On-line version ISSN 1982-0216
Rev. CEFAC vol.15 no.1 São Paulo Jan./Feb. 2013 Epub May 29, 2012
Thaís de Lima FernandesI; Cynthia Maria Barboza do NascimentoII; Fabiana de Oliveira Silva SousaIII
ISpeech Therapist; Speech Specialist in Public Health, Faculty of Dentistry of Pernambuco / University of Pernambuco-FOP/UPE
IISpeech Therapist, of the NASF Camaragibe; Professor of the Specialization Course in Speech in Public Health, University of Pernambuco; Master in Public Health Research Center at Aggeu Magalhães - FIOCRUZ-CpqAM
IIIPhysiotherapist of NASF Camaragibe; Professor of the Specialization Course in Speech in Public Health, University of Pernambuco; Master in Public Health Research Center at Aggeu Magalhães - FIOCRUZ-CpqAM
PURPOSE: to examine the roles of speech therapists at Family Health Support Centers (NASF) according to GM directive No. 154, of January 24, 2008.
METHOD: data were collected through a semi-structured questionnaire applied to the speech therapists who work at NASF in the Metropolitan Region of Recife (RMR). The questionnaire is divided into two axes, one related to the profile of the speech therapists and the other one regarding the activities and organization of the work.
RESULTS: it was found that 100% of those surveyed are women, who claim to have experience in low-income communities. 80% of them performed home care service and 60% reported experience in multi- or interdisciplinary work. Regarding the work process of speech therapists at NASF, it was observed that 60% had a diagnosis of the area before starting the work, confirming the agreement with the Health Family Groups (ESF) to prioritize groups. All of them claim to perform integrated actions along with ESF, NASF and social institutions, with projects and intersectoral actions to include people with disabilities in 80% of them. Among the ones surveyed, 60% prioritize actions for rehabilitation.
CONCLUSION: the study on the professional profile and the work process of speech language therapists at NASF can help identify challenges in their daily routines, as well as support actions that promote changes in training and work process toward a more integral and effective care.
Keywords: Family Health; Speech, Language and Hearing Sciences; Primary Health Care; Public Health
Although the insertion of Speech Therapy in the Brazilian Public Health System was conducted between the seventies and eighties, access to speech therapy assistance was difficult. Only in the eighties, when the present Brazilian Health System was established, speech therapists were hired by the public sector and the first researches in the area appeared1.
Nowadays, there is an increased demand for speech therapists' assistance in public service. However, there are few professional in the area, which makes necessary to increase availability of speech therapists, especially in preventive and collective field, in which speech therapy still presents an incipient performance and view2.
Public Health work is related to social, collective and health issues of the entire population. A speech therapist who works in public service must be generalist, must identify speech issues of major relevance in the community combining with the elaboration of preventive actions, whenever possible, focusing on life quality improvement3.
The performance of speech therapists in Basic Care concerns both the clinical and social fields, fulfilling an important role in the health care network. This work necessarily involves an interdisciplinary team and the creation of therapeutic devices, articulating both individual and collective actions whose objectives are to treat and to monitor illness processes and social participation4.
The necessity of stimulating speech therapists performance has intensified due to the important contribution and the complexity of their work. Therefore, universities have aimed to adequate themselves to the field of speech therapy, reorganizing their curriculums in order to provide future professionals tools for promoting health and diseases prevention.
Scientific production in speech therapy is in expansion and the critics on professional training and practice are intense, resulting in a movement for curricular and public service' actions changes. Professionals and universities have a fundamental role to overcome this challenge5.
In February 2002, the National Education Council and the Board of Higher Education approved new curriculum guidelines for the undergraduate course in Speech Therapy, in the place of the older curriculum, representing an important step for inserting changes in the formation process of speech therapists. Universities will then be able to qualify capable and generalist professionals who will be able to develop actions aiming a humanized assistance. However, the process of curriculum change is slowly occurring, lagging behind the rapid transformation of other health courses and service needs6.
In order to strengthen basic care, the Health Ministry instituted the Family Health Support Center (NASF) through the GM Ordinance nº 154, in January 24th, 2008. The Ordinance's objective is to expand the reach and scope of basic care, as well as its resolution, supporting the insertion of Family Health Strategy in the service network; it also supports the territorization and regionalization processes, acting not only as the front door of the system, but in a unified and integrated way7.
NASF teams must be defined by local managers, prioritizing local needs and professional availability. The last must act together with the Family Health Teams (ESF), offering core, technical-pedagogical support and, if necessary, conducting specific actions8.
Therefore, the full understanding that NASF does not have the "obligation" "to solve demand problems of ESF implies in the challenge of building a new work process which favors responsibility share among families in the place of the guidance logic"9.
NASF has been implemented in several cities based on the strategy of core arrangement. In this arrangement, NASF teams work together with reference teams, the ESF, providing technical support to expand action resolution in basic care. Thus, there is a guarantee of daily management and workers commitment with health work reorientation, according to the guideline of therapeutic links between teams (ESF and NASF) and users, and the interdisciplinary characteristic of performances and knowledge9.
Structuring work processes in core arrangements among teams provides the expansion of alternatives to compose individual therapeutic projects, without decreasing responsibility on cases and without creating infinite send/forward paths, aligning network actions. Moreover, ESF clinic expansion is needed and it will increase intervention and resolution capacity, as well as professional motivation to work with other realities and points of view, apart from their own center 9.
Facing the commitment of the Health Ministry concerning NASF implementation, the insertion of new professional in basic care, in other words, a proposal which may culminate in the progress of the Health System, the insertion of speech therapist is indispensable.
The speech therapist inserted in NASF may come across obstacles on team and intersector work. However, this is a paradigm which must be disrupted by speech therapy. Its performance must prioritize the collective, contributing to citizenship emergence, social support strengthening and community integration 9.
Therefore, the objective of this work is to analyze speech therapists profile and attributions in NASF according to recommendations of GM Ordinance nº 154, January 24th, 2008.
This is a descriptive and transversal study which was conducted in the metropolitan region of Recife, in cities which contain NASF where speech therapists are part of the professional team.
Among fourteen cities of the metropolitan region, only in four a speech therapist is part of NASF team. These cities are Camaragibe, Abreu e Lima, Paulista and Recife.
Data from the city of Camaragibe was excluded because one of the members of this research was its speech therapist. Also, data from Recife was excluded because the NASF was not implemented in the time of the interview. Therefore, only two cities and five speech therapists participated in this work.
Subjects of this research signed a term of free and informed consent, which contained the objectives, benefits and risks, besides insuring confidentiality of personal data and participation autonomy.
The study was approved by the Ethic Committee of CISAM-UPE for researches involving human beings, in accordance to the Resolution nº 196/96 of the National Health Council, view nº 016/010.
Data was collected through a semi-structured questionnaire assessed by speech therapists of NASF in the metropolitan region of Recife (RMR), divided into two axes: the first related to the speech therapists' profile; and the second related to work activities and organization. For processing and data analysis, Excel 2007 was used.
Profiles of speech therapists in NASF
According to the profile, it was found that 100% of the respondents are female, 60% completed their degree after 2000, 100% confirmed experience in working with communities, in which 80% consisted of house calls, and only 20% consisted of group sessions meetings.
Regarding the time of work in primary care, 80% of them have less than two years of experience in this area. As for the activity exercised before working in NASF, 80% of respondents performed outpatient or home calls and 60% said they had made multiprofessional or interdisciplinary work.
Attributions of speech therapists in NASF
It appears that 60% of interviewees conducted area diagnosis before initiating their work in NASF, and only 40% created assistance protocols. In relation to the formation of priority groups in Family Health Unities (USF), 60% stated participation in pactuation with ESF professionals and 60% conducted multiprofessional activities.
Concerning elaboration of therapeutic projects, 100% of speech therapists assured they have elaborated projects. However, only 60% conducted meetings on case discussion between ESF and NASF. This data emphasize the need of analyzing how to elaborate therapeutic projects, in which meetings and articulation among professionals from both teams are essential.
A fact which outstands is that 100% of interviewees confirmed that all actions are integrated between the teams (ESF and NASF) and social parts, conducting and developing rescuing actions and humanizing practices. Prevention actions are integrated to social parts, and in 80% of them there are intersector projects and inclusion of citizens with disabilities.
It is worth point out that 100% of speech therapists mentioned they promote information about activities conducted by them and by NASF professionals in the community, through posters, folders, among others.
In the development of rehabilitation actions, 60% of speech therapists prioritize collective calls.
In terms of evaluation processes of actions developed by speech therapists in NASF, 80% confirmed the existence of a method by the city center.
Profile of speech therapists in NASF
Considering the profile of speech therapists in NASF concerning the year bachelor degree conclusion, it is possible to observe an influence between the graduation year and the development of speech therapy actions for collective health, especially in NASF activities. In 2002, curriculum changes in speech therapy courses were approved. From this moment, courses were able to provide generalist professionals, and these changes were the main reasons for transformations in professional practices5,6.
In relation to past activities developed in NASF, it was observed that speech therapists have experience in working with the community. However, their actions were mainly related to home and outpatient calls, which explain the fact that for a long time speech therapists acted mainly in specialized and outpatient calls. Thus, it is necessary to transform speech therapy practices by overcoming biomedical paradigms, centralizing individual and fragmented actions, through a more integrated, interdisciplinary and collective care method9.
Noticing that many interviewees act on basic care for less than two years, and that its insertion and contact with collectivity was initiated by NASF, is it possible to foresee challenges in action development and implementation. The first is to face a different reality, demanding practices' restructure for working in NASF.
In this study, most interviewees stated experience in multiprofessional and multidisciplinary work. It is important to note that interdisciplinary work is not the sum of disciplines or juxtaposition of actions and knowledge. Interdisciplinary behavior occurs where overcoming fragmented work is needed and achieved by the production of new interrelation standards among teams and by bringing down structural and communications barriers9.
Attributions of speech therapists in NASF
In the development of speech therapists attributions in NASF, most professionals have conducted area diagnoses for identifying necessities and particularities of each territory and population. This is one of the structural actions in the processes of collective health work, because promotion and prevention actions must be planned based on necessities and social indicators of the community. In addition, some authors stated that NASF implementation process must pass through some steps, among these the action mapping in order to obtain social-demographical and epidemiological information11,12.
An important point is that most interviewees had not made activities protocols in NASF. This fact may contribute for weakening NASF performance, due to the importance of protocols in activities such as planning and monitoring. Moreover, a study conducted in Dendê community, where the speech therapy profile was conducted, emphasized the importance of protocols in providing precise information and establishing improvements in health determiners and constraints by speech therapy13,14.
Case discussion between ESF and NASF, by part of interviewees, is in accordance to recommendations of Ordinance nº 154, 2008. Moreover, these meetings are important for organizing and planning team work for the elaboration of singular therapeutic projects which aim broader assistance, marked by care production and life quality improvement, not focused in clinical assistance. Therapeutic projects' elaboration with team cases discussion benefits the spread and flexibility of science, because they promote an exchange among involved areas7,15,16.
In all NASF experiences in which speech therapists were part, there are integrated actions among teams. This is an aspect of great importance since there are ESF in which the work of a speech therapist is unknown, as shown in a research conducted with health agents who conducted community related practices, in which two of the five interviewees thought speech therapy could intervene only in cases involving daycare children17.
All speech therapists stated they have conducted practices oriented by rescuing and humanization. This is a relevant data due to the importance of reception process for a more humanized treatment, not only focusing on immediate necessity and daily life18.
The conduction of intersectorial actions by speech therapists meet one of the principles and guidelines of NASF, in which this way of working, governing and building public policies promotes understangin and social structures fragmentation overcome, producing significant effects on populations' health13.
One of the main professional attributions which compose NASF team is to promote activities developed together with ESF and the population, since it can contribute for expanding communities' comprehension on the role of the innovative health care proposal. In this study, it was observed that professionals have conducted promotion through educational group activities, poster, and folder distribution.
It is important to note the relevance of each city evaluating the impact of NASF actions on health indicators and in the process of family health team works. In addition, implemented actions evaluation is also considered one of the main professional attributions in NASF13.
Most professionals stated they have already conducted activities related to collective health, mainly through home intervention. According to a speech therapist experience on primary care, conducted in Novo Hamburgo (RS) in 2006, home visits consist in one of the most important tools for forwarding and assisting health issues of greater prevalence, and especially, "in health promotion and co-morbidity prevention"19. Based on these evidences it is worth to point out that speech therapists need to restructure their actions and to stop making efforts towards individual clinical patients.
It was also verified that all NASF centers in cities under study have developed activities which integrate social elements, strengthening action which promote health and disease prevention, in accordance to Ordinance 154/087.
The amount of speech therapist in NASF at the metropolitan region of Recife is relatively inferior than other health related professions. This is probably due to the incipient understanding of managers on the importance of speech therapists for basic care.
Speech therapists who are involved with NASF activities have developed actions such as health territory diagnosis, home visits, calls for family guidance, educational groups and meetings for discussing clinic cases with Family Health teams. Therefore, they are in accordance with Ordinance 154/08.
It is worth to note that the development of multidisciplinary and intersectorial actions is also relevant to broader populations' and other health professions understanding on speech therapists work.
Especially noteworthy was the necessity of better analyzing how the working processes of speech therapists in NASF may contribute to transform professional practice, to broader their professional skills and abilities on interdisciplinary actions and to develop diseases prevention and health promotions actions.
I sincerely thank all professors, students and coordinators from the 1st Specialization Course on Speech Therapy in Public Health (UPE), especially Cynthia Baroza and Fabiana Oliveira.
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