EVALUATION OF AN INFANT MONITORING PROGRAM BASED ON THE POINT OF VIEW OF THE FAMILIES Avaliação de um programa de acompanhamento de lactentes sob a óptica da família

Purpose: the aim of our research was to evaluate a child development monitoring program conducted by speech and language therapists taking into account the point of view of the families. Method: a qualitative study analyzed a focus group attended by eight subjects during two meetings. All group participants had at least attended two evaluations of the program. Data was collected with the support of a moderator, an observer and a reporter; it was then analyzed by grouping the most relevant and frequent categories found in the speeches of the participants. The discussion focused on the following aspects: reception, health promotion, empowerment, health care team, interdisciplinary work, integrality and bonding. Results: program participants recognized the importance of speech therapists for health promotion and prevention insofar as they offer awareness training to child care providers and empower family members regarding infant development, which results in bonding between professionals and child care providers and integrated work. Conclusion: we analyzed the quality of the current health management model and suggest it be continued. However, it should start during gestation, include a higher number of follow up consultations and develop more multidisciplinary work.


INTRODUCTION
The need to ensure the right to health and to promote access to health services to everyone made up the scenario of the International Conference on Primary Health Care, known as the Alma Ata Conference, held in 1978 1 that highlighted, among other issues, the importance of intersectional actions, primary health care, and the participation of the population in planning and implementing primary health care.The guidelines set forth in that emphasizes rather the process than the product and aims to render the perspective of the participants.
One way of evaluating a service or program is by forming groups.A focus group, a kind of interview or conversation in small and homogeneous groups, is used to collect information by encouraging the interaction among participants to obtain consensus or disagreement.A schedule is applied that takes the researcher from the general to the specific; it requires a moderator to coordinate the group, involving everyone and getting the point of view of every single participant.
Focus groups allow us to understand the problems from the standpoint of population groups, to get to know the aspirations expressed by the community, to minimize the number of programs that show poor case-solving capacity and the number of distorted initiatives based on the interests of the establishment rather than the population itself.The interview schedule applied to the focus group should be provocative, encourage an enthusiastic and participative debate, and promote a thorough discussion of the analyzed issues.Different media may be used, such as formulating a central question, audiovisuals or producing a text that focuses on the discussion 12 .
Our research schedule featured eleven questions that focused on what motivates child care providers to participate in the Observation Program for the Development of Language and Visual Function in Infants, on how patients were received, on team work, and on the guidelines on language development, oral and visual communication, and breastfeeding (Figure 1).First, a pilot study was carried out with two of the eight participants, to check if the subjects understood the schedule of the semistructured interview and to make the necessary adjustments.
We invited mothers/child care providers and their children to join the group if they had attended two of the four evaluations offered by the Observation Program for the Development of Language and Visual Function in Infants 11 from January 2007 to August 2008.Evaluations were carried out at the first, fourth, eighth and eleventh months of the child's life.The investigation included eight participants of the Program of the Basic Health Unit of the Maria Beatriz District of the City of Mogi Mirim, i.e., six mothers, one grandmother and one child care provider, who had accompanied the infants taking part in the Program.
All the mothers and child care providers live in the city's urban area and have low socioeconomic level.In terms of education, four of them didn't finish elementary school, three completed elementary school and one completed high school.Regarding War, aiming to improve the effectiveness of the application of state resources, and methods were developed to analyze program benefits and costs 7 .In Brazil, public policy evaluation surveys are developed from the '80s; they are initially performed academically 7 and then incorporated into the routine of public administration 8,9 .
The way services are evaluated depends on what has to be examined and on the point of view of the researcher, i.e., more than just one single method exists.However, to evaluate the perceptions of social actors by how they experience programs, a qualitative research approach is essential.This research perspective is based on intersubjectivity, i.e., on the meeting of the subjectivity of the experience of informants with the experience of the researcher, since shared understanding and interpretation is taken into account 10 .
In the field of speech therapy, there are few studies about service evaluation 11 .In the city of Mogi Mirim, a town in the interior of the state of São Paulo, the first speech therapy actions were applied to a health prevention and promotion program aimed at pregnant women of a Basic Health Unit (Unidade Básica de Saúde -UBS) according to the guidelines of the Unified Health System (SUS).The role of speech therapy was to advise pregnant women on breastfeeding and promote the development of oral functions, speech and child language.
Since we believe that health promotion and prevention actions should be continued after birth, we suggested extending that infant intervention program called "Observation Program for the Development of Language and Visual Function in Infants", which includes the application of the Observation Protocol for the Development of Language and Visual Function in Infants 11 .
Our research aimed to evaluate a child development monitoring program that took place in primary health care and was conducted by the area of speech therapy, taking into account the point of view of the families.

METHOD
Our study was approved by the Research Ethics Committee of the Faculty of the host institution under the protocol no.393/2009.
To carry out our study, we adopted a qualitative approach, since the objective of the study was to examine how mothers assessed the Observation Program for the Development of Language and Visual Function in Infants by means of a focus group.
Qualitative research operates with descriptive data obtained from the researcher's direct contact with the environment and the situation studied; it 1.How were you invited to attend the first counseling session?Did you receive some information on the reason and the importance of speech therapy follow up?
2. What motivated you to take part in the monitoring?
3. Talk about the way you were received and the guidelines provided by the speech therapist during the time your child was monitored.
4. Talk about the guidance on breastfeeding.How did it influence the development of your child?
5. Discuss the guidelines on the use of pacifiers and bottles.How did they influence the development of your child?
6. Talk about the guidelines on language stimulation.How did they influence the development of your child?
7. Talk about the guidelines on the interaction between mother and baby.How did they influence the development of your child?
8. What were the reasons for you to skip some follow-up visit?their age, three are between 20 and 30 years old, three are between 30 and 50 years old and two are over 50 years old.Four of them work at home, i.e., one is a cake maker, one is a manicure and another two are child care providers.One mother works at a factory performing general services, another one is a daycare help and two have no regular occupation.Participants were selected by analyzing child development forms.The invitation, made by the researcher, was delivered by Community Health Agents at participants' homes.
Two focus group meetings took place, with a minimum of six and a maximum of ten participants each.Each group featured a moderator, a reporter and an observer.Instruments used included: observation, a prior schedule of the meetings, and document analysis.
The meetings lasted one hour and thirty minutes and took place in the meeting room of the Basic Health Unit.The meetings were filmed by a Community Health Agent and after that, all speeches were transcribed.Participants were seated around a table, which allowed eye contact and observing their body language.The room was well lit, had good ventilation, comfortable chairs, and an adequate space to perform the suggested technique.After the meetings, participants were offered a snack.The first meeting was attended by eight participants and the second one by three.
Participation in our research was voluntary and to take part in the groups, mothers and child care providers had to sign an Informed Consent Form.We excluded mothers and child care providers/ grandmother who decided to leave the research before its completion.
Data collection began in July 2009 and their analysis was made by means of the hermeneutical method, according to the following steps: data sorting, data classification, and final analysis.We expected to get feedback from the mothers about the proposed work to adapt it to local needs.
The transcribed material was analyzed by means of the hermeneutic method, since it allows interpreting data in a qualitative manner 12 .The answers to the questions asked by the researcher were classified and divided into categories of greatest frequency and of greatest relevance to the participants.
[...] When they made an appointment, I didn't need to know the reason ... I already knew, I had been instructed to make an appointment after childbirth.When my first child was born, it was not like that ... there was only a pediatrician, no speech therapist; we only came when the baby got sick.Not now, we are instructed to make appointments to check up, to check its eye sight, its hearing, its movements [...] (P3) [...] to get more frequent monitoring, suddenly it's every three months, I think it would be important for a smaller child [...] (P8).
In this research, several participants shared the need for team work with an interdisciplinary focus, as they expressed that health professionals don't always articulate their knowledge and actions: [...] so, one thing that's confusing is to wean the child, the milk carton we buy, now they tell us to breastfeed the child until two years of age, the pediatrician says that up to one year is enough, but if you can breastfeed up to two, it's great and the speech therapist recommends weaning the baby under the age of two.So we go: wean before two years of age, allow it suck up to two years, wean at six months or let the child decide?[...] (P2).Some participants pointed out the importance of the involvement of various specialties in the work process, showing that some professions are not always part of the teams: [...] I think you should do it (the research) in other areas, as well ... e.g., ENT, should be more involved, as well as the pediatrician [...] (P8).
The participants agreed that the program has improved the health of infants, when compared with others who didn't participate: [...] M. learned to chew easily ... he was eight months old, he wanted to chew, so I think it's very important, so they say, when the child is breastfeeding, to develop that part here (shows the jaw), so I think that was it, because he learned to chew food easily [...] (P3).
[...] My A. has already started to speak, she already speaks almost everything ... she is very clever ... from the age of eleven months, she has hardly ever gotten ill [...] (P7).

RESULTS
After transcribing the tapes, reinterpretation of the answers of the families, and organizing the data, the most frequent and most relevant categories in the speeches of the mothers were: reception of families attending the service, health promotion and empowerment, health team and interdisciplinary work, integrity and bonding.
Regarding the reception of families, most group participants agreed on the importance of trusting the professional who performs the monitoring, to establish a relationship based on that feeling: [...] I think it depends on the professional in charge, because not all of them attend us the way we want.If we get well attended, we'll always come back; if you are dissatisfied, you'll obviously find an excuse not to come back.I've always been well attended and I never missed a follow-up visit.Attending well, in my opinion, is paying attention, is trying to help me solve my issues, since many simply won't help [...] (P8).
The participants showed that they believe in the new care model based on listening, counseling and health promotion, which has had a positive impact on the development of users: [...] I think they suggest us to continue with the speech therapist; the pediatrician is only for diseases, fever, throat; for guidelines, it's the speech therapist, that's the suggestion we get, since the doctor is for one thing and the speech therapist has to guide us [...] (P5).
The speeches show that the participants integrated the information about the importance of breastfeeding and its positive influence on the development of infants: [...] The guidance I got is that breastfeeding is essential for the child until six months of life, there is no need to give the child any water, that breastfeeding..., he even began having juices only after six months ..., which was the only nutritional source, without the need of giving him anything else ... each case is different [...] (P2 e P8).
Regarding the understanding of mothers and child care providers, they received guidelines before childbirth, integrated the information and had therefore enough autonomy to choose to participate or not in the program and to question the information they received, prioritizing their real needs: questions; that's why I think that all the points were positive.There wasn't anything missing, I had no questions, and all the ones I had, all were answered, so I see no downside [...] (P8).

DISCUSSION
Our research successfully evaluated the Observation Program for the Development of Language and Visual Function in Infants by analyzing the speeches of mothers of a focus group, which provided important elements about the Program, stressing its health surveillance features and especially emphasizing the promotion of child development.
First, we observed that part of the population that attended the program acknowledged the speech therapist and his/her importance in terms of health prevention and health promotion.For mothers and child care providers, the way they were received by the speech therapist marked their relationship with him/her, which, according to them, was essential in terms of good attendance, listening, and establishing a good relationship between professionals and users.
According to some authors, the way patients are received allows to reflect on the work process, so as to overcome a practice dominated by curative logic, centered on the complaint and on medical knowledge, which has resulted in poor case-solving capacity of health care services, generating dissatisfaction both to users and health workers 13 .This is a work proposal that provides adequate answers to those who seek health services, since it is based on relationships and on the act of receiving them well and listening to them 13 .In addition to that, the way people are received is related to the link between users and the health service unit, to the caseresolving capacity of the medical attendance and the capacity to adapt the services to patient needs 14 .
A survey conducted among pregnant women in the Greater São Paulo Area highlighted that the model recommended by the Family Health Program, according to which care is usually provided by the same professionals every time a certain user contacts a health service unit, provided, in the case of pregnant women, the desired and necessary security throughout their pregnancy 15 .Another study, conducted with 78 women who were rooming in a public hospital in Ceará, revealed that 74.3% reported being highly satisfied with the services offered and some reasons included: good medical attendance, professionals were good, caring, treated them with respect and would answer their questions 16 .We believe that regarding the Program It was also noted by participants that comprehensive care enhanced their autonomy in taking decisions regarding infant health: [...] As she said, I received directions to breastfeed up to six months, but I kept going, I thought that the other, if I had breastfed him up to six months, he would have spoken.Her, I'll breastfeed until she doesn't want it anymore [...] (P7).
Most group participants supported the idea of the program to ensure health promotion and prevention: [...] I, to have gotten the direction to eliminate the pacifier and the bottle helped a lot, because he started talking soon after that and learned it easily, he had no problem talking, he says everything right [...] maybe, if he had used a pacifier and a bottle, it would have been more difficult [...] As I got the direction to eliminate these two vices [...] it helped a lot, because today, he speaks well [...] (P8).
The bond with the families favored the exchange of knowledge, the establishment of a horizontal relationship, since the knowledge of the participants is as recognized as the one of the speech therapist: [...] In my case, everything the speech therapist told me, I told her (the mother), because the mother came only once ... because every time I attend the speech therapy, everything they tell me, I pass on to her.I think that influenced her in a very positive way, because both are living very well.The mother brought her only once, and once with her father, who was also very well advised, he even stayed one hour, she took advantage of the day her father was present.Every time I passed on everything to V., she did everything right [...](P5).
[...] Some people say it's silly, here, but we're here to take advantage from the lecture, we are not here by chance, some people don't listen to the speech therapist, as they say, what the speech therapist advises; they do nothing right, don't pass anything on to the mother.That's very good, folks, as I said, if that had existed at the time of C.J., it would have been better, they gave us some other type of advice, so I lost a lot.Now with L. A., I haven't missed one [...] (P5).
[...] well, with speech therapy alone?I think that in my case, there was no downside; I never had to complain about anything, so I never went home with any unanswered results in isolated practices by the different professionals and excludes common goals 20 .The participants of our study mentioned the importance of an integrated team that allows professionals to interact and articulate their actions based on the elaboration of a common care project that aims at integrated actions and at meeting the established goals.
The principle of Integrality implies providing a health system geared to the different care stages, to the care process, to the relationship between health professionals and users.Integrality can be defined as "good life conditions", the result of environmental factors and a space in the production process, access to technologies that improve and extend life, "affective bonds" between users and health team / health professionals 22 .
In addition to that, participants appreciated professionals featuring a health prevention and health promotion vision which doesn't just prioritize the disease and the patient, but who gives users a voice, who takes into account their perception on programs and the way services are offered, according to their actual needs.
We observed that the program has proved important for the early detection of diseases, for monitoring breastfeeding and for reducing vicious habits.Therefore, the inclusion of speech therapists into Basic Health Units meets the new management model, emphasizing health prevention and promotion activities as part of the health making process and encouraging the humanization of health care services 23 .It also allows evaluating the quality of the current health management model, which emphasizes how important it is to continue that Program, which, in turn, should be made known better to pregnant woman, include more frequent follow-up visits and increasingly include interdisciplinary work.
The subjects' reports show that all professionals should rethink their practices and reflect on a new way of following up on users.Participants' perception on fragmented health practice should be analyzed by all Basic Health Unit professionals, which would contribute to the reorganization of the work processes and include the interdisciplinary work suggested by them.

CONCLUSION
Taking into account the large amount of SUS principles and guidelines and the complexity of health needs, it becomes clear how important it is that different professional groups, including speech therapy, participate in organizing services and actions that make up the Unified Health System.The valorization of a professional category is related to in question, the adhesion of these mothers and child care providers and the bonding with a professional may be due to the way they were received, including the permanency of the speech therapist.
Regarding the empowerment of the individuals in question, we observed that mothers and child care providers had acquired quite some knowledge on several aspects of child development.Empowering the families supports promoting citizenship, which is achieved by reaffirming the autonomy of the individual, the freedom of choice, and the understanding about oneself and one's life.Health professionals come to understand that the other has some knowledge about himself that must always be taken into account.On the other hand, users stop seeing the professional as the only one who owns the truth 17 .
The pursuit of equity and the improvement of life and health quality are guidelines that are part of the National Health Promotion Policy 18 .Fostering social participation is critical to the outcome of health promotion, particularly in terms of equity and the empowerment of individuals and the community.
The public health system must contribute to increase the autonomy of the population.Adopting co-construction of autonomy requires revamping medical management and care models, whose goals include health promotion and co-building the capacity of reflection and autonomous action of those involved in the processes, of health professionals and of users 19 .
Those new medical management and care models require interdisciplinarity in health practice, which occurs when professionals with different backgrounds and experiences come together to share a common goal, recognizing that piecemeal actions won't do to address illness, care, and cure 20 .In this research, several participants shared the need of interdisciplinary team work, since they stated that health professionals do not articulate their knowledge and actions.
A new vision of teamwork underlies the health care work management methodology, which is based on reference teams and matrix support.The reference team is organized by taking into account the management power level and the interdisciplinary team.The matrix support requires a change in the relations between specialists, integrating them into the different teams, providing medical assistance, and thus producing a space in which knowledge is exchanged between the different specialties and professions 21 .
Health services still feature a stiff structure, according to which professionals may only refer patients to other professionals and have no space for exchanges or questions.That model of interaction individuals, are important in the encounter between users and health professionals to achieve health.Medical care from the earliest years of life, such as the Observation Program for the Development of Language and Visual Function in Infants, which provides health promotion and early detection of health problems, significantly reduced referrals for specialized care and minimized the negative impacts that communication disorders may have on people's health.
the quality of the service offered to users.Therefore, our evaluation of the Program not only contributes to its reorganization according to the real needs of the population, but also stimulates professionals to reflect on their current work to overcome that isolated and fragmented form of intervention that prevents them from achieving positive goals and results.