ABSTRACT

The paper aimed to compare the satisfaction of black and non-black individuals assisted by Psychosocial Care Centers for Alcohol and Drugs in three Brazilian states. This is a quantitative, cross-sectional and evaluative study, with inferential analysis of the data we collected through interviews. A total of 707 individuals participated in the study, mostly men, self-declared black, with an average age of 44 years. The results show that black and non-black individuals were equally satisfied with the assistance offered, especially with the competence and understanding of the professionals, embracement and help received. These results contradict the traditional literature that reveals racism in health services. We believe that the Psychosocial Care Centers on Alcohol and Drugs are powerful and differentiated services in the health system, more welcoming and inclusive of their. This result is consistent with the history of these health devices in our country, being central services in the network that is substitutive of hegemonic and asylum-centered psychiatric care.

KEYWORDS
Mental health service; Health services research; Patient satisfaction; African continental ancestry group

Introduction

The Brazilian psychiatric reform movement led to the restructuring of mental health services with the purpose of promoting humanized and integral care. Since 2002, through the implementation of the Alcohol and Drugs Psychosocial Care Centers (Caps AD), the building of a network of services for people with problems of abuse of psychoactive substances began. The logic of Caps AD is that of harm reduction and its purpose is to fulfill the needs of the users of the services in a systematic and active manner, according to the cultural and community environment they are in and following the principles of the psychiatric reform and of the Brazilian Constitution in what relates to equality and universality¹1 Fagundes Júnior HM, Desviat M, Silva PRF. Reforma Psiquiátrica no Rio de Janeiro: situação atual e perspectivas futuras. Ciênc. Saúde Colet. [internet]. 2016 [acesso em 2017 nov 17]; 21(5):1449-60. Disponível em: http://www.scielo.br/pdf/csc/v21n5/1413-8123-csc-21-05-1449.pdf.
http://www.scielo.br/pdf/csc/v21n5/1413-...

2 Brasil. Ministério da Saúde. Portaria GM nº 336, de 19 de fevereiro de 2002. Estabelece sobre a proteção e os direitos das pessoas portadoras de doença mental e redireciona o modelo assistencial em saúde mental. Diário Oficial da União. 19 Fev 2002. [acesso em 2020 set 1]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2002/prt0336_19_02_2002.htm.
https://bvsms.saude.gov.br/bvs/saudelegi... ^-33 Brasil. Ministério da Saúde. Portaria nº 130, de 26 de janeiro de 2012. Redefine o Centro de Atenção Psicossocial de Álcool e outras Drogas 24 h (CAPSad III) e os respectivos incentivos financeiros. Diário Oficial da União. 26 Jan 2012. [acesso em 2020 set 1]. Disponível em: http://www.saude.gov.br/images/pdf/2015/marco/10/PORTARIA-130-26--JANEIRO-2012.pdf.
http://www.saude.gov.br/images/pdf/2015/... .

However, this universal and egalitarian access to health has bumped into several hindrances which include the existing socioeconomic differences, with the black population being subject to much of the impact for reasons relating to the long historic period of slavery in Brazil, racism, poverty, specific diseases and the fact that they are more than half of the Brazilian population (53,1%). They are self-declared black people (black and pardo race) requesting public policies with specific actions to bring balance to such differences⁴4 Jaccoud L. O combate ao racismo e à desigualdade: o desafio das políticas públicas de promoção à saúde. In: Theodoro M, Jaccoud LB, Osório GR, et al., organizadores. As políticas públicas e a desigualdade racial no Brasil: 120 anos após a abolição [internet]. Brasília, DF: IPEA; 2008 [acesso em 2019 jul 23]. 131 p. Disponível em: http://www.clam.org.br/bibliotecadigital/uploads/publicacoes/1107_1899_Livrodesigualdadesraciais.pdf.
http://www.clam.org.br/bibliotecadigital... ^,55 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa. Painel de Indicadores do SUS nº 10. Temático Saúde da População Negra. [internet]. Brasília, DF: Ministério da Saúde; 2016 [acesso em 2019 jul 24]; 83 p. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/tematico_saude_populacao_negra_v._7.pdf.
http://bvsms.saude.gov.br/bvs/publicacoe... .

From that perspective, the National Integral Health Policy for the Black Population (PNSIPN), established by the Ministry of Health in 2009, with the purpose of fighting ethnic and racial discrimination in health services, as well as to provide equity in the access of the black population to health, includes strategies for strengthening mental health care, especially regarding problems resulting from the use of alcohol and other drugs⁵5 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa. Painel de Indicadores do SUS nº 10. Temático Saúde da População Negra. [internet]. Brasília, DF: Ministério da Saúde; 2016 [acesso em 2019 jul 24]; 83 p. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/tematico_saude_populacao_negra_v._7.pdf.
http://bvsms.saude.gov.br/bvs/publicacoe... .

Recent research has shown that the black population has even less access to health services than the white population. The black population reports having been discriminated at given times during the care provision process. Besides, black people, in their majority, lack health insurance (78,8%), thus depending on the services provided by the Single Health System (SUS), and representing more than half of the population to whom it provides care⁶6 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013[internet]. Rio de Janeiro: IBGE; 2013 [acesso em 2019 jul 30]; 105 p. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv94074.pdf.
https://biblioteca.ibge.gov.br/visualiza...

7 Brasil. Ministério de Saúde. Boletim Epidemiológico. Indicadores de Vigilância em Saúde, analisados segundo a variável raça/cor [internet]. Brasília, DF: Ministério de Saúde, Secretaria de Vigilância em Saúde; 2015 [acesso em 2019 jul 30]; 46(10):35. Disponível em: http://portalarquivos2.saude.gov.br/images/pdf/2015/abril/22/Boletim-raca-cor-09-04-15-v2.pdf.
http://portalarquivos2.saude.gov.br/imag... ^-88 Instituto Brasileiro de Geografia e Estatística. Síntese de indicadores sociais: uma análise das condições de vida da população brasileira [internet]. Rio de Janeiro: IBGE; 2016. [acesso em 2019 jul 30]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv98965.pdf.
https://biblioteca.ibge.gov.br/visualiza... .

In that sense, the Caps AD service is fundamentally important for providing care for black individuals making use of alcohol and other drugs, which implies the need to have it constantly evaluated. A recent study on patterns of crack use showed that most users are black⁹9 Almeida CS, Luis MAV. Características sociodemográficas e padrão de uso de crack e outras drogas em um CAPS AD. Rev enferm UFPE [internet]. 2017. [acesso em 2019 jul 23]; 11(supl4):1716-1723. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/15269/18073.
https://periodicos.ufpe.br/revistas/revi... . In another review study it was suggested that the selection by race is an important social marker that can provide scientific evidence and contributions to a better performance of the health services¹⁰10 Silva NG, Barros S, Azevedo FC, et al. O quesito raça/cor nos estudos de caracterização de usuários de Centro de Atenção Psicossocial. Saúde Soc [internet]. 2017 [acesso em 2019 jul 24]; 26(1):100-114. Disponível em: http://www.scielo.br/pdf/sausoc/v26n1/1984-0470-sausoc-26-01-00100.pdf.
http://www.scielo.br/pdf/sausoc/v26n1/19... .

Furthermore, satisfaction with these services contributes to better life quality, reduction in the number of hospitalizations and better adherence to treatment and to treatment frequency¹¹11 Bandeira M, Silva MA. Escala de Satisfação dos Pacientes com os Serviços de Saúde Mental (SATIS-BR): estudo de validação. J Bras Psiquiatr [internet]. 2012 [acesso em 2019 jul 24]; 61(3):124-32. Disponível em: http://www.scielo.br/pdf/jbpsiq/v61n3/02.pdf.
http://www.scielo.br/pdf/jbpsiq/v61n3/02... . Therefore, a study analyzing the satisfaction of the black and non-black population at the Caps AD would provide information and understanding of the subject matter. This way, the aim of this study is to comparatively analyze, within a racial perspective, the levels of satisfaction of black and non-black individuals receiving care from the Caps AD in three Brazilian states.

Material e methods

It is an evaluative, transversal and quantitative approach research. Studied population is made of 707 users at 30 Caps AD distributed along 19 cities of the three chosen states: São Paulo (SP), Minas Gerais (MG) and Amapá (AP). A draw was made of 30 names of possible research participants for each Caps AD. The loss criteria related to refusal to participate or impossibility to contact prospect after five attempts, requiring a new draw for replacement. Sample was calculated based on a pilot study. Individuals included were of ages ranging from 18 to 65 and had been participating in Caps AD activities for at least six months, having problems resulting from abusive use and addiction to alcohol and other drugs, with cognitive capacity to respond to questionnaires and who agreed to sign the Free and Clarified Term of Consent.

Data collection was performed from 2013 to 2016. In order to evaluate the degree of satisfaction with the service, the Satis-BR Mental Health Service Patient Satisfaction Evaluation Scale was used. This scale was elaborated by the Division of Mental Health of the World Health Organization and was validated for Brazil¹¹11 Bandeira M, Silva MA. Escala de Satisfação dos Pacientes com os Serviços de Saúde Mental (SATIS-BR): estudo de validação. J Bras Psiquiatr [internet]. 2012 [acesso em 2019 jul 24]; 61(3):124-32. Disponível em: http://www.scielo.br/pdf/jbpsiq/v61n3/02.pdf.
http://www.scielo.br/pdf/jbpsiq/v61n3/02... . A recent validation study states that the scale has an internal consistency rate (Cronbach’s Alpha) equal to 0.88, a value considered valid by the literature. Furthermore, the scale showed a convergent validity made evident when comparing the correlation with scale scores measuring a similar construct. The analysis of correlation of factors with the global scale demonstrates a positive and statistically significant correlation¹¹11 Bandeira M, Silva MA. Escala de Satisfação dos Pacientes com os Serviços de Saúde Mental (SATIS-BR): estudo de validação. J Bras Psiquiatr [internet]. 2012 [acesso em 2019 jul 24]; 61(3):124-32. Disponível em: http://www.scielo.br/pdf/jbpsiq/v61n3/02.pdf.
http://www.scielo.br/pdf/jbpsiq/v61n3/02... .

Satis-BR has 12 items grouped into three factors to evaluate the satisfaction degree of patients regarding: the degree of skill and understanding of the team regarding the patient’s problem (factor 1); the quality of the help received and of the team’s welcoming (factor 2); and the physical conditions and the comfort of service (factor 3).

The reply alternatives to the items were organized in a scale of the Likert type with a score of up to 5 points, where 1 means that user is deeply unhappy and 5 means he is deeply satisfied with service. The instrument was applied by making use of online Google Forms®. The collected data were tabulated, coded and processed using version 15 of Stata® programs and version 20 of IBM SPSS for Windows®.

A multiple logistic regression analysis was performed to examine the relationship between the independent variables with the fact of the user being black or not, and the analysis was controlled according to education, literacy and income levels. A multiple logistic regression was used to find the equation that could best predict the values of the dependent variables considering the values ​​of the independent variable. In this case, black or non-black¹²12 Marconi MA, Lakatos EM. Fundamentos de metodologia científica [internet]. São Paulo: Atlas; 2003. [acesso em 2019 jul 24]. Disponível em: https://docente.ifrn.edu.br/olivianeta/disciplinas/copy_of_historia-i/historia-ii/china-e-india.
https://docente.ifrn.edu.br/olivianeta/d... . In other words, the analysis allows to visualize the probability of obtaining a particular value for outcomes to affect either a black or a non-black population. It was assumed that there is inequality in the way blacks are treated compared to non-blacks and this was confirmed by the literature, since international and national studies show that racism reinforces even the distribution of resources in the health area, this being an obstacle to integral, universal and equitable health¹³13 Bailey ZD, Krieger N, Agénor M, et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017 [acesso em 2020 set 1]; 389(10077):1453-63. Disponível em: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30569-X/fulltext.
https://www.thelancet.com/journals/lance...

14 Pirtle WNL. Racial capitalism: a fundamental cause of novel coronavirus (COVID-19) pandemic inequities in the United States. Health Educ Behav. 2020 [acesso em 2020 abr 26]; 47(4):504-508. Disponível em: https://pubmed.ncbi.nlm.nih.gov/32338071/.
https://pubmed.ncbi.nlm.nih.gov/32338071...

15 Mota CS, Atkin K, Trad LA, et al. Social disparities producing health inequities and shaping sickle cell disorder in Brazil. Heal Sociol Review. 2017 [acesso em 2020 set 1]; 26(3):280-92. Disponível em: https://www.tandfonline.com/doi/full/10.1080/14461242.2017.1361855?scroll=top&needAccess=true.
https://www.tandfonline.com/doi/full/10....

16 Mayer-Foulkes D, Larrea C. Racial and Ethnic Health Inequities: Bolivia, Brazil, Guatemala and Peru. 2005. [acesso em 2020 set 1]. Disponível em: https://www.academia.edu/404293/Racial_and_Ethnic_Health_Inequities_Bolivia_Brazil_Guatemala_and_Peru.
https://www.academia.edu/404293/Racial_a... ^-1717 Bosque RM, Oliveira MAF, Silva NN, et al. Satisfação dos Trabalhadores, Usuários e Familiares dos Centros de Atenção Psicossocial em Álcool e Outras Drogas. Rev enferm UFPE [internet]. 2017 [acesso em 2019 jul 30]; 11(supl11):4598-606. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/download/231199/25195.
https://periodicos.ufpe.br/revistas/revi... .

In this inferential analysis of inequality in treatment, we controlled the variables for income, literacy and education, so that the effect of the race variable was not confused with these social determinants. Thus, when the race variable is found among the dependent variables, it can be said that this effect does not depend on the level of literacy, education and income of individuals. Values ​​of p <= 0.05 are considered statistically significant.

The study derives from a matrix research evaluating Caps AD, approved by the Research Ethics Committee of the School of Nursing at the University of Sao Paulo and by the Municipal Health Secretariat of Sao Paulo under the opinions 1001/2011 and 054/12, respectively, considering the ethical precepts of Resolution nº 196/96 and nº 466/12 of the National Council of Ethics in Research.

Results

Of the total of 707 study participants, 420 (59.4%) were of African origin, 297 (42%) of them being black and 123 (17.4%) of pardo race, whereas 287 (40.6) were non-black. Their profile is described in the frequency distribution of sociodemographic variables according to their state in the federation, sex, ethnicity, marital status, family income, literacy, education and age (table 1).

Table 2 shows the comparative distribution of the percentage frequency of socio-demographic and economic variables of blacks and non-blacks. It is observed that the family income of most blacks (75.2%) is of up to 2 minimum wages, while for non-blacks this percentage drops to 65.2%. It is also observed that only 5.5% of blacks receive more than 4 minimum wages, whereas the percentage for non-blacks rises to 11.4%.

Regarding education, despite the fact that the majority of blacks (93.3%) and non-blacks (95.8%) know how to read, there is a higher level of education among non-blacks, given that they are in higher percentages when it comes to having completed both elementary education as well as medium and high education, even more so because blacks show a higher percentage of people with no education whatsoever (33.1%) compared to non-blacks (18.1%).

As for how long participants are assisted in the services, we highlight that there is a higher proportion of black individuals who have been provided services for a shorter period.

Table 3 presents the results of the descriptive analysis of the global satisfaction score and of the satisfaction score of the participants according to factors (1,2,3,4) for each item of the Satis-BR scale, in median values. The results show a positive evaluation of overall satisfaction for all items, with a median of 4.4 for blacks and non-blacks.

The questions about Help received and Welcoming (factor 2) were the best evaluated, with values ​​of 4.6 points for blacks and non-blacks. The same happened with factor 1, about the team’s Skill and Understanding, which presented positive scores of 4.5 and 4.4 for blacks and non-blacks, respectively.

Despite having been given a good score, the physical conditions and comfort of Caps AD (factor 3) showed the lowest score among the scale items, with a score of 4.0 points for both groups.

Factor 4 - Satisfat4 compared the results obtained at Satis-BR with the data from the CSQ-8 (Client Satisfaction Questionnaire) – a standardized scale for evaluating satisfaction with mental health services, developed by Larsen, Attkisson, Hargreaves and Nguyen (1979). This comparison between the responses of the scales aims to constantly reassess the concomitant validity of the scale used in the study. This factor also showed a positive result, with values ​​of 4.6 for blacks and 4.5 for non-blacks.

Table 4 shows the multiple logistic regression analysis of the satisfaction evaluation among black and non-black participants. The results obtained demonstrate that there were no significant associations for this study, regarding the fact that the user is black, even when controlling the influence of literacy, education and income variables.

Discussion

The 707 individuals who took part in this study were from the AD Caps of three Brazilian states: SP, MG and AP. Sociodemographic characteristics were as follows: the majority were men (57.3%), single (59.0%) and with an average age of 44 years. These data are similar with data of other studies in the area⁹9 Almeida CS, Luis MAV. Características sociodemográficas e padrão de uso de crack e outras drogas em um CAPS AD. Rev enferm UFPE [internet]. 2017. [acesso em 2019 jul 23]; 11(supl4):1716-1723. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/15269/18073.
https://periodicos.ufpe.br/revistas/revi... .

Of this total, 420 were of African origin (297 black and 123 of pardo race) and 287 (40.6) were non-black. Comparatively, the number of blacks (75.2%) with family income of up to 2 minimum wages is higher than that of non-blacks (65.2%). And, in spite of the fact that the majority of blacks and non-blacks know how to read, there was a higher level of education among non-blacks. Such differences in sociodemographic variables have been associated in the international literature to a racial belonging that leads to inadequacies in terms of life condition, lifestyle, employability, and access to food and health services¹⁸18 United States of America. National Center for Health Statistics. Healthy people 2010: final review. Washington, D.C.: U.S. Government Printing Office Washington; 2012 [acesso em 2019 dez 10]. Disponível em: https://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review.pdf.
https://www.cdc.gov/nchs/data/hpdata2010... ^,1919 Andresen EM, Miller DK. The future (history) of socioeconomic measurement and implications for improving health outcomes among African Americans. Journals Gerontol Ser A Biol Sci Med Sci. [internet] 2005. [acesso em 2019 dez 10]; 60(10):1345-50. Disponível em: https://doi.org/10.1093/gerona/60.10.1345.
https://doi.org/10.1093/gerona/60.10.134... .

Satisfaction was then assessed in relation to the assistance received by applying the Satis-BR Scale with a racial profile, considering literacy, education and income variables. It was assumed that there is a difference in the assistance provided to blacks and non-blacks, with a consequent impact on the referred satisfaction.

In this case, the multiple logistic regression analysis showed that there were no differences in overall satisfaction between the two population groups, providing a good general assessment regarding the assistance provided by the studied AD Caps, this effect being independent of the literacy, education and income of these individuals.

Studies have reaffirmed that, although the black population presents the same diseases as the population in general, comparatively, there are differences in the account they make of them and in the care provided. Such differences are related to situations of prejudice, stigmatization, social exclusion, and inequalities, with consequent restricted access to health services. In the latter, they refer to interferences regarding the professional relationship in the services²⁰20 Araújo EM, Costa MCN, Hogan VK, et al. A utilização da variável raça/cor em Saúde Pública: possibilidades e limites. Interface [internet]. 2009 [acesso em 2019 dez 10]; 13(31):383-394. Disponível em: http://dx.doi.org/10.1590/S1414-32832009000400012.
http://dx.doi.org/10.1590/S1414-32832009... ^,2121 Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annu Rev Public Health [internet]. 2011 [acesso em 2019 dez 10]; 32:381-98. Disponível em: https://doi.org/10.1146/annurev-publhealth-031210-101218.
https://doi.org/10.1146/annurev-publheal... .

It is important to consider the singularities of the black population in different scenarios and contexts²²22 Spricigo JS, Alencastre MB. O Enfermeiro de Unidade Básica de Saúde e o Usuário de Drogas - um estudo em Biguaçu-SC. Rev Lat-Am Enfermagem [internet]. 2004 [acesso em 2019 jul 24]; 12(esp):427-32. Disponível em: http://www.scielo.br/pdf/rlae/v12nspe/v12nspea19.pdf.
http://www.scielo.br/pdf/rlae/v12nspe/v1... , and it is necessary to reflect on how the results of this study are justified in view of the similar levels of satisfaction analyzed for the groups of blacks and non-blacks conferred to the services of Caps AD, from the racial perspective.

The progress made by the Brazilian psychiatric reform led to an important expansion in the number of Caps AD throughout the national territory. Although this number is still insufficient to meet the demands of the population, literature has shown that such devices play a fundamental role in the psychosocial care network as protagonists in the process of providing care to people with needs resulting from the use of alcohol and other drugs²³23 Brasil. Ministério da Saúde. Sala de Apoio à Gestão Estratégica [internet]. 2016 [acesso em 2019 dez 10]. Disponível em: http://sage.saude.gov.br/.
http://sage.saude.gov.br/... .

In addition to this, and although incipient, there has been an increase in the last few years in the Brazilian research addressing ethnic-racial issues, which contributes to a better understanding and better access to health actions and services, as well as to specific public policies²²22 Spricigo JS, Alencastre MB. O Enfermeiro de Unidade Básica de Saúde e o Usuário de Drogas - um estudo em Biguaçu-SC. Rev Lat-Am Enfermagem [internet]. 2004 [acesso em 2019 jul 24]; 12(esp):427-32. Disponível em: http://www.scielo.br/pdf/rlae/v12nspe/v12nspea19.pdf.
http://www.scielo.br/pdf/rlae/v12nspe/v1... , including public policies for the health of the black population, evaluation of the service network and of work processes, among others.

The national and international literature on the evaluation process in mental health has identified that the user’s positive satisfaction with the service is related to the bonds they make with the health team, to how they are welcomed to the appointments, to quality of services, to the monitoring during and after treatment and to guaranteed access¹⁷17 Bosque RM, Oliveira MAF, Silva NN, et al. Satisfação dos Trabalhadores, Usuários e Familiares dos Centros de Atenção Psicossocial em Álcool e Outras Drogas. Rev enferm UFPE [internet]. 2017 [acesso em 2019 jul 30]; 11(supl11):4598-606. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/download/231199/25195.
https://periodicos.ufpe.br/revistas/revi... ^,2323 Brasil. Ministério da Saúde. Sala de Apoio à Gestão Estratégica [internet]. 2016 [acesso em 2019 dez 10]. Disponível em: http://sage.saude.gov.br/.
http://sage.saude.gov.br/...

24 Oliveira MAF, Cestari TY, Pereira MO, et al. Processos de avaliação de serviços de saúde mental: uma revisão integrativa [internet]. Saúde debate. 2014 [acesso em 2019 ago 2]; 38(101):368-378. Disponível em: http://www.scielo.br/pdf/sdeb/v38n101/0103-1104-sdeb-38-101-0368.pdf.
http://www.scielo.br/pdf/sdeb/v38n101/01...

25 Newman D, O'Reilly P, Lee SH, et al. Mental health service users' experiences of mental health care: an integrative literature review. J Psychiatr Ment HLT. 2015 [acesso em 2020 set 1]; 22(3):171-82. Disponível em: https://doi.org/10.1111/jpm.12202.
https://doi.org/10.1111/jpm.12202... ^-2626 Sohn M, Barret H, Talbert J. Predctors of Consumer Satisfaction in Community Mental Health Center Services. Community Ment Health J. 2014; 50(8):922-925., a data that can be reinforced in this study, as we did not see differences related to race or color.

On the other hand, this positive satisfaction with the service has also been related to a certain fear participants have of possible loss of the right to access care, often expressed in negative evaluations but not necessarily expressed in opinions, a situation known as gratitude bias²⁷27 Barbosa GC, Oliveira MAF, Moreno V, et al. Satisfação de usuários num Centro de Atenção Psicossocial em Álcool e Outras Drogas. Revista Portuguesa de Enfermagem de Saúde Mental [internet]. 2015 [acesso em 2019 jul 24]; 14(dez2015):31-7. Disponível em: http://www.scielo.mec.pt/pdf/rpesm/n14/n14a05.pdf.
http://www.scielo.mec.pt/pdf/rpesm/n14/n... . It is necessary to consider that Caps meet the demands of a population much fragilized from the physical, emotional and social points of view, and that this can be worsened by the stigmatization, discrimination and prejudice that involves substance use, which can be intensified by racial issues. It is therefore essential to welcome all who access the services⁶6 Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013[internet]. Rio de Janeiro: IBGE; 2013 [acesso em 2019 jul 30]; 105 p. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv94074.pdf.
https://biblioteca.ibge.gov.br/visualiza... ^,2828 Porto MSG. Polícia e violência: representações sociais de elites policiais do Distrito Federal. São Paulo em Perspectiva [internet]. 2004 [acesso em 2019jul 24]; 18(132):132-41. Disponível em: http://www.scielo.br/pdf/spp/v18n1/22235.pdf.
http://www.scielo.br/pdf/spp/v18n1/22235... . Relevant factors that could influence the findings of this study.

The satisfaction expressed by individuals assisted by mental health services involves the need for fundamental change in the context of the user’s relationship with health professionals to facilitate the engagement in the care offered²⁵25 Newman D, O'Reilly P, Lee SH, et al. Mental health service users' experiences of mental health care: an integrative literature review. J Psychiatr Ment HLT. 2015 [acesso em 2020 set 1]; 22(3):171-82. Disponível em: https://doi.org/10.1111/jpm.12202.
https://doi.org/10.1111/jpm.12202... , together with an offering of an assistance free of judgment and regardless of race or color²⁹29 Pereira MO, Souza JM, Costa AM, et al. Profile of users of mental health services in the city of Lorena - São Paulo. Acta Paul Enferm [internet]. 2012 [acesso em 2019 jul 24]; 25(11):48-54. Disponível em: http://www.scielo.br/pdf/ape/v25n1/en_v25n1a09.pdf.
http://www.scielo.br/pdf/ape/v25n1/en_v2... ^,3030 Lopes F. Experiências desiguais ao nascer, viver, adoecer e morrer: tópicos em saúde da população negra no Brasil. In: Brasil. Ação Nacional de Saúde. FundaSaúde da população negra no Brasil: contribuições para a promoção da equidade [internet]. Brasília, DF: Funasa; 2005. 446 p. [acesso em 2019 jul 24]. Disponível em: http://bvsms.saude.gov.br/bvs/pop_negra/pdf/saudepopneg.pdf.
http://bvsms.saude.gov.br/bvs/pop_negra/... , as also demonstrated by this study.

As for the factors on the Satis-BR scale assessed in this research, it was found that factor 1, about Team Competence and Understanding, and factor 2, about Help and Welcoming, received the best assessment scores, corroborating other studies in this area¹⁷17 Bosque RM, Oliveira MAF, Silva NN, et al. Satisfação dos Trabalhadores, Usuários e Familiares dos Centros de Atenção Psicossocial em Álcool e Outras Drogas. Rev enferm UFPE [internet]. 2017 [acesso em 2019 jul 30]; 11(supl11):4598-606. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/download/231199/25195.
https://periodicos.ufpe.br/revistas/revi... ^,3131 Resende KIDS, Bandeira M, Oliveira DCR. Assessment of patient, family and staff satisfaction in a mental health service. Paidéia [internet]. 2016 [acesso em 2019 dez 10]. 26(64):245-53. Disponível em: http://dx.doi.org/10.1590/1982-43272664201612.
http://dx.doi.org/10.1590/1982-432726642... .

A recent study obtained a similar result, showing good evaluation of Caps AD by 88.3% of the individuals, mostly black, who reported that the service could be improved in terms of physical structure, indicating that this may be the greatest weakness found¹⁷17 Bosque RM, Oliveira MAF, Silva NN, et al. Satisfação dos Trabalhadores, Usuários e Familiares dos Centros de Atenção Psicossocial em Álcool e Outras Drogas. Rev enferm UFPE [internet]. 2017 [acesso em 2019 jul 30]; 11(supl11):4598-606. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/download/231199/25195.
https://periodicos.ufpe.br/revistas/revi... , a weakness also revealed in other studies³²32 Kantorski LP, Jardim VR, Wetzel C, et al. Satisfação dos usuários dos centros de atenção psicossocial da região Sul do Brasil [internet]. Rev. Saúde Públ. 2009 [acesso em 2019 ago 2]; 43(supl1):29-35. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102009000800006.
http://www.scielo.br/scielo.php?script=s... ^,3333 Silva MA, Bandeira M, Scalon JD, et al. Satisfação dos pacientes com os serviços de saúde mental: A percepção de mudanças como preditora [internet]. J. bras. Psiquiatr. 2012 [acesso em 2019 ago 2]; 61(2):64-71. Disponível em: http://www.scielo.br/pdf/jbpsiq/v61n2/02.pdf.
http://www.scielo.br/pdf/jbpsiq/v61n2/02... .

We evaluated that the positive results observed by the individuals assisted in the services, regardless of their race or color, indicate that Caps AD are services that surpass the rigid and segregationist construction of other models of health care found in Brazil and in the world^13-16, lying on their progressive nature ever since their implementation.

Caps are seen in the literature as services that provide space to diversity, citizenship, cultural appreciation, with a focus on the rights and protagonism of the assisted individuals³⁴34 Lavrador MCC, Lima Ribeiro W. As forças do CAPS: uma experiência cartográfica. Rev. Psicol. Saúde. 2015 [acesso em 2020 set 1]; 7(2):90-98. Disponível em: http://pepsic.bvsalud.org/pdf/rpsaude/v7n2/v7n2a02.pdf.
http://pepsic.bvsalud.org/pdf/rpsaude/v7... . We understand that the role Caps AD play in the Psychiatric Reform, along with their history and their central service for an integral health system, are all responsible for the results found here.

Unfortunately, the scenario of comprehensive mental health care has been threatened in recent years by practices and services that bring back the conservative and asylum centered mentality. Some services, such as therapeutic communities, use labor therapy and offer healing through religion, departing completely from evidence-based practices³⁵35 Lussi IAO, Ferigato SH, Gozzi APNF, et al. Saúde mental em pauta: afirmação do cuidado em liberdade e resistência aos retrocessos. Cad. Bras. Ter. Ocup. 2019; 27:1-3. Disponível em: http://www.cadernosdeterapiaocupacional.ufscar.br/index.php/cadernos/article/view/2502/0.
http://www.cadernosdeterapiaocupacional.... . This approach hampers the progress that came along with the Brazilian psychiatric reform and there is literature we support confirming this. Such setback may soon threaten the existence of the psychosocial care network, making prevail again the psychiatric hospital and asylum centered perspectives³⁵35 Lussi IAO, Ferigato SH, Gozzi APNF, et al. Saúde mental em pauta: afirmação do cuidado em liberdade e resistência aos retrocessos. Cad. Bras. Ter. Ocup. 2019; 27:1-3. Disponível em: http://www.cadernosdeterapiaocupacional.ufscar.br/index.php/cadernos/article/view/2502/0.
http://www.cadernosdeterapiaocupacional.... .

However, we are faced with the dialectic relation between conservative and progressive practices, which brings tension to the care provided by the psychosocial field valued by the Brazilian psychiatric reform taken place between the 1980s and the year 2016, when a clear conservative wave took hold of Brazil³⁶36 Almeida R. A onda quebrada - evangélicos e conservadorismo [internet]. Cad. Pagu. 2017 [acesso em 2020 jul 22]; 50. Disponível em: https://www.scielo.br/pdf/cpa/n50/1809-4449-cpa-18094449201700500001.pdf.
https://www.scielo.br/pdf/cpa/n50/1809-4... ^,3737 Almeida R, Toniol R. Conservadorismos, fascismos e fundamentalismos: análises conjunturais. Campinas: Unicamp; 2018., with its effects being seen in the system as a whole. The clashes between asylum and other forms of care in the community, the psychiatric field versus the psychosocial field, the goal of total abstinence as a norm versus harm reduction as an option of choice and, last but not least, the war on drugs policy – historically instituted as a war against the poor, black and peripheral population – are elements that challenge mental health and alcohol and drug practices and impose constant barriers to be overcome. It is necessary to rely on scientific evidence and on humanized, inclusive and comprehensive care, such as that provided by the Caps AD, so as to resist to this setback scenario and think over public policies that support the subject’s decriminalization model³⁵35 Lussi IAO, Ferigato SH, Gozzi APNF, et al. Saúde mental em pauta: afirmação do cuidado em liberdade e resistência aos retrocessos. Cad. Bras. Ter. Ocup. 2019; 27:1-3. Disponível em: http://www.cadernosdeterapiaocupacional.ufscar.br/index.php/cadernos/article/view/2502/0.
http://www.cadernosdeterapiaocupacional.... .

The assistance provided by Caps AD in the states of São Paulo, Minas Gerais and Amapá is satisfactory, regardless of the race and color variable, with emphasis on the competence and welcoming of the health team, given that it highlights the potential of community mental health services to provide care to the entire population with needs arising from substance use, without reinforcing the place of difference related both to drug use and ethnic-racial issues.

Limitations to study

Given that it is transversal, this study did not evaluate cause and effect relations. Besides, the small amount of papers on the theme found in the literature restrained the discussion to a few findings.

Contributions of the study to the practice

Caps AD are considered satisfactory among users of alcohol and other drugs, regardless of race or color. Evaluating satisfaction with the service through a racial approach allows giving a voice to participants, especially those from the black population, reflecting on the role and quality of the assistance provided. Such an attitude provides for the continuous understanding, elucidation and co-responsibility of the actors involved, i.e., professionals, managers, broader society and those assisted by the service, towards an assistance that may be increasingly equitable, integral, effective, participatory, non-judgmental or stigmatizing.

Conclusions

The findings of this study showed, in general, good satisfaction of users regarding the service offered in the analyzed Caps ADs, creating the possibility of larger access to treatment, as well as a positive image of these venues, seen as powerful places for care in the network. Although there was no difference in the level of satisfaction reported between blacks and non-blacks, such similarity can be an indication of quality of care.

It is true that more research evaluating these services is necessary as it allows reflections on the role and quality of the assistance provided, in addition to giving voice to the service users about the experiences lived in these places. In addition, the evaluation through the racial cut contributes to strengthening the National Policy of Integral Health of the Black Population (PNSIPN) focused on the attention to mental health, allowing, thus, a greater understanding towards an increasingly equitable and integral assistance.

The best scores, obtained by both blacks and non-blacks, were related to factors Help, Welcoming and Understanding, all of them related to the bond between the professional and the user. These factors indicate, respectively, the fulfillment of the objectives of the service and its importance, representing an important advance in the Brazilian psychiatric reform from the perspective of care and reception for all types of population, despite difficulties faced in terms of comfort and physical structure, a factor with a lower satisfaction score compared to other factors.

In view of the small amount of publications that address this issue from a racial perspective, this study represents an important estimate of the evaluation of the black population in these three states, requiring an expansion of the evaluation to other regions of the country. In this way, it is expected that the results will contribute to local policies in the improvement of actions that expand comprehensive care, generating greater evidence with a racial profile.

References

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History