Psychological Ways of Providing Primary Medical Sanitary Help for People who Use Psychoactive Substances

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Psychological Ways of Providing Primary Medical Sanitary Help for People who Use Psychoactive Substances

Yevhen Kharchenko

Dr. in Medicine, Professor, Rivne Medical Academy, Rivne (Ukraine)

Denys Kurytsia

Ph.D. in Psychology, Senior Lecturer, Kamianets-Podilskyi National Ivan Ohnenko University, Kamianets-

ABSTRACT

The purpose of the research is to study the state of the problem of the usage of psychoactive substances in the institutions of primary health care of Ukraine and in other countries all over the world.

The following theoretical methods of the research were used to solve the tasks formulated in the article: a categorical method, structural and functional methods, the methods of the analysis, systematization, modeling, generalization. Also in our research we used empirical methods, such as the observation, the interview, a questionnaire, testing, the method of expert assessments.

The results of the research. The urgency of the provision of comprehensive primary health care to those who use psychoactive substances is in line with the strategic task of preserving and improving the health of Ukrainian citizens. The problem of the usage of psychoactive substances among the population of different countries, in particular in Ukraine, is one of the most important medical and social issues of nowadays. At the beginning of 2016, 1.7 million of people in Ukraine who were in need of psychiatric and narcological care had been registered in the health care system. It is almost 4% of the total population of the country. In the structure of mental disorders in 2015, the most common mental and behavioral disorders due to the use of psychoactive substances (alcohol, narcotic substances), representing 58.41% of all reported cases. There were 8.9% of health disorders which are related to stress, neurotic and somatoform disorders, there were 1.8% mood disorders. Among persons with a pathology of the psyche and behavior there were registered in 2015, there had been 62.7% of people of working age. In 2020 there were 1.9 million of people in Ukraine who were in need of psychiatric and narcological care had been registered in the health care system. There were 10.1% of health disorders which are related to stress, neurotic and somatoform disorders, there were 2.3% mood disorders.

Our own researches data for 2020 also indicate a high level of PS usage among young people: on average, 86.1% of pupils used any alcohol drink at least once in their lives. In the age of 17 this figure is 79.4%, and at 16-17 years old it is approaching 88%.

Conclusions. We explain these results having been obtained by us by COVID-19 pandemic in the whole world. In Ukraine people began to use more psychoactive substances. Let's try to explain this logic with the help of psychological frames. It should be noted that the rich phenomenology of ecopsychological expeditions and the small number of scientific researches of the mental state of individuals during the COVID-19 pandemic allowed us to identify some phenomena of Environmental Psychology categorically and, for the first time, although to determine well-known scientific concepts which have been used.

It should be noted at once that under the influence of the COVID-19 pandemic human behavior acquires a sufficiently explicit eco-attribution. Eco-attribution (from the Greek oikos - the environment and from Latin - attribuo - to give, to provide) is a lifestyle that provides the primary importance of the environment, the natural expediency of caring for nature, a kind of harmony of a man and a nature, as well as the world around us. Eco-attribution or eco-attri-butive behavior presupposes the understanding not only of well-balanced harmonizations in the space of nature, but also in the living environment in general, as well as adequate inclusion of human activity in the environment, performance of its activities, on the one hand, in accordance with the laws of nature taking into account the conditions of existence in the society, taking into account the pandemic COVID-19 and working out its own style of the behavior, which is natural and viable under such conditions.

Eco-attributive behavior and the activity involve the search for adequate forms and principles, especially for biological adaptation and protection in changes of living conditions. As we predicted, the characteristic features of eco-psychological stress, manifested in the person's desire to change the situation, significantly changes the very behavior and activities of people. Personal content, which is now formed in the case of absence of practical experience and practical skills of adaptation to such experiences and actions, forms, as it turned out, not flexible behavior. The basis of such behavior was rigid, torpedo mental states, pandemic or «covid» accentuations, anxiety and fear.

Key words: primary health care, family medicine, psychoactive substances, the influence of the COVID-19 pandemic human behavior, the explicit eco-attribution, eco-attributive behavior.

АНОТАЦІЯ

Харченко Євген, Куриця Денис. Психологічні шляхи надання первинної медичної санітарної допомоги людям, які вживають психоактивні речовини

Метою статті є вивчення стану проблеми використання психоактив- них речовин і лікування хворих у закладах первинної медико-санітарної допомоги України й інших країн світу.

Для роз'язання сформульованих у роботі завдань було використано такі теоретичні методи дослідження: категоріальний, структурно-функціональний, методи аналізу, систематизації, моделювання, узагальнення. Також у дослідженні нами використано емпіричні методи, такі як спостереження, інтерв'ю, анкетування, тестування, метод експертних оцінок.

Результати дослідження. Актуальність надання комплексної первинної медико-санітарної допомоги тим, хто вживає психоактивні речовини, відповідає стратегічному завданню збереження та поліпшення здоров'я громадян України. Проблема вживання психоактивних речовин серед населення різних країн, зокрема України, є однією з найважливіших медичних і соціальних проблем сучасності. На початок 2016 року в Україні в системі охорони здоров'я було зареєстровано 1,7 млн людей, які потребували психіатричної та наркологічної допомоги. Це - майже 4% від загальної кількості населення країни. У структурі психічних розладів у 2015 р. діагностовано найпоширеніші психічні та поведінкові розлади внаслідок вживання психоактивних речовин (алкоголю, наркотичних речовин), що становить 58,41% від усіх зареєстрованих випадків. Діагностовано 8,9% розладів здоров'я, пов'язаних зі стресом, невротичними та соматоформними розладами, серед яких було 1,8% ментальних розладів. Серед зареєстрованих у 2015 р. осіб із патологією психіки та поведінки було 62,7% людей працездатного віку. У2020 р. в Україні на обліку перебувало 1,9 млн осіб, які потребували психіатричної та наркологічної допомоги. Серед цих людей діагностовано 10,1% розладів здоров'я, пов'язаних зі стресом, невротичними та соматоформними розладами, у тому числі 2,3% розладів настрою.

Дані власних досліджень за 2020 рік також свідчать щодо високого рівня використання психоактивних речовин серед молоді: в середньому 86,1% учнів хоч раз у житті вживали будь-які алкогольні напої. У віці 17 років цей показник становить 79,4%, а у 16-17 років він наближається до 88%.

Висновки. Отримані результати ми великою мірою пояснюємо пандемією СОУІЮ-19 у цілому світі. В Україні люди стали вживати більше пси- хоактивнихречовин. Слід зазначити, що феноменологія екопсихологічних експедицій і невелика кількість наукових досліджень психічного стану людей під час пандемії СОУІЮ-19 дозволили вперше звернути увагу на деякі явища екологічної психології, відомі наукові концепції, що використовувалися. Слід одразу зазначити, що під впливом пандемії СОУІЮ-19 поведінка людини набуває досить явних екологічних характеристик.

Екоатрибуцію ми розглядаємо як спосіб життя, який забезпечує охорону довкілля, природну доцільність дбайливого ставлення до природи, своєрідну гармонію людини та природи і світу навколо нас. Екоатрибу- ція, або екоатрибутивна поведінка, передбачають розуміння не тільки збалансованих гармонізацій у просторі природи, але й у життєвому середовищі загалом, а також адекватне включення людської діяльності в парадигму навколишнього середовища, виконання її діяльності, з одного боку, відповідно до законів природи з урахуванням умов існування в суспільстві, з урахуванням пандемії СОУІЮ-19 і вироблення власного стилю поведінки, який є природним і життєздатним за таких умов.

Екоатрибутивна поведінка та діяльність передбачають пошук адекватних форм і принципів, особливо для біологічної адаптації та захисту в змінних умовах життєдіяльності. Як ми і передбачали, характерні риси еколого-психологічного стресу, що виявляються в прагненні людини змінити ситуацію, суттєво змінюють як саму поведінку, так і діяльність людей. Особистісно значущий зміст, що зараз формується у разі відсутності практичного досвіду та практичних навичок адаптації до таких переживань і дій, формує, як виявилося, негнучку поведінку. В основу такої поведінки покладено ригідні, торпедні психічні стани, пандемічні або «ковідні» акцентуації, тривогу і страх.

Ключові слова: первинна медична допомога, сімейна медицина, пси- хоактивні речовини, вплив пандеміїСОУІЮ-19 на поведінку людини, експлі- цитна екоатрибуція, екоатрибутивна поведінка.

Харченко Евгений, Курица Денис. Психологические пути оказания первичной медицинской санитарной помощи людям, которые употребляют психоактивные вещества

АННОТАЦИЯ

medical people psychoactive substances

Целью статьи является изучение состояния проблемы использования психоактивных веществ и лечения больных в учреждениях первичной медико-санитарной помощи Украины и других стран мира.

Для нахождения путей решения сформулированных в работе задач были использованы следующие теоретические методы исследования: категориальный, структурно-функциональный, методы анализа, сис-тематизации, моделирование, обобщение. Также в исследовании нами использованы эмпирические методы, такие как наблюдение, интервью, анкетирование, тестирование, метод экспертных оценок.

Результаты исследования. Актуальность предоставления комплексной первичной медико-санитарной помощи тем, кто употребляет психоактивные вещества, соответствует стратегической задаче сохранения и улучшения здоровья граждан Украины. Проблема употребления психоактивных веществ среди населения разных стран, включая Украину, является одной из важнейших медицинских и социальных проблем современности. На начало 2016 года в Украине в системе здравоохранения было зарегистрировано 1,7 млн человек, которые нуждались в психиатрической и наркологической помощи. Это - почти 4% от общего населения страны. В структуре психических расстройств в 2015 г. диагностированы распространенные психические и поведенческие расстройства вследствие употребления психоактивных веществ (алкоголя, наркотических веществ), что составляет 58,41% от всех зарегистрированных случаев. Диагностированы 8,9% расстройств здоровья, связанных со стрессом, невротическими и соматоформными расстройствами, среди которых было 1,8% ментальных расстройств. Среди зарегистрированных в 2015 г. лиц с патологией психики и поведения было 62,7% людей трудоспособного возраста. В 2020 г. в Украине на учете находилось 1,9 млн человек, нуждающихся в психиатрической и наркологической помощи. Среди этих людей диагностированы 10,1% расстройств здоровья, связанных со стрессом, невротическими и соматоформными расстройствами, в том числе было 2,3% расстройств настроения.

Данные собственных исследований, проведенных в 2020 году, также свидетельствуют о высокой степени использования психоактивных веществ среди молодежи: в среднем 86,1% учащихся хотя бы раз в жизни употребляли любые алкогольные напитки. В возрасте 17 лет этот показатель составляет 79,4%, а в 16-17лет он приближается к 88%.

Выводы. Полученные результаты мы во многом объясняем пандемией СОУЮ-19 во всем мире. В Украине люди стали употреблять больше психоактивных веществ. Следует отметить, что феноменология экопсихологических экспедиций и небольшое количество научных исследований психического состояния людей во время пандемии СОУЮ-19 позволили впервые акцентировать внимание на некоторых явлениях экологической психологии, известных используемых научных концепциях. Следует сразу отметить, что под влиянием пандемии СОУЮ-19 поведение человека приобретает достаточно явные экологические характеристики.

Экоатрибуцию мы рассматриваем как образ жизни, который обеспечивает охрану окружающей среды, естественную целесообразность бережного отношения к природе, своеобразную гармонию человека и природы и мира вокруг нас. Экоатрибуция, или экоатрибутивное поведение, предусматривают понимание не только сбалансированных гармонизаций в пространстве природы, но и в жизненной среде в целом, а также адекватное включение человеческой деятельности в парадигму окружающей среды, выполнение ее деятельности, с одной стороны, согласно законам природы с учетом характеристик существования в обществе с пандемией СОУЮ-19 и выработки собственного стиля поведения, который является естественным и жизнеспособным при таких условиях.

Экоатрибутивное поведение и деятельность предусматривают поиск адекватных форм и принципов, особенно для биологической адаптации и защиты в постоянно изменяющихся условиях жизнедеятельности. Как мы и предполагали, характерные черты эколого-психологического стресса эксплицируются в стремлении человека изменить ситуацию, существенно меняют как само поведение, так и деятельность людей. Личностно значимый смысл, который сейчас формируется в случае отсутствия практического опыта и практических навыков адаптации к таким переживаниям и действиям, формирует, как оказалось, негибкое поведение. В основе такого поведения находятся ригидные, торпедные психические состояния, пандемические или «ковидные» акцентуации, тревога и страх.

Ключевые слова: первичная медицинская помощь, семейная медицина, психоактивные вещества, влияние пандемии СОУЮ-19 на поведение человека, эксплицитная экоатрибуция, экоатрибутивное поведение.

Introduction

A distinctive feature of primary care is its priority focus on counseling and disease prevention within the existing health care system, which is based on the long-term contact of a healthcare doctor with a patient. In foreign countries such assistance is provided to the population by general practitioners or family physicians, as well as by middle-range medical personnel (Choi, Chau, Tsang, Tso, Chiu, Tong, Lee, Tak, Wai, Lee, Lam, Yu, Lai, Lai & Sik, 2003). In Ukraine, in the conditions of reforming the health care system, the issue of provi-ding primary health care to people who use psychoactive substances (PS) requires careful scientific, theoretical and practical justification on the basis of both Ukrainian researchers and the study of analogical experiences of economically developed countries.

The purpose of the research is to study the state of the problem of the usage of psychoactive substances in the institutions of primary health care of Ukraine and in other countries all over the world.

Methods of the research

The following theoretical methods of the research were used to solve the tasks formulated in the article: a categorical method, structural and functional methods, the methods of the analysis, systematization, modeling, generalization. Also in our research we used empirical methods, such as the observation, the interview, the questionnaire, testing, the method of expert assessments.

Results and their discussion

Despite the diversity of specific forms of organization of the public health system, the specifics of economic relations in this area of life of the society, we can identify a number of parameters that reflect the commonality of the directions of the development of this industry, inherent in different states:

* the characteristics of basic types of property;

* financing methods (obtaining resources);

* the mechanisms for stimulating doctors (or producers) and the population (consumers);

* forms and methods for controlling the volume and the quality of medical care (Epstein, Blake & Gonzdlez, 2017).

In each state, an authentic way of attracting economic instruments for the provision of medical care, preservation and improvement of public health is historically established and developed. The quantity and quality of the resources allocated by the community, the effectiveness of their usage in the healthcare sphere are determined by a complex system of economic, political, moral, ethical and other relations that have historically developed in the country (Li, Guan, Wu, Wang, Zhou, Tong, Ren, Leung, Lau & Wong, 2020).

The presence in a particular state of the relevant health care system is determined by many circumstances which underlie the classification of the health care system (Hayden, Farrar & Peiris, 2014). Some authors believe that within the modern approach according to the typology of different systems of this industry the legal characteristics of the universal relations between the physician and the patient might be dominant. These characteristics, in turn, are predetermined by the fundamental (constitutional) liberties of the person (Villar, Blanco & del Campo, 2015).

The experts of the World Health Organization (WHO) proposed a classification that distinguishes three primary types of health care system:

1) State or Beveridge system;

2) a system based on comprehensive health insurance, or a system of Bismarck;

3) non-state or private health care system (Huang, Wang & Li, 2020).

At the primary level, medical care begins and ends with up to 80% of the patients in the diagnostic and treatment. According to the statistics, from 1000 citizens 750 people have health problems each month. About 250 people are also seek and they allow medical help, and only 5 of them require consultations of a specialist of a specified profile, 9 people require in-patient care, 1 person requires high-tech health care, the others -- the help of a primary care physician (Hardeman, Rachel, Medina, Eduardo & Kozhimannil, 2016).

The main causes of mortality and population disability that can potentially be alerted are partly due to increased availability and quality of health care. Therefore, today the role of the primary care physician is becoming more and more relevant in improving the health of the population, especially when appealing to people who use psychoactive substances (Onufriieva, Chaikovska, Kobets, Pavelkiv & Melnychuk, 2020). The activities of the doctor of the outpatient clinic are aimed at:

* detecting the use of psychoactive substances during conducting preventive medical examination, medical treatment help;

* carrying out necessary preventive measures (in order to prevent the use of psychoactive substances), therapeutic and rehabilitation procedures (if it is available addictive status associated with the use of psychoactive substances).

A doctor of outpatient clinic determines the indications and scope of necessary diagnostic studies to clarify the use of psychoactive substances, the presence or absence of addictive status, indicates the indication for hospitalization, selects patients who require specialized treatments, conducts a dynamic observation of patients with detected species of chemical ad-diction, as well as carries out treatment and rehabilitation in accordance with the individual plan of treatment and rehabilitation measures (Khwaja, 2012).

Turning to the experience of the most economically developed countries of the world, we have to note the following. A general practitioner is the foundation of the primary healthcare sector in the Netherlands, where the drug treatment system began to emerge in the 30s of the XX century. In 1953, the Federation of Alcoholics was founded in the country, in 1988 the Netherlands Institute of Alcoholism and Drug Addiction was established in the Netherlands, which carries out the necessary studies, analyzes the situation in the country, develops recommendations for the government, coordinates the work of advisory centers and training personnel. The National Drug Addiction System forms Consultative Centers for people with alcoholism and drug addiction that are independent from the outpatient psychiatric care system. There are about 1000 professionals working in the Advisory Centers -- they are nurses, social psychologists, psychologists and psychiatrists. At the municipal level, projects on drug treatment with own sources of temporary funding are being implemented. In the Netherlands, medical institutions are funded primarily by insurance funds. The state also finances prevention programs, science and medical education. Social services, when they re-ceive funds from different sources, cooperate with medical institutions (Holshue, DeBolt, Lindquist, Lofy, Wiesman, Bruce, Spitters, Ericson, Wilkerson & Tural, 2020).

The UK primary care provider is represented by general medical practices, which are in a form of group or individual. Such practices are independent non-profit organizations. In the most cases, the doctor (or a group of doctors) has their own practice (premises, equipment) on the right of ownership. They hire the rest of the staff. Only in rare cases, practitioners rent a room for their work. General practitioners build their activities on the basis of the individual contract with the family health departments. The contract form is the only one for the whole country. The staff of practitioners consists of nurses, administrative staff. In one of the English cities, 8 thousand people are served by 5 doctors (4.5 rates) with a total staff of 30 people. These institutions provide assistance to the adult population and children. With such a job, one general practitioner in England has an average of 1.900 patients (Chen, Zhou & Dong, 2020).

Structurally, in Germany about half of the doctors working in ambulatory care, are doctors-specialist; 5% of all doctors who practice privately have the right to treat patients in a hospital; others send their patients for in-patient treatment into the hospital, and after discharge they take them for treatment and rehab. In recent years, outpatient care in Germany has also been provided by special departments at hospitals. A contract has been developed to provide such assistance at hospitals for 400 interventions, and for 150 diseases, outpatient (one-day) surgery has become mandatory. The most part of the urgent help in working hours and non-working hours is provided by ambulatory doctors in their reception rooms. The vast majority of family doctors visit patients at home, and in rural areas, and even during non-working hours. Clinical care is often provided by outpatient departments of hospitals. Emergency assistance in Germany is also combined with various types of emergency services and centers with single telephone numbers and the ability to call an emergency rescue or emergency medical team (Edwards, Lee & Esposito, 2019).

In France, primary and specialized ambulatory medical care that does not require hospitalization is carried out by private practitioners, other health professionals, and also doctors who work at hospitals and in clinics. The share of hospitals accounts for about 15% of all outpatient counseling. Ambulatory care, albeit on a smaller scale, with a large family about 1000 clinics are provided (state-owned, mutual-liability insurance companies, charitable foundations, etc.). As a rule, patients directly pay for medical services, and then receive from their insurance fund a refund in the prescribed amount (Kalil, Metersky & Klompas, 2016). Ambulatory care in France is provided mainly by private practitioners, most of them work alone. Only 38% of physicians are grouped together, thus seeking to optimize the time of admission of patients, as well as to share the usage of expensive equipment. The treatment without hospitalization is organized in two directions: the structure of reception and orientation of the open type, as well as the structure of rehabilitation of the patients. An important role is played by medical and psychological centers. Usually they are located outside the hospitals and provide advice to all those who wish the help, in the direction of the doctor or on their own initiative (Chan, Ng & Chan, 2003). Medical psychological centers do not only consult, but also conduct outpatient treatment, organize visiting home. They provide post-hospital therapies and social integration. The primary and current receptions are carried out by the nurses. They «lead» patients, coordinate meetings with a psychiatrist, a narcologist, a psychologist, social psychologists. Together with doctors, nurses develop a treatment plan, performing the necessary administrative and financial demarche, help patients to organize their daily lives in the interests of therapy (Ranieri, Rubenfeld & Thompson, 2012).

It should be noted that the peculiarity of primary care is that the same specialist provides such assistance to patients of different ages and socio-economic groups; citizens who want to prevent the development of diseases and maintain a healthy lifestyle, and who have chronic or acute physical, mental illnesses (Mykhalchuk, Pelekh, Kharchenko, Eduard Ivash- kevych, Ernest Ivashkevych, Prymachok, Hupavtseva & Zu- kow, 2020). That is, a doctor, providing such broadly-targeted assistance, should have a significant amount of knowledge in many branches of medicine and have clearly regulated contact with specialists of the specialized profile in cases where the patient will need more specified care (Lane, Marston & Fauci, 2016). For example, in the United States, in order to become a general practitioner, for a family doctor, to full medical education or already for existing degree, it is necessary to complete a three-year residency (with studying therapy, pediatrics, obstetrics and gynecology, psychiatry and gerontology with a special focus on holistic treatment of a man at all stages of his / her life, additional training on adolescent, palliative, sports medicine), providing family medicine, after which the doctor has to take the exam and obtain the right to be certified as a family one. The period of a three-year residency also includes the need for certification every 7--10 years. During this period, the doctor is a subject to audit in order to improve the quality of the provision of medical services. Since 1969 in the US, the entire district service has moved to family medicine. In Canada, general practitioners and family physicians become real doctors after 2 years of admission to basic education and certification of the College of Family Medicine with the obligatory regular confirmation of this certificate. In Sweden, a doctor's certificate of this specialty is obtained after 5 years of additional basic education. In India, the additional training period is for 3 years (Arabi, Balkhy, Hayden, Bouchama, Luke, Baillie, Al-Omari, Hajeer, Senga, Denison, Nguyen-Van-Tam, Shindo, Bermingham, Chappell, Van Kerkhove & Fowler, 2017).

Family medicine, with effective organization and training of specialists, occupies the most important place in the health system of any state. In the United States, for example, ap-proximately 25% of visits to doctors are visits to general practitioners or family doctors: 208 million visits to doctors per year, about 83 million of these visits to general practitioners or family physicians, and the need for people of such specialists today is far exceeded the offer. Since 1998, the number of residents specializing in family medicine has dropped signifi-cantly: from 3.292 in 1998 to 1.172 in 2008, and as a result, since 2000, 4/5 of all programs in institutions involving the preparation of residents for family medicine, were closed. In 2006, there were 100.431 practitioners of general practice in the country, and according to the calculations of the American Academy of Family Medicine, by 2020, the real need for doctors would be 139.531. In the United States, several types of the activities of family doctors were legalized: private practice (one doctor or group of doctors), practice in municipal, private health care facilities. Family medicine practitioners can work as consultants in various medical and insurance companies (Yang, Yang & Shen, 2020).

The world experience, generalized by the World Health Organization, shows that the development of primary care on the basis of family medicine is the most effective mean of achieving equitable distribution and rational usage of resources, and improving the performance of the health sector. In the most countries, primary health care in quality organizations provides up to 90% of the total volume of medical care. The number of doctors in general practice, family medicine is 30-50% of the total number of doctors (Zou, Ruan & Huang, 2020).

Today, the basis of the national health care system in Ukraine is primary care and preventive care, which is provided mainly by the general practitioner. Polyclinics, medical ambulatory clinic, nursing and midwifery centers and health centers are structural subdivisions of primary medical care providing primary pre-hospital medical-sanitary, primary medical-sanitary, primary specialized medical-sanitary, urgent, and also palliative medical care to the population.

The principle of availability of medical and preventive care is implemented in accordance with Article 49 of the Constitution of Ukraine, according to which «everyone has the right to health care, medical care and medical insurance. The state creates positive conditions for effective and accessible medical services for all citizens. In state and communal health care facilities, medical care is provided free of charge; the existing network of such facilities can not be reduced. The state promotes the development of medical institutions of all forms of ownership».

In our country primary health care is represented by structures that are functionally, organizationally and financially combined with specialized outpatient care. For a long time, attention has been focused on the development of sufficiently expensive types of specialized and emergency medical care. The financial support of the primary link was less than 10% of the funds allocated for health care, which did not allow to achieve optimal distribution of work volumes between types of medical services. In Ukraine, at primary level, only 30% of patients in cities and up to 50% of patients in rural areas start and end treatment. However, until now, indicators of quality of primary care have not been improved and implemented into widespread practice.

The irrational organization of primary care and its inadequate funding have led to a loss of complexity and continuity in providing medical care, a formal approach to prevention and dispensary treatment. As a result, there are high rates of late detection of severe illnesses and complications of chronic diseases, including chemical addictions, which cause an exces-sive need for expensive, specialized treatment.

In the current conditions of management of the primary health-care unit, the usage of economic instruments is practically impossible. There are also other primary health care problems that are caused by:

* the irrational healthcare infrastructure;

* low availability of primary care for the population, especially in rural areas;

* insufficient quality of primary health care due to technological backwardness of medical institutions, lack of staff motivation, treatment standards that do not meet current conditions of funding principles of health care institutions;

* improper personnel support;

* lack of effective primary health care and management system;

* lack of scientific substantiation and regulatory framework for the functioning and development of primary health care.

According to Article 35 of the Law of Ukraine «Fundamentals of Ukrainian Health Law», the state guarantees the provision of affordable socially acceptable primary health care as the main part of medical care for the population, which involves consultation of a doctor, simple diagnosis and treatment of the most common diseases, injuries and poisoning, preventive measures, referral of the patient for the provision of specialized and highly specialized care.

Thus, in Ukraine today the process of reforming the health care system is at the stage of initial structuring in extremely difficult economic conditions, which does not allow to formu-late rapidly and implement in medical practice the most expedient and effective model of provision of primary medical care to those who use psychoactive substances. In spite of this, based on similar experience in economically developed countries of the world, representatives of scientific and practical sectors of health care in Ukraine formulate the basic principles of primary health care, including those who use psychoactive substances.

The urgency of the provision of comprehensive primary health care to those who use psychoactive substances is in line with the strategic task of preserving and improving the health of Ukrainian citizens. The problem of the usage of psychoactive substances among the population of different countries, in particular in Ukraine, is one of the most important medical and social issues of nowadays. As of the beginning of 2016, 1.7 million of people in Ukraine who were in need of psychiatric and narcological care had been registered in the health care system. It is almost 4% of the total population of the country. In the structure of mental disorders in 2015, the most common mental and behavioral disorders due to the use of psychoactive substances (alcohol, narcotic substances), representing 58.41% of all reported cases. There were 8.9% of health disorders which are related to stress, neurotic and somatoform disorders, there were 1.8% mood disorders. Among persons with a pathology of the psyche and behavior there were registered in 2015, there had been 62.7% of people of working age. In 2020 there were 1.9 million of people in Ukraine who were in need of psychiatric and narcological care had been registered in the health care system. There were 10.1% of health disorders which are related to stress, neurotic and somatoform disorders, there were 2.3% mood disorders.

According to the WHO, psychiatric disorders are most often recorded in countries of Eastern Europe, which also belongs to Ukraine. Indicators of suicide in the Eastern Europe are particularly high, and the level of alcohol consumption is super-high and continues to grow.

The negative variability of moral and ethical criteria, the practical availability of various types of PS (alcohol, drugs, and tobacco products) have become a real cause of active growth and the spread of psychoactive substances among adolescents and young people. Undoubtedly, this problem has similar grounds for dependence on psychoactive substances in the countries of near and far abroad, therefore, the features of the model of medical and social assistance for this pathology have a common ground. According to epidemiological data, in recent years, mental and behavioral disorders due to the use of surfactants in Ukraine exceed the incidence of disorders of other registers. In addition, the situation in our country is characterized by a gradual increase of the indicators of chemical (alcohol, tobacco, narcotic, etc.) and non-chemical addictions.

According to the WHO, alcohol is the most widely used surfactant among children and adolescents in Ukraine. One person from four Ukrainians who suffers from alcohol depen-dence is a person under the age of 35.

According to the WHO, Ukraine ranks the first position in terms of the development of adolescent alcoholism. According to the researches, among adolescents in the age of 13--15 the teenagers drink alcohol (about 90% of them); smoking tobacco -- 63%; have an experience of using narcotic substances -- more than 14% of respondents. The cause of mortality of two thirds of young people in the age from 15 to 20 years old is poisoning with alcohol or accidents due to intoxication with surfactants. According to the Institute of Sociological Studies of Ukraine, alcoholic beverages were used by 36% of ten-years- old people, 49% and 54% -- of eleven and twelve years old; 78% teenagers are in the age of 14 years old, 85% -- 15 years old. Most of the respondents in the age of 16 and 22 used alcohol (93% and 98%). Researches of specialists of the National Medical Academy of Postgraduate Education named after. P. L. Shupyka of the Ministry of Health of Ukraine and the Institute of Pediatrics, Obstetrics and Gynecology of the National Academy of Medical Sciences of Ukraine testify that at the age of seven, the experience of using alcohol of children is acquired in families in the presence of parents (that is, on their initiative) on average from 11% to 16% of cases. One of the most common types of PS is tobacco. According to statistics, the number of people who smoke cigarettes daily is 10.2 million people, more than 500 thousand new consumers are joining for tobacco smoking every year. The most widespread age of smoking among children in Ukraine is 12--15 years old. Those who start smoking less than 11 years old, there are about a quarter. According to the latest data, among adolescents in age 14--17, a marked increase in tobacco smoking is from 3.3% to 4.3%. Girls, in general, begin to smoke a little later than boys (we speak about the age), gradually «catching up» boys studying in high school and after high school.

One of the factors that increases tobacco usage is alcohol and drugs. 37% of adolescents reported smoking much more preferable after drinking alcohol and drugs. Our research on «Youth and Youth Policy in Ukraine: Socio-Demographic Aspects» having been done in 2020 showed that 9% of respondents in the age of 15--34 have had the experience in the use of any narcotic substances during their lives. Significantly widespread among young people are cannabis, opioids, and psychostimulators. The first use of narcotic substances in 32% of respondents was at the age of 12--16 years old, in another 32% -- from 17 to 18 years old, and at the age of 19--28 -- 30% of young people have used narcotic substances. Among men, 34.4% tested drugs for the first time at the age of 12--16 years old, and among women -- 44.4% at the age of 19--28 years old. The given data confirms a dangerous period for taking narcotic drugs, it's the period of adolescence. Our results of the research among schoolchildren «Health and Behavioral Orientation of School-age Children (HBSC) (2020)» showed that 16% of all students had the experience of using alcohol, but they didn't use alcohol or marijuana. The highest percentage was observed among the students of vocational schools and universities of the I--III levels of accreditation -- by three percent, much lower -- by 1.5%, among pupils of 10--11 grades of secondary schools. Guys use drugs two times more often than girls.

The level of PS usage among young people shows low effectiveness of preventive measures according to using psychoactive substances among this target group. The majority of respondents started to use PS at the age of 13--15 years old. However, 15% of respondents at the first time tried PS at the age of 11 years old or even earlier. According to a lot of re-searches, the most risky age is 15 years old. The respondents who have used PS proved that among adolescents and youth (15--20 years old) had confirmed that 10--15% of them, besides alcohol, had the experience in taking different types of drugs. Among high school students, 80--90% have already taken alcohol occasionally, and regularly take it 3 or more times a month every 4--5 teenagers. Consumption of surfactants at this age leads to significant deterioration of health, as well as a deviant behavior, suicidal actions, also criminogenicity and injuries.

Our own researches data for 2020 also indicate a high level of PS usage among young people: on average, 86.1% of pupils used any alcohol drink at least once in their lives. In the age of 17 this figure is 79.4%, and at 16--17 years old it is approaching 88%.

Prophylactic work in Ukraine to prevent the usage of PS by the population, of course, is carried out, but its scale and features of the organization do not provide the proper effect.

Thus, the formation of the principles of the effective primary health care for those who use PS requires careful scientific, theoretical and practical substantiation according to their own developments and also because of studying similar experiences of economically developed countries all over the world. The leading factor of the implementation of healthcare reform in Ukraine is the development and providing the effective economic mechanism for the development of the above- mentioned medical care in a market environment, justifying the introduction of necessary changes to the laws of Ukraine and the decisions of the Government of our country.

In addition, the problem of implementation highly professional training of personnel of family doctors, general practitioners, medical psychologists and middle-level staff for the provision of medical care to the citizens of our country at a high level is still open.

Conclusions

We explain the results having been obtained in a great degree by COVID-19 pandemic in the whole world. In Ukraine people began to use more psychoactive substances. Let's try to explain this logic with the help of psychological frames. It should be noted that the rich phenomenology of ecopsychologi- cal expeditions and the small number of scientific researches of the mental state of individuals during the COVID-19 pandemic allowed us to identify some phenomena of Environmental Psychology categorically and, for the first time, although to determine well-known scientific concepts which have been used.

It should be noted at once that under the influence of the COVID-19 pandemic human behavior acquires a sufficiently explicit eco-attribution. Eco-attribution (from the Greek oikos -- the environment and from Latin -- attribuo -- to give, to provide) is a lifestyle that provides the primary importance of the environment, the natural expediency of caring for na-ture, a kind of harmony of a man and a nature, as well as the world around us. Eco-attribution or eco-attributive behavior presupposes the understanding not only of well-balanced harmonizations in the space of nature, but also in the living environment in general, as well as adequate inclusion of human activity in the environment, performance of its activities, on the one hand, in accordance with the laws of nature taking into account the conditions of existence in the society, taking into account the pandemic COVID-19 and working out its own style of the behavior, which is natural and viable under such conditions.

Eco-attributive behavior and the activity involve the search for adequate forms and principles, especially for biological adaptation and protection in changes of living conditions. As we predicted, the characteristic features of eco-psychological stress, manifested in the person's desire to change the situation, significantly changes the very behavior and activities of people. Personal content, which is now formed in the case of absence of practical experience and practical skills of adaptation to such experiences and actions, forms, as it turned out, not flexible behavior. The basis of such behavior was rigid, torpedo mental states, pandemic or «covid» accentuations, anxiety and fear.

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