COMMUNITY HEALTH WORKERS TRAINING ON INFANT HEARING HEALTH : INFORMATION RETENTION Capacitação de agentes comunitários de saúde na área de saúde auditiva infantil : retenção da informação recebida

(1) Programa de Pós-Graduação em Fonoaudiologia da Faculdade de Odontologia de Bauru – Universidade de São Paulo – FOB-USP), Bauru, São Paulo, Brasil. (2) Departamento de Fonoaudiologia da Faculdade de Odontologia de Bauru – FOB-USP, Bauru, São Paulo, Brasil. This study was held at Department of Audiology and Speech Pathology of the College of Dentistry of Bauru University of São Paulo FOB-USP Bauru, SP, Brazil. Conflict of interest: non-existent importance of promoting linkages between educational institutions and other strategic programs of the Labor Management and Health Education Secretariat, such as the “Pró-Saúde”, “PET-Saúde”, “UnA-SUS”, “Profaps” and “Telesaúde”. It is noteworthy that several definitions have been attributed to the permanent health education (PHE), some of which correspond to in-service education, continuing education and formal education of professionals. Nevertheless, the conceptual debate has advanced considerably with the proposal2 of quadrilateral training in health – education / healthcare management / care practices / social control, to place this training as an educational project that goes beyond education, to the technical-scientific domain of the profession and proposes the construction and organization of an education responsible for  INTRODUCTION

At the national level, the census showed that 5.1% of the Brazilian population declared disability, with some or great hearing difficulty 11 .In relation to Bauru, specifically, a prevalence of 0.96: 1,000 sensorineural hearing loss was observed in the analysis of the results of the Newborn Hearing Screening Program developed at a local Public Maternity Hospital, which assists children at high risk and is a reference for the city 12 .
The previously developed studies on hearing health were based on the WHO´s requirements, using the material proposed at the International Workshop on Primary Ear and Hearing Care 13 .Initially, this material was adapted to the Brazilian reality and validated, and later, used in a classroomtraining program 14 .In subsequent studies, the effectiveness of different interactive tele-education tools such as videoconference 15 , Cybertutor 16 and CD-ROM 17 was analyzed in subsequent studies.In the analysis of the results, the methodology used in these studies was the comparison of the participants´ performance through a questionnaire administered in the pre and immediate post-training moments, which showed retention of information in the short term, with a significant difference in general knowledge in both assessment moments.
However, it is essential that professionals manage to apply the knowledge in their daily performance activities not only at the immediate post-training time, but continuously.Thus, the maintenance of the information retention level over time is questioned.
Hence, the present study aimed at verifying the retention of information on infant hearing health by CHWs who participated in a training course.

METHODS
This is a longitudinal study, approved by the Human Research Ethics Committee of the School of Dentistry -University of São Paulo (FOB-USP) at Bauru, SP, process No. 038/2010, with the free and clarified consent term signed by the participants.
Twenty-four CHWs with representativeness of different FHS teams in Bauru and who had participated in a training program in the area of infant hearing health, joined the study.
Table 1 shows the absolute number of CHWs and FHS teams, as well as the relative amount of population coverage of both, at the federal, state and municipal levels, with reference to the period in which the study was conducted.

(Insert table 1)
interactive processes of action in reality to make changes (a desire for the future), mobilizing paths (negotiating and agreeing with processes), calling protagonisms (pedagogy in acto) and detecting the interactive and mobile scenarios of individuals, groups and institutions, such as knowledge and inventions (continuous mapping).
PHE also increased the debate on adult education and training opportunities that presupposes the use of teaching and learning active methods, the innovative pedagogical model being that of learning by doing, which assumes the inversion of the classical sequence theory/practice in knowledge production and assumes that it occurs dynamically, through action/reflection/action 3 .Tutoring must be present, both in classroom or distance activities, providing agility in the communication between professionals and tutors / facilitators / supervisors, so as to monitor the work and coping with critical situations 3 .
More recently, the Care Network for People with Disabilities within the Public Health System was established through decree No. 793 of 24 April 2012 4 .Primary care is one of the components in which this network will be organized and human resources training, both in the basic network, including family health teams and community health workers, and in physical, hearing, visual and intellectual rehabilitation services, remains as one of the guidelines of the National Health Policy for disabled people 4 .
In the specific literature, it is verified that health education actions for FHS professionals are generally directed to Community Health Workers (CHW) and nurses, occurring predominantly by means of introductory courses and within programs such as those of AIDS, Tuberculosis, Hemodialysis, Dengue, among others [5][6][7] .
As for speech therapy, some studies have been conducted in order to develop tools or provide training programs for CHWs 8,9 .In relation to hearing health, specifically, at the national level, since 2005, the researchers of this study at the Department of Speech Pathology of the institution have developed studies aimed at training the CHWs along with the Department of Health of Bauru, SP, Sorocaba, SP and Itajaí, SC.
Hearing impairment is considered a public health problem owing to its prevalence as well as its impact on the development of the individual, involving language and social, emotional, academic and professional aspects.According to the World Health Organization (WHO), the estimated number of people presented with disabling hearing loss was 278 millions, in 2005 10 .The possible answers were "true", "false" and "do not know" and the score was computed from the form proposed in previous 14,15 .A point was scored at every correct answer, thus, the total score of the questionnaire is at most 20 points, totaling 100% correct.rehabilitation of hearing impairment, organized into five modules: (1) Sound and audio system; (2) Hearing, language and hearing impairment; (3) Causes of hearing impairment and health care; (4) identification and diagnosis of hearing loss in the first year of life; (5) (Re)habilitation of hearing loss,

-Training in infant hearing health:
The training program was conducted through a Cybertutor, an interactive tele-education tool based on the web.This training was conducted in a previous study 16 and its syllabus involved the prevention and Tabela 1 -Absolute number of community health workers and family health strategy teams and the relative amount of population coverage of both, at the federal, state and municipal levels.including the use of static, dynamic images and illustrative videos.

Overview of the amount of CHW and FHS -Reference
The CHWs accessed the material individually and directed their own learning, but guided by the electronic tutor, which verified their performance and study schedule.The tutor allowed moving to the next study module only after the completion of the preceding one, including the correctness of reinforcement exercises at the end of each module.Importantly, all CHWs took the course at the same period and workload.
Immediately after completing the studies of all the modules, the CHWs completed a questionnaire containing 20 multiple choice questions related to the content covered in the training (Figure 1).The questionnaire used was previously translated and adapted to the Brazilian reality 11 and the questions which comprise it were divided into four domains: The data were submitted to descriptive and inferential statistical analysis, using the Wilcoxon test and adopting a significance level of 5%.

RESULTS
The scores obtained by domains and the total score of the questionnaire applied right after training and 15 months after training (Table 2) were analyzed through descriptive statistics.

-Information retention analysis:
In order to verify the retention level of the information obtained in the training program, after a 15-month period, once again the CHWs completed a questionnaire that had been applied immediately after the training (Figure 1).The application took place on a single date for all participants, in a meeting held specifically for this purpose.
By comparing the answers of the post-training questionnaire, after a 15-month period, it was possible to analyze the information retention level of the participants.

Questions
True False Do not know 1. Hearing impairment always means that the person is deaf.2. Deafness can not be inherited.3. A child born deaf can not develop oral language, normally.4. Sensorineural hearing loss is when the change is in the cochlea, in the auditory nerve, or in both, simultaneously.5.The ear mold engages the hearing aid to the child´s ear canal.6.Every hearing impaired child will have a hard time hearing what people say.7. Non-treated ear infections may cause hearing impairment.8. Cochlear cells injuries by exposure to loud noise is always reversible. 9. Some drugs used for a given period of time can lead to hearing impairment.10.Vaccination against Measles, Mumps and Rubella can prevent hearing impairment.11.Hearing assessment and hearing screening are the same thing.12.The hearing impaired child can receive the hearing aid through the Public Health System.13.Some questions can be used to investigate the hearing of babies.14.Children under 1 year of age, usually repeat words when asked.15.The cochlea is the main sensorial organ of hearing.16.The human ear is capable of hearing low, medium and high frequencies.17.Cochlear implant is a surgical treatment, however, it does not cure deafness.18. Deaf children can not attend school.19.Hearing aids amplify the sound for children to hear.20.Health workers could guide caregivers in day-care centers to observe the hearing of young children.The analysis of information retention can be accomplished through tasks of free or aided evocation and also through information recognition, being that recognition tests require less attention and fewer cognitive resources, allowing greater support in the search and recovery of the information 18 .In in Figure 2 and indicate a significant reduction in the general knowledge of the CHW on infant hearing health (p = 0.03).
The results of the comparative inferential analysis of the performance across domains and the total score in the two assessment times are shown

DISCUSSION
Information retention analyzed in the short term is important to check the information assimilated, however, it does not mean that it will be kept along the time.In this study, the results demonstrated a significant reduction in the general knowledge of CHWs on hearing health, 15 months following the training.This finding shows the importance of p=0,01* p=0,33 p=0,90 p=0,53 p=0,03* through experience, which gives meaning to education.Thus, adult education is self-directed and should be organized according to situations of life / work, instead of content unit 25 .
Other factors that could influence the retention level would be age, socioeconomic status and education, however, no significant correlations between education and level of information retention, as well as socio-economic status and the level of information retention were observed in a previous study conducted with patients in the area of Audioloy 22 .
Demographic aspects were not analyzed in this study due to sample homogeneity, since the participants were in the same age range, occupation and level of education.
The literature shows that the information retention level is also related to the involvement of the individual and use of the information, that is, if not used frequently, the learnt content goes through the working memory and then is discarded.On the other hand, if such content is used routinely, it reaches the long-term memory and is retained 26,27 .
Although all CHWs performed their duties for 15 months, as determined by the ESF, no rigorous control was imposed on the activities they undertook during that period, considering whether or not all CHWs had the same opportunity to apply the content.This would involve the scope of the performance area, number of households visited, contact with hearing impaired children, among others.Thus, further studies are necessary, so as to control the activities performed by these professionals, after training.
Faced with this with this limitation, we sought to verify evidence that could clarify the obtained findings.In this sense, the information retention level for different domains assessed by questionnaire was analyzed.The results showed a significant reduction of information for domain 1, which represents conceptual aspects, that are, therefore, more distant from the CHWs´ daily performance.
On the other hand, the content assessed across the remaining domains consists in more practical aspects, and, therefore, the daily activities of these professionals may have favored the maintenance of the level of information retained for these domains, and even caused a slight improvement in the performance, in domain 4 (Table 1).
This finding is consistent with results reported in a previous study 22 , which shows that individuals have a greater ability to retain concrete information than abstract information.The conceptual aspects on hearing and hearing impairment represent the basis for CHWs to perform their technical/practical work in hearing health effectively, since they need this study, the questionnaire focused on the task of information recognition, since it was constituted by statements that the participant should judge as true or false, i.e., developed contents were presented in the questions, which may have been a facilitator for evocation of the correct answer.
No studies analyzing information retention in CHWs training programs were found in the literature.The analysis of studies related to the retention of information transmitted to patients in other areas of health [8][9][10][11][12][13][14][15][16][17][18][19][20] as well as in Audiologia 21,22 , showed loss of the information provided by health professionals and that, some patients evoked erroneous information regarding their health condition.
The capacity to retain information is influenced by a number of factors such as the amount of information and how it is acquired, the duration of exposure and the interventions in this process 23 .Thus, the organization of training programs focused on these factors is essential, since they can facilitate the ability to retain information when properly applied.
In addition, the absorption of knowledge is given by various communication channels, both verbal and nonverbal, and may involve reading, hearing, vision and practical execution of situations..
These aspects were taken into account in the training program the CHWs underwent, previously, since the interactive tele-education tool used provided different audiovisual aids and also allowed the CHWs to guide their own study, a feature inherent to the tool used, that allows the users to review the contents, according to their need and advance in their studies according to their pace of learning.
Thus, the results of this study showed that even administering factors which influence the retention capacity, there was a significant reduction of the information retained over time, demonstrating that other parameters should be considered.
The educational program Cybertutor -an internet based electronic tutor -besides using the methodology of problem-based learning (PBL) also features interactive resources and is being used not only by the distance learning programs, but also to complement traditional learning 24 .
This methodology aligns with the principles of adult education or andragogy, which is the art and science of helping adults learn, fostering learning that put the subjects as actors of this learning, the design of new research involving the training and retention of information for CHWs, in the Cybertutor´s environment, should include other strategies such as problematization through simulation of everyday problem-situations discussion forums, among others.Support material such as a primer to help guide families and the register in the form of CHWs´ reflective diaries, addressing the theme in home visits, may facilitate the applicability of information in their daily routine.

CONCLUSION
A significant reduction of the general knowledge of CHWs on infant hearing health was observed, thus, the training of these professionals should not take place in a single moment, but be based on a proposal for continuing health education, so as to provide greater possibilities for information retention and transformation of the reality in health.
to know what hearing loss is, for them to work on its identification.
Thus, one notes that the results found in the analysis per domains can direct the structuring of continued education programs or even continued health education directed to SUS workers.The theoretical and conceptual aspects addressed in such educational processes must be constantly reinforced, since they get to the working memory, but it is difficult to maintain the level of information retained in the long term.
The retention of information related to infant hearing health allows CHWs to effectively contribute to promote hearing health as well as to develop preventive actions in the area.Studies aimed at verifying information retention through evocation tasks and investigating ways to improve the retention level in training programs directed to these professionals, are extremely important.

Figure 1 -
Figure 1 -Questionnaire administered in the two assessment times.

Figure 2 -
Figure 2 -Comparison of average performance, in percentage, in the two assessment times: right after training (Moment 1) and 15 months after training (Moment 2).

Table 2 -Measurements, in percentage, of the global and domain scores of the questionnaire applied to community health workers right after training (Moment 1) and 15 months after training (Moment 2).
*p ≤ 0,05: significant difference.
In general, individuals manage to retain 10% of what they read, 20% of what they hear, 30% of what they see, 50% of what they see and hear, and 80% of what they see, hear and do