SOCIAL REPRESENTATION OF SPEECH THERAPY IN PORTUGUESE HEALTH PROFESSIONALS AND NON-HEALTH PROFESSIONALS Representação social da terapia da fala nos profissionais e não profissionais de saúde portugueses

Conflict of interest: non-existent the object and the subject, in which there is an implicit relationship between symbolisation and interpretation that gives them meaning3,4. The historical and transforming dimension of social representations allows an interpretation to be made of everyday reality that is composed of information, images, beliefs, values, opinions, and also cultural and ideological aspects4,5. This information can be used as the basis on which to organise the representation structure in a central system and a peripheral system; these are dependent on each other and influence the position taken by the individual and the group. The central system is made up of one or more elements that  INTRODUCTION

speech therapy was also determined by means of a visual analogue scale in which zero indicates no knowledge and ten represents full knowledge.
A pre-test was conducted which confirmed the need to restructure the questions: order of importance of the terms recalled and meaning attributed.Following the data collection, a dictionary was compiled with the definition of each concept recalled, and those with the same or similar meanings were grouped together and given the same designation in order to homogenise the content.A representational system divided into categories was produced on the basis of this homogenisation and the content analysis of the terms recalled.
The Statistical Package for Social Sciences (SPSS, version 19.0 for Windows) was used to make the quantitative analysis by means of descriptive statistics (frequency of occurrence of terms recalled, average occurrence and mean of the average weighted orders of the set of terms recalled).This made it possible to define the cut-off points, which result from: (1) the option based on which the minimum frequency should be considered in the succession of words -the words with few recalls can be utilised; (2) the description of the average frequency -depending on the analysis of the frequency distribution table.On the basis of this distribution, three zones of frequency can be identified: one in which there are very few words for the same frequency; another in which there are few words for the same frequency, and a third zone in which the number of words for the same frequency is extremely important; (3) the average number of words recalled/number of recalls per subject; (4) the calculation of the average order of importance in which they appear in the set of recalls, given the number of requested words produced.The closer the recall is to the value 1, the more important it is.Therefore, a word that has been recalled quite frequently may not have much importance in the hierarchisation process and vice versa.
The four-house framework technique 8,9 was used for the qualitative analysis of the categories obtained by free recall and it shows the central nucleus (most frequent and most important elements arranged in the upper left quadrant), 1st periphery (most important peripheral elements situated in the upper right quadrant), contrast zone (less frequent elements, but were considered important, in the lower left quadrant) and the 2nd periphery (less frequent and less important elements, located in the lower right quadrant) 11 .This technique made it possible to visualise the arrangement of the representational content, revealing the structure subjacent to the cue "Speech therapy".
give meaning to representation and guarantee the identity and permanence of the group; the peripheral system establishes the interface with the central core, regulates and defends it and thus allows reality to be anchored in the moment.
Departing from this theoretical assumption, our aim was to glean an understanding of the kind of social image associated to the speech therapy profession as social representation studies about this are currently scarce.This cognitive representation is influenced by society in general and by the contexts of naturalistic and interventionist action in the field of health and disease in particular; therefore, in accordance with the theory of social representations (together with central nucleus theory) 6,7 , it was possible to reflect on the speech therapy profession.Our research aimed to identify and analyse the dimensions of meaning (or semantic universes) that organise the ideas, emotions and images of health professionals and non-health professionals in relation to speech therapy.

METHODS
The study was approved by the Ethics Commission of the Garcia de Orta Research Centre at Garcia de Orta Hospital, E.P.E.(resolution nr 7/2013).Free and Informed Consent was obtained in writing from participants.
It is a qualitative and quantitative study of crossover design using an intentionally selected sample of 166 individuals of both sexes and aged over 18 years.
The independent variables were age, gender, education, years of professional experience and contact with speech therapy.The sample was collected from health professionals at the hospital of the institution of origin, Portuguese speech therapists and the general population during February 2013.
The following instruments were used: a questionnaire that defined the socio-demographic and situational profile of the sample; and a semi-structured interview script based on the free recall technique, the axiom of importance and the order of recall 8,9 that permitted data collection about social representations in response to the cue "speech therapy".The interview began by asking each participant to recall up to five words or expressions related to the term "speech therapy".They were then asked to sequence the terms produced in order of importance on a scale of one to five from the most to the least important 9,10 .Finally, the participants were asked to define the expressions or concepts recalled so they could be contextualised for future categorisation.The level of perception of knowledge about age of 36 years ( age Range = 18-75).Most had higher education 124 (74.7%) and more than 10 years' professional experience 73 (43.9%).Contact with speech therapy was the most representative; however, 49 (56.3%)people from the group of non-health professionals had never had any contact with it (Table1) .

RESULTS
The study had the participation of 166 individuals: 79 (48.0%) doctors, nurses and specialists in diagnosis and therapy, 40 (24.1%)speech therapists, 39 (23.5%) other health professionals and 87 (52.4%) non-health professionals, with an average As regards the perception of knowledge about the profession, Figure 1 shows that 50% of speech therapists report their knowledge of the profession on the visual scale as between 9 and 10, and significant differences (p≤0.05) in relation to the remaining groups.While 55% of the group of other health professionals classify knowledge as between 5.5 and 10, 50% of the non health professionals report knowledge of between 5.0 and 10, with no statistical significance (p≥0.05) between the two groups.
These results reveal that just 50% of speech therapists have full knowledge of their profession and the remaining professionals have below average knowledge, which suggests inadequate dissemination of information about the profession.
In relation to the number of free recalls, the health professionals and non-health professionals recall 830 words in response to the cue "speech therapy" as can be seen in Table 2. Following the homogenisation and analysis of the terms recalled, 495 registry units were reproduced and a representational system of 13 categories was defined, 3 of which were rejected due to the low number of recalls presented.
Turing to the average order of recall, it is found that professional (speech therapists) is the category recalled (on average) in 1st place by other health professionals, and it is also the most important.This category also stands out in the average order of recall for speech therapists.Communication is the most evidenced category for the average order of recall, and the most important for speech therapists and other health professionals.Moreover, prevention On average the most recalled categories for the three groups were treatment and communication, while professional and motivation were the least recalled.Other important categories for the groups studied were: well-being for the speech therapist (16;30.2%)and for non-health professionals (28;52.8%),and diagnostics with the highest recall frequency among the other health professionals (24;43.6%).Most of the remaining categories were recalled by the group of non-health professionals.The combination of the frequency and the hierarchy of recalls allows us to define the following cut-off points: (average ƒ 12.5 and AOR 2.5) for speech therapists (average ƒ 11.6 and AOR 2.3) for other health professionals, and (average ƒ 24.6 and AOR 2.4) for non-health professionals; it also is found to be the most important category for non-health professionals.
For the order of recall, diagnostics was the category recalled on average in last place by the speech therapists, followed by relationship by non-health professionals, and treatment by other health professionals.Professional stands out in terms of the order of importance for speech therapists, motivation for non-health professionals and prevention for the other professions.
In relation to the group of speech therapists when associated to years of professional experience, it can be seen in Table 3 that speech therapists with less than one year's experience give greatest importance to qualification and least importance to treatment; on the other hand, the most experienced therapists highlight the importance of relationship, communication and well-being, and refer to professional, diagnostics and prevention as the least important.of representation and that foster the interface between the reality and the central nucleus.The terms "treatment" and "well-being" (elements forming the first periphery) are categories of great relevance to the groups.Other health professionals and speech therapists emphasise treatment as a form of practical knowledge about the reality of speech therapy, while non-health professionals underline well-being 2,6,8 .Qualification, relationship, professional, diagnostics, prevention and motivation are the terms found in the second periphery of the representation and they reflect the decision making and conduct in response to the actual situation at the time of the speech therapy by the groups under study.
In light of the above, in general the cognitions in the periphery comprise the operational part of the representation and play an essential role in the functioning and dynamics of the cognitive representations about speech therapy, and they regulate, adapt and protect the core elements 11 .

DISCUSSION
Communication is the most consensual among health professionals and non-health professionals.This is evidence of a generally positive representation of the speech therapy profession in Portugal insofar as it is associated to optimising capacities of human communication.This dimension is also less sensitive to changes in the external context or social practices as it was found to be anchored to the core representation 1,2,11 .
Despite the great diversity found in the domains related with the profession, speech therapists did not have full knowledge of their profession.The representational reality is marked by the lack of importance and involvement in social practices, which means the visibility of speech therapy is given little recognition in professional practice as a whole.
However, this could in part be related with the years of professional experience.Speech therapists with less than one year's experience refer to the importance of its representation in the qualification because they are going through a process of change, of establishing links with the profession and the group, and the resulting social acceptance 12,13 .On the other hand, the therapists with over a year's experience consider the dimensions of relationships, communication and well-being the priorities in clinical practice.
This reveals the need to restructure interventions in speech therapy, reverting to individual clinical consultancies as part of the health and education teams' actions.Even though their self-image is limiting, they advocate a holistic vision of health and The most prominent element was the field of communication for health professionals and non-health professionals.Under this designation, the words or expressions were homogenised if they indicate therapeutic activities involving communicative functions, and are related with persons that either have communication disorders or are in contact with them.For speech therapists, this house also includes the fields of qualification and wellbeing, which are associated to the description of the actual importance of professional skills and specialisation in the areas of therapeutic intervention and the contribution of this profession to positive health, expressed in the dimension of well-being which is recalled as a driver of quality of life 2,11,12 .For the other health professionals, (doctors, specialists in diagnosis and therapy, and nurses), the field of diagnostics stands out.The presence of this cognition indicates that a process of change may be taking place in the context of the social representations of speech therapy, given that the statements of significance reflect the professional and his/her importance to the treatment of a person's disease in the differential diagnostic process in the health services.For the population in general, the recalls are associated to the descriptive characteristics and the effectiveness of speech therapy in social practices, demonstrated by the therapeutic approaches to the person's state of health in the life cycle.
In the lower left quadrant, we find relationship, motivation, professional, well-being, diagnostics and prevention.These elements characterising the contrast zone have a smaller number of recalls, but are perceived as very important by speech therapists, other health professionals and non-health professionals 7,9 .The terms professional and prevention are considered the most important to the social representation of speech therapy by other health professionals and for non-health professionals.This entails the professional recognition of both speech therapy in the ambit of health and clinical practice and also health education on verbal and non-verbal communication disorders and swallowing disorders; this reaffirms the dimension of professional skills, identified as probably the core element, as well as the cognition of diagnostics and well-being 1,2,10,11 .The remaining cognitions in the contrast zone, relationship and motivation, have distinct representations but are marked by a discourse focussed on the importance of the therapeutic relationship as a facilitator and the need to maintain the quality of and satisfaction with therapeutic interventions, referred by speech therapists.
The upper and lower right quadrant contains cognitions that form the first and second periphery accessibility to speech therapy.This demonstrates the need for health promotion initiatives, especially public/community health 18,19 , that call for social and policy changes aimed at the inclusion of the practice of speech therapy in community health projects.
The social representations of the speech therapy profession constructed by speech therapists, doctors, specialists in diagnosis and therapy, nurses and the population in general are basically associated to the processes of diagnosing and treating communication disorders, and the biopsychosocial well-being of the person with the disease.

CONCLUSION
Social representation constructed about speech therapy by health professionals and non-health professionals permitted access to a broad set of cognitive semantics centred on the disease of the person with communication disorders, diagnosis and treatment.While this is a positive image of the impact of clinical practices in society, it is not very representative of the profession's involvement therein.
While this contribution is not representative of the population in general, it serves as a starting point for working towards the restructuring and stimulation of clinical practices both in health and education with the aim of improving community health.
disease in the life cycle, insofar as they value wellbeing 14,15 and quality of life, and support national and international guidelines for therapeutic practice in the profession 1,2,16,17 .
In relation to doctors, specialists in diagnostic and therapy, and nurses, most of whom have been practicing for more than 10 years, the importance of the speech therapists as a member of the health team emerges; the focus is on the applicability of their performance in the diagnosis processes 15, , and it is a positive social representation of the speech therapists' participation.On the other hand, barriers to the work of these professionals in health as well as a lack of understanding of it are visible.This is partly explained by poor dissemination and general ignorance about the work of speech therapists among both these professionals and others; although they are perceived as important, the perception of their inclusion in health teams differs.

Figure 1 -
Figure 1 -Distribution of the perception of knowledge of the social representation of speech therapy; prof.-professionals

Table 1 -Socio-demographic characterization of the sample
*age (average and range)

Table 3 -Frequency of recall, average order of recall and average order of importance, categorized, in relation to the social representation of speech therapy
ƒ: frequency; ; AOR: Average Order of Recall; AOI: Average Order of Importance

Table 5 -Four-house framework of the free recalls to the cue "speech therapy" health professionals
ƒ: frequency; OI: order of importance

Table 6 -Four-house framework of the free recalls to the cue "speech therapy" non health professionals
ƒ: frequency; OI: order of importance