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Revista CEFAC

On-line version ISSN 1982-0216

Rev. CEFAC vol.18 no.5 São Paulo Sept./Oct. 2016

http://dx.doi.org/10.1590/1982-0216201618520615 

ORIGINAL ARTICLES

Child’s language development surveillance: knowledge and practices among primary health care professionals

Raquel Aparecida Pizolato1 

Luciana Mara Monti Fonseca2 

Roosevelt da Silva Bastos3 

Adriano Yacubian Fernandes1 

Fernando Lefévre4 

Luciana Paula Maximino5 

1Faculdade de Odontologia de Bauru da Universidade de São Paulo; FOB-USP, Bauru, SP, Brasil.

2Departamento de Enfermagem Materno-Infantil e Saúde Pública da Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo, USP; Ribeirão Preto, SP, Brasil

3Departamento de Odontopediatria, Ortodontia e Saúde Coletiva da Faculdade de Odontologia de Bauru da Universidade de São Paulo. FOB-USP; Bauru, SP, Brasil.

4Faculdade de Saúde Pública da Universidade de São Paulo. USP, São Paulo, SP, Brasil.

5Departamento de Fonoaudiologia da Faculdade de Odontologia de Bauru da Universidade de São Paulo. FOB-USP, Bauru, SP, Brasil.

ABSTRACT

Purpose:

to analyze the knowledge and practices of nurses, doctors and dentists working in Primary Care for the development of the child's language early in life

Methods:

it is a qualitative research with 30 professionals from a network of Primary Care, among them doctors, nurses and dentists. An individual consultation was carried out through a semi-structured questionnaire. The technique of thematic speech analysis was used using three methodological approaches: The Central Idea, Expressions-Keys and the Collective Subject Discourse.

Results:

the knowledge that professionals have about the development of children's language were anchored to the core ideas to meet some milestones of development, the child's language depends on the middle stimulus, the family and normal hearing to know little or know nothing about the subject. The professionals reported that they would like to get more information on the subject in relation to the milestones of the child's language development, normal deviations and guidelines for parents in order to improve the care of children's health.

Conclusion:

the knowledge of professionals on the subject has been limited, and there is a need to expand educational practices in health through speech therapy, in partnership with the institutions of education and professionals of the Family Health Support Centers, with professionals of the Family Health Strategy Team, highlighting the work of the milestones of the child's language development.

Keywords: Primary Health Care; Interdisciplinary Communication; Child Health; Speech, Language and Hearing Sciences

Introduction

The monitoring of development is an integrating axis of attention for children's health, including activities related to the promotion of normal development and the detection of deviations in the process. Monitoring the acquisition and development of language is one of the axes to be observed by health professionals in child health surveillance, in addition to the characteristics of neuropsicomotor development1-3.

Health Surveillance has been defined as the active role of professionals and health services in the face of risk and vulnerability, tying planning and specific actions to minimize the damage and carry out proper health monitoring of the population4.

In Primary Health Care (PH) in Brazil, the model of Health Surveillance has been intensified during the process of reorganization of the Unified Health System (SUS), which has recently been incorporated into the care model of the Family Health Strategy (FHS). This, in turn, seeks the comprehensive care for the care of individuals and families over time and resolute answers for the population and community needs5.

It is recognized that PH nurses, doctors and dentists perform actions of administration and assistance in nature. However, reflecting on this aspect, it was considered important to know how these professionals develop such actions in their daily practice in the family health units (FHU) in order to analyze their professional contribution to the comprehensive care for the health of children6.

It is known that the surveillance of language development in children is related to the integral attention to children's health and needs to be observed by the professionals working in the team of the Family Health Strategy as a way to promote prevention, early promotion and diagnostic changes in the first years of life. It is estimated that one in eight children have developmental disorders that significantly interferes in their quality of life and inclusion in society 5. The diagnosis and early intervention in the early years of life are crucial for the development of a prognosis for these children6,7. It is important that monitoring is carried out by health professionals and that they have knowledge of the major milestones of the development of children's language to guide parents and also as an aid in decision-making in referrals to other areas8-10.

Through the Primary Care, known as the preferred gateway for the National Health System, the health team should know the most important aspects of development and be prepared to make some interventions, if needed, but mainly to clearly identify those children who should be referred to specialized treatments11.

When discussing with professionals from various fields regarding child development, there are several answers, since, in fact, human development is permeated by heterogeneous concepts from many different backgrounds. It is believed that this is due to the fact that development can be defined or understood, depending on the theoretical framework they want to adopt and what aspects one wants to address. It may be that to the doctor, the definition of development is to increase the capacity of the individual in performing increasingly complex functions. Pediatric neurologists think of the maturation of the central nervous system and the integrity of reflexes. Nurses worry more with the physical examination, guidance with vaccination and also with care for child nutrition12.

In Primary Care, with the insertion of health professionals in the Family Health Strategy Team (FHST) and the Support Centers for Family Health (SCFH), monitoring the child's growth and development is not only based on data annotation skills belonging to a particular system, but in the complex web that involves the whole development of the child as well as their relationship with their environment, parents and family. Considering the importance of comprehensive health care for children, the Ministry of Health created the National Health Care Policy for the Child (NHCPC), to which a set of programmatic and strategic actions were established to ensure the full development of the child and all life cycle stages, considering the different cultures and realities, focusing on health promotion, prevention of diseases and conditions, assistance and rehabilitation for the health and protection of children's rights. Each contact between the child and health services, regardless of the reason, must be treated as an opportunity for the integrated analysis of their health for resolute action to promote health with a strong resolute character. The monitoring of child growth should occur in a systematic way, constituting a central axis of comprehensive care13.

Among the axes which the NHCPC delegates is health care for the newborn, and the encouragement and qualification of monitoring growth and development are of upmost importance for the training team of the Family Health Strategy on themes related to the child's development and growth. Knowing the stages of language development in children early in life by the professionals of Primary Care, specifically by professionals of the Family Health Strategy Team, where making assessments and following the development of the child is of utmost importance for the prevention and health promotion of human communication and also the early detection of some kind of abnormality that does not correspond to the expected normal development11.

The evaluation of the development and growth of the child should be carried out by health professionals from the Primary Care, global and shared, because it is an educational process, providing an opportunity for professionals to assist parents in understanding the issues related to development, highlighting the typical process characteristics and reformulating maladaptive and inappropriate perceptions about manifested bahviors12. However, it is believed that there is a lack of knowledge about the milestones of language development in children by health professionals, especially nurses, doctors and dentists of the Family Health Strategy Team working in primary care, making it difficult in most cases for adequate guidance for parents during routine consultations and also to identify changes at an early age and required referrals for specialized centers12.

The present study aimed to carry out an exploratory study on the knowledge related to the monitoring of the child's language development in the early years by doctors, nurses and dentists who work in the Family Health Strategy Team in a municipality in the state of São Paulo in order to propose strategies for Health Education that will improve the knowledge of these professionals.

Methods

The present study was approved by the Committee of Ethics in Research of Ribeirão Preto Nursing School-USP (Protocol 814.561 approved on October 1, 2014). The research was qualitative and descriptive in nature. Invited to participate in the study were 44 professionals, including doctors, nurses, and dentists of 10 Health Strategy Teams of the Western District Family, 5 Health Districts that make up the city of the Interior of São Paulo researched. Agreeing to participate in the survey were 30 professionals, including sixteen doctors, eleven nurses and three dentists of the health units visited. In the present study, the Community Health Agents were not included, only professionals with higher education in order to homogenize the sample and avoid bias in the study, considering academic training as the eligibility criteria. Professionals who agreed to participate were informed about the risks and benefits of participation in the research and all signed a clarified consent form.

The method used was qualitative from a descriptive study. For data collection, a semi-structured questionnaire (Annex 1) was used and for the qualitative analysis, the Collective Subject Discourse approach was adopted. The survey questions were automatically answered by the participants. To perform the analysis of qualitative data, the Collective Subject Discourse technique was used14,15. This technique is a proposal for the organization and tabulation of qualitative data of testimony, either in oral or written form by each participant, and is based upon the theory of Social Representation and its sociological assumptions; the proposal is basically to analyze the written material extracted from each of the statements 14,15.

The Collective Subject Discourse is a form of presentation of qualitative research results, which have testimonials as raw material in the form of one or more synthetic discourses written in the first person singular in order to express the thought of a collectivity as if this community were the issuer of a speech15. This technique consists of selecting, for each individual response to a question, the expressions-keys, which are the most significant stretches of these responses. These expressions-keys correspond to Central Ideas that are the synthesis of discursive content expressed in the Key Expressions. Synthetic discourses are built from the material of Key Expressions of Central Ideas, in the first person singular, which are collective subject discourses, where the thought or collectivity of a group appears as if it were an individual speech 16.

The procedures for the analysis of the Collective Subject Discourse basically involve the following operations on the collected speeches:

  • Selection of key expressions of each answer to a question. The key phrases are continuous or discontinuous segments of speech that reveal the main discursive content; It is a kind of "discursive empirical proof" of the "truth" of the central ideas.

  • Identification of the main idea of each of these key phrases: a summary of the content of these expressions, that is, what they want to actually say.

  • Identification of similar or complementary core ideas.

  • Meeting of the key expressions relating to central ideas and synthesis in expressions that reveal the Collective Subject Discourse (CSD).

The CSD is therefore a time or methodological resource to make clear and expressive social representations, allowing that a particular social group (health professionals in Primary Care, in the case of the present study) can be seen as an author and issuer of common discourses among its members. With the collective subject, the speeches do not cancel or reduce to a common unifying category since what it seeks to do is precisely the opposite, that is, reconstructing, with pieces of individual speeches, as in a puzzle, as many synthetic discourses as is considered necessary to express a given "figure", a given thought or social representation of a phenomenon16.

The Qualiquantisoft Program was used for the data analysis.

Results

In the evaluated sample, 73.33% (22) of the subjects were female and 26.66% (8) male. Among the professionals, 53.33% (16) were physicians, 36.66% (11) nurses and 10% (3) were dentists. The average age was 36.86 with a standard deviation of 9.97 years. Most professionals worked in the profession for less than 10 years (66.66%) and only 33.33% had more than 10 years of experience in the profession.

All participating health staff professionals reported that the development of speech is related to the hearing health of the child with the encouragement of the family environment. To be observed on the suspicion that the child has a communication problem, 75% of the participating physicians discuss the case with the team, 72.72% of the nursing participants and 66.66% of the dentists have the same procedure.

During the routine vaccines, clinical care, home visits and educational childcare activities, 81.25% of the medical professionals reported that they guided parents to stimulate the child's language, 72.72% of nursing professionals also guided the family, and 66.66% of dentists reported having the same attitude.

All dentists of the present sample said they did not know how to identify the child's language changes.

All professionals showed interest in deepening and enhancing the knowledge of the subject through a refresher course.

Table 1 shows the percentage of participants who know how to identify changes in child language early in life. Table 2 presents the knowledge that professionals of the Family Health Program Team have about the milestones in the development and acquisition of child language in the early years of life.

Figures 1 and 2 show the analysis of the Collective Subject Discourse and the theme investigated.

Table 1: Knowledge about identifying changes in language development in children early in life by the professionals of the Family Health Strategy Team 

% Percentage

N: number of study subjects

Table 2: Knowledge of the landmarks of the acquisition and language development in children early in life by the professionals of the Family Health Strategy Team 

% Percentage

N: number of study subjects

Figure 1: Central idea and collective subject discourse of 30 professionals in the primary care network in response to the question, "What do you know about the acquisition and language development in children at age 0-24 months". 

Figure 2: Central idea and collective discourse of 30 professionals from the primary care network in response to the question: "By participating in a course on acquisition and development of children's language, what would you like to know?" 

Discussion

Knowing the perspective of health professionals working in the Primary Health Public System regarding the Surveillance of Child Language Development is an important step in the process of health education in order to propose facilitating strategies to contribute to the process of improvement of knowledge in the care of children`s health by health professionals 17.

The quantitative descriptive data of the tables showed that only 53.33% of the participants are able to identify changes in language in the early years of a child's life. These data reveal that there is a need for the area of speech therapy to achieve a partnership among the other professionals in the Family Health Strategy Team in order to share knowledge on the subject, contributing to health actions in which these professionals can perform what they say regarding the prevention and promotion of human communication in the early years of a child's life. The difficulty in knowing how to correctly identify the milestones of language development in children early in life was evidenced in the data presented in Table 2. It is important to note that each of the participants think of ways in which experiences in the professional practice may have more experience than the other and thus, less difficulty, but thinking towards the health team. Everyone should know the developmental milestones to facilitate and propose health actions jointly 11. Considering that the nurse, the doctor and the dentist of the Family Health Strategy Team are responsible for making assessments and monitoring of child growth and development during routine consultations at the Health Unit, it is of great importance that these professionals expand their knowledge of the milestones in the development of children's language so they can identify risk factors, interventions required and necessary referrals to other professionals.

Although professionals have difficulty identifying children with abnormal language development in early in life, it became apparent that a large part of the participants have concerns to discuss with their team, any suspected case of change. Thus, it is necessary that health professionals be prepared to request help from another colleague (if applicable, the matrix support), or to clarify the user that the problem cannot be solved in that instance (Primary Care), and then provide the reference to another level, for example, medical clinics and phonoaudiological specialty centers. The important thing is to show solidarity to the problem and do not forget the responsibility of the Family Health Team regarding the health of the population of their territory18.

The comparative analysis between the professionals was not evidenced because of the disparity of the number of participants in each group, in addition to recommending the decoupling of professionals working in the context of Primary Care, since they are considered as members of an integrated team - the Family Health Strategy.

Considering the qualitative analysis, the first central idea, "I know some milestones in the development of language" (Figure 1), there is emphasis on the fact that the development of the child's language occurs with babbling, evolves to the emission of words in the eighth to twelfth month of life, and the child begins to form sentences from the twenty-fourth month. It was evidenced that the professional participants had knowledge of the acquisition and language development in children, although they had little depth and some uncertainties in defining the stages of language development. Knowledge of the normal pattern of language acquisition is essential so that it can be compared with the pathology and thus, perform guidelines for parents and caregivers in educational interactive activities in health, and make referrals as early as possible to specialized treatment 2,19.

On the other hand, the central idea "I know very little about language" (Figure 1) shows difficulties and failures in the field of knowledge of the participants on the development of children's language, but consider language as an important factor in the child's learning needs be evaluated periodically. Similar results were found in the study of other authors and indicated that physicians who work in Basic Health Units (UBS) had error rates and difficulties regarding the acquisition and development of infant language10. Knowledge about normal language development and monitoring practices should be part of routine consultations, especially for doctors, but also nurses and dentists.

The central idea, "The children's language depends on the middle stimulus, family and normal hearing" (Figure 1) shows that health professionals make association of the child's language development with the stimulus it receives from the environment and family. According to the participants, the environment in which the child develops is influenced by the affective partner relationship regarding the verbal forms and experiences that are provided. Some authors 20 report that home stimuli such as, for example, encouraging reading, presence of books and conversations with children placed in family practice has a great importance in the association factor for the development of children's language. The main incentive to promote communication development in childhood is to identify the protective factors and social support that should be considered as one of the best alternative intervention strategies, being of great importance that health professionals guide families as to the encouragement of child language in the early years of life21,22.

In addition, models of communication such as the medium provides the child with influence of the language, quantity, quality and the situations experienced by the child22. The biological factor such as hearing and the change in the behavior of auditory stimuli in the child should be seen by health professionals during routine consultations. Professionals reported that it is important that a behavior observation to sound stimuli should be performed in order to check whether the child has a change in hearing. The first years of life are considered the most important for the development of hearing and language skills, and primary health care professionals should be alert for signs of possible changes and needs of early intervention 21.

The central idea of "Do not know" shows that professionals do not have dominion over the milestones of language development in children, but would like to acquire knowledge to feel safe in performing the child's assessment in routine care. In the literature, another work also sought to evaluate the knowledge of physicians in relation to the language and identified shortcomings, and the need for training continued so that they could expand the knowledge on what was missing on the subject 12.

Figure 2 shows the central ideas about what the participants would like to know should they be invited to participate in courses on the subject. The suggestions reported by participants focused on the main features of language development for each age, guidance for parents and family and also knowing about anything regarding the screening of child language in routine work. It was possible to observe a great interest on the part of health professionals in learning more about the subject related to the field of speech therapy. It considers the development of Health Education Strategies for work, and actions should be thought out together in order to strengthen the interdisciplinary work. The term interdisciplinary implies coordinated work with a common purpose, shared by several branches of knowledge in an integrated and convergent manner, which immediately reports on the basis of performance of the Family Health Strategy Team. However, the practice leads to a completely different reality, where teamwork is closer than one might label as multidisciplinary, since the professional knowledge of the components of the teams do not interact, reproducing what has been learned in the graduation courses. This lack of integration and communication between professionals certainly have their origin in graduation because each professional is formed without interacting with other health professionals, without a common work space that allows the exchange of knowledge and enables coordinated action to achieve a common goal 23.

Considering that healthcare professionals who are part of the Family Health Strategy Team should seek knowledge about the formation of each professional who works in Primary Care through interdisciplinary action so they can act in health promotion, prevention diseases and disorders for improvement of the community assisted quality of life and the health user can be viewed as a whole. Knowledge about the acquisition and language development in children early in life by the professionals of the Family Health Strategy Team should be of great relevance in the shared Permanent Education process between team professionals and the field of speech therapy.

Training courses through distance or semi-distance education can contribute to the permanent education of health professionals of Primary Care, favoring the expansion and the exchange of knowledge between them. Thus, prevention, health promotion, diagnosis and rehabilitation can be better targeted to children's health by strengthening the knowledge and dissipation of exchange by health professionals. It is hoped that through pedagogical support performed by audiologists of Family Health Support Centers and distance education courses offered by higher education institutions can contribute to the monitoring of the Acquisition and Development of Child Language by the Family Health Strategy Team. In this way, promoting the improvement of child health care for the prevention and health promotion, thus, the identification of developmental disorders not expected for the age, guidelines for caregivers and parents and thus, it promotes dialogue between the areas 24.

Considering the importance of human communication in the integral development of the individual, the speech therapist is an essential professional in Primary Care because he knows the role of language as an individual training tool and can help other professionals from different areas to better understand about the acquisition and development of children's language 25.

The role of professionals in Primary Care is emphasized since the contact with the child early in life happens continuously during routine care, and parental guidance is paramount for health promotion and prevention, and also the detection of deficits visualizing early intervention, as well as the active search for cases, favoring the premise in the Surveillance of Children`s Health. It is believed that the exchange of knowledge among health professionals in Primary Care that interface with professional speech therapy can add new knowledge to these professionals and can provide professional health conditions to realize the man as a whole, taking the development process of human communication as important in child development.

Conclusion

The knowledge of doctors, nurses and dentists of the Family Health Strategy Team regarding the acquisition and development of children's language in the early years proved to be restricted. There is need for Health Education Strategies for professionals of Family Health Strategy Teams developed by audiologists of Family Health Support Centers in partnership with educational institutions, highlighting work on the milestones of language development.

Acknowledgment

Thanks to the financial support of CNPQ and the Postdoctoral scholarship.

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Support: CNPQ (processo 150022/2015-8)

Annex 1: Questionnaire on Child Language Acquisition Skills in Early Years

Received: December 17, 2015; Accepted: May 08, 2016

Mailing address: Raquel Aparecida Pizolato, Rua Miguel Martini nº 101, Jaboticabal -SP - Brasil, CEP: 14871-415, E-mail: raquelpiz@yahoo.com.br

Conflict of interest: non-existent

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