CHANGES PERCEIVED BY USERS OF PSYCHOSOCIAL CARE CENTERS IN ALCOHOL AND OTHER DRUGS

Objective: to evaluate if users of Psychosocial Care Centers in Alcohol and Other Drugs perceive changes with treatment received and what variables are associated with such changes. Method: quantitative, evaluative, transversal, descriptive and exploratory study, with a sample of 263 users. As an instrument of data collection, an adapted instrument was built based on Administrative Rule no. 336/2002 from the Ministry of Health. Responses were recorded in Microsoft Excel® 2010 software and processed with SPSS software, version 20.0. To verify the association between the variables, univariate and multiple linear regression models were elaborated using the least squares method (OLS). Results: users reported good changes in relation to self-confidence, humor, personal problems, interest in life, ability to endure difficult situations and quality of sleep. Little changes were noticed in the coexistence with friends, emotional stability, coexistence with the family and with other people. Conclusion: the users, in general, perceived changes with the assistance received in the Centers of Psychosocial Care in Alcohol and Other Drugs and the results allow directing investments in the therapeutic project of the people under treatment. Descriptors: Evaluation of Health Care; Disorders Related to Substance Abuse; Mental Health Services; Treatment Results. RESUMO Objetivo: avaliar se os usuários dos Centros de Atenção Psicossocial em Álcool e Outras Drogas percebem mudanças com o tratamento recebido e quais as variáveis associadas a tais mudanças. Método: estudo quantitativo, avaliativo, transversal, descritivo e exploratório com amostra de 263 usuários. Como instrumento de coleta de dados, utilizou-se um instrumento adaptado construído com base na Portaria n.° 336/2002 do Ministério da Saúde. As respostas foram registradas no software Microsoft Excel® 2010 e processadas com o programa SPSS, versão 20,0. Para verificar a associação entre as variáveis, elaboraram-se modelos de regressão linear univariada e múltipla pelo método de mínimos quadrados ordinários (OLS). Resultados: os usuários referiram boas mudanças em relação à confiança em si próprios, humor, problemas pessoais, interesse pela vida, capacidade de suportar situações difíceis e qualidade do sono. Pequenas mudanças foram percebidas na convivência com amigos, estabilidade emocional, convivência com a família e com outras pessoas. Conclusão: os usuários, no geral, perceberam mudanças com a assistência recebida nos Centros de Atenção Psicossocial em Álcool e Outras Drogas e os resultados permitem direcionar investimentos no projeto terapêutico das pessoas em tratamento. Descritores: Avaliação de Serviços de Saúde; Transtornos Relacionados ao Uso de Substâncias; Serviços de Saúde Mental; Resultados do Tratamento. RESUMEN Objetivo: evaluar si los usuarios de los Centros de Atención Psicosocial en Alcohol y Otras Drogas perciben cambios con el tratamiento recibido y cuáles son las variables asociadas a tales cambios. Método: estudio cuantitativo, evaluativo, transversal, descriptivo y exploratorio, con muestra de 263 usuarios. Como instrumento de recolección de datos, se utilizó un instrumento adaptado construido basado en la Portaría n °. 336/2002 del Ministerio de Salud. Las respuestas se registraron en el software Microsoft Excel® 2010 y se procesaron con el programa SPSS, versión 20,0. Para verificar la asociación entre las variables, se elaboraron modelos de regresión lineal univariada y múltiple por el método de mínimos cuadrados ordinarios (OLS). Resultados: los usuarios mencionaron buenos cambios en relación a la confianza en sí mismo, humor, problemas personales, interés por la vida, capacidad para soportar situaciones difíciles y calidad del sueño. Pequeños cambios fueron percibidos en la convivencia con amigos, estabilidad emocional, convivencia con la familia y con otras personas. Conclusión: los usuarios, en general, percibieron cambios con la asistencia recibida en los Centros de Atención Psicosocial en Alcohol y Otras Drogas y los resultados permiten dirigir inversiones en el proyecto terapéutico de las personas en tratamiento. Descriptores: Evaluación de Servicios de Salud; Trastornos Relacionados con Sustancias; Servicios de Salud Mental; Resultados del Tratamiento. Master (Doctorate student), School of Nursing, University of São Paulo / EEUSP. São Paulo (SP), Brazil. E-mail: gabriellaboska@usp.br ORCID iD: http://orcid.org/0000-0002-5827-6486; PhD (Post-Doctorate student), University of São PauloSchool of Nursing / EEUSP. São Paulo (SP), Brazil. E-mail: helo.claro@usp.br ORCID iD: http://orcid.org/0000-0003-1504-7074; PhD, Federal University of Recôncavo da Bahia / UFRB. Cruz das Almas (BA), Brazil. Email: paulapinho@usp.br ORCID iD: http://orcid.org/0000-0001-8922-0699; PhD, School of Nursing, University of São Paulo / EEUSP. São Paulo (SP), Brazil. E-mail: marciaap@usp.br ORCID iD: http://orcid.org/0000-0002-10698700 ORIGINAL ARTICLE Boska GA, Claro HG, Pinho PH et al. Changes perceived by users of psychosocial... English/Portuguese J Nurs UFPE on line., Recife, 12(2):439-46, Feb., 2018 440 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i2a25068p439-446-2018 The Centers for Psychosocial Care in Alcohol and Other Drugs (CAPSad) are mental health services implemented by ordinance 336, of 2002, to develop psychosocial actions aimed at the treatment of users of psychoactive substances (PAS) in the community. Their actions must be guided by the Damage Reduction (DR) strategy, seeking prevention, recovery and treatment, carried out by a specialized multiprofessional team. These services have emerged as substitutes for pre-existing hospital models, guaranteeing users, a new form of health care that is sustained by the perspective of social reintegration and goes beyond the search for abstinence. However, in order to guarantee the quality and effectiveness of actions developed by CAPSad, the evaluation of an integrative approach, that considers the levels structure, process and results, becomes essential. This approach proposes to include the participation of the main agents involved in the care process (users, family and professionals) which may reveal the weaknesses and potentialities of the service. The World Health Organization (WHO) highlighted the need to incorporate the evaluation of treatment outcomes by these agents as a continuous and ongoing practice, using these data to improve the quality of care provided, 5 and stating that the results obtained should coincide with the user’s perspective. Otherwise, the quality of treatment may be compromised. It is understood, therefore, that only the users themselves can provide an in-depth understanding of their clinical status and the effects of the interventions performed in their lives, sharing information that is not present in the clinical measures of the professionals. Their experiences with drug use, treatment received, and many other outcomes can only be experienced and reported by themselves. One way to measure objectively if the user perceives changes in their life after initiation of treatment in a CAPSad, is by using the Perceived Change Scale (PCS). This instrument was developed in Canada and validated for Brazil with small changes and allows to evaluate treatment outcomes, from the perspective of the users themselves, demonstrating the impact of interventions on their lives. ● To evaluate whether users of Psychosocial Care Centers in Alcohol and Other Drugs perceive changes with treatment received and what variables associated with such changes. This research integrates the matrix project titled "Evaluation of Psychosocial Care Centers in Alcohol and Other Drugs of the Municipality of São Paulo". It is an evaluative research that used transversal, descriptive and exploratory quantitative methods to collect and analyze the data. The sample was calculated from a pilot study carried out in a CAPSad in the city of São Paulo. The appropriate sample size was estimated from the highest standard deviation value of the domains of the User Satisfaction Scale with the Mental Health Services (SATISBR) questionnaire: 0.8. In order to have an average of the evaluation of the services studied, a sample of 360 users was calculated. A total of 12 CAPSad of the city of São Paulo, accredited to the Ministry of Health, with a minimum of one year of operation (CAPSad II Cachoeirinha, CAPSad III Center, CAPSad II Ermelino Matarazzo, CAPSad II Ipiranga / Arapuá, CAPSad II Jabaquara, CAPSad II Pinheiros, CAPSad II Pirituba, CAPSad II Sacomã, CAPSad III Santana, CAPSad II Santo Amaro, CAPSad III São Miguel, CAPSad II Vila Mariana), totaling 30 users for each service selected by a simple random sample consisting of same chance of any individual being selected. Of the 360 individuals selected to compose the sample, 263 subjects were interviewed, since there were 97 losses and seven exclusions. As sample loss, it was considered a refusal to participate or it was not possible to contact the user after at least five attempts (via telephone and home visit) and, as an exclusion, users with less than six months of participation in the activities. The study included users who were active in services for more than six months and who continue to attend, with mental disorders due to the use and dependence of alcohol and / or other drugs, aged between 18 and 65 years. The interview was carried out in the CAPSad's own space, at the interviewee's home, and some subjects opted for a telephone interview conducted after authorization to record it and the signing of the Informed Consent Form (ICF). OBJECTIVE INTRODUCTION

The Centers for Psychosocial Care in Alcohol and Other Drugs (CAPSad) are mental health services implemented by ordinance 336, of 2002, 1 to develop psychosocial actions aimed at the treatment of users of psychoactive substances (PAS) in the community. However, in order to guarantee the quality and effectiveness of actions developed by CAPSad, the evaluation of an integrative approach, that considers the levels structure, process and results, becomes essential. 3This approach proposes to include the participation of the main agents involved in the care process (users, family and professionals) which may reveal the weaknesses and potentialities of the service. 4e World Health Organization (WHO) highlighted the need to incorporate the evaluation of treatment outcomes by these agents as a continuous and ongoing practice, using these data to improve the quality of care provided, 5 and stating that the results obtained should coincide with the user's perspective.Otherwise, the quality of treatment may be compromised. 3 is understood, therefore, that only the users themselves can provide an in-depth understanding of their clinical status and the effects of the interventions performed in their lives, sharing information that is not present in the clinical measures of the professionals.Their experiences with drug use, treatment received, and many other outcomes can only be experienced and reported by themselves. 4,6e way to measure objectively if the user perceives changes in their life after initiation of treatment in a CAPSad, is by using the Perceived Change Scale (PCS).This instrument was developed in Canada 7 and validated for Brazil with small changes and allows to evaluate treatment outcomes, from the perspective of the users themselves, demonstrating the impact of interventions on their lives.Of the 360 individuals selected to compose the sample, 263 subjects were interviewed, since there were 97 losses and seven exclusions.As sample loss, it was considered a refusal to participate or it was not possible to contact the user after at least five attempts (via telephone and home visit) and, as an exclusion, users with less than six months of participation in the activities.The study included users who were active in services for more than six months and who continue to attend, with mental disorders due to the use and dependence of alcohol and / or other drugs, aged between 18 and 65 years.The interview was carried out in the CAPSad's own space, at the interviewee's home, and some subjects opted for a telephone interview conducted after authorization to record it and the signing of the Informed Consent Form (ICF).

OBJECTIVE INTRODUCTION METHOD
English/Portuguese J Nurs UFPE on line., Recife, 12(2): 439-46, Feb., 2018  441   ISSN: 1981-8963  ISSN: 1981-8963  https://doi.org/10.5205/1981-8963-v12i2a25068p439-446-2018As an instrument of data collection, an adapted instrument was built based on Administrative Rule no.336/2002 of the Ministry of Health containing sociodemographic issues related to the CAPSad service, as well as EMP 4,7 and SATIS-BR. 9 The PCS has 19 items and 18 of them are arranged in three multidimensional subscales: 1. Occupation and Physical Health; 2. Psychological Dimension and Sleep; 3. Relationships and Emotional Stability and the last item is the overall assessment of treatment.Response alternatives are arranged on a three-point Likert scale, indicating that one aspect of a patient's life may be: 1. worse than before; 2. no change and 3. better than before.The measurement of the score varies continuously from one to three; the higher the perceived changes. 4,6SATIS-BR is also a fivepoint Likert type, and the higher the score, the greater is the degree of patient satisfaction with the service, which varies continuously from one to five. 9 The study-dependent variable was the perception of change obtained by means of the calculation of the mean of the PCS scale.The independent variables were the characteristics that showed the sociodemographic and clinical profile of CAPSad users (age, sex, race / color, marital status, current residence, schooling, first admission to the service, how often do they attend, considers frequency attending CAPSad sufficient, psychiatric hospitalization prior to CAPSad treatment, psychiatric hospitalization during CAPSad treatment, smoking, alcohol consumption in the last four weeks, use of illicit drugs in the last four weeks), as well as satisfaction with the service calculated by the mean satisfaction of the SATIS-BR scale and the sufficiency of attendance at the services.
Responses were recorded in Microsoft Excel® 2010 software and processed with the Statistical Package for Social Sciences (SPSS), version 20.0, for Windows®.In order to verify the association between the variables, univariate and multiple linear regression models were developed by the least squares method (OLS), which aims to draw a line that predicts the response variable from one or more explanatory variables, minimizing the sum of square of the errors. 8As a basic assumption for the use of the OLS, we have the approximately normal distribution of the dependent variables. 8This assumption was verified by means of the proximity of the means and medians of the variables, as well as by the density estimation graph kernel.
The inferential analysis was done in two steps: 1. univariate analysis of each variable and separation of variables with p-value ≤ 0.3 to be included in the multiple model.We opted for the more permissive p-value (≤0.3) to reduce the possibility of excluding variables that are significant for the multiple model and 2. assembly of multiple model from the selected variables after univariate analysis (variables with p-value ≤0.3).The standard errors are robust to heteroscedasticity according to the method proposed by White. 10 The age of the interviewees ranged from 18 to 76 years, with a mean of 43.9 years.The other characteristics classified as sociodemographic and clinical are presented in Tables 1 and 2. The mean age of perception of problems with the use of SPA was 30.79 years and median of 28.00 years, with a 95% confidence interval and a lower and upper limit of 29.19 and 32.39, respectively.Regarding the results of the SATIS-BR scale, it had, as a global average, 4.5 and median 5.0, demonstrating a high level of users' satisfaction with the service.

RESULTS
Regarding the change perceived by the users in follow-up in the CAPSad, the mean of the factors that compose the scale was calculated and a discrete asymmetry between the data was observed, with the majority of the averages closer to three points, which is equivalent to a good perceived change in aspects of everyday life evaluated by the scale, as shown in table 3. To verify the normality of data distribution, the kernel density plot was performed for EMP, finding that the variation of the dependent variable was approximately normal, which shows a greater tendency of the population to perceive changes with the treatment received by the services.
In the univariate analysis, from the crossing of the data, some variables obtained statistical significance with p-value ≤ 0.30 and are distributed in table 4.
The variables, that presented statistical significance, were included in the multiple model and those that did not present remained as controls.The sociodemographic variables did not present correlation and statistical significance with the PCS.On the other hand, the clinical variables had both a negative significance and correlations as well as positive, as shown in table 5.The final model explained 16.8% of the variance of perceived change in the life of users who attend the service.
The most evident changes corresponded to factor 2 of the scale that includes: selfconfidence; humor; personal problems; feeling of interest in life; ability to withstand difficult situations and sleep quality, factors that appear in another study as important to contribute to a better quality of life of the patient. 11en it comes to users of alcohol and other drugs (AOD), it is understood that problematic use can lead to physical and moral effects that affect the totality of the subject, 11,13 but when it is being treated, it is usually , there is a greater control over its consumption, which may aid in the perception of more significant changes in these aspects of life that may have been unusual aspects, but now they are linked to important motivational dimensions.
Coexistence with friends, emotional stability, coexistence with the family and with others (Table 3 -factor 3) were referred to by the users as the points of least change.Studies have shown that chemical dependence causes significant impacts on the family and personal relationships of users, since the drug may represent a symbol of disaggregation and this association may require a longer period of time to be rebuilt exacerbating existing conflicts 13,15 or, in this case , so that the changes are perceived.
Chronicity in the use of PAS has been increasing and bringing important consequences, often evidenced by biopsychosocial problems, because the longer the use of drugs, the greater the negative effects on quality of life, social relations and support networks , 16 that is, the difficulty also increases the resumption of these aspects of life, making the changes less perceived, especially in what encompasses factors 1 and 3 of the PCS.
The age of perception of problems with the use of PAS (average of 30.7 years) influenced, with negative correlation, the change that the user perceived during the follow-up in the CAPSad.Therefore, the older the user understood that he had problems with substances, the less the change perceived in the treatment.
Other studies 17 showed that the age of perception of problems with the use of PAS varied from 20 to 50 years, according to the average found in this investigation.In these cases, the CAPSad have an important role in sensitizing users who have difficulties in perceiving problems with their use, as well as stimulating the motivation to seek treatment by proposing DR strategies that promote broader care where risks and, consequently, changes are perceived early.
With regard to smoking, in this study, smokers (57.4%) perceived fewer changes in some aspects of their life, in relation to nonsmokers.This result corroborates a clinical trial conducted for the treatment of smoking, in which it points out that the success of the treatment of nicotine addiction may depend, in part, on the adequate treatment of problems with other substances. 18is is an important data for conducting treatment, since tobacco is often considered of lesser relevance when compared to the use
Since 33.8% of users maintained some use of licit or illicit substance in the last four weeks, except for tobacco (Table 2), it is emphasized the need for CAPSad practitioners to work with the RD approach that does not advocate abstinence as only option respecting the right of choice of these subjects, as well as their singularities, when understanding the use of drugs as a multidimensional and historical phenomenon and not only related to delinquency and pathology. 19other finding that was inversely proportional to EMP was hospitalization, ie, the greater the number of psychiatric hospitalizations before treatment at CAPSad, the lower the change perceived by users.
Perceiving changes with the treatment in the territory, since, in this perspective, the user is co-responsible for their treatment and the control of drug use is not answered with the distance from the context of life. This is a finding that allows practitioners to perceive cases with previous hospitalization histories differently, perhaps waiting for clearly perceived changes in the longer term and setting specific goals for treatment.The night-care beds in CAPSad III should be considered as an important device for managing poisoning cases and / or crises for a short period of time so that they can avoid hospitalization.
As for the frequency of attendance in the evaluated services, if the user considered this sufficient to meet their needs, he noticed more changes in his life, which did not mean that the higher the frequency, the greater the changes.
In order for the singular demands presented by them to be perceived, it is essential that they be seen as protagonists in their treatment.Therefore, the elaboration of its unique therapeutic project (UTP) must be done together with the multiprofessional team so that it has a therapeutic meaning for its current moment.This need is highlighted when verifying that 70% of the post-discharge referrals of hospitalizations of the PAS users are for CAPSad. 22tisfaction is the variable that appeared strongly related to the perceived change (p≤0.01),because, according to the results, the more satisfied the user was, the greater changes he noticed in his life.This data corroborates other studies that point out that the degree of change perceived by the user in relation to treatment is what determines their satisfaction. 6,23e low R 2 (16.8%) explains little of the variables proposed for the analysis, then, as limitations of the study, an insufficiency of variables that could elucidate the studied phenomenon (change perceived by users) which, due to its complexity, is expected.The fact that the research was directed at users who had been active in the services for more than six months and who were followed up until the time of collection is an important bias that significantly reduces the magnitude of the findings with regard to perceived change in understanding that those who remain linked to CAPSad perceive benefits with treatment.
Overall, CAPASad users, at some point in treatment, have noticed changes in their lives that vary depending on the area of change, the factors that involve use, and satisfaction.
It is clear that the issue of problematic use of substances is a complex area to explore and suffers from various interferences of many others.Consequently, those who perceive changes with follow-up in CAPSad are satisfied, as those who have gone through previous hospitalizations find it difficult to perceive improvement with this type of care.Thus, these data can identify practices that need to be improved and better observed in the services, in order to direct the investments in the UTP of the people that arrive in search of treatment, contributing with an improvement in the results.In light of this, it is suggested that other investigations in this field of practice and other researches that show other variables or that, qualitatively, present other complementary results.
This study was approved by the Ethics and Research Committee under opinion number: 1,001 / 2011 of the School of Nursing of the University of São Paulo and 054/

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To evaluate whether users of Psychosocial Care Centers in Alcohol and Other Drugs perceive changes with treatment received and what variables associated with such changes.
CAPSad: Centers of Psychosocial Attention in Alcohol and other Drugs.Regular: own / rented house or apartment or friends house.Irregular: street, shelter, pension, hospital or institution.Table 2. Clinical variables of CAPSad users.São Paulo (SP), Brazil, 2014.

Table 4 .
Univariate analysis of sociodemographic and clinical variables in correlation with the overall item of MMS.São Paulo (SP), Brazil, 2014. PCS:

Table 5 .
Multivariate analysis of sociodemographic and clinical variables in correlation with the global EMP item.São Paulo (SP), Brazil, 2014.