Activities of speech-language-hearing therapists in the Extended Family Health and Primary Care Center from the perspective of team cooperation

ABSTRACT Purpose: to describe the activities of speech-language-hearing therapists in the Extended Family Health and Primary Care Center from the perspective of team cooperation. Methods: an exploratory study with a quantitative and qualitative approach. The participants in the research were 4 speech-language-hearing therapists and 3 speech-language-hearing residents who were developing their practices in the Extended Family Health and Primary Care Center of Vitória de Santo Antão, PE, Brazil. The data were collected at two moments: The first one involved the analysis of the instrument where the activities of the speech-language-hearing therapists in the Extended Family Health and Primary Care Center were registered; in the second one, these professionals were interviewed to understand their work process in PHC, in relation to team cooperation. Results: the speech-language-hearing therapists presented an adequate understanding of the concept of team cooperation and the broad range of activities carried out, predominantly individual attention (27%) and shared group activities (18%). The need to strengthen their professional training to work with primary care and the little knowledge of the teams and population about the work of the speech-language-hearing therapists are the main challenges reported by the interviewees. To improve the work of the teams, they suggested more continuing education opportunities and more participation of the administrators in interpersonal conflict mediation. Conclusion: despite the difficulties related to professional education and the work process, the speech-language-hearing therapists in the Extended Family Health and Primary Care Center have been performing activities from the perspective of team cooperation, collaborating to the comprehensiveness and solvability of care.


INTRODUCTION
The objective of the Extended Family Health Care Center (NASF, its Portuguese acronym), created by the Ministry of Health in 2008, was to give support to the Family Health Strategy and broaden the solvability and coverage of primary health care (PHC) in Brazil. The guidelines with which the teams worked were based on overcoming the fragmented health care mindset, striving instead for comprehensive health care for the population that used the health system 1 .
The NASF is characterized by a multiprofessional team that may include, among others, speechlanguage-hearing therapists, nutritionists, physical therapists, psychologists, physical educators, and veterinarians. The team's makeup is defined by the municipal administrator and depends on various factors, such as the needs of the populations and the availability of professionals 1,2 .
In recent years, the NASF has been going through some changes. In September 2017, the new National Primary Health Care Policy (PNAB) revised the guidelines that organized PHC, included other modalities of PHC teams to be supported by the NASF, and changed its name to Extended Family Health and Basic Care Center (NASF-AB) 2, 3 . In November 2019, The Ministry of Health approved Regulation no. 2,979 to institute the program Previne Brasil (Prevention Brazil), which establishes the new model to pay for the costs of the PHC and extinguishes the specific resource for the NASF-AB teams. In February 2020, the Ministry of Health promulgated a new regulation, changing again its name to Extended Family Health and Primary Care Center (NASF-AP); it also excluded the description of the types of teams involved in it and the number of Family Health Teams they should support 4,5 .
The NASF-AP, as a multiprofessional team, can offer support to the Family Health Strategy in health promotion and injury prevention. The speech-languagehearing therapist belonging to this team can help identify factors that lead to changes that might affect human communication health, with health promotion and prevention, and thus help maintain the quality of life 6,7 .
The cooperation between teams has been a useful tool in various care contexts, including the NASF-AP teams, to organize the teams' work process and ensure the integration of the various categories. This tool, considered a health care administration methodology as well, was first incorporated in the mental health services. The team cooperation aims to provide specialized support to the teams responsible for the attention to health problems of a given population. It can be implemented based on two dimensions, namely: the assistance, providing direct clinical action with the user, and the technical-pedagogical, providing educative support actions, with and for the reference teams, increasing the intervention possibilities 8,9 . Considering that until recently the work of the speech-language-hearing therapists focused only on the medium-and high-complexity services and understanding the importance of their work in PHC, it is necessary to carry out scientific studies on these professionals' work process in the context of PHC. The analysis of local circumstances, based on the theoretical-methodological reference proposed for the work of the NASF-AP teams, can help develop a basis to strengthen the quality of health care in this assistance level, as well as the training of health professionals, such as the speech-language-hearing therapists 10 . This study aimed to analyze the work of the speechlanguage-hearing therapist in the NASF-AP, from the perspective of team cooperation.

This research was approved by the Human
Research Ethics Committee of the Universidade Federal de Pernambuco (Federal University of Pernambuco), Brazil, under protocol no. 141007/2019. The professionals that participated in the research signed the informed consent form, which provided important information about the study. This is an exploratory study with both a quantitative and qualitative approach. The research was conducted in the municipality of Vitória de Santo Antão, Pernambuco, Brazil, at the community health centers where the NASF-AP work. This municipality counts with five NASF-AP teams who give support to 35 Family Health Teams. Four speech-language-hearing therapists who belonged to the NASF-AP participated in the research, as well as three speech-language-hearing residents who developed their practices in that same service. The speech-language-hearing therapists hired by the Municipal Department of Health are identified in the text as T1, T2, T3, and T4. The residents are named R1, R2, and R3.
The data were collected at two moments. In the first one, the document that registered the activities of the speech-language-hearing therapists in the NASF-AP was analyzed, with variables related to the types of practice developed at the workplace, such as individual and shared attention, group activities, home visits, and so forth. In the analysis, the activities were characterized according to the dimensions of team cooperation, namely: The technical-pedagogical, more related to educative support with the reference teams, and the assistance dimension, characterized by the direct clinical action with the users. The results are presented in a bar chart, showing the activities carried out by the speech-language-hearing therapists.
At the second moment, the speech-languagehearing therapists were interviewed with a semi-structured questionnaire about their professional education, work in PHC, potentials of the speech-language-hearing therapists in the NASF-AP, their understanding of team cooperation, and difficulties faced in the work routine in PHC. The interviews were digitally recorded, then transcribed and submitted to successive readings and Bardin's content analysis. It is important to highlight that the saturation criterion was not necessary because all the speech-language-hearing therapists that worked in the NASF-AP of the said municipality participated in the study.
In the data analysis, the words of the interviewees were systematized per theme categories, based on the core meanings that made up communication -which, depending on the presence or frequency, may have some meaning to the analytical objective 11 . This content analysis method comprises three major stages: 1) Pre-analysis, consisting of the reading and re-reading of the material collected in the interviews; 2) Exploration of the material, which defines the rules to count and classify the information into categories; 3) Treatment of the results and interpretation, aiming to assimilate the content expressed in the words of the professionals that participated in the study 12 .

RESULTS
Regarding the profile of the speech-languagehearing therapists who participated in the research, most of them were 20 to 35 years old, and all of them were females, with less than 5 years' experience at the NASF-AP; three had just graduated (health residents).
Most of the activities -approximately 27% -carried out by the speech-language-hearing therapists at the NASF-AP were individual attention, followed by shared activities (18%), and team meetings (15%) (Figure 1).

Figura 1. Gráfico tipos de atividades desenvolvidas pelos fonoaudiólogos inseridos no NASF-AP
team meetings and cooperation. These are the tools that the Ministry of Health aims for, right? There are also the home visits and technical instructions, and the work process goes on that path..." (T3) A broad field of work was identified in the speechlanguage-hearing therapists' words, ranging from health promotion and prevention to attention and rehabilitation. The diversity of activities listed by the professionals encompass the technical-pedagogical and technical-assistance dimensions of team cooperation -although the latter evidently predominated.

Challenges of the speech-language-hearing therapists in PHC
The challenges identified are related to the difficulty, on the part of the professionals of the Family Health Strategy and the population, to understand the role of the work carried out by the NASF-AP team. Many professionals of other fields of knowledge also have difficulties perceiving the possibilities in the work of speech-language-hearing therapists -which consequently decreases their opportunities and often makes them uncomfortable.
"The family health team doesn't understand our work process, which makes the relationship rough sometimes..." (R1). In the interview content analysis, six theme categories came up: professional education, speechlanguage-hearing therapists' work in PHC, challenges of the speech-language-hearing therapists in PHC, solvability of the speech-language-hearing therapists in PHC, their understanding of team cooperation, and suggestions to strengthen the work process in the NASF-AP.

Professional Education
This category identified aspects related to the role of professional education in the development of professional skills for the speech-language-hearing therapist to work in PHC. "

Speech-language-hearing therapists' work in PHC
As for the work carried out by speech-languagehearing therapists in the NASF-AP, a variety of activities was identified, encompassing promotion, prevention, and rehabilitation for individuals and groups.
"We're in the community, we can screen the population and give them satisfactory and effective guidelines.
"The work, not only of the speech-language-hearing therapist but also of the whole NASF team, includes more investments in the practical continuing education of the professionals who work in PHC. It was also suggested that administrators participate more in conflict mediation between the teams. Speech-language-hearing therapists believe that some problems related to the work process could be solved if the administration drew closer to the workers.
"It's essential to reinforce the practical continuing education and use this setting to present the work of a speech-language-hearing therapist, how the NASF works because it's still a critical dilemmapractical continuing education with the professionals to explain what the work at NASF is because they sometimes have a strong bias, seeing it as an essentially outpatient care..." (R3).
"More opportunities for the Strategy and the NASF to meet and discuss, speak, promote continuing education..." (T1).
"I would suggest that the administration be strengthened and that they give more attention because I see that many of the problems could be solved by the administration..." (T3).
"I really think the administration could invest more in the professionals' training..." (R2).

DISCUSSION
Professional education is the basis for every worker to carry out their profession. The pedagogical framework in the Speech-Language-Hearing Sciences has been going through changes for some years in the effort to adjust it to the demands with which the profession has been dealing in recent years. Speechlanguage-hearing therapy is increasingly growing within public health; hence, the undergraduate programs have felt the need to train professionals to work in this field. However, some programs are not prepared yet to train professionals with a generalized look with which to join public health 6,[13][14][15] .
It is expected that the speech-language-hearing undergraduate student will have contact with content in the field of public health (including PHC) during their training. It is also expected that this professional will graduate with theoretical and practical knowledge of the work process in the NASF-AP.
This study reveals that the speech-languagehearing therapists mainly develop individual and group activities, team cooperation meetings, home visits, and so on. According to the Ministry of Health, the work

Solvability of the speech-language-hearing therapists in PHC
It was observed that the great potential of the speech-language-hearing therapists in PHC is to detect and solve human communication disorders at the first health care level, besides interacting with other professions, strengthening the comprehensive care of people in the community.
"The speech-language-hearing therapist, along with the other professionals who make up the NASF team, aims at comprehensive care for the users. Since these therapists deal with communication disorders, their presence in the NASF team is extremely important because they will work in rehabilitation, mental health, child health. Since primary care is the users' entry point into the public health system, some problems can be solved there..." (R2).
"Since I began here until now, I'm more and more in love with it because I see our importance in primary care. In NASF, our dialogue dynamics between centers, our involvement with physical therapy and social work, the home visits. We can detect pathologies related to our field, solving some cases, promoting groups in the health center..." (T1).

Understanding of team cooperation
The speech-language-hearing therapists understand team cooperation as a strategy to organize the teamwork and strengthen the link between teams that work with primary care. "I understand team cooperation as a strategy to organize the health work that took place thanks to this integration between the NASF team and the Family Health Team..." (R2).
"Team cooperation is exactly this, the NASF team drawing near the Family Health Team in this support, this guideline, this partnership..." (T2).

Suggestions to strengthen the work process in the NASF-AP
From the professionals' standpoint, it is necessary to strengthen the work process of the NASF-AP teams. To achieve such a goal, they believe there should be conducted by the NASF-AP must be based on providing support to the Family Health Teams, improving their solvability, and reinforcing comprehensive care. The presence of speech-language-hearing therapists has broadened the range of activities and early intervention in PHC 6,7,10 .
There are various possibilities for the speechlanguage-hearing therapist to work in PHC, both specific and shared, either in their core knowledge or in the common field of health. Nevertheless, it is still common to find difficulties in the workplace regarding the speech-language-hearing therapists' field of work. The professional education may once again be related to this since little is observed concerning the preparation for interprofessional work 15,16 . Thus, undergraduate programs could develop a relationship with those of different professions and learn about work in that field, as shown in a study conducted in João Pessoa, Paraíba 17 .
Another great challenge listed by the speechlanguage-hearing therapists is related to the narrow perception of both the professionals in the Family Health Strategy and the community regarding the work process in the NASF-AP. The way these teams carry out their activities is often misunderstood, leading to interpersonal conflicts. Therefore, professionals in PHC need to get acquainted with how other professions work and learn to work together. This would help the community understand the role of primary care and value health promotion and injury prevention actions 7,18,19 .
Along with the challenges, there are also the potentials of the speech-language-hearing therapists working in PHC. Those who participated in this research predominantly used the term "solvability" to communicate the importance of having them in a multiprofessional team. According to the Ministry of Health, one of the objectives of the NASF-AP team is to provide specialized support to the Family Health Teams and promote comprehensiveness and solvability in health care 7 .
Another point emphasized in the words of the speech-language-hearing therapists was the shared teamwork. A study conducted in the city of São Paulo aimed to understand the work of the speech-languagehearing therapists in the NASF-AP and identify technologies integrated into the work process. Its interviews revealed that the shared teamwork is important not only for the reassurance in having an NASF-AP workmate but also the learning, exchanging, and sharing when they need to decide what is best in each given case. This corroborates the results of this study 6,16 .
To guide the organization of the NASF-AP work process, the Ministry of Health initially defined some technological tools such as team cooperation, whose concept was outlined in the 1990s. It has been implemented since then as a theoretical-methodological reference to reorganize work processes in the field of mental health in some Brazilian cities 20 .
In general, "cooperation" is understood as participating, supporting, sharing the responsibility for specific health needs presented by a person, family, or community. Team cooperation has two dimensions: Assistance, directly related to the care for individuals, and technical-pedagogical, related to support to the teams, with the possibility of broadening the intervention, furnished by a new look and knowledge acquired during case discussions and shared attention 21,22 .
Those who participated in this study expressed their understanding of team cooperation as a work organization logic 6 . It is through cooperation that the NASF-AP as a team of specialists works in various shared activities with the Family Health Teams. Hence, it is possible to broaden the range of possibilities for the existing needs in the community, based on the logic of cooperation, in which professionals of different standpoints and fields discuss, debate, intervene, and contribute to comprehensiveness and solvability 23 .
Another perspective of the speech-language-hearing therapists in this research refers to team cooperation as a means to draw closer to the Family Health Strategy and improve the relationship with them. As mentioned before, the cooperation can take place in two contexts, the clinical-assistance and the technical-pedagogical. In both perspectives, the NASF-AP professional is cooperating and somehow improving relationships with either the community or the reference team 22 .
Implementing this logic in everyday routine does not seem to be quite easy. A previous study carried out in São Paulo city identified many difficulties for the NASF-AP to work along with the Family Health Teams, as these last ones felt they were being inspected. Thus, discussing any case together led to uneasiness. They felt this could expose their flaws and, in a way, reveal unskillfulness 24 .
In this study, when the speech-language-hearing therapists reinforced the team cooperation as a strategy to strengthen the relationship with the supported teams, they seem to point out that this methodology allows for greater communication and mutual learning with exchanged experiences, thus favoring a better relationship between the teams. When these teams meet and have mutual understanding, the noises, myths, and challenges of interprofessional work can be tackled and overcome, leading to a better quality in health care 18 .
The speech-language-hearing therapists made suggestions that, in their understanding, could strengthen the NASF-AP work process. The first suggestion was related to greater investment in practical continuing education for the PHC teams. It would be possible to solve most of the difficulties found in the work process with continuing education activities. Practical continuing education promoted by administrators reveals they are interested in always training and updating the professionals to provide quality health care to the population. It also brings about changes in the professionals and their work processes, resulting in a service closer to the population's health needs 18,24 .
The training themes and proposals must be chosen based on the needs of each specific team in its work process. As a result, health professionals can offer quality services and the users' needs are met 18 . A study carried out in inland Santa Catarina State showed the difficulties in professional training initiatives, hindering the work process. In it, the interviewees linked this fact to the administration's lack of knowledge of the importance of practical continuing education as one of the guidelines for health work, corroborating the findings of this study 25 .
Another suggestion expressed in the words of the speech-language-hearing therapists refers to the effective participation of the health administrator in problem-solving. It is believed that many difficulties in the work process would be solved or mitigated if the administration participated more. According to Parisi and Silva 26 , it is by proposing comprehension, accepting the differences, and encouraging dialogue that conflict mediation in the context of health takes place.
For the work to be developed in an organized fashion, the administration must be committed to monitoring and assessing its teams, ensuring good working conditions, planning, providing continuing education to the professionals, and valuing their work. Thus, the likelihood of consolidating the teams working in PHC increases [27][28][29] .
This study helped understand more in-depth the role of the speech-language-hearing therapists in the NASF as a professional who has various working possibilities available, individually and/or in groups, working based on the logic of team cooperation, always aiming at health promotion, prevention, and recovery 7,10 . Besides understanding the difficulties involved in the work process as expressed in the reports, good suggestions to improve it were observed, such as strengthening continuing education settings, given the importance of constantly updating the professionals involved with PHC striving to offer quality services with properly trained professionals 24 .
Further studies are suggested on the work process of the speech-language-hearing therapist in PHC.
The analysis of their work from the standpoint of other NASF-AP professionals and the Family Health Teams may reveal potentials and challenges for this profession. This would help furnish the basis to qualify the work process and strengthen the training of speechlanguage-hearing therapists to work at this assistance level.

CONCLUSION
The good understanding the speech-languagehearing therapists have about the concept of team cooperation, thus carrying out the activities guided by this tool, was observed in this study.
Even though there are difficulties related to the professional education and the work process, the speech-language-hearing therapists in the NASF-AP have been performing individual and group activities, working with health promotion, injury prevention, recovery, and rehabilitation, aiming, always, at the comprehensiveness of care and the greater solvability of the cases.