Satisfaction of deaf patients with the health care

Purpose: to investigate the satisfaction of deaf people in relation to the health services, to characterize the sample regarding sociodemographic, socioeconomic, and self-perception of deafness,and to verify if there is an association between satisfaction with care,communication, professionals, and self-perception of deafness. Methods: an observational, cross-sectional study conducted with a semi-structured questionnaire in 74 deaf adults. A descriptive analysis of the characterization of the sample and attendance, and an analysis of the association between satisfaction, professionals, self-perception, service used, and schooling level was performed, using the chi-square test. The level of significance adopted was 5%. Results: the sample was composed mainly of women (66.2%), 18 to 28 years old (46.5%), of socioeconomic class D (51.3%), having finished high school (56.76%), and employed as an office assistant or typist (90%), 63.5% self-declared as deaf, 51.3% were bilingual, and 54.4% were not satisfied with the medical care. There was a statistically significant difference between the level of satisfaction of the volunteers with the health care received in relation to the different health professionals who attended them (p< 0.05). Conclusion: most of the population was not satisfied with medical care, although this service was most sought. The type of communication used by the professionals and the presence of an interpreter were not effective. It is necessary to implement strategies to ensure accessibility and comprehensive care to this population.


INTRODUCTION
Hearing loss (HL) is defined by the Ministry of Health as the total or partial loss of the ability to hear 1 . It manifests invarious levels, reducing auditory sensibility and discrimination 2 .
In an attempt to correct this hearing problem, health professionals may prescribe technological devices, such as hearing aids and cochlear implants 3 . However, these devices may not be efficient, and some deaf people may choose not to use them. In these cases, oral communication may suffer loss and increase barriers, as the counterparts do not share the same language 4 , which could interfere in their standard of living 3 . Without imposing the major language of the country where they live, their right to communicate in their native tongue is secured in Brazil by Law no. 10.436, of 2002, which recognizes the Brazilian Sign Language (BSL) as a legal means of communication for the Brazilian deaf people 5 .
The implementation of the law by Decree no. 5.626/2005, specifically in its chapter VII, secures to people with hearing loss the right to health care through the service network of the Brazilian Unified Health System(SUS), performed by professionals either trained to use BSL or assisted by translation or interpretation 6 .
If to comply with such secured rights the health professionals were in fact trained to communicate in the BSL, they would have the opportunity to know the peculiarities of the deaf culture and the healthcare for this group. Therefore, these professionals could search for strategies so that the communication with the deaf people would be effective, contributing to clearer information exchanged in the patient/health worker relationship 4 .
The law, as it is, presupposes changes in the health services, the training in BSL for these professionals included. It is also necessary to broaden the dialogue regarding the theme with these health workers, raising awareness of the impact on the quality of health care for the deaf population.
Developing research that investigates the patient's perception regarding this patient/health professional relationship is essential to implement policies targeting the population with impairments of different kinds 2 .
In this context, knowing the characteristics of the health care aimed for the deaf and these patients' satisfaction with the care offered them contributes to planning actions intended to improve the quality of the service provided.
This study aimed to investigate the satisfaction of people with hearing impairment with the health services, to characterize the participants regarding their sociodemographic and socioeconomic data and their self-perception of impairment, and to verify whether there is a relationship between their satisfaction with the health care, the means of communication used, the health professionals, and the self-perception of impairment.

METHODS
This is an observational, analytical, cross-sectional study, approved by the Research Ethics Committee (REC) of the Universidade Federal de Minas Gerais -UFMG, MG, Brazil, under evaluation report no. 06950212.5.0000.5149. This study is an integral part of actions taken by the Projeto COMUNICA, tied to the NeuroEduca outreach program, developed in a partnership between the Departments of Morphology and Speech-Language-Hearing Pathology at UFMG.
The study was carried out in two philanthropic institutions of support to the deaf community in the Belo Horizonte metropolitan area, in Minas Gerais, Brazil, between April 2013 and February 2014. A survey in these two institutions revealed a total of 484 employees and registered users. The inclusion criteria were: being self-declared deaf or with hearing loss, over 18 years old, user or employee of any of the two institutions of support to the deaf community, and agreeing to participate in the research. The exclusion criterion was abstaining voluntarily from participating in the research. Considering the exclusion criterion, the eligible population had 74 participants.
The data were collected with a semi-structured questionnaire designed by the researchers, composed of three parts, each one addressing different aspects of the participant, their care for their own health, and their perspectives for improvements in the health care: 1) the participants' characteristics: sex, age, profession, means of communication used, the term they used in their self-perception of hearing loss, schooling level, type of health service used, and socioeconomic data, according to the Critério Brasil 7 ; 2) the communication strategy used with health workers: physician, nutritionist, dentist, speech-language-hearing therapist, and psychologist, and satisfaction level regarding the general care provided by each health worker; 3) the user's perspective for the improvement of the health care of deaf people. The third part was presented with open-ended questions (Annex 1).
In this study, only the first and second parts were analyzed.
The participants answered the questionnaire individually, in a separate room, in the facilities of the philanthropic institutions or the participant's workplace, in a single meeting with the researcher, lasting approximately 15 minutes, using the means of communication they desired. The collection procedure could happen in three ways: a) the participants answered their own questionnaire; b) the researcher interpreted the questions in BSL and the participant filled out the questionnaire, c) the researcher interpreted the questions in BSL, received the answers from the participant in BSL, and filled in the questionnaire as well, always checking with the participant, by means of BSL communication, the accuracy of the registered answer. In any of the cases, the researchers helped the participants while the questionnaire was being administered, in case it was requested.
For the satisfaction level regarding the care evaluation, in the second part, the alternatives were referred on a Likert-type standardized scale, with five possibles cores, namely: 5 -very good; 4 -good; 3 -average; 2 -poor; and 1 -very poor. The answer options were presented for each field of health considered in the questionnaire.
In the occasion, all the information regarding the research and the Informed Consent Form (TCLE) were clarified, using the means of communication of the participant's choice. All the interviews were filmed using Digital Versatile Disc (DVD) video formats, for an accurate record of the statements and greater reliability of the data analysis.
A descriptive analysis was performed with the variables used in the study. For the categorical variables, the frequency distribution analysis was conducted. An association analysis was made between the satisfaction with the care provided by each health worker and the mean of communication used; the general satisfaction with the service; and the satisfaction with the care provided by each health worker regarding the hearing impairment. For that purpose, the chi-squared test was used, using the SPSS program, version 0.18, and considering the 5% significance level.

RESULTS
The sample in this study was composed mostly of women (66.2%) aged from 18 to 28 years (46.5%), belonging to the social rank D (51.3%), having finished high school (56.76%), and reporting their occupation as an office clerk or typist (90%). A great part of the participants self-declared themselves as deaf (63.5%), bilingual (51.35%), or able to communicate with BSL (36.49%) ( Table 1).
The private health service was responsible for 47.3% of the services in the last two years, but 44.59% of the studied population used the services of community health centers (UBS, its Portuguese acronym). A total of 33.8% visited the physician twice a year on average,and 27.42%, three to four times a year ( Captions: Brazilian Sign Language -BSL | Emergency Room -ER | * 1 participant didnot answer this question | ** 4 participants did not answer this question | † The participant could check more than one alternative (p=0.001); and regarding the medical care, in which the participant was more satisfied when they went to the appointment accompanied by a hired interpreter, in comparison to the participant that went accompanied by a volunteer interpreter (p=0.024).
There was no statistically significant relationship between the general satisfaction with the service and the communication strategy used by the health worker, except for two situations ( Table 2): The use of speech by the speech-language-hearing therapist, as the health workers that also used speech,were better evaluated Table 2. General satisfaction with the service* executed by each health worker and the communication strategy used by each professional, of deaf people (n=74) users or employees of the support institutions to the deaf community in the metropolitan area of Belo Horizonte, Minas Gerais, Brazil, from 2013 to 2014  The analysis of the general satisfaction with the care provided by each health worker indicated that most of the patients were not satisfied with the medical care. Out of the 74 participants, 68 attended medical care, of whom only 45.5% considered their satisfaction as "good" or "very good". However, no statistical relevance was observed (Table 3). The general satisfaction considered "very good" was more frequent concerning the psychologist (25%), followed by the speech-language-hearing therapist (12.5%), the dentist (11.5%), and the physician (5.9%).
Even though they are patients with hearing loss, not all of them were undergoing speech-languagehearing therapy, as shown in Table 3. Only 15 participants reported attending a speech-language-hearing therapist. Table 4 shows the results of the relationship between general satisfaction and the type of health service used, the schooling level, and their self-declared situation. The results reveal a statistically relevant relation ship between the medical care and the self-perception of impairment (p=0.016), indicating that the participants that considered the service as good or very good declared themselves as deaf.   11 . The previously imposed oralism defended that deaf people should speak without the use of signs 8,11 . However, when the BSL was officialized in Brazil, in 2002 5 , and the bilingual-bicultural education was adopted, this scenario started changing 12 , pointing to greater respect towards diversity and openness to include individual strategies.

DISCUSSION
The participants schooling level, predominantly high school, can restrict their career options -office clerk and typist -with repercussion on the socioeconomic classification of the studied group, according to cutoff scores of Critério Brasil (51.3% in class D) ( Table 1). An integrative literature review on the inclusion of deaf people, carried out in Brazil in 2013, points out that this scenario could be a reflection of the lack of inclusion of deaf people in school environments and the job market 13 .
Regarding health care, it was noted that the deaf person needs this service, since the studied group of deaf people attended, in the last two tears, not only private health services (47.3%) but public as well (44.59%), visiting a physician at least once a year (85.48%) ( Table 1). Hence, health services should be prepared to welcome people with hearing impairment, ensuring accessibility to this group. To provide services that offer better conditions to approach deaf patients, like professionals trained in the sign language 6 , quality and equal care must be provided to groups with specific demands.
Health workers must be informed about the law and be trained to use the BSL. Thus, they would actually comply with the law, providing to the hearing-impaired person the opportunity for better care for their health, fostering more humane assistance.
A recent study, conducted in the Federal District, to trace a regional overview of the knowledge of BSL by health workers and their perception of care towards an unaccompanied deaf patient, point out the importance of implementing or broadening the study of BSL before and during graduation in health-oriented programs 14 .
Although this study has not demonstrated a statistically relevant relationship between communication strategy and the general satisfaction with professional health care, the patient that went to the physician accompanied by a professional interpreter, hired by the deaf person, was more satisfied with the service provided by the professional (Table 2). However, it is worth mentioning that most of the studied population (54.4% out of 68 participants), was not satisfied with the medical care, since they graded it as "very poor" (4.4%), "poor" (8.8%), and "average" (41.2%) ( Table 2).
The presence of professional interpreters is legally secured in Brazil through the Law no. 10,436, of April 24, 2002 5 , as stated in the 3rd article; "the public institutions and accredited companies of public services and health assistance must ensure adequate care and treatment to those with hearing loss, following the existing legislation 5 ".
However, Oliveira et al. (2015) 15 showed a different reality at Fundação Centro de Atendimento à Pessoa Portadora de Deficiência (Center for the Assistance of People with a Disability -FUNAD), in João Pessoa, Paraíba, Brazil. In their study, they evaluated how deaf people understand communication with health workers and the meaning of the presence of an oral companion as an interpreter, during the care in the public network of health services. The research revealed that the population of 11 deaf people interviewed preferred to be assisted by professionals that knew sign language, to establish direct communication, keeping his privacy and independence.
According to the means of communication, in the present study, the oral speech was pointed as the most frequent means in speech-language-hearing therapy, and the second most frequent in medical care ( Table 2).
According to Oliveira et al. (2015) 15 , oral or written communications are still the most used means in appointments between health workers and patients. In addition, the results pointed out that strategies like lipreading and reading were not efficient for effective communication. The authors concluded that qualification with a specific minor degree in the culture and language of deaf people would be a determining factor to minimize the difficulties reported by deaf people who search for health services.
In the present study, lipreading was not an efficient strategy either, being the fourth most used means of communication in the services with a physician and dentist, and the third with a speech-language-hearing therapist ( Table 2). This strategy requires a lot of attention because many phonemes are reproduced with similar points of articulation 16 , which can hinder comprehension, leading to loss of information.
Regarding the requirement of BSL studies in healthoriented programs, only the speech-language-hearing therapists are provided by law 6 , as it establishes an obligatory curricular subject in the Speech-languagehearing Pathology programs. Hence, since there is no legal regulation yet referring to the course load and its modality, if in-person or remote 17 , the students are not being adequately trained for effective communication with deaf patients during their professional practice. Regarding other health-related programs, there is no initiative whatsoever that ensures the training in sign language in its initial education.
In this regard, studies 16,18 report the difficulties in attending these patients and the importance of the continuous training of these health workers, thus assuring, de facto, the access of deaf people to communication. A study with a qualitative approach with health managers carried out in Porto Alegre, Rio Grande do Sul, in 2013, revealed that community health workers search for different tools to remedy the difficulties in communication with deaf people and that the professional stance, in general, expresses discomfort and unpreparedness to care for this population 19 .
Beyond the importance of effective communication, health literacy is another important ability in the process of interaction between health workers and patients, since the information and orientations must be comprehended to be properly carried out, without affecting the subject's health condition, as clarified by Passamai et al. (2012) 20 .
The fact that 51.3% of the participants in this study were bilingual (Table 1) can be an influential factor in user satisfaction. If the patient has the alternative of oral language, the lack of health worker's training in BSL will not totally compromise the service. The idea is subject to argument, due to data in the integrative review by Oliveira et al. (2015) 15 , that suggests that when deaf patients and physicians meet, they encounter communicative barriers that compromise the link to be established and the care to be provided, and it may harm the diagnosis and treatment 21 .
In this regard, it is believed that if the communication is not restricted to BSL, it can be effective, diminishing harms and minimizing the difficulties for better-quality care.
Poor education can also contribute to a less rigorous evaluation, by the deaf people themselves, of their health care, considering that just 2.7% of the participants had college education (Table 1). A study about patient satisfaction in Brazil pointed out education as an influencing factor in health care satisfaction 22 . The population with higher schooling levels tends to be more demanding of quality service and, therefore, has shown to be less satisfied 23 .
The investigation around patient satisfaction is a way of evaluating the efficiency of health services and to orient corrective measures to be implemented in them, aiming for real contributions incaution and health care 24,25 . The satisfaction has been an important component in health evaluation results, regarding the received or provided care, obtaining information that benefits the coordination of these services and its users 26 .
The removal of barriers in health services used by deaf people provides equalitarian possibilities, when compared with people with no impairments 27 , and promotes greater access for the group to better health conditions. Thus, investing in the initial education of the futures health worker and training the already practicing professionals about deaf culture and BSL, stimulating health promotion actions and disease prevention, oriented to deaf people, and monitoring the user satisfaction can be relevant contributions for making the deaf person very satisfied with a better caring for their health.

CONCLUSION
Most of the participants of this study were women 18 to 28 years old, in social rank D, having finished high school, self-declared deaf, and bilingual communicators. They showed dissatisfaction with the medical care and satisfaction with the service of other health workers. Also, the physician was the professional most required by this group, as well as private services.
Regarding the relationship between general satisfaction and the care given by each health worker, the study reveals a greater satisfaction with the speechlanguage-hearing therapy.
These results point to a need for implementing BSL and deaf culture training actions in undergraduate and continuing education programs for these professionals. Besides, it is necessary to structure health care so that deaf people can have adequate access, with human resources that achieve an efficient and good quality communication with this group, promoting better care to the deaf.