Resumen de Efectos de una intervención a familiares de consumidores de alcohol en una región indígena en México

Guillermina Natera Rey, Perla S. Medina Aguilar, Fransilvania Callejas Pérez, Francisco Juárez García, Marcela Tiburcio Sainz

• español

  El consumo de alcohol en la región indígena del Estado de Hidalgo representa un problema de salud importante. Según la ENA 2008, el consumo diario es de 1.4%, el consuetudinario de 6.6% y el índice de abuso y dependencia de 6.8%, todos por encima de la media nacional de 0.8, 5.3 y 5.5%, respectivamente. Hidalgo presentó en 2007 una tasa de mortalidad por cirrosis hepática de 40.2 por cada 100 000 habitantes, primer lugar del país, que en promedio tiene una tasa de 26.3 habitantes por cada 100 000.

  La familia es el grupo más inmediato que se ve afectado por el consumo de alcohol, con implicaciones graves para la salud psicológica y física de sus miembros. Para conocer cómo enfrentan esta situación las familias en zonas indígenas del Estado de Hidalgo, se llevó a cabo un estudio etnográfico donde se encontró que el consumo de alcohol es una costumbre arraigada en la comunidad, que proporciona identidad y solidaridad de grupo. Un resultado relevante del estudio fue la queja de las mujeres de no saber qué hacer frente a las consecuencias que tiene el consumo excesivo de alcohol en la familia, así como la fuerte influencia patriarcal que limita a las mujeres para solicitar apoyo psicológico. La pobreza, las difíciles condiciones geográficas, transportes insuficientes y la prioridad de resolver necesidades básicas limitan la búsqueda de apoyo profesional. Como resultado de la exploración etnográfica, se identificó la necesidad de atención a las familias para encontrar mejores formas de enfrentar la problemática; por ello se adaptó un programa para ofrecer acciones de apoyo a familias indígenas. La intervención se llevó a cabo entre 2008 y 2009, los resultados se presentan en este trabajo.

  Modelo de atención: La intervención breve tiene como meta ayudar a los familiares a encontrar formas de enfrentar las situaciones de consumo de manera más benéfica para su salud y establecer o fortalecer redes de apoyo. Consta de cinco pasos: 1. Escuchar la problemática del familiar, 2. Brindar información relevante, 3. Analizar los estilos de enfrentamiento utilizados, 4. Búsqueda de fuentes de apoyo y 5. Canalización en caso de requerir atención especializada.

  Éstos se llevan a cabo en aproximadamente cinco sesiones. Material y método Objetivo: Evaluar los efectos de la intervención breve sobre la presencia de sintomatología física y psicológica, los estilos de enfrentamiento utilizados y la presencia de sintomatología depresiva, en personas que conviven con un familiar con consumo excesivo de alcohol.

  Muestra: 60 mujeres entre 18 y 65 años con problemas por el consumo de alcohol de un familiar (esposo o padre). Se integraron dos grupos, uno con intervención y otro sin ella. Para formar el primero, el personal de los centros de salud canalizó a los familiares con las orientadoras (dos psicólogas) para recibir atención, que concluía una vez que las mujeres manifestaban confianza para utilizar nuevos estilos de enfrentamiento, lo que ocurrió entre las sesiones cuatro y seis. El «grupo sin intervención» se formó con quienes, teniendo el problema, no aceptaron acudir a las sesiones, pero accedieron a contestar los cuestionarios y a ser contactadas cuatro meses después para responder los instrumentos. Instrumentos: Tres cuestionarios adaptados y validados para la zona: Escala de Síntomas (SRT), Cuestionario de Enfrentamientos (CQ) y Escala de Depresión CES-D.

  Diseño: Comparación antes y después de la intervención (tres meses después) con un grupo sin intervención. Análisis de datos: prueba t y análisis de varianza de medidas repetidas para determinar los cambios entre los dos grupos. El proyecto fue aprobado por el comité de ética del Instituto Nacional de Psiquiatría.

  Resultados El grupo que recibió la intervención tuvo una disminución significativa de síntomas físicos y psicológicos, así como de depresión, mientras que éstos aumentaron en el grupo sin intervención. Los enfrentamientos comprometido y tolerante disminuyeron entre la primera y segunda medición, mientras que el independiente se mantuvo en el grupo con intervención. Lo contrario ocurrió con el grupo sin intervención, quienes mantuvieron los enfrentamientos que implican más estrés. Discusión El modelo fue exitoso para la población indígena. Se hace una reflexión sobre los aspectos culturales de llevar a cabo una intervención de esta naturaleza.

• English

  The 2008 National Addictions Survey reports that dependence on alcohol consumption is higher in Mexico's rural and indigenous communities (10.6%) than in urban areas (9.5%), and that its consequences for the social and health environment are correspondingly greater. This is compounded by the marginalization and poverty of these regions and the scant resources available for dealing with health, particularly alcoholism. The study was carried out in the indigenous zone of El Mezquital in the state of Hidalgo. In this state, the National Addictions Survey (2008) reports that daily consumption is 1.4% and habitual consumption is 6.6% while the index of abuse and dependence is 6.8%, all of which are above the national mean of 0.8%, 5.3% and 5.5%, respectively. One of the consequences is having a mortality rate for hepatic cirrhosis of 40.2 for every 100 000 inhabitants, making this the area with the highest mortality rate from this cause in Mexico, which has an average rate of 26.3 cirrhosis-related deaths for every 100 000 inhabitants.

  The family is the most immediate group affected by the alcoholism of one of its members, which has severe implications for the psychological and physical health of the other members. Since little is known about the way families in Mexico's indigenous or rural zones deal with this problem, a research project was carried out to find out more about the situation. To this end, an ethnographic study was undertaken to identify the role of alcohol in everyday life and determine families' needs for support and the cultural challenges that must be overcome to undertake an intervention. The results of the ethnographic exploration showed that alcohol consumption is a deeply-ingrained custom in the community that provides group identity and solidarity, particularly for men. Its consumption is closely linked to work, particularly agricultural activities and construction. One important aspect was women's complaints that they did not know what to do about the consequences of excess alcohol consumption on the family's health and economy. In addition to this, a powerful patriarchal influence was identified that prevented women from seeking psychological assistance for the problem of alcohol abuse, which is essentially male.

  Poverty is one of the characteristics of the desert area of El Mezquital where this study was carried out. It constitutes yet another obstacle to seeking and requesting help, partly because of the adverse geographical conditions that limit transport. In addition to the scant transport services, there are communities in which the nearest health center is just over an hour's walk away. Moreover, families' scant resources are used to cover basic needs, ignoring both physical and mental health aspects. On the basis of an ethnographic study, an intervention program was linguistically and culturally adapted to provide support for families. This resulted in a specialized manual suitable for the region, designed to train health professionals to help relatives cope with a family member's excess consumption. This intervention was carried out between 2008 and 2009 and the results are presented in this study.

  Intervention model This brief intervention, based on the stress-coping-health model, is designed to help relatives find means of coping with their relatives' consumption in a more beneficial way for their health and to establish or strengthen support networks on the basis of their needs. Three coping styles have been documented: committed, tolerant and independent.

  The intervention consists of five steps that can be carried out in approximately five sessions. These involve: 1. Exploring family concerns; 2. Providing essential information on the effects of alcohol consumption; 3. Analyzing the coping styles used; 4. Exploring social support networks; and 5. Referring family members to specialized care, where necessary. Through these five stops, the intervention seeks to: a) Reduce the presence of physical and psychological symptomatology; b) Improve coping styles in a way that will benefit the relative's mental health and c) Reduce the presence of depressive symptomatology.

  Method Objective: The purpose of this study was to evaluate the effects of the brief intervention on relatives of a person who consumes excess amounts of alcohol and to compare these results with relatives who, despite having the same problem, refused to participate in the intervention program. Procedure: the intervention was carried out by two psychologists (facilitators). Health center personnel referred relatives to the facilitators (group that experienced the intervention). The intervention ended when the women felt confident enough to be able to use the new coping styles, which took between 4 and 6 sessions (which lasted from 6 to 8 weeks). The "group without intervention" consisted of those that did not agree to attend the sessions yet agreed to answer the questionnaires and be contacted 3 months later so that the questionnaires could be re-applied. The questionnaires were administered by three interviewers. On this occasion, they were invited to attend the intervention again, but no-one accepted. Sample: Sixty women aged 18 to 65 with problems due to a relative's alcohol consumption. Application of intervention: most of the intervention sessions were carried out at the community health centers. Instruments: Three questionnaires, adapted and validated for the zone, were used, namely the: Symptom Scale (SRT), Coping Questionnaire (CQ) and the Center for Epidemiological Studies Depression Scale (CES-D). Design: quasi-experimental, pre- and postintervention evaluation (3 months later) compared with a group without intervention. Data analysis: t tests were used to compare the initial mean scores for each instrument. A variance analysis of repeated measures was carried out to determine changes between the two groups (with and without the intervention) before and afterwards, for physical and psychological symptoms, depression levels and coping styles. Ethical considerations: The project was approved by the ethics committee of the National Institute of Psychiatry.

  Results It was found that the group that received the intervention experienced a significant drop in physical and psychological symptoms and depression, whereas these symptoms increased in the group without the intervention. The average number of committed and tolerant coping styles fell between the first and second measurement, while independent coping was maintained in the group with the intervention. Conversely, the group without the intervention maintained its committed and tolerant coping styles and significantly reduced its independent behavior.

  Discussion The analysis shows that the model can successfully be used in indigenous zones, since there was a reduction in the number of physical, psychological and depressive symptoms in the group that received the intervention. They also reduced their tolerant and committed coping styles and maintained their independent behavior, which involves a less stressful response. This in turn enables them to focus more on their personal needs and seek more beneficial alternatives for themselves and the rest of the family. In other words, the greater, the independence, the fewer the psychological symptoms. Conversely, in the group without the intervention, their symptoms not only continued but actually worsened over time, with group members continuing to use tolerant mechanisms, which produce more stress.

  The group of women that completed the intervention and attended the entire process probably did so not only to reach the goal they had pledged to meet but because during the process they obtained immediate benefits that enabled them to cope with the challenges of everyday life and attend sessions regularly despite their adverse circumstances.

  One of the advantages of this program is that it does not require specialized areas or personnel, just training in the model, meaning that it can be carried out anywhere that guarantees confidentiality. One of the limitations of the study was that the groups were not formed strictly randomly, because of the characteristics of the community and the high costs this entails. It would be useful to have larger samples from other indigenous communities in order to be able to generalize results.