Evaluation of the shares of Speech Therapy in the NASF in Recife

Andrade, Aline Fernanda de; Lima, Mirella Muzzi de; Monteiro, Natália Pereira; Silva, Vanessa de Lima

doi:10.1590/S2317-64312014000100010

Abstracts

Purpose : This study aimed to evaluate the actions of Speech in Support Centers for Family Health in Recife (PE).

Methods : We carried out an evaluation study with a normative approach, considering aspects related to structure and process. For the evaluation model, we compiled logical speech therapy at the Center for Support from the analysis of the official documents that govern the operation in Support Centers for Family Health. We then constructed a matrix evaluation and prepared the instrument for data collection. Speech therapists were interviewed by ten members of the county teams studied by the Support Center for Family Health (NASF). To determine the degree of appropriateness of actions in audiology, the NASF used a scoring system that allowed them to classify actions into adequate (75-100%), partially adequate (50-74.99%), nephropathy (25-49.99%), and critical (<24.99%).

Results : The logical model resulting from this study pointed to a speech therapy based on the Support Matrix and activities to support Care and Management. Regarding the valuation of the shares, the structure and process dimensions were classified as incipient and appropriate, respectively. Considering the two dimensions evaluated, shares of Speech in the NASF could be considered adequate.

Conclusion : Speech has played a consistent role in the city of Recife, although its performance is grounded in the work process, highlighting the need to intervene in matters related to the structure in order to enhance the development of actions carried out in this context.

Health evaluation; Primary health care; Speech; language and hearing sciences; Health promotion; Family health

Objetivo : Avaliar as ações da Fonoaudiologia nos Núcleos de Apoio à Saúde da Família da cidade do Recife (PE).

Métodos : Foi realizado um estudo de avaliação com abordagem normativa, considerando os aspectos relacionados à estrutura e processo. Para a avaliação, foi elaborado o modelo lógico da atuação fonoaudiológica no Núcleo de Apoio, a partir da análise dos documentos oficiais que regulamentam a atuação nos Núcleos de Apoio à Saúde da Família. Em seguida, foi construída uma matriz de avaliação e elaborado o instrumento para a coleta de dados. Foram entrevistadas dez fonoaudiólogas integrantes das equipes NASF do município pesquisado. Para definição do grau de adequação das ações fonoaudiológicas no NASF, foi utilizado um sistema de escores que permitiu classificá-las em adequadas (75-100%), parcialmente adequadas (50-74,99%), incipientes (25-49,99%) e críticas (<24,99%).

Resultados : O modelo lógico resultante deste estudo apontou para uma atuação fonoaudiológica fundamentada no Apoio Matricial e com atividades de apoio à Atenção e à Gestão. Em relação à avaliação das ações, as dimensões “estrutura” e “processo” foram classificadas, respectivamente, como incipiente e adequada. Considerando as duas dimensões avaliadas, as ações da Fonoaudiologia no NASF puderam ser consideradas adequadas.

Conclusão : A Fonoaudiologia tem desempenhado de forma coerente seu papel nos NASF da cidade do Recife. Embora sua atuação seja fundamentada no processo de trabalho, aponta-se a necessidade de intervir em questões relacionadas à estrutura, a fim de aprimorar o desenvolvimento das ações realizadas nesse contexto.

Avaliação em Saúde; Atenção Primária à Saúde; Fonoaudiologia; Promoção da Saúde; Saúde da Família

INTRODUCTION

The Speech Therapy experiments in primary care and, more recently, in the Support Center for Family Health (NASF) represent one of the most promising proposals to increase the population’s access to fully comprehend human health communication ⁽ ¹ ⁾ .

Despite the accounts of various experiences in primary care and in Family Health Strategy (FHS), Speech Therapy had few legal incentives for use in this context. Although it is known that a principle of completeness values the participation of different professionals, the speech therapist was recognized primarily as a professional in specialized care. Since the NASF was created, this concept has been changing ⁽ ² ⁾ .

The inclusion of speech therapists in the NASF requires the ability to work interdisciplinarily in multi-professional teams. Thus, an speech therapist’s work in this context goes beyond scientific specificities and traditional clinic practice, connecting with diverse knowledge and developing projects capable of handling the complexity of health/disease processes ⁽ ¹ ⁾ .

The performance of speech therapists in the NASF should be based on the Matrix Support concept, which, at the same time, is an organizational arrangement and a methodology for the management of healthcare aimed at ensuring backup care and technical and pedagogical support for the Family Health Teams (FHT) with specialized knowledge without assuming the reference of healthcare ⁽ ³ ^, ⁴ ⁾ .

The NASF speech therapist plays the role of management support and healthcare. For this, he or she makes use of technological tools consisting of, among other things, a joint preparation of therapeutic projects, territorial health projects, and a work process agreement ⁽ ³ ^, ⁵ ⁾ . The use of such tools increases the possibility of solving cases in primary care, thereby reducing the number of referrals to Speech Therapy services so scarce in some regions that, in most cases, they do not meet the population’s demand ⁽ ⁶ ⁾ .

The NASF speech therapist acts as a boundary between the clinical and social fields. Therefore, his or her performance should consider other social facilities in the region, such as schools, daycare centers, and churches, promoting health communication and stimulating the strengthening of social networks ⁽ ⁷ ⁾ .

Another strong area of intervention for the NASF speech therapist is in the existing community groups, linked or not to the family health teams, like pregnant women, the elderly, and teenagers, with proposals of health education in order to provide healthy habits and lifestyles ⁽ ⁷ ⁾ .

Although an speech therapist’s activities, in an interdisciplinary perspective, can be developed in all nine strategic areas of care proposed for the NASF, the interventions in elderly health/rehabilitation and child health areas stand out.

In the elderly health/rehabilitation area, the speech therapist conducts activities aimed at reducing disabilities and handicaps in order to improve the individuals’ quality of life. In this sense, home visits are an important tool for monitoring, conducting adjustments, and guidance, especially for those who are bedridden and their families/caregivers ⁽ ³ ^, ⁸ ⁾ .

Regarding child health, among other activities, child development risk monitoring and the incentive for exclusive breastfeeding are conducted.

In fact, there are many actions that Speech Therapy can carry out in the primary care context. In addition to the activities already mentioned, one can also highlight participation in team meetings and with the community, diagnosis of the local health condition, participation in health campaigns, co-participation in continuous team education, and preparation and publication of research ⁽ ⁹ ^, ¹⁰ ⁾ .

Given the importance of the activities listed above, it is necessary to ensure that they are being effectively implemented and that there are standardized activities for speech therapists in the Support Centers.

In this sense, conducting assessment studies in the context of the NASF can be of great assistance given that the health assessment, when judging an intervention, provides information that assists in identifying potential problems in order to ensure the development of an intervention as advocated ⁽ ¹¹ ⁾ .

Furthermore, the theoretical and practical approach to this subject by evaluating health provides the possibility to enrich the Speech Therapy literature, since there are few publications dealing with the subject ⁽ ¹ ^, ¹² ⁾ . Working with and around this theme will certainly help to find answers that will provide greater consistency to the work of speech therapists in the context of primary care.

Thus, this study aimed to evaluate the activities of Speech Therapy in the Support Centers for Family Health in Recife (PE).

METHODS

A normative assessment of the activities of NASF Speech Therapy in the city of Recife was performed, considering aspects related to the structure and process.

The normative assessment consisted of an intervention evaluation by comparing resources used (structure) and services produced (process) with pre-established criteria and standards ⁽ ¹¹ ⁾ .

The city of Recife is divided into 94 districts distributed in six political and administrative regions (PAR). Each PAR corresponds to a health district (HD), which is the minimum management unit of the Municipal Health Secretariat. During the study, between March and April 2012, the city of Recife had 20 NASF teams distributed among the six health districts.

Among these NASF teams, 12 included speech therapists. However, only ten agreed to participate in the research. Therefore, ten female speech therapists were interviewed; they were members of the NASF teams of health districts (HD) I, II, IV, and VI.

The Speech Therapy activities were assessed using a logical model built on the basis of formal documents that regulate and guide the activities of the NASF, namely: Ordinance 154/2008 ⁽ ¹³ ⁾ , NASF Guidelines ⁽ ³ ⁾ , and Implantation Project of Support Centers in Recife ⁽ ¹⁴ ⁾ . To build the logical model, articles related to the NASF speech therapist actions published between 2010 and 2012 in indexed journals were also used.

A logical model consists of a visual design that exposes the behavior of a program from the relationship between the components of an intervention, the inputs, outputs, and results ⁽ ¹⁵ ⁾ .

The proposed model was built from components and subcomponents. For each component, items were identified relative to the dimensions “structure,” “process,” and “results” (Figure 1).

Figure 1
Logical model of the NASF speech therapist performance, 2012

To validate the logical model, component checking ⁽ ¹³ ⁾ was performed, and, for this procedure, active speech therapists were invited to review and suggest changes to each model element.

Based on the logical model, assessment matrices were constructed from the method proposed by Bezerra, Cazarin, and Alves ⁽ ¹⁵ ⁾ with criteria and standards set for each dimension and a maximum score assigned to each. In the present study, the dimensions “structure” and “process” were assessed.

From the matrices, a structured questionnaire was developed containing 43 questions. Initially, a pilot study with three speech therapists was performed in order to set the instrument for data collection.

Each question from the questionnaire was evaluated by identifying the presence or absence of items needed for the development of NASF Speech Therapy activities. The absence of an item received a score of “0” (zero) and the presence a score of “1” (one). To summarize the answers of the ten speech therapists interviewed, the arithmetic mean of the scores was calculated for each item. The dimension “structure” contained evaluated 20 items, and the dimension “process” contained 23 items (Charts 1 and 2).

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Chart 1.
Score obtained and degree of suitability of Speech Therapy in the Support Center for Family Health (NASF) actions in the city of Recife – dimension structure

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Chart 2.
Score obtained and degree of suitability of Speech Therapy in Support Center for Family Health (NASF) actions in the city of Recife – dimension process

To identify the degree of suitability for dimensions “structure” and “process,” the response percentage was identified in relation to the total of the items assessed for each dimension.

To identify the degree of suitability of NASF Speech Therapy in Recife, the weighted average was calculated for the percentages of the dimensions “structure” and “process.” For this, a value of three was assigned for the dimension “structure” and seven for the dimension “process.” The values were defined considering the emphasis on the dimension “process” in all documents that support NASF performance.

For the classification of degree of suitability (SD) of NASF Speech Therapy action in Recife, the cutoff points were divided into quartiles: “adequate” for SD of 75 to 100%, “partially adequate” when the result obtained was between 50 and 74.99%, “incipient” when the result was between 25 and 49.99%, and “critical” when the result was less than 24.99%.

This study was approved by the Ethics Committee on Human Research of Universidade Federal de Pernambuco (UFPE) (Registration No. 443/11; CAAE 0429.0.172.000-11) according to Resolution 196/96 of the National Health Council. All participants signed a free and informed consent form.

RESULTS

The logical model of the NASF speech therapist actions prepared in this study showed the components of Healthcare and Management Support. The component Matrix Support of Healthcare was divided into two subcomponents: common actions of FHT and the NASF and specific actions of the NASF speech therapist. The Management Support component presented Consent support as a subcomponent.

The dimension “structure” in this logical model included items related to physical structure, material, and human resources. For all intervention components, the same structure items were listed (Chart 1).

In the dimension “process,” the main activities related to the process of the NASF speech therapist were listed, such as developing actions for health promotion, disability prevention, breastfeeding incentive, group support and participation, school and daycare center activities, home visits, and other social facilities planning (Chart 2).

The activities listed in the dimension “process” led to results to be achieved in the medium and long term. Some of the intermediate results listed were: increased integration between social facilities, a decrease in new disabilities cases, increase in nursing mothers who practice exclusive breastfeeding, and decreased referrals to other levels of care. As a result, there was increased care completeness and FHS effectiveness.

Regarding the SD assessment of the NASF Speech Therapy activities, the SD dimensions of “structure” and “process” were initially obtained separately.

In the “structure” assessment (SD=39%), none of the criteria related to the physical structure and available materials obtained the highest score. The lowest scores were found for the following criteria: presence of data projector, telephone line, telephone, and printer. Only the “territory assistant management” criterion relating to human resources achieved the maximum expected score (Chart 1).

In the “process” assessment (SD=91.73), 14 out of the 23 listed criteria obtained a maximum score: common action planning; information material preparation; health promoting activities; disability prevention; orientation and follow-up of granted prostheses; admittance of children at risk; incentive to exclusively breastfeed; activities in schools and daycare centers; support and participation in educational groups; home visits for guidance, fitting, and follow-up; strategies to disseminate the activities of NASF Speech Therapy; queries and joint interventions; matrix documentation; and case discussion with FHS for PTS formulation.

The criteria relative to the case that obtained lower scores were: collective clinical service for users that require rehabilitation care and development of Community-Based Rehabilitation (CBR) activities.

Considering the dimensions assessed in this study (“structure” and “process”), the role of NASF Speech Therapy in the city of Recife was classified as adequate (SD=75.91%) as the dimension “process” (adequate) obtained a much higher degree of suitability than the dimension “structure” (incipient).

DISCUSSION

Building a logical model to represent Speech Therapy activities in the Support Centers for Family Health provided a picture of how this intervention is advocated for in official documents and literature, and reflects an NASF Speech Therapy based on the concept of Matrix Support. However, it was not possible to capture all activities performed in a NASF speech therapist’s routine. As new clarifications are being made about the performance of Support Centers, the logical model of Speech Therapy activities will be revised and improved.

The division of the model components in Support Care and Support Management reflects the definition of Matrix Support as an organizational arrangement that aims to provide specialized support to reference teams and, at the same time, establish itself as a methodology for management of healthcare ⁽ ⁴ ⁾ .

The selection of subcomponents “Common actions of FHT and the NASF,” “NASF speech therapist specific action,” and “Consent support” reflects the concept of division of the work process in Field Work and Support Center activities. According to Campos ⁽ ¹⁶ ⁾ , the support center defines the identity of an area of knowledge and professional practice, and the field is a space without limits where each discipline and professional seeks others’ support to fulfill its theoretical and practical tasks. For an interdisciplinary performance, as is expected of the NASF teams, the speech therapist must be able to balance the field and support center activities.

The activities listed for each subcomponent represent the support and educational dimensions of Matrix Support, given that these activities blend into the daily lives of NASF teams. Thus, a home visit that would initially have a supportive nature is also educational to the extent that the speech therapists explain to the professionals that accompany them the issues related to their support center and help them to deal with the specificities of the visited family.

Through this model, it was also possible to observe that, as recommended, the work process is the key element of NASF performance ⁽ ³ ^, ¹⁷ ⁾ . This dimension received greater emphasis in the assessment of the NASF Speech Therapy activities.

Despite the low score for the criteria relating to the dimension “structure,” the Speech Therapy activities, as a whole, were considered appropriate. This is due to the fact that the NASF is not an independent primary care service. Rather, it establishes its working process with the FHS, not requiring a physical structure to perform its work. Meanwhile, for the activities to be developed in the best way possible, it is necessary to provide human resources and materials through municipal administration in order to perform the minimum activities described for the NASF team and for each professional, including speech therapists ⁽ ¹⁷ ⁾ .

After the publication of Ordinance 154/2008, which established the NASF ⁽ ¹³ ⁾ , the Health Ministry clarified some important issues about the Support Centers by reviewing the guidelines and the inclusion of NASF in the National Primary Health Care Policy. However, it still is possible to see different interpretations of the NASF by the management in their municipalities ⁽ ⁵ ⁾ .

It is known that, in many places, the NASF speech therapist ceases to play the role of a supporter in order to complement the FHS or to address the lack of professionals in specialized care ⁽ ¹⁸ ^, ¹⁹ ⁾ .

Unlike this reality, the working process of the speech therapist in the health districts of the city studied is in line with the legislated actions, as shown by the high degree of suitability obtained in the dimension “process.”

Although this study has verified the suitability of the NASF Speech Therapy activities to regulation, it did not provide a conclusion about why this result was obtained. Factors such as the training of speech therapists, length of general and specific service to NASF, and personal skills could explain this result and need to be addressed in further studies.

Included in the subcomponent “Common actions of FHT and the NASF” are the preventive and health promoting actions, which received great emphasis in the work process of the NASF teams and obtained excellent ratings. The criteria related to the incentive for exclusive breastfeeding, participation in educational groups, and activities in schools and daycare centers obtained the maximum score. Such activities are described by various authors associated with Speech Therapy or related areas such as effective strategies for promoting and maintaining health ⁽ ¹ ^, ³ ^, ⁷ ^, ¹⁰ ⁾ .

The speech therapists’ participation in educational groups in the community is very positive, since these groups represent a good opportunity to work on issues related to health promotion and prevention of communication disorders. Several groups including teenagers, pregnant women, and the elderly are trained to provide health education with the aim of creating favorable environments for human development by adopting healthy habits and lifestyles that bring greater quality of life for the population ⁽ ⁷ ⁾ .

However, more than performing these actions, it is crucial to pay attention to how they are performed. The traditional triages, workshops, and lectures used by Speech Therapy for decades as a means of promoting health should give rise to dialogue with the objective of preserving and enhancing individual and social potential of promoting healthier ways of life. Instead of just conveying information, it is necessary that the health promoting actions have an educational basis grounded in Popular Health Education ⁽ ³ ^, ¹⁸ ⁾ .

Regarding disability prevention, especially hearing loss, it is observed that, because of increasing cases of premature hearing loss, it is relevant to have direct actions with the population, such as newborn hearing triage dissemination and personal hearing care, as well as FHT matrixing actions with themes related to hearing health ⁽ ²⁰ ⁾ .

When working with communities, it is important that the primary care professionals look at the potential of the territory, exploring the diverse social facilities, such as schools and daycare centers.

The National Primary Health Care Policy ⁽ ¹⁷ ⁾ brings to attention the School Health Program (SHP) established in 2007. This is an intersectorial policy between the Health and Education Ministries that aims to contribute to the complete education of students in the network, using preventative, dissemination, and healthcare activities.

The criterion regarding the assessment of the activities performed in schools and daycare centers obtained a maximum score in the work process, which indicates that the NASF speech therapists have the opportunity to assist with SHP activities and perform them together with FHT in schools in the territory.

Other criteria that received a maximum score were: domiciliary visit performance and conducting a unique therapeutic project (UTP).

In the speech therapist working process, the visits should focus on conducting guidance, assessments, or user follow-up. Through these, one can better understand the reality of the visited families and contribute in a more significant way ⁽ ⁸ ⁾ . Home visits also allow for the sharing of information among NASF and FHS team professionals, given that, in most cases, visits are made by more than one professional.

As well as visits, clinical case discussion - especially the more complex, such as UTP building - can be considered a good point in all of the NASF Speech Therapy actions in Recife, considering that this feature increases the resolution of cases and constitutes a privileged space for Matrix Support ⁽ ³ ⁾ .

In assessing the subcomponent “NASF speech therapist specific actions,” we found that the majority of the speech therapists participating in this study performed some kind of individual care, but only in exceptional cases.

Despite the large number of users with some type of communication disorder and who required rehabilitation care, it was observed that the NASF Speech Therapy in the studied city was not focused on individual care, as occurred in other cities. Rather, it acted in accordance with the guidelines of the Health Ministry, which recommends that the NASF should not be freely accessible to individual care but, if needed, should be regulated by primary care teams ⁽ ³ ^, ¹³ ^, ¹⁷ ⁾ .

A positive factor for performance focused on health promotion and not on clinical care is the existence, in the city, of the Domiciliary Care Services (DCS). The DCS was implemented in Recife in 2010 and includes all health districts. The DCS team has an speech therapist who performs direct care for patients with chronic diseases and terminal cancer and gives guidance to caregivers. However, by having specific care criteria and because of the small number of speech therapists, the DCS is not able to meet the demand.

As for group care, the low score received by this criterion shows that this is not a very common practice among the NASF speech therapists in Recife. It is possible to find published studies of therapeutic groups with Speech Therapy treatment in primary care ⁽ ¹ ^, ⁷ ⁾ . Such reports indicate that therapeutic groups can also serve as places to promote healthcare and help reduce referrals and queues in specialized care.

Nevertheless, these groups need to conform to FHT, taking into account the local reality and the kind of case in which they intend to act, not forgetting the main focus of the NASF activities.

Regarding the component “Management Support,” the performance of the NASF speech therapist in Recife can be considered positive, given that the criteria concerning the subcomponent “Consent Support” obtained a good score.

It was found that the criterion for common planning of activities received the maximum score, as did the criteria for goal definition and work indicators. Thus, from the evaluated speech therapists, it was possible to understand the supporter role that the NASF professionals practice with management, encouraging the sharing of actions and care management ⁽ ⁵ ⁾ . By discussing and agreeing on actions and goals, the NASF speech therapist participates in the management model operationalization of the Municipality ⁽ ⁵ ⁾ .

The NASF speech therapist has an important role in implementing healthcare guidelines - strategies used to organize healthcare that will guide practitioners on the paths that patients should take and measures adopted to have their needs adequately met ⁽ ²¹ ⁾ .

By acting in a shared manner and without hierarchy between the premises of healthcare, the speech therapist can become a public management tool in order to enhance the Healthcare Networks (HCN) ⁽ ¹⁹ ^, ²² ^, ²³ ⁾ .

It is important to note that, although this study has considered only the activities of the NASF Speech Therapy, one should understand that the actions performed by the speech therapist in a NASF team should be guided by the specific reality of the served population and should be executed in an interdisciplinary manner ⁽ ²⁴ ^, ²⁵ ⁾ .

In this sense, the speech therapist seeks to look beyond the specificities regarding his or her core knowledge. The matrix supporter function requires from this professional willingness to act in balance with field and core actions aimed at strengthening primary care and improving patients’ healthcare.

CONCLUSION

Overall, the assessment results pointed to the correlation between audiological actions performed in the surveyed districts and the guidelines in the documents that direct the actions of the NASF. Although the population surveyed covers only four of the six health districts in the city where the study was conducted, it was possible to get a sense of how Speech Therapy has helped with the NASF proposal to strengthen family health teams and increase the completeness actions of primary care.

One must highlight, however, the importance of conducting further studies on different aspects of Speech Therapy intervention in the NASF.

Although the performance of the NASF is based on the work process, there is a need to also intervene in matters related to structure in order to enhance the development of the actions included in that context.

References

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Study performed at Universidade Federal de Pernambuco – UFPE, Recife (PE), Brazil.

Publication Dates

Publication in this collection
Mar 2014

History

Received
17 Apr 2013
Accepted
09 Dec 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[2] ²Cavalheiro MTP. Fonoaudiologia e saúde da família. Rev CEFAC. 2009;11(2):editorial II.

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» http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html

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