Introduction

Currently, crack cocaine has been considered a public health issue in Brazil and worldwide due to its high incidence in the population. This is due to its powerful rewarding and short-lived effect, stimulating repeated administration, in such a way that, after smoking it, there is an intense and compulsive use, and the drug starts playing a central role in the user’s life, that is, it becomes a priority to the expense of behaviors previously relevant.¹

At the beginning of the 1990s, in Brazil, less than 10% of hospitalizations of drug addicts were of crack cocaine users. However, at the end of the decade, this number rose to 80%.² According to data on the use of illicit drugs in the USA, cocaine appears as the main responsible for hospitalizations, and, among the forms of cocaine used in this country, crack is the most used.³

The compulsive use of crack cocaine interferes in the individual dimension of users, also compromising their social relationships, in such a way stable social and family bonds are progressively weakened and broken. The difficulty in social interactions between users and their relatives is characterized as one of the several obstacles to be faced in relation to the use of crack cocaine.^4-5

Hence, the family, while a core of care and partnership in healthcare actions to cope with the abusive use and dependence on crack cocaine, should also be deemed by healthcare teams as a unit that requires attention and care when facing the physical and emotional wear caused by the drug use. Thus, members of the family core need attention, welcoming, information so they can be strengthened, assisting their relatives in recovery.

Thus, the family plays an essential role in the therapeutic process because, when it begins to be part of the daily routine of healthcare services, it can understand the context of drugs and their specificities, consequently understanding the needs of users.^6-7

Within the context of mental healthcare services, we highlight the Psychosocial Support Centers (Centros de Atenção Psicossocial Álcool e Drogas III – CAPS AD III), specialized services that provide integral and continuous care to people with needs related to consumption of alcohol, crack cocaine, and other drugs, operating 24 hours of the day and every day of the week, including weekends and holidays.⁸

CAPS should involve the family in the treatment of crack cocaine users, seeking to support them to overcome difficulties in coping with the use of the drug and the emotional burden generated in the relatives of crack cocaine users.⁹

Among the numerous strategies of support, insertion, and stimulation to the participation of relatives in the treatment of crack cocaine users at the CAPS AD, we highlight individual care, welcoming, home visits, workshops, and family groups. These activities may assist in living with users, strengthening relatives, and learning to cope with situations arising from the use of substance, since in crack cocaine dependence personal and social values are weakened by the central role played by the drug in the lives of users.

Thus, we question: what is the evaluation of workers of a CAPS AD III on the care provided to relatives of crack cocaine users from the perspective of the Fourth Generation Evaluation?

We intend to contribute to the advancement of scientific knowledge in the field of mental health, especially regarding demands related to crack cocaine consumption in the investigated region, providing means to advance in healthcare actions that consider the family as a protagonist of care. Thus, we understand that the reference of the Fourth Generation Evaluation can emerge the empowerment of professionals as protagonists of the necessary changes for the qualification of CAPS AD in the care of relatives of crack cocaine users.

We shall present partial data from the research entitled Familiares dos usuários de Crack em um CAPS AD III: avaliação das necessidades de cuidados [Relatives of crack cocaine users at a CAPS AD III: assessment of healthcare needs]¹⁰ in which the Fourth Generation Evaluation reference was considered. We aim to know the evaluation of professionals of a Psychosocial Support Center (CAPS AD III) on the care provided to relatives of crack cocaine users.

Method

This study was conducted at a CAPS AD III operating for two years, located on the Western border of the state of Rio Grande do Sul, Brazil, being an assistance reference for 125,435 inhabitants.¹¹

This is a research that used the methodological theoretical reference of the Fourth Generation Evaluation¹², of hermeneutic-dialectical approach and constructivist and responsive nature.

The Fourth Generation Evaluation is implemented through methodological assumptions of the constructivist paradigm. This is a responsive assessment, in which demands, concerns, and issues of stakeholders comprise an organizational focus (basis for determining what information is needed). It constitutes an important methodological possibility in the field of mental health, to the extent it enables the access of dimensions that are poorly capable of being apprehended by measurements and indicators. In addition, a participatory methodology allows for control of the process and evaluation results shared by evaluators and stakeholders.¹³

The hermeneutic-dialectical approach is hermeneutic because it enables the interpretation of data created through subjectivities; and it is dialectical for proposing a discussion of different points of view, in order to obtain an evaluative result closer to the reality in which opinions are produced. On the other hand, the responsive approach uses claims, concerns, and issues of stakeholders as aspects that direct all the evaluative process.¹²

Data collection occurred from June to September 2013, and had 15 professionals appointed as stakeholders of the totality of 30 workers of the service at that period. Four psychologists, three caregivers, two nursing technicians, three workshop leaders, one occupational therapist, one nurse, and one physician participated in data collection, with a workload of 40 hours per week. Of these, 12 were women and 10 aged between 30 and 49 years. Nine of them had no education in mental health or chemical dependence.

As inclusion criteria of the professionals, were established: working in the service for more than six months and providing direct care to users of crack cocaine and their relatives, because it is understood that this period is sufficient for the worker to make an evaluation of the care provided to family members of crack cocaine users. Ten professionals who had less than six months of service, and five who were absent due to vacations and medical leaves were excluded from the study.

To consolidate the qualitative evaluation process, data collection followed the theoretical and methodological assumptions of the Fourth Generation¹², which are summarized as: Contact with the field (when meetings were held with the service team to discuss the research proposal); stakeholders identification (in this study, we deemed the healthcare professionals); development and broadening of joint constructions (development of the hermeneutic-dialectical approach); presentation of data for the stakeholders (carried out from the negotiation process, which consisted in organizing joint constructions, validating information, and verifying consensus); and the construction of the final results of the evaluative process (performed after negotiation).

Data collection was carried out through observation and individual audio-recording interviews, established through the hermeneutic-dialectical approach.

Based on the hermeneutic-dialectical approach, the first interview was performed with Respondent 1, called R1, and at the end of this interview, such was requested to indicate another respondent, called R2, who could point out new formulations . However, before the interview with R2, themes, concepts, ideas, values, concerns, and central issues proposed by R1 were synthesized by listening to the audio of the interview, in order to extract relevant points that enabled the construction 1 ( C1), which served as a source of information to carry out the interview with R2, who was also invited at the end of the interview to indicate a new R3 respondent.

To do so, the interview with R2 enabled a new construction, designated as C2, which in turn served to direct the interview with the respondent 3 (R3) and so on, successively. As the initial respondent (R1) among the professionals, we elected the one working for the longest time in the service.

The field contact meeting was held in March 2013. In June, the observation was initiated, which consisted, at first, in the approach of the researcher with the dynamics of care established in the service, totaling 150 hours. At this moment, called “previous ethnography,” the objective is for the evaluator to know the service without being engaged in the evaluation activity yet.¹² Then, a more systematic observation of the care provided to relatives of crack cocaine users began, totaling 150 hours. This stage allows the evaluator to know the object to be evaluated more deeply, assisting in an understanding of the questions presented by stakeholders in the hermeneutic-dialectical approach. Observation may also allow the evaluator to identify themes/issues deemed relevant to be presented to the participants, in such a way they manifest themselves regarding such themes. All observations were recorded in a field diary, totaling 300 hours of observations.

The interview stage, through the development of the aforementioned hermeneutic-dialectical approach, began in August and ended in September. The interview with the first member of the team was guided by a semi-structured script, containing the following questions: In your opinion, how does the care provided to relatives of crack cocaine users take place at CAPS? What are the spaces provided for this assistance?

To analyze the content of the interviews, we used the Constant Comparative Method,¹² which consists of analyzing data, by listening to the statements shortly after its collection, to identify the constructions of each respondent and to present the content of previous interviews in subsequent interviews, in order to make new formulations about the questions pointed out in the statements.

With the completion of the hermeneutic-dialectical approach, interviews were fully transcribed. Thus, we started the phase of organizing and analyzing previous results to be presented at the negotiation meeting, in which a consensus about the group was reached. This occurred through previous scheduling and the participation of the 15 interviewees.

For this moment, a printed material was produced, containing the synthesis of data on the interviews, which was distributed to each interviewed professional. Then, results obtained in the interviews were explained by the evaluator, through presentation with the aid of the Power Point software, aiming at the discussion, validation, and negotiation of data, as a priority axis of the evaluation.

The role of the evaluator consists in carrying out an evaluation in which everyone involved, through dialogue and negotiation, can reach a consensus on the demands, concerns, and issues faced at that time. Hence, there is an interaction and reintegration of the evaluation.¹⁴

After the negotiation stage, data were reorganized based on constructions and consensuses established by the stakeholder, in order to be described as thematic axes in our study. The thematic axis developed in this article was denominated “Care provided to family members of crack cocaine users,” originating from the units of meanings: Individual care, family group, home visit, and welcoming.

Observations allowed the evaluator to include questions in the interviews and also led to a deeper analytical understanding of those presented by interviewees themselves. Moreover, in the final negotiation, there is a collective moment of reconstruction of this set of information that enables both its deepening and its adjustment.

The Informed Consent Form was used in two copies, according to Resolution no. 466/2012 of the National Health Council, which approves guidelines and regulatory standards for research involving human beings.¹⁵ This study was approved by the Research Ethics Committee of the Federal University of Rio Grande do Sul (UFRGS), under Opinion no. 75635. To guarantee the anonymity of participants, excerpts of the statements are identified with the letter P (professional) followed by an indicative number of the sequence in which the interviews were performed and a brief characterization of the subjects.

Results

Interviewees evaluated the care provided to family members of crack cocaine users as paramount in supporting the treatment, and added individual care, home visit, support group, and welcoming as spaces for care and strengthening. These care spaces strengthen the insertion of families in the service, assisting them in a troubled moment at the beginning of treatment and in the relationship between family members and users, which are weakened due to the use of crack cocaine.

Professionals evaluated individual care as an important space for the relatives of crack cocaine users, considering that many families prefer an individualized moment, with privacy to open up with healthcare professionals about personal issues related to the drug user, without exposure.

I believe individual care is one of the most important modes of assistance, ‘cause there is where we can find out what is happening with the family. (I5)

There are relatives, especially those of crack cocaine users, who are ashamed to tell something in the groups and therefore prefer individual care. (I8)

There was a relative who, although stimulated to speak in the group, didn’t verbalize her story, she only said she would report her doubts and fears in individual care. (OBS day 10).

The individual care provided to relatives of crack cocaine users at CAPS AD emerges as a space of care, especially in moments of crisis. In addition, many families are not and/or do not feel prepared to deal with the difficulties arising from the use of crack cocaine, and therefore, they may prefer a more individualized space with the professional of the service.

Home visit was evaluated by CAPS AD healthcare professionals as an important space for the care of the family and the crack cocaine user, considering that it provides observation of the family dynamics, monitoring users in their territory, support, and active search of absences in the activities of the service.

In some special cases, we perceive the need to do the home monitoring of the family. In case of any kind of recurrence, we do it too. Those who come to the group once and don’t come anymore, we have to find out why they didn’t come, we have to search them by calling, visiting their home. (I9)

I think it’s very important to make visits to these families and crack cocaine users to monitor their reality, I think it’s better to go to their homes indeed, to know where they live, what they do, what they fail to do. (I10)

I accompanied a home visit and realized how important it is for strengthening the bonds between professionals, users, and family members. The CAPS professional questioned why the relative has not been attending the service. (OBS day 7)

Another space verbalized by interviewees was the welcoming. Welcoming is a moment of listening, and it allows the identification of care demands of the relatives of crack cocaine users, in which the team can provide guidance and give referrals in a safe, private, and confidential environment. This welcoming requires the healthcare professional to have a qualified listening in order to deal with the demands brought up by these relatives.

When we perform the welcoming, we see what is the need, whether we need to make an appointment or not, to listen, and anyone can do that first welcoming. But there must not be easy for family members of these users to get here in the service and expose themselves and tell everything, so it’s more confidential. (I8)

Sometimes, relatives come with the issue of crack cocaine, but within this issue there are others that the professional, if unprepared to meet these families, will let things slide and won’t be able to rescue these users and the families. (I13)

At CAPS AD, there are four family groups, each with an average of 15 relatives in the morning, afternoon, and night shifts in an attempt to provide several schedules. Thus, interviewees evaluated the existence of groups as an important care space for the relatives of drug users, including crack cocaine.

I think the group treatment is extremely valid, one is always helping the other with their experiences. We also help, we provide guidance, we talk about how important is the participation of the family in this context, we speak the same language. I think there’s a lot of results, the family is very present. There’s always a mirror, bringing to the group a problem common to everyone. (I15)

Groups are good because they exchange experiences with others, because they have the same problem. It’s always a good thing. They say: “Do that! It’s not like this because it doesn’t work.” (I10)

Write that down, here at the CAPS there are four group schedules to relatives because we know the importance of this space for these families, who are very fragile with crack cocaine in their daily life. (Negotiation)

However, interviewees evaluated the need for preparation and training of coordinators of the groups aimed at relatives of crack cocaine users, considering that the group work requires the professionals’ knowledge of group techniques in addition to academic education.

We have no technique, because we didn’t have training for it. What I know of group [work] is what I have learned in college, I think we should have training to assist this group. (I15)

We should attend a course, a training of how to do group [activities], ‘cause most professionals here don’t have this knowledge. (Negotiation)

Moreover, it is also important to consider the acquisition of knowledge related to chemical dependence, inherent to care at a CAPS AD, enabling to establish groups with quality in these services.

Discussion

Crack cocaine users are more likely to abandon treatment due to problems with the law and the low social coping ability.¹⁶ Thus, individual care spaces at the CAPS are important in strengthening family members within this context with many challenges. In addition to bonding, individual care to the family member can clarify the role of relatives in the treatment of chemical dependence. In another study,¹⁷ relatives are aware of their role in the treatment, seeking to be close to the service. Thus, the availability of spaces where relatives feel supported establishes a partnership relationship between them and the team, strengthening the inclusion of the family in the services.

It is imperative for family members to receive guidance on the repercussions that crack cocaine use may cause, because the more they are informed, the greater the chances of understanding that their presence in the mental healthcare service goes beyond a request for a specific assistance, consisting in a partnership that should be effective both in the stages of instability and balance.^17-18

Home visit emerges as a tool that allows the professional to understand the context of the users and their relatives. In addition, access to the home and the community as a whole can enable CAPS workers to know other care aspects available to the user and the family, which are part of the local support network.¹⁹ Knowledge of the context and the network qualifies the care provided by the service, since it enables the development of approaches consistent with the family dynamics and the articulation with the other care aspects. Thus, the use of home visits is also important in allowing the healthcare professional to be aware of the reality of the family, and to seek understanding and assisting their healthcare demands and needs.

This strategy should emphasize the humanization of care, generating bonds between user, team, and family, promoting the protagonism of the family in the care of crack cocaine users. This mode of care can be a good prospect for the team to provide humane, creative, and sensitive care, and disregarding hospitalization.²⁰ From this perspective, home visit requires healthcare professionals to strive in order to effectively perform their job with quality, thus supporting the family, which is monitored in their territory.

Another mode of care at the CAPS AD to relatives was the welcoming, understood as a way to ensure greater access of users and relatives to healthcare services, favoring the establishment of bonds by the genuine listening of demands in a perspective of integral, humane, and resolutive care.²¹ Family members who come to the service seeking help expect to have their demands met and, for this purpose, welcoming works as a starting point. When it comes to a first moment of care, it is noteworthy the importance of healthcare professionals being available to effectively welcome and provide a moment of trust, empathy, and possible referrals.

From this perspective, we propose a redirection of actions, of which the entire team are responsible, promoting integration of knowledge and practices, broadening their resolution, from a user-centered logic.²² Welcoming, from this understanding, requires the team to feel prepared to meet the demands of family members, perform active listening, and plan referrals. These professionals’ skills can be developed and start by the insertion of user-centered and family-oriented logic, as a reality in the service. Therefore, welcoming and listening, while light technologies, are paramount devices for the solvability of mental health care, because they favor the permanence of users and their family in the service and, consequently, in the treatment.¹⁸ Hence, welcoming emerges as a primary space in the establishment of bonds between team and family.

Support groups for family members of crack cocaine users in the studied service consist in spaces of care, enabling a moment in which families can share problems between themselves, in such a way families feel included in the treatment, contributing to overcoming difficulties inherent in the use of crack cocaine.^9,17

Thus, group activity becomes an essential tool for relatives of crack cocaine users, because it helps them to live with problems due to the use of this substance, learning to handle them in a healthier way.⁹ Improving family relationships through support groups is to rescue the family again as a protective factor in the prevention of relapse and in the continuity of treatment, stimulating the users’ motivation to follow the care plan developed by the CAPS AD professionals.⁹

The group coordinator establishes the speech time of each member, and it is essential to have knowledge of the chemical dependence and its consequences for the provision of a quality care, guaranteeing safety to the professional in this assistance.

Therefore, group coordinators need to understand their role in this space in a practical-theoretical approach, in such a way to use the group as a teaching-learning tool that enables the reflection of personal concepts and conflicts.²³ This moment allows individuals to establish a process of changes of resolutions, finding their own way through reflections that arise during the participation in the group.^24-25 Thus, the application of groups techniques by the coordinator of the group with relatives presupposes empathy and knowledge of the topic of drug use, especially the use of crack cocaine, which facilitates the interaction of the professional with the relatives and the resolution of conflicts.

Final considerations

Throughout the investigation process, and by analyzing and discussing the results, we sought a response to the research problem: to know the evaluation of workers of a CAPS AD on the care provided to the relatives of crack cocaine users from the perspective of the Fourth Generation Evaluation.

During this study, we evidenced that the care provided to the relatives of crack cocaine users in the service consists in four spaces: Individual care, family group, home visit, and welcoming.

The individual care to these relatives was evaluated as an important space, considering that many families prefer a private moment to open up and tell aspects of their daily life with the user without exposure.

Another space provided by the studied service was the support groups for family members of crack cocaine users. Professionals evaluated that the availability of four group schedules favors the participation of these families and stimulates their insertion in the service. However, interviewees assess the need for training of group coordinators, considering that teamwork requires professionals to know group techniques in addition to what was acquired at the university. Thus, these professionals must seek qualification for the coordination of groups.

Welcoming and home visits were evaluated as spaces that provide moments for listening to health and care demands provided to these relatives, in which the team can give guidance and referrals in a private environment, thus providing the approximation between professionals and families in times of crisis.

From these results, we perceived the importance of heterogeneous spaces for family inclusion in the services; however, there are much more in addition to those presented here. The inclusion and participation of the family should be thought and problematized according to the contexts, without established “formulas,” favoring the opening and approximation of these families according to singular possibilities and realities.

As an innovative character of this research, we highlight the use of the Fourth Generation Evaluation method, since this theoretical-methodological reference, which comprises constructivist research, with a formative and responsive focus, brings out the empowerment of workers as protagonists of transformations required to improve the service.

The involvement of workers in the assessment of care provided to family members of crack cocaine users enabled to consider the experience of this group, in such a way to produce knowledge concerning the practices of psychosocial care at CAPS AD, based on their daily life, often disregarded in traditional assessments.

It is noteworthy that this study has as limitation to gather data regarding a specific service and, therefore, does not allow generalizations. Furthermore, we consider that the dialectical hermeneutic process is dynamic, with information that could have been more contemplated in discussions on the evaluative process; however, the time of the study interfered in the research process.

Therefore, we highlight the importance of professionals of these substitutive services, with emphasis on alcohol, crack cocaine, and other drugs, seeking to further qualify the care provided to these families. Thus, there is urgency of educational and health institutions to invest in the discussion and qualification of professionals, among them the nurse, evidencing the potential of this worker in these services.

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Corresponding author

Maria de Lourdes Custódio Duarte

E-mail: malulcd@yahoo.com.br

Address: R. São Manoel, 963 - Rio Branco, Porto Alegre - RS

ZIP CODE: 90620-110

Authorship contributions

1 – Maria de Lourdes Custódio Duarte

Concepção e planejamento do projeto de pesquisa, análise e interpretação dos dados, redação e revisão crítica.

2 – Leticia Passos Pereira

Análise e interpretação dos dados, redação e revisão crítica.

3 – Agnes Olschowsky

Concepção e planejamento do projeto de pesquisa, análise e interpretação dos dados, redação e revisão crítica.

4 – Juliana de Carvalho

Análise e interpretação dos dados, redação e revisão crítica.

How to cite this article:

Duarte MLC, Pereira LP, Olschowsky A, Carvalho J. Fourth generation evaluation: assisting family members of crack cocaine users. Rev. Enferm. UFSM. 2019 [Acesso at: 2019 jun 15];vol ex:1-19. DOI:https://doi.org/10.5902/2179769229057