a time when the doctor here was doing matrix support over there to facilitate their flow here, something like that (Leveza AD).

These difficulties, in turn, meet some specificities of SP, pointed out by the professionals and which constitute obstacles for the continuity of follow-up in the device. They have a different way of functioning, they aren't institutionalized like us, we have a fixed corner, an opening and closing time and they are more dynamic (Pureza AD).

Given the above, there is a reflection that it is necessary to understand the specifics of working with SP, with internal adaptation of the services in their operations in order to respond to the demands of this group. The need is highlighted to build a line of care for street people that is based on their characteristics, the determinants of the health-disease process, clinical problems, and difficulties faced in the inter-sectoral care network⁽¹⁵⁾.

Throughout the workshop, another obstacle can also be observed in the flow, related to the articulation of the care and health services with the Therapeutic Communities (TCs). The speeches of the professionals from CENTRO POP portray that the interest in routing these spaces is still very present among people living on the street. It can be seen that the TCs emerge as a strategy to escape from certain situations and not as a strategy intended to protect, in some way, as mentioned in the following statement: Many arrive here in the greatest euphoria saying that they want to go to the recovery house but when we go to see, they are running away from something, from something they did on the street, that the person just wants to go there to hide. He doesn't really want treatment (Parceria POP).

One of the professionals from CAPS AD pointed out that many users arrive at the service only to be referred to the TCs. Most of the users who come to the reception already arrive with the intention to go to the therapeutic communities and this is very strong. And they say that they think it's bad because it delays access, that they need to come to the appointments (Responsabilidade AD).

In the third stage of the Arc, the theoretical foundation about the theme worked is carried out⁽⁶⁾. Thus, in the second workshop of each service, a time line was drawn up with the main theoretical frameworks about the PRD. It can be understood that the concept of harm reduction is still very limited and can be misinterpreted by some professionals. As I see it, that word harmreduction was poorly worked, poorly constructed, poorly passed on, because all the devices that were talked about do some kind of harm reduction (Bondade AD).

Another professional spoke about the social, religious, and family issues that are involved around the PRD and that make it difficult to strengthen this policy in the services. And it's also a logic built right, it cut-crosses religious, family issues, harm reduction is a difficult policy to understand, starting from a society that is crossed by several issues (Leveza AD).

In this sense, it is debated that the power devices (related to justice and the exercise of the law) assume a criminalizing and penalizing attitude towards the PAS user⁽¹⁶⁾.

They also pointed out limitations that some professionals have within the context of some aspects of the PRD, such as the individual's autonomy in deciding the best way to proceed with treatment, whether based on abstinence, reduced consumption, or any other strategy. I think that sometimes it's not even the professional's unwillingness to understand, but the understanding of being in the logic of abstinence, that the ideal for the patient is to stay abstinent, so if we start from this logic, it becomes very difficult to work on harm reduction and mainly think that the best for us is not the best for him (Leveza AD).

The importance is understood of reflecting that there is not just one treatment that is ideal for all people; to consider the needs of individuals, contemplating, not only the issue of the use of PAS, but the integral perspective and contextual diversity, in addition to the presence of multi-professional care, which must be evaluated frequently and which preserves the autonomy and the desire of this individual⁽¹⁷⁾.

Associated with the timeline, a practical workshop was held with professionals from both services, with the aim of discussing some possible strategies that can be used to promote improvement in the quality of life of the users followed-up by the services. In addition, it was sought to bring a broader perspective, also directed to the importance of guaranteeing the autonomy and citizenship of these individuals, in relation to their use and the way they relate to substances.

The strengthening of the PRD with the users is observed. However, there are some challenges to be overcome, such as the lack of funding to make supplies available to the users. From the statement below, an example is identified of a professional who purchases supplies on his own, to continue this type of care in the service: Lately I've been buying tissue paper, it's there in the coordination room and I usually give them to the users who use tobacco (Gratidão AD).

Throughout this workshop, in the face of an open dialog with the professionals, it can be understood that, within this complex care, based on the PRD for street people, there are several aspects that need to be present, such as: building bonds of trust before a care practice centered on listening and knowledge of the other; humanized treatment; recognition of their material and symbolic conditions of their existence; development of a view that can move away from a normative and moralizing perspective. We try to work with them and for them. It is through mutual work, an exchange, it is giving that we receive. The way I talk to them depends on everything. It needs to be an exchange of each one of us with the user (Felicidade POP).

In this sense, the implementation of soft technologies becomes fundamental, based on human relationships such as bond production, autonomy, and welcoming, in the encounter between the professional and the user. From these technologies, based on open dialog and respect for the singularities that is built, and the positivity among the individuals involved in the care relations is consolidated⁽¹⁸⁾. There was a reflection on the importance of the professionals being available, of having sensitivity to treat and care for people seeking their subjective aspects, histories and life needs of SP.

In the third workshop of each service, the Talking Map Methodology was used as a strategy to survey the hypothesis of solutions (fourth stage of the Charles Maguerez Arc). In this sense, the talking map comes to be characterized as a powerful instrument to make a reading of reality from its multiple dimensions. It is characterized as an expression of a territory, which considers the objective and symbolic representation of the live space, allowing for the visualization of information from a town and the representation of areas of relevance and interest to a set of actors⁽¹⁹⁾.

First, a hypothetical case of a homeless woman was presented who had clinical and social demands related to substance use. In view of this, the participants built a possible flow of care for this user, in view of the articulation through the devices of the Health Care Network (Rede de Atenção à Saúde, RAS), and social assistance equipments, as well as the informal care mechanisms.

The professionals from both services pointed out the importance of articulation with Primary Health Care (PHC), as the main gateway to health care and reorganization of other processes, in partnership with the specialized team and the care. I believe that PrimaryCare needs to be right at the front of the map (Felicidade POP).

In this perspective, based on the PHC logic, it is understood that the essence of this point of health care must be based on the reception and responsibility for the users' health problems. Using bond relations and listening skills to ensure continuity and longitudinality in serving the assigned population. In addition to constituting the territory, as a basis for organizing care practices, according to the individuals' singularities⁽²⁰⁾.

About the Reception Unit (Unidade de Acolhimento, UA), it was also portrayed that it was on the talking map, but that is not yet functioning in the municipality, as pointed out in the following sentence: So, the CENTROPOP, which could be a partner, has CREAS that could be a partner, but it will depend a lot on the sensitization of each one to gain strength to open the reception unit, because there's only the CAPSAD to be intending about openness, about strengthening the harm reduction policy (Bondade AD).

In this speech, the concern of a professional is perceived when portraying the need for social assistance services, involved in care, to be integrated in gaining strength in order to make it possible to open the UA (as a place for welcoming users who are in situations of great vulnerabilities, whether social, family, or physical)⁽²¹⁾.

As the fourth and fifth phase of the Arc, hypotheses of solution and application to reality were stressed, so that the discussions proposed in the interventions could be applied to reality, in order to seek the improvement and enhancement of the care of this public, from the perspective of the PDR.

 

Conclusion

Through this research, it was noticed that the two devices act with demands related to street people but, even acting in this group, it is identified that the approaches to health and social assistance still differ in the way they deal with issues related to the target population.

In this regard, the importance of strengthening the inter-sectoral articulation between the services is reflected, with the alignment of the care developed, through the strengthening of communication, systematic meetings, referral with more detailed information about each user, and potentiating the spaces that already exist in both services, in addition to matrix support for more complex cases.

During the workshops, several difficulties arose, such as availability of hours, adequate space, and some prohibitionist positions by some professionals. In this logic, there is a limitation of developing practical and theoretical activities in the work environment, and it is essential that the micromanagement gets involved and participates in what is being discussed about the work processes. In addition, there is the idea of complexity linked to the theme.

In this context, even in the face of the obstacles, it is understood that the use of problematization with the support of the Charles Maguerez Arc, proved to be very valuable in the development of the workshops, being pointed out as a simple method, but that generated important reflections about the work process.

However, the need was identified for more moments and research studies be carried out in view of the complexity of the theme and of the need to strengthen the PRD within the scope of care for this public. Among them, the importance of involving PHC professionals in discussions.

 

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Corresponding Author:
Lorenna Saraiva Viana
E-mail: lorennasaraiva0@gmail.com

Received: Apr 27^th 2019
Accepted: Apr 23^th 2020

 

 

Authors' Contributions: Research conception and design: Lorenna Saraiva Viana, Eliany Nazaré Oliveira, Maria Suely Alves Costa, Claudine Carneiro Aguiar, Roberta Magda Martins Moreira and Andriny Albuquerque Cunha. Data collection: Lorenna Saraiva Viana and Eliany Nazaré Oliveira. Data analysis and interpretation: Lorenna Saraiva Viana, Eliany Nazaré Oliveira, Maria Suely Alves Costa, Claudine Carneiro Aguiar, Roberta Magda Martins Moreira and Andriny Albuquerque Cunha. Manuscript writing: Lorenna Saraiva Viana, Eliany Nazaré Oliveira, Maria Suely Alves Costa, Claudine Carneiro Aguiar, Roberta Magda Martins Moreira and Andriny Albuquerque Cunha. Critical revision of the manuscript: Lorenna Saraiva Viana, Eliany Nazaré Oliveira, Maria Suely Alves Costa, Claudine Carneiro Aguiar, Roberta Magda Martins Moreira and Andriny Albuquerque Cunha. Research orientation: Eliany Nazaré Oliveira.
All authors approved the final version of the text.
Conflict of interest: The authors have stated that there are no conflicts of interest.