Perceptions of deaf subjects about communication in Primary Health Care *

ABSTRACT Objective: to analyze the perceptions of deaf individuals about the communication process with health professionals of the state of Rio de Janeiro. Methods: cross-sectional observational study. Data were collected through the application of a questionnaire with quantitative and qualitative questions to 121 deaf adults. Objective responses were studied descriptively through frequency tables and analyzed by inferential statistics and logistic regression. The data from the open questions were analyzed through content analysis. Results: the lack of interpreters and the lack of use of the Brazilian Sign Language by professionals were perceived as the main communication barriers. In turn, the presence of companions who are listeners (73%) and the use of mime/gestures (68%) were among the strategies most used by the deaf. The majority of deaf people reported insecurity in consultations, and those who best understood their diagnosis and treatment were the bilingual deaf (p = 0.0347) and the deaf who used oral communication (p = 0.0056). Conclusion: communication with the professionals was facilitated when the deaf people had a companion or when they used mimics and gestures. Sign language was neglected, despite the fact that the provision of care to the deaf by professionals trained to use this language is guaranteed in the legislation.


Introduction
Comprehensive health care, with a view to autonomy of the subject, is one of the pillars of primary care. It is, therefore, imperative that communication between users and professionals occurs in a satisfactorily way in oder to preserve quality of care (1)(2) .
The 2010 Brazilian demographic census indicated that 9.8 million people, or 5.1% of the Brazilian population, had hearing impairment (3) . It is known that the impairment caused by hearing loss, in terms of perception of sounds, can negatively impact people because of the importance of this ability to the development of communication, speech and language (4) .
It is important to highlight the difference between hearing impairment and deafness, according to the Brazilian legislation. Impairment is linked to hearing loss, while the deaf subject is perceived based on an identity, characterized by the use of sign language (5) .
In view of the need to maintain the quality of care, based on qualified listening, mutual conceptual understanding, interaction with the user and perception of his singularity, communication is fundamental in the work process of health professionals (1)(2) .
In this scenario, when seeking health care, the main obstacles faced by deaf people involve the professionals' lack of knowledge of sign language, and the lack of interpreters in the units (6) . It is important to note that such difficulties hamper the access of these subjects to health services. In the United Kingdom, a study revealed that the level of dissatisfaction with primary care physicians is higher among deaf patients than among listeners (7) .
In addition to the above, the lack of informative and accessible systems for the deaf increases their vulnerability to preventable diseases, as a result of lack of mechanisms that take into account the peculiarities of minority groups when disclosing health information (8) . In deaf communities in Nigeria, Brazil and the United States, a study pointed out that communication barriers inhibit the insertion of deaf people into health promotion programs and compromise their acquisition of knowledge (7) .
At the same time, communication barriers generate negative feelings and discourage deaf individuals to seek health units, because of fear of not being understood causes, making them to seek care only in case of illness. Therefore, it is fundamental that the professionals invest in strategies to facilitate the understanding and the reception of these subjects through effective communication (8) .
The present study sought to answer the following question: regarding the communication process

Methods
This is a cross-sectional, descriptive and analytical study with a mixed (qualitative and quantitative) approach (9)(10) . Data were collected through the application of a questionnaire to deaf adults of the For sample calculation, an expected response rate of 50% for any item of the questionnaire was considered, with an additional of 10% in case of possible losses, margin of error of 7%, and inferential statistics generated with a significance level of 5%, resulting in a sample of 121 deaf adults (10) . Multiple logistic regression was used for multivariate statistics (10)(11) . Regarding the open questions, data were explored through content analysis based on Bardin (12) .
In order to identify the subjects and preserve their anonymity, the code UD/UT/Q/E followed by

Results
The sample consisted of 121 adult deaf people, most of whom were male (58%) and had a mean age of 27 years (SD: 9.1 years). The participants attended high school and resided in the city of Rio de Janeiro,  strategy mentioned was use of LIBRAS, pointed out by 93% of the participants.
According to the Prevalence Odds Ratio, bilingual deaf individuals were approximately six-fold more likely to understand their diagnoses than those who were not. Similarly, deaf individuals who were able to verbalize were approximately twice as likely to understand their diagnosis as those who were not speakers. Deaf individuals who used signs were 79% less likely to fully understand their diagnosis (p = 0.0403) ( Table 2).
The use of lip reading and verbalization as ways of communicating were also related to the deaf persons' perception of their diagnosis. Therefore, deaf individuals who used lip reading and oral communication were 6.13-fold and 5.79-fold more likely to understand their diagnoses, respectively, when compared to individuals who did not use these methods of communication. It was also noted that the prevalence of deaf people who understood their diagnoses was 3.81-fold and 3.57-fold higher for those who used oral communication and lip reading, respectively (Table 2).  Regarding the understanding the treatment guidelines, it was seen that bilingual users and individuals who used verbalization were more likely to understand, in the first case, 6.6 times more than nonbilingual users (p = 0.0556), and in the second, 3.28 times more than those who did not use verbalization (p = 0.0268).
It was observed that the level of education of deaf subjects influenced the understanding of information given by the health professional during the consultation.
Individuals with high school were 3 (three)-fold more likely to be understood than those with only elementary school (p = 0.0125).

Discussion
The rights of the deaf are guaranteed and regulated by law, which determines that the care in public health services must be provided by qualified professionals who know how to use LIBRAS or who can translate and interpret it (13) . However, it is noteworthy that, generally, the cultural identity of the deaf community is not taken into account; deaf people are devaluated as individuals and have their rights to equality in health care disrespected (14) .
In order to develop integral health care and promote social and structural changes, it is essential that the subjects be seen in their particularities. Understanding the reasons that pose a distance between them and the health units subsidize the remodeling and choice of strategies to receive these individuals.
The absence of caregivers and the lack of professional preparation were pointed as the main motivators for the deaf adults not to seek care in health services, according to studies conducted in Paraíba and Rio Grande do Sul (15)(16) . In the present study, it was found that the absence of a mediator to facilitate communication with the professionals was a reason for the majority of deaf people to stop seeking care.
Considering the distinction between languages adopted by deaf people and listeners, it is possible that communicational difficulties exist between them. The obstacles most faced by the deaf participants in the present study involved the lack of interpreters in health facilities, the non-use of sign language by professionals, and the lack of patience on the part of professionals as well as their unpreparedness to assist such clientele.
In Brazil, sign language translators/interpreters have a regulated profession. They are responsible for interpreting and translating LIBRAS into Portuguese, as well as Portuguese language into LIBRAS. These professionals should promote communication between deaf people and hearing people and contribute to the accessibility of the deaf to public services (17) . Given the importance of communicational intermediation between deaf and hearing people, the absence of interpreters hampers the daily life of the deaf and encourages the adoption of other strategies that facilitate such process in the health units (3,17) .
In the face of communication barriers and lack of interpreters in health facilities, deaf people are forced to use someone as mediator, be it friends and/or family members. However, in many cases, the companions do not fully know LIBRAS, and this makes the intermediation enigmatic, generating anguish to the deaf subjects, for not knowing whether they were understood by the interlocutor and the health professionals (18) .
In spite of its importance to facilitate communication, the participation of a third party, compromises the privacy and the autonomy of the deaf people, and in some situations can cause embarrassment and omission of information because of exposure to shame (1) . This situation inhibits the deaf person to speak about her health, when they pass it to the other person the control over this information (18) .
Although studies indicate the presence of intermediary mediator as negative, in the present study, the presence of a mediator was highlighted as considering their intellectual capacity and responsibility over their own health (18) .
Health care is directly linked to interpersonal relationships and requires communication skills for mutual understanding (19)  subject regarding health guidelines and, consequently, feelings of fear, frustration and mistrust (20) .
Besides the doubts regarding their own health and the difficulty to understand the professional, the deaf also face the offer of very little information during the realization of procedures, which intensifies their insecurity and fear (18) . In a study carried out in São Luís-MA, it was noted that the lack of information for the deaf subjects was responsible for their difficulty to express their doubts and questions regarding their own health (18) .
Hence, the failure to embrace these clients generates negative feelings, that is, anguish, fear, insecurity and impatience, and, at the same time, pose a distance between professionals and the users (19) .
The perception of the subjects is based on effective communication. However, after health care, deaf patients still misunderstand their diagnosis and treatment, a fact that ratifies the difficulty in communication between deaf people and health professionals (19) .
Likewise deaf subjects, health professionals recognize the need to overcome communication barriers.
In a study carried out in Maranhão, the professionals identified the lack of training and the lack of resources to aid in communication as the main obstacles. In this scenario, the presence of a companion was pointed out as the main strategy used, and considered indispensable for the maintenance of an effective communication (21) .
It should be stressed that the main role of the deaf person should be maintained; the interaction with the professional should allow the individual to express his needs through strategies that ensure his independence and privacy (21) .
By guaranteeing the right to receive care from characteristics are not a reality for most deaf people (17) .
Attention to those who communicate in a different way requires that the professionals develop skills to use the most appropriate methods, preferably LIBRAS (1) .
Assistance by professionals who know sign language enables communication without mediators and promotes the autonomy of the deaf (1,22) .
Legally recognized, LIBRAS characterizes the culture and identity of the deaf. Consequently, it is important that health professionals know LIBRAS; the lack of mastery of this language is a barrier to the interaction between the team and deaf individuals (23) .
The improvement of the quality of care for deaf users requires changes in the physical environment of the basic health units and in the training of professionals.
Brazilian laws include LIBRAS as a compulsory topic for teacher training courses, speech therapy courses, and for all licentiate courses, being optional in other courses (22) .
The lack of content related to the care of deaf people during training may be one of the explanations for the difficulty of interaction between professionals and deaf users (22) . Therefore, it is important to emphasize the need for LIBRAS to be included in the curriculum of health professionals in order to promote the communication of deaf people with health professionals and to enable the integration of new entries in sign language (24) .
The investment in qualification does not ensure the training of health professionals interpreters or totally fluent in sign language, but enables the development of skills that allow effective communication with deaf users, with a view to social inclusion and respect for the rights of these subjects (17) .
Written Portuguese is frequently used by health professionals to communicate with deaf individuals.
However, this is the second language of the deaf, and they often have difficulty understanding it fully (25) .
The use of written Portuguese can embarrass the deaf individual and was described as the strategy that makes it more difficult to exchange information in the care.
The multiple logistic regression revealed that the difficulty in understanding written Portuguese is inversely proportional to the expansion of the level of education.
Thus, deaf people who had finished high school were more likely to be understood by professionals than those who only finished the elementary school.