Atitudes de profissionais de Centros de Atenção Psicossocial sobre álcool, alcoolismo e alcoolistas* Attitudes of professionals from Psychosocial Care Centers towards alcohol, alcoholism, and alcoholics

Objective: to assess the attitudes of professionals from Psychosocial Care Centers towards alcohol, alcoholism, and alcoholics. Methods: a cross-sectional evaluation study with 288 professionals from 12 healthcare services. Sociodemographic data, Patient Satisfaction Scale with Mental Health Services and Attitude Scale for alcohol, alcoholism, and alcoholics were collected. Results: the professionals who showed a more critical attitude towards their work routine and those who worked in the healthcare services for longer had positive attitudes towards alcohol, alcoholism, and alcoholics. Professionals from the administrative team and health technicians had more negative attitudes. Conclusion: the attitudes of professionals towards alcohol, alcoholism, and alcoholics, in general, are positive and were associated with longer working time in the field and the manifestation of disapproving situations with work. Descriptors: Attitude; Health Personnel; Substance Abuse Treatment Centers; Alcohol-Induced Disorders; Alcoholism. *Extraído da Tese “Avaliação global das necessidades individuais – na Rede de Atenção Psicossocial”, Universidade de São Paulo, 2019. 1Universidade de São Paulo. São Paulo, SP, Brasil. 2Universidade Estadual de Campinas. Campinas, SP, Brasil. 3Universidade Federal do Recôncavo da Bahia. Santa Cruz das Almas, BA, Brasil. 4Universidade Federal do ABC. Santo André, SP, Brasil. Autor correspondente: Júlia Carolina de Mattos Cerioni Silva Escola de Enfermagem da Universidade de São Paulo. Avenida Dr. Enéas de Carvalho Aguiar, 419 CEP: 05403-000. São Paulo, SP, Brasil. E-mail: jucarol80@usp.br EDITOR CHEFE: Ana Fatima Carvalho Fernandes EDITOR ASSOCIADO: Renan Alves Silva José Gilberto Prates1 Márcia Aparecida Ferreira de Oliveira1 Heloísa Garcia Claro2 Paula Hayasi Pinho3 Gabriella de Andrade Boska1 Ivan Filipe de Almeida Lopes Fernandes4 Júlia Carolina de Mattos Cerioni Silva1 Como citar este artigo: Prates JG, Oliveira MAF, Claro HG, Pinho PH, Boska GA, Fernandes IFAL, et al. Attitudes of professionals from Psychosocial Care Centers towards alcohol, alcoholism, and alcoholics. Rev Rene. 2021;22:e62765. DOI: https://doi.org/10.15253/2175-6783.20212262765 Prates JG, Oliveira MAF, Claro HG, Pinho PH, Boska GA, Fernandes IFAL, et al Rev Rene. 2021;22:e62765. 2 Introdução Atitudes podem ser definidas como predisposição adquirida para agir sempre do mesmo modo a uma determinada classe de objetos diante de uma situação. No contexto do cuidado em saúde, as atitudes dos profissionais são fatores que determinam a qualidade da assistência, pois impactam significativamente o tipo da resposta oferecida, sendo geralmente classificadas como atitudes positivas ou negativas. Especificamente na assistência às pessoas com problemas decorrentes do consumo de álcool, os profissionais tendem a apresentar atitudes estigmatizantes comparáveis ao público em geral, que podem levar à manifestação de comportamentos evitadores durante o processo assistencial e interferir negativamente na identificação, encaminhamento e tratamento desses casos(1-3). Estudo experimental sobre as atitudes dos enfermeiros em relação ao álcool e ao alcoolismo evidenciou o predomínio de concepções morais e condenatórias, tendendo a culpar o alcoolista pela sua doença(2). No geral, crenças pessoais e culturais e falta de habilidade para o manejo desses casos refletem em atitudes negativas que precisam ser trabalhadas na equipe multiprofissional dentro desses serviços(4). De acordo com relatórios recentes, o consumo problemático de álcool, apesar de ser uma substância lícita, acomete 43% da população global(5) e 18,8% dos brasileiros(6). No Brasil, os indivíduos que apresentam problemas ou dependência com relação ao álcool podem ser encaminhados para os Centros de Atenção Psicossocial em Álcool e Drogas. Os Centros de Atenção Psicossocial em Álcool e Drogas são serviços especializados, de caráter aberto e comunitário, pertencentes à Rede de Atenção Psicossocial, que oferecem assistência integral para pessoas que usam drogas. Constituídos por equipes multiprofissionais, atuam sobre a lógica interdisciplinar, estão em contato direto com os usuários e planejam ações conjuntas, sendo referência na promoção do cuidado(7). Em serviços especializados de cuidados como os referidos centros, as atitudes negativas dos profissionais prejudicam a assistência, ofuscam a real situação do indivíduo, levam a uma comunicação deficiente, rompem com a aliança terapêutica e, portanto, prejudicam a qualidade do cuidado(8). Estudo realizado com enfermeiros colombianos identificou que a experiência profissional na área e o contato diário dos profissionais com pessoas que fazem uso de bebidas alcoólicas relacionam-se com atitudes mais positivas(9). O estereótipo negativo, que cerca o paciente alcoolista e o alcoolismo, exerce forte influência nas atitudes dos profissionais(2). Atitudes negativas podem ocorrer pelo fato de os profissionais de saúde mental entenderem a abstinência como única alternativa possível ao uso problemático de álcool e drogas e, consequentemente, tenderem a considerar os usuários como pessoas difíceis e complexas para se prestar o cuidado, estando distantes das propostas de redução de danos recomendadas pela atual política nacional(10-11). Posto isto e considerando os dados epidemiológicos e a necessidade de uma equipe capacitada para atender à demanda gerada pelo uso problemático de drogas, investigar as atitudes dos profissionais que atuam nos Centros de Atenção Psicossocial em Álcool e Drogas é de fundamental importância. Neste contexto, o estudo objetivou avaliar as atitudes dos profissionais de Centros de Atenção Psicossocial frente ao álcool, alcoolismo e alcoolista.


Introduction
Attitudes may be described as an expected result to always respond in a particular way to a certain class of objects in a situation. In the healthcare context, the attitudes of professionals are factors that establish the quality of care, as they considerably impact the type of response, generally classified as positive or negative attitudes. Specifically, in the care for people with problems related to alcohol consumption, professionals tend to have stigmatizing attitudes when compared to the general population, which may lead to avoidance behaviors when providing care and negatively interfere in the identification, referral, and treatment of these cases (1)(2)(3) .
An experimental study on nurses' attitudes towards alcohol and alcoholism showed the prevalence of moral and judgmental conceptions, with a propensity to blame the alcoholic for his/her illness (2) . In general, personal and cultural beliefs and lack of ability to manage these cases reflect negative attitudes that need to be conducted by the multidisciplinary team within these services (4) .
According to recent reports, problematic alcohol consumption, even though is a legal substance, affects 43% of the global population (5) and 18.8% of Brazilians (6) . In Brazil, individuals who have alcohol issues or dependence can be referred to the Psychosocial Care Centers Alcohol and Drugs.
The Psychosocial Care Centers Alcohol and Drugs are specialized services, open and for the community, belonging to the Psychosocial Care Network, which offers comprehensive care for people who use drugs. Composed of multidisciplinary teams, they work in an interdisciplinary way, are in direct touch with users, and plan mutual actions, being a reference in the promotion of care (7) .
In specialized care services such as these centers, the professionals' negative attitudes affect care, conceals the individual's real situation, lead to poor communication, break the therapeutic alliance and, therefore, impair the quality of care (8) . A study carried out with Colombian nurses identified that professional experience in the field and the daily contact of professionals with alcoholics are related to more positive attitudes (9) .
The negative stereotype, which characterizes the alcoholic patient and alcoholism, has a strong influence on the professionals' attitudes (2) . Negative attitudes may occur because mental health professionals understand abstinence as the only possible option to cease the problematic alcohol and drug use and, consequently, are likely to consider users as difficult and complex people to provide care, far from the proposals of harm reduction recommended by the current national policy (10)(11) .
That said and considering the epidemiological data and the need for a trained team to meet the demand generated by the problematic use of drugs, investigating the attitudes of professionals working in Psychosocial Care Centers Alcohol and Drugs is of major importance. In this context, the study aimed to assess the attitudes of professionals from Psychosocial Care Centers towards alcohol, alcoholism, and alcoholics.

Methods
This is a cross-sectional evaluation study. Data collection was conducted between September 2017 and July 2018 with professionals from 12 Psychosocial Care Centers Alcohol and Drugs in the city of São Paulo, accredited by the Ministry of Health, with at least one year of operation and distributed among all regional municipal health coordinators.
As an inclusion criterion, professionals should have at least one year (12 months) of experience in the service. As exclusion criteria, those who did not answer the instrument's questions. Thus, the population was composed of all classes of workers in Psychosocial Care Centers Alcohol and Drugs (doctors, nurses, psychologists, occupational therapists, social workers, pharmacists, speech therapists, physical educators, Pharmacy technicians, Nursing technicians, Nursing assistants, administrative officers, maintenance technicians, and workshop instructors).
The 12 Psychosocial Care Centers Alcohol and Drugs were selected by convenience. Once the 12 services were chosen, all workers were invited to participate in the survey. Of the 349 workers, 288 participated. There was a loss of 59 (17.4%) since they were on vacation, on leave, refused to participate, or were relocated to other services during data collection. Two professionals were excluded because the interview was not properly finished.
For data collection instrument, it was used a sociodemographic data questionnaire created by the researchers, with variables such as income (continuous), race/color, date of birth, education, among others, as well as the Patient Satisfaction Scale with Mental Health Services (SATIS-BR) and the Scale of Attitudes toward Alcohol, Alcoholism, and Alcoholics (EAFAAA).
The SATIS-BR scale was developed by the World Health Organization, adapted, and validated for use in Brazil in 2009, with a global Cronbach alpha of 0.84, and assesses patients, families, and professionals' satisfaction with mental health services through 13 questions encompassing: competence and understanding of the team, support, user embracement and physical structure of the service. The answers are organized on a Likert-type 5-point scale, with one -strongly disagree, two -disagree, three -indifferent, four -agree and five-strongly agree, the maximum degree of satisfaction (12)(13) .
The EAFAAA was developed in Brazil in 2005 and validated in 2014. With a global Cronbach's alpha higher than 0.80 and tested in different settings, it was created to assess the main groups of health professionals' attitudes towards alcohol, alcoholism, and alcoholics (moral factor, disease factor, etiological factor, professional factor, and human factor). It has 50 items organized into four factors that assess the attitudes of professionals on a Likert-type 5-point scale.
Higher scores correspond to more positive attitudes, with a mean of 3.15 (3) as a cutoff score for each factor. The attitudes of professionals were evaluated as posi-tive when the general average of the EAFAAA reached this score.
The EAFAAA factor 1 factor addresses the professional's relationship with the alcoholic, addressing view, perception, opinion, feelings, and attitudes about the care provided. Factor 2 deals with the individual with an alcohol use disorder and what the professional thinks about the patient, their attitudes about individual characteristics, and expectations regarding the patient. Factor 3 is about the etiology of alcoholism and the professional's perceptions, assessment of biopsychosocial models, biological and moral aspects assigned to alcoholism and alcoholics. Factor 4 concerns items about alcoholic beverages, knowledge about alcohol use, and the right to use it (3) .
The dependent variable was the attitude of the professionals, which was measured using the EAFAAA scale. The independent variables adopted were: gender; color/race; age (continuous); time working at the Psychosocial Care Center Alcohol and Drugs; professional category; total income; marital status; graduate studies; change in working conditions; disapproving situations observed in the work environment; work flexibility; treatment modality; type of inclusion in the treatment (criteria considered for user embracement) and, finally, global satisfaction with the service measured by the general score of the SATIS-BR scale. This ranges from one to five, and the closer to five, the greater the user's satisfaction.
Data were analyzed using the IBM Statistics ® program, Statistical Package for Social Sciences, version 20.0. A descriptive analysis was performed, and then univariate and multiple linear models were estimated to verify potential associations between variables. In the first stage of inferential analyses, univariate models were estimated whose results with a p-value of ≤0.3 were included in the multiple models.

Results
Participants were predominantly women, white, married or with partners, and with a mean age of 40 years. Most professionals (35.4%) have a graduate degree, followed by those with higher education (17.7%). A large portion of the sample (20.8%) have medium and elementary degrees of nursing, namely technician and nursing assistant; 12.8% have administrative activities; 11.5% are psychologists; 8% are doctors; 7.6% are nurses; 7.3% are social workers; 7.3% are occupational therapists, followed by workshop instructors (5.9%), Pharmacy technicians (4.2%), Physical Education professionals (3.1%), pharmacist (3.5%) and speech therapist (0.3%). It is observed that 43.4% of professionals work in Psychosocial Care Centers Alcohol and Drugs between two and four years. Most workers (71.9%) do not have another job and earn four to seven minimum wages (39.2%).
The satisfaction score calculated using the SA-TIS-BR scale, with a continuous numeric variable from   Table 1). The mean score achieved in the EAFAAA was 3.57, showing that, on average, the multidisciplinary team of the Psychosocial Care Centers Alcohol and Drugs in São Paulo has positive attitudes towards alcohol, alcoholics, and alcoholism. Cronbach's alpha for the internal consistency of the EAFAAA scale was 0.867, (95% CI 0.844 -0.888), indicating an internal consistency of the assessment measure for the attitudes of professionals in this study, as this value is greater than 0.7 (12) . Factor 3 (attitudes towards alcoholism (etiology)) has the lowest score of positive attitudes (2.97) and the only score below the cutoff of 3.15 as described in Table 2. Table 3 shows the analyzes of the predictor variables of more positive attitudes among professionals at the Psychosocial Care Centers Alcohol and Drugs. There is an association among those who work in the services from eight to ten years, that is, with a little more experience and who have a more critical view of the disapproving situations in the work environment. Attitudes were also negatively associated with belonging to the following professional categories, administrative, maintenance, and technicians in healthcare positions (especially Nursing, as it represents most of the sample), while workshop instructors and higher education professionals do not differ in terms of attitudes. The multiple model explains 33% of the variation in the EAFAAA scale score, according to the adjusted R².

Discussion
As for study limitations, although there was no refusal by the professionals, there were 61 losses, totaling 17% of the interviews carried out. Professionals on leave, on vacation, or a sick leave were not interviewed. It is worrisome, above all, the deficiency of information on leaves of absence, which can be an interesting object of study, as they may be related to the attitudes of professionals. The regression model explains about a third of the variation in the data, and further studies are needed to increase the understanding of the determinants of professionals' attitudes.
This study sought to contribute to the discussion of the training and characteristics of professionals with more positive attitudes in Psychosocial Care Centers Alcohol and Drugs. We could identify some variables that are predictors of better attitudes on the part of professionals, which will allow the planning of actions in health, continuing education, and the pursuit for better working conditions with a focus on improving the outcome of users of these services.
The positive attitudes of the multidisciplinary team of Psychosocial Care Centers Alcohol and Drugs towards alcohol, alcoholism, and alcoholics, when positive, seem to determine the provision of adequate care, influencing health promotion and adherence to care for these users (14) , as observed in this study. In a study carried out in Psychosocial Care Centers in the State of Goiás, it was found that global satisfaction was considered good, however, there was unanimity in the professionals' wish for improvements in the physical structure of the units and also for a salary improvement policy (15) .
A study conducted with nurses found that the professional experience acquired after a while working directly with patient care, as well as the sharing of knowledge and interdisciplinary experiences, lead to a change in attitude (10) , which seems to be observed in the data presented here since the professionals who have been working in the services for longer had more positive attitudes.
Research conducted in the context of a mental health hospital emergency unit identified that nurses who did not feel comfortable in treating alcoholics as patients had attitudes with a degree of rejection towards these people, especially males (16) . This perception can help nurses to acknowledge that people who have problems with alcohol consumption need mental health care, which is stimulated by the establishment of interpersonal relationships.
In a survey that evaluated the attitudes of multidisciplinary teams, it was observed that negative attitudes were associated with the age of professionals (14) , a variable not used in the multiple model of this research.
In another study on the theme, it was found that this type of conduct is associated with little consideration or absence of the subject during the training process, especially in technicians' training (8) . This fact denotes the need to include the themes of alcohol and other drugs in the training of professionals with a high-school degree. There is evidence that access to the discussion of the problematic use of alcohol and other drugs during training is associated with more positive attitudes (17) .
On the other hand, professionals still report difficulties in understanding that alcohol addiction is a health problem that can be treated in different ways, which results in approaches generally of a coercive and punitive nature (9,16) . They also reject considering moderate alcohol consumption as part of the treatment (14) , disregarding the precepts of harm reduction, which are part of the Brazilian Mental Health Policy.
Despite the advances achieved with the Psychiatric Reform and the pursuit for users' rights, it is understood that the stigmatization of these individuals happens when people attribute negative descriptions and stereotypes to certain behaviors. Throughout history, alcohol dependence has had deplorable attributes, such as subjects with personality deviation, weak personality, sinners, among many others, until nowadays day, especially among professionals who do not work directly with this population (18) .
Continuing Education in Health is a powerful learning practice at work that may serve as a strategy for technical, maintenance, and administrative professionals as a way to improve their attitudes (4) . Continuing Education in Health is planned based on the problems faced, considering the knowledge and experiences that the professionals involved already have. It is considered an essential part of institutional changes and, even being pointed out as a fundamental method for the improvement of the work process, it is rarely established as a sustainable strategy (19) . The data found here emphasize the importance that the literature gives to Permanent Education in Mental Health and the use of alcohol and other drugs. It is a noteworthy fact that technicians who work in these services have fewer positive attitudes towards users.
The perception of disapproving situations at work was another factor associated with the positive attitude of professionals, as those with better attitudes seem to be more critical about their work environment and process. Literature indicates that health workers constantly assess the service in which they are inserted. The professional's perception of the healthcare service in which he/she works allows diagnosing the characteristics and problems of the service, both in its administrative aspects and in the professional-user relationship (2) . However, it is worth noting that time working in the same service can promote security against these opinions, being more easily exposed.

Conclusion
Based on the assessment of the professionals' attitudes, it was found that attitudes towards alcohol, alcoholism, and alcoholics, in general, are positive and are associated with a longer experience in the field, as well as the acknowledgment of disapproving situations at work.

Collaborations
Prates JG and Oliveira MAF contributed to the project design and writing of the article. Claro HG collaborated in the writing of the article, analysis and interpretation of data, relevant critical review of the intellectual content, and approval of the final version to be published. Pinho PH contributed to the writing of the article and data interpretation. Boska GA, Fernandes IFAL, and Silva JCMC contributed to the writing of the article and relevant critical review of the intellectual content.