SUS users’ perception: a speech-language pathology approach based on health promotion

Purpose: This study aimed to analyze the perceptions of users of the Brazilian Unified Health System (SUS) about the treatment Center where they were assisted, as well as about the speech-language pathology services rendered by this Center. Methods: This is a transversal study composed of an interview with 26 open questions and 14 closed questions applied to 111 individuals who were assisted at the SUS Center in August 2013. The quantitative content analysis was conducted through the use of the GraphPadPrisma 5.1, Statistic Package for Social Sciences (SPSS) 15.0 software and the application of the D’agostino & Person, F-test and chi-squared test. Results: Most participants reported a positive perception about the facilities and staff of the treatment center. They were also positive about the waiting time and the speech-language pathologists’ explanations and conduct, especially in the audiology department. Most responses from participants were short and did not present an argumentative context. Conclusion: The treatment center received a high approval rating by most users. The audiology department had better grades than the clinical services related to language and oral motor pathologies.


INTRODUCTION
The guarantee of health services for the Brazilian population is closely related to the country's democratization and the establishment of a unified health system. In 1986, the 8th National Health Conference (CNS), which had the theme, "Democracy is Health", organized a discussion forum for the decentralization of the health system and the implementation of social policies that defend and take care of life. Thus, the discussions on public health in the second half of the 1980s were instrumental in promoting Brazilian health reform, affirming the inseparability among a health guarantee as an irrevocable social right, other human rights, and citizenship (1) .
The Unified Health System (SUS), created in Brazil in 1988 with the promulgation of the new Constitution, established free access to health services to the whole population. The Constitution defined in Article 196 that health "is everyone's right and the duty of the State." It should be noted that, until then, the Brazilian health model was organized according to three categories of people: one geared to people who could afford private health services; another directed to those entitled to public health because they were insured by social security as registered workers; and, finally, the third, which was comprised of people who were treated as indigent and had no rights at all (2) . With the implementation of SUS, health became a right of all people, no longer the exclusive responsibility of the federal executive branch and administered by states and municipalities.
It should be noted that the creation of SUS was based on a broader health concept (3) . Before its creation, health was seen as the state of having no disease, causing the system to revolve around the healing of health problems. However, with the implementation of SUS, the way of thinking that only dealt with the effects of disease, with less emphasis on the causes, was replaced with a broader understanding of healthy living, which focuses on health promotion and incorporates improved conditions for nutrition, housing, employment, and education, as well as ensuring access to public services responsible for the promotion, protection and recovery of health (4) .
In this way, users of public services are understood to be "social beings" with life stories covered by concerns, frustrations and longings, contrary to the biomedical model that divides the human being into specific parts and treats it as if it were a machine (5) . Thus, through the SUS principles of universality and equity, the life of each person is understood in its uniqueness and multidimensionality. Such principles call into question statements on the concept of health merely in its biological dimension, as well as prescriptive and normative ways to intervene in the reality of the subjects and their communities (6) .
In order to provide public health services with quality and in accordance with the principles proposed in the Federal Constitution, the practices of these services started being constantly reevaluated. In view of this, the qualification of public services has been reported in current research (2,7) as important to generating stability in the context of public health. Social participation, while an organizing principle for SUS, has been guiding such research in that it emphasizes the role of individuals who use health services, possibly and more effectively leading to organizational guidelines to improve care, focused on the patients who use public health services.
Gauging the perception of users regarding the public services they have received is a necessary tool to promote the improvement of such services, and patient satisfaction is an important criterion in assessing the quality of service (7) . The evaluation of public services by its users is necessary so that the users become part of the discussion that directly involves aspects related to their quality of life. Thus, the analysis of the perception of speech therapy services linked to SUS is essential for planning and coordinating activities in public health, as it contributes to the improvement in care by targeting patients, along with the development of more humane and welcoming speech therapy practices.
Thus, taking into account the relevance of the qualification of public services by its users, as well as speech therapy care in SUS, this study aims to analyze the perception of users at a SUS-approved health center have about the center itself as well as about the speech therapy services provided. The research took place in a SUS-approved health center located in Cascavel, Paraná, Brazil. The care provided in this center are linked to SUS, as proposed by the Brazilian Constitution which refers to private participation in the public health system, in a complementary manner with respect to the provision of services -provided that the private center follows SUS principles and guidelines. It is noteworthy that the center's infrastructure and health professionals are supported financially by the private sector.

This
To participate in the study, the individuals must have undergone some speech therapy during the month of August in 2013 at the Audiology Sector and/ or in other sectors aimed at speech-language therapies. For patients younger than 16 years old, the parents were invited to participate. During the period of data collection, the assisted population consisted of 190 patients linked to SUS. Individuals were excluded if they presented neurological and/ or mental disorders related to language, or if they were unwilling or unable to respond to the specific questions in the study. Thus, 111 individuals participated in the study, 17 patients were 17 years of age or older and 94 were adults who were responsible for patients 16 years of age or younger, of both genders.
Knowledge of the purpose of the research and necessary procedures were presented in the consent form, which was read and signed by all participants. After signing, the participants answered a questionnaire in a room at the health center.
The questionnaire (Appendix 1), developed by the researchers, contained twenty-six (26) open questions and fourteen (14) closed questions related to SUS services and grading the services on a scale from 1 to 5. A grade of one (1) meant poor; two (2) meant fair; three (3) meant good; four (4) meant great; and five (5) meant excellent. It should be pointed out that the questionnaire was given orally by the researchers to the patients who then responded orally. These exchanges were recorded in audio and later transcribed by the researchers.
For quantitative analysis of the data, Windows Excel  and Statistic Package for Social Sciences  (SPSS) system version 15.0 were used, both in the Windows XP operating system. Graph Pad Prism 5.1 was also used for the comparative nonparametric F-test and chi-squared test. The variables were analyzed by observing the minimum and maximum values, calculating averages, standard deviations and medians. For qualitative variables the absolute and relative frequencies were considered, based on content analysis frequency (8) , along with the axis of hermeneutic interpretation, and guided by the production of inferences and scope, not a priori.
The analysis categories were subdivided into: 1) overall rating of health center -including the facilities and the secretarial/ reception staff; 2) specific assessment of speech therapy services -including expectations of service, quality of speech therapy, behavior/ explanations provided by professional speech therapist, amount of time waiting for appointment/ exam.
The descriptions of the individuals participating in the study were identified with the letter P (referring to the word, participant) followed by the numbers 1-111.

RESULTS
The sample consisted of 111 participants, 60.4% (n=67) of participants were adults responsible for children of up to one year of age; 24.3% (n=27) were adults responsible for children attending speech therapy who were between one and 16 years of age; and 15.3% (n=17) were patients between 17 and 86 years of age.
Most participants, or 42.34%, reside with their spouse and a child. The average salary of the study population is two to four times the minimum wage (52.25% of respondents). As for education, most, 36.94%, have completed high school, followed by 28.83% with only elementary education, and 17.12% with some high school, 11.7% did not finish elementary school, and 5.41% have a college degree.
Regarding patient referral, doctors and hospitals in the western region of Paraná were responsible for the majority of referrals to the health center, i.e., 86.49% of the total (doctors 45.95% and hospitals: 40.54%).
In terms of the overall assessment of the health center, the infrastructure and secretarial/ reception staff were mentioned, as shown in Chart 1.
The facilities of the center were by given high approval ratings by the individuals. The score ranged from good to great and excellent. In relation to the care provided by the staff of secretaries, only two participants, or 1.8%, classified the service as poor, with most participants rating the service as good (24.3%) or great and excellent (combined for 73.9%). When those who rated the service as bad were asked about why they gave such a grade for the services provided by the secretaries, the participants stated that the staff appeared to be in a "bad mood" in a given situation.
For 40.22% of individuals, the service provided by the secretaries and receptionists was the most positive part of the center in the general assessment, followed by the service being cost-free (18.18%), and the organization and cleanliness of the location (15.3%).
This positive perception of the secretaries' and receptionists' service can be seen in the testimonials presented below: As for the specific evaluation of speech therapy services offered, it should be noted that this evaluation addressed: the areas of speech for which care was sought; the waiting time to be seen; the fulfillment of the expectations related to services rendered; and the conduct and explanations provided by the audiologist during the visits.
Most participants, 60.36% (n=67), sought out speech therapy in the audiology department, followed by the oral language department for 35.14% (n=39) of participants. Written language was the department visited by only 1.8% (n=2) of individuals, and oral motor skills by 2.7% (n=3).
For individuals' perception of the specific assessment of speech therapy services, participants were separated into guardians for patients who underwent the infant ear exam (60.36%) and other patients and/ or their guardians (39.64%) who receive speech-language therapies at the health center, as shown in Figure 1. This separation is justified by the fact that there is a percentage difference in the qualification of services among patients who only underwent hearing tests from other patients who come for weekly therapy at the center. The latter group has more frequent contact with the center, while those who underwent only hearing tests had no further contact with the speech therapy services after their child's exam.
Of the respondents who underwent the infant ear exam, 61.19% (n=41) classify the service as excellent; 20.89% (n=14) as good, and 17.91% (n=12) as great. Of the patients undergoing therapy at the center, 36.36% (n=16) classify it as excellent; 27.27% (n=12) as great; 34.09% (n=15) as good, and 2.27% (n=1) as fair. There were no grades of bad for the health service in either of the two groups interviewed.
Regarding the scoring of the quality of speech therapy services provided by the audiologist, it was based on the "efficiency of treatment", cited by 83.8% of the individuals as good for the service in carrying out the exam, with 61.6% of the undergoing individuals the infant ear exam. The subject that gave a grade of fair mentioned the "coarseness and moodiness" of the audiologist who provided care.
The stories below illustrate the analysis of the scoring for quality of speech therapy services: In relation to the waiting time for audiological treatment, most individuals who underwent the infant ear exam, 74.62% (n=50), did not have to wait for their appointment, 22.38% (n=15) waited up to three months for an appointment, and 2.98% (n=2) waited up to six months ( Figure 2). The percentage of individuals who waited three to six months can be explained by the fact that there was a breakdown of equipment (for OAE) in the period scheduled for hearing testing. Therefore, these patients were given a later date because the equipment needed to be repaired.
This study showed a high percentage of SUS user satisfaction concurrently with a shorter waiting time for therapeutic session appointments. To clarify the answers given by the individuals, below is a statement from P34: It was observed that 14.5% of respondents mentioned waiting time, using terms that were widely cited in individuals' answers, such as: "I was not on the waiting list," "short waiting time," "There was no wait." Regarding expectations about the service, the scoring for the quality of labor and conduct/ explanation by the audiologist were analyzed as shown in Table 1, shown below.
Data were tested for normality using the D'Agostino and Person statistical test, observing homogeneity in the sample. Then the comparative non-parametric F-test and chi-squared test were applied. The data is not significant for p<0.05, when comparing individuals who underwent the infant ear exam and other patients.
It can be seen that the scoring on the quality of the work was considered excellent by 61.19% of infant ear exam participants, while only 36.36% of the other patients who underwent oral/ written and oral language motor skills therapy assessed their service as excellent. It is noted also that the question related to the audiologist's conduct obtained an excellent grade by 71.64% of the infant ear exam individuals, whereas 36.36% of the other language therapy patients (for oral/ written and motor skills) gave such a high grade.
Grades of "partially fulfilled" or "did not fulfill" expectations for the infant ear exam on the questionnaire can be explained by the fact that these individuals were unable to perform the hearing tests completely, that is, those responsible had to reschedule the testing due to the fact that the baby who would perform the test did not sleep, or the baby was colicky/ crying, which caused such grades for the speech therapy services provided.
The grade of "partially fulfilled" by two individuals who had speech-language therapies was justified by the fact that they had "been in treatment for a long time" and others related as to "not liking to do audiology exercises".
The answers below may illustrate the evaluation of individuals regarding the audiologist's conduct/ explanations regarding the care and the work performed:

DISCUSSION
This study presented a profile of early-age patients in speech therapy, most still in early childhood. Brazilian research also shows that the highest incidence of therapeutic sessions occurs in children up to 12 years of age (9)(10)(11) .
In addition, there was a greater number of male patients, but no significant difference between genders. This finding is supported by most of the literature, where there is a predominance of speech therapy in male patients (12)(13)(14)(15) .
Male predominance, according to previous research, may be due to the fact that acquisition and development of language occur differently between genders because of their different ways of interacting with the environment and the fact that brain development maturation rates are slower in boys than girls. However, there are no significant studies showing the relationship between the predominance of males and audiological alterations (9,16) .
With regard to referrals from the individuals, physicians were the group that referred the most patients to the center, coinciding with the studied literature (10,13,17) .
The main reason for seeking speech therapy services is linked to hearing concerns, followed by complaints related to oral language. These data do not coincide with national studies, in which the predominant area of complaints was with oral language (10,11,13) . The different result found in this research can be explained in the fact that most patients treated at the center were referred by doctors who conduct hearing testing, a factor that contributed to the high number of services related to audiological tests.
The grading on quality for the health center showed that most of the statements by the study's participants were positive with respect to the facilities and secretary/ reception staff.
It should be noted that this study was conducted in a public health center that is run by a private entity, FAG, which is a private institution that has an agreement with SUS, according to the Ordinance 1034 from the Ministry of Health, and this factor may have a differential impact on user ratings, generating a high quality-related score.
The character of private participation in the provision of public services implies the constitutional content of complementarity. In the logic of the health system, contracted and covered services follow the same principles and guidelines as the public sector. However, investment in this health center's infrastructure is made by the private sector and does not represent most of the existing physical structures in the public health sector. For example, the center has no shortage of materials for the sessions; the rooms are spacious, airy, well-lit, and sanitized.
Nevertheless, the positive image created by such a clean and well-kept center is evident by the evaluations of the SUS patients who took part in this survey, citing as positives for the center: the service at reception, proper cleaning, modern equipment, the facilities, and services at no cost.
Feeling good and being well received is an indication of satisfaction with the work by the secretaries, who, by being friendly to patients and willing to help them, are in line with the SUS principle of being appealing to users. Although the secretaries of this center are not health professionals, they perform essential initial care, as patients in the reception are in their company for a certain time until being served by specific departments. This study reveals that patients satisfied with initial responsive service may have greater interest in the professional health procedure that follows (18) .
As for the specific evaluation of speech therapy services provided, there was a high demand for audiological services. One factor that may have led to these findings was that since 2010, by Federal Law 12.303/2010 (2) , the infant ear exam became mandatory for newborns throughout country, triggering an increased demand for care in the center's audiology department. Another significant factor is that there are no other centers in the city that perform these exams through SUS, which explains the significant demand for audiology services at the studied center.
One point highlighted in the study was the interest shown by professionals in resolving the patients' problems, which is focused on significantly in the training for speech therapy services through SUS. The service based on the patient's hearing and good professional performance provide for a service-user binomial link in healthcare. This link improves the healthcare process, providing for quality service.
This study reveals that there is a direct relationship between users satisfied with the positive outcome of treatment and greater adherence to it (19) . In the statements by P01 and P44, this relationship was clear. It was noticed that the condition of the patient improves and the insistence in getting positive outcomes were guiding factors for the positive evaluations, which indicated satisfaction with speech therapy services.
The statements were significant in illustrating that the quality of speech therapy received was also consistent with the improvement in quality of life for SUS patients. And it should also be pointed out that quality of life and quality in therapeutic sessions are also related to another factor that may be helping this positive view: the short waiting period for appointments.
Short waiting time can be a factor that contributed to the high scores in quality of speech therapy services, as other research indicates generally long waiting times for examinations and/ or queries related to audiological health services (13,20,21) .
P34's statement shows that SUS services are not thought of as being fast or efficient. In this sense, it is clear that the fact that there was a short waiting time for appointments in this center, possibly due to the number of professionals available for carrying out speech therapy services. At this center there are four speech therapists: one who works full time (40 hours/ week) and the others part time (20 hours/ week). Thus, this number of professionals makes it possible to decrease waiting times and increase the number of appointments for the community.
Setting an appointment, as a condition for health care, is presented as a picture highlighted in the perception of the public regarding SUS. There is, therefore, a barrier to be overcome so that the service actually takes place Currently there is a vision of how much waiting weighs on the system in the real sense, so it must be resolved existentially and the solution to the problem blends into the perception that users have of their own public health system (22) .
Respondents report the short wait as a positive point at the studied center, since the vast majority did not have to wait at all to get appointments. In this sense, the literature indicates that there is a differential related to purely public SUS services and those carried out in private-public partnerships (21,22) . The waiting for appointments at some public centers for consults/ exams can reach years, while for private partner centers, such as the center in this study, the wait is less, reaching up to around a six-month wait.
Through analyzed reports, you can see that the constant use of a health service can generate a more accurate analysis of the processes of care, because the perception of speech-language services by users the infant ear exam, and other users who underwent speech therapies aimed at language and oral motor skills were distinct. The first had a single contact the health center, while the second remained in treatment longer and probably assessed the services in more detail than patients who only came in once for a test. This continued view of the speech therapy process exposes parameters not perceived by users who attended the only center to perform hearing tests. From this difference, you can infer that the continued use of the service can produce a lower satisfaction index regarding care and the explanations given by audiologists.
Another issue that may have contributed to such differentiation was the importance given in solving the patients' problems. Here, audiological work has more evident and faster results than, for example, therapeutic work with an aphasic patient, which requires numerous therapies to begin to show improvement in orality. We can also report here the issue of planning actions and therapeutic prognosis, which in the audiology industry are conducted objectively and are clearly palpable, while therapeutic work is directed gradually, using the subjective perception of the patient.
Still on the analysis of the responses by the individuals, it is noteworthy that 52% of the analyzed statements the most common response was "just because" -a succinct answer. Such a response, devoid of further argument, brings to light the lack of empowerment felt by the participants in this research. Through empowerment, it is possible that individuals and groups are able to further analyze public health services, developing a capacity for intervention and improving such services.
In the logic of empowerment, which seeks to equip SUS users with autonomy to strengthen the public system, social participation of individuals ensures better quality in the execution of public policies. Therefore, it is possible to infer that the participants of this research -as SUS patients -are people who need some kind of action to show them their rights and duties, thereby ensuring their role in the process.
Empowerment, in this context, can be considered to be a process that gives a voice to marginalized groups and, at the same time, removes barriers which limit the promotion of a healthy life to different social groups. Empowerment promotes social participation, aimed at the integration of excluded groups and those deprived of basic materials for survival, generating increased control over life for individuals and communities, as well as political efficacy for greater social justice and improved quality of life (23) . This process -which intensifies increasing political awareness of the individuals and mobilizing communities for the sake of clarifying and defending their solutions to the public health system -butts heads with the installed political structure that Brazil has had since its inception. The social health organization meets management and education models that make up the Brazilian reality, in which people are taught not to get involved in these debates. Thus, in the same way that social involvement is directly related to education and political/ social awareness, non-involvement reflects the success of models for social alienation of the population (24) . Therefore, it is necessary to promote the role of SUS through actions that trigger the empowerment of individuals. It is through this role that users can be seen as social change agents, through the monitoring and supervision of public policies and the discussions of public health situations.
In this direction, we must also reflect on professional conduct as seen through the biomedical lens, which establishes an impersonal relationship with patients. Research reaffirms the interference of the hegemonic model characterized by work centered on the medical consultation and little appreciation as to the beliefs and subjectivities of patients, excluding them from the construction of their own therapeutic process (25)(26)(27) .
The model commonly practiced in public health in general consists of a fragmented and dehumanized practice, which fails to appeal to patients. Time constraints, organizational aspects of care, difficulty in orientation capacity, and a lack of actions that should be performed are all problems that hinder the quality of health promotion work. The introduction of these activities throughout clinical practice remains a challenge in most public services (5) .
To rethink the whole of health care, it is necessary to deepen the debate on its theoretical foundations, particularly the nature and organization of health care processes centered on users and their needs (28) . In this sense, the formation of social networks and community empowerment is needed, as well as their accountability and participation in the definition of actions to be developed (29) .
The strengthening of popular involvement in political and social issues is directly related to the development of actions that reach the consciousness of the individual as a transforming agent of collective reality. Knowledge of civil and governmental duty to health is part of an indispensable process for the development of public services. The reflections generated by the incentive of a model of society with greater popular participation fall not only on public health, but also on building a just society that is fairer, more comprehensive and universal.
We would like to point out that, after this study, managers at the health center in question installed a suggestion box in the center's reception in order to listen to users, and the suggestions are now analyzed once a month, at a meeting with the interdisciplinary team. After this study, the center also obtained a greater acceptance by health professionals in engagement with the humanization of practices, and the manual, "Humaniza SUS" ("Humanize SUS") was distributed to the professionals of the institution in order to strengthen these actions.
In this sense, this research confirms the importance of social participation in the context of public health and emphasizes that professionals working in public health services, including speech therapists, need to overcome the traditional practice based on the biomedical model -taking a more humane and welcoming perspective.

CONCLUSION
The facilities and the reception of the health center were given high approval ratings by SUS users. More specifically, with regard to speech therapy, it was possible to relate the positive perception of the user to the short waiting time, the explanations provided by audiologists during visits, and the expectations related to the service performed. The audiology department received higher grades than the clinical areas related to therapies for oral motor skills and language. Most of the justifications of respondents on the grading of services was answered succinctly and without an argumentative thread.
This research considers that grading the quality of SUS-related services by users is necessary, in general, to promote the improvement of the health system itself and, specifically, to make speech therapy a more humane practice.

Author contributions
JTC participated as project author, collected data and prepared the article. GM participated as project advisor, and reviewed and organized the article. ACG participated in the revision of the text and the translation into English. FMP carried out the statistical analysis and preparation of graphics.