Speech, language and hearing sciences and the family health strategy: the state of the art

Abstract:

The insertion of Speech, Language and Hearing Sciences in the Family Health Strategy is something new and studies in this field are scarce. In light of this, the objective of this study was to identify, from national and international literature, the state of the question on the performance and the insertion of Speech, Language and Hearing Sciences in the Family Health Strategy. For this purpose, we conducted a survey in the Virtual Health Library, annals from the Brazilian Congress of Speech, Language and Hearing Sciences, and Theses and Dissertations. From the study, it was possible to detect that lack of training for the speech, language and hearing therapist for work in Family Health Strategy is one of the main limiting factors for the insertion and performance of these professionals in this scenario; it was evident that few scientific publications address the theme; and it revealed that the Multi-professional Residency in Family Health has become essential to bridge the gap in the training of the speech, language and hearing therapists in Primary Health Care. There are many challenges for the Speech, Language and Hearing Sciences category to consolidate their performance in the Family Health Strategy, but, in spite of these weaknesses, their work in the territory promotes care that provides more quality of life and health to the population.

Keywords:
Speech, Language and Hearing Sciences; Family Health Strategy; Primary Health Care; Public Health

Resumo:

A inserção da Fonoaudiologia na Estratégia de Saúde da Família é algo novo e estudos sobre este tema são escassos. À luz disto, o objetivo desta pesquisa foi de identificar, a partir da literatura nacional e internacional, o estado da questão sobre a atuação e inserção da Fonoaudiologia na Estratégia de Saúde da Família. Para isso, foi realizada uma pesquisa na Biblioteca Virtual em Saúde, anais do Congresso Brasileiro de Fonoaudiologia, Teses e Dissertações. A partir do estudo, foi possível detectar que a deficiência na formação do fonoaudiólogo para o trabalho na Estratégia Saúde da Família é um dos principais fatores limitantes para a inserção e atuação desses profissionais neste cenário; Também identificou a falta de publicações científicas sobre o tema; E evidenciou que a Residência Multiprofissional em Saúde da Família, se tornou indispensável para diminuir a lacuna na formação do fonoaudiólogo sobre Atenção Básica. São muitos desafios para a categoria de Fonoaudiologia consolidar a sua atuação na Estratégia de Saúde da Família, mas, apesar das fragilidades, o seu fazer no território promove um cuidado que propicia mais qualidade de vida e saúde a essas pessoas.

Descritores:
Fonoaudiologia; Estratégia Saúde da Família; Atenção Primária à Saúde; Saúde Pública

Introduction

Primary Health Care has Family Health as priority strategy for its organization. Characterized as the preferential point of entry to the health system, with allocated territory, it should allow, among others, decentralized planning and programming, in line with the principle of equity; implementing integrality in its different aspects; developing relationships and responsibility between the teams and the population, guaranteeing the continuity of actions in health and the longitudinality of care¹. The Family Health Strategy (FHS) is understood as a refocusing of strategies for the assistance model, operationalized through the implantation of multi-professional teams in the Primary Health Care Units². It integrates professional categories, in order to address detected problems with more resolubility³.

With the implantation of the Family Health Program (FHP) in 1994 and its consolidation as a FHS, it was possible to expand universal access to health services, generating the need for changes and consolidating a new health care model based on the Unified Health System (UHS) (Sistema Único de Saúde - SUS)⁴.

Considering the importance of the theme, the Regional Council of Speech, Language and Hearing Sciences, with support from the Committee of Public Health of the Brazilian Society of Speech, Language and Hearing Sciences, in 2002, conducted a forum with the objective of preparing a document, in participatory manner, which defined a "Proposal for the Inclusion of Speech, Language and Hearing Sciences in the Family Health Strategy"⁵, since then the speech, language and hearing therapist has become an important component in the multidisciplinary team, as a professional trained to work with communication alterations in the community.

Human communication has a significant role in the maintenance of health and the quality of life of human beings. It is the primordial condition for the insertion of man in society, permeating all relationships, allowing social participation, learning and contributing to emotional integrity⁶. Therefore, the skill and the effectiveness of communication have become relevant to the concepts of health and changes in public policies⁷.

Hence, it is possible to observe that the perspective of Primary Health Care is one of the most recent in the history of Brazilian Speech, Language and Hearing Sciences, and it is involved in a process of achieving its own distinctive features, in the (re)construction of its own identity⁸. Thus, the insertion of Speech, Language and Hearing Sciences in the FHS is somewhat new and it has occurred timidly due to the lack of professionals with oriented training in public health. This has promoted limitations in the conceptions regarding its object of study and the range of its field of action⁹.

As Speech, Language and Hearing Sciences is a new science, there is a lack of studies that may provide technical and scientific knowledge capable of expanding its domain of performance in Public Health¹⁰. Unfortunately, studies in the field of primary health care are still scarce, especially when compared with production for specific areas of Speech, Language and Hearing Sciences. For this reason, advances in this area are extremely important to strengthen this category, based on evidence, and highlighting the value of their actions in the FHS. Therefore, the leading question of this study was: What are the main advances and challenges faced by Speech, Language and Hearing Sciences for insertion in the FHS?

In the light of this, the objective was to identify, from national and international literature, the state of the question regarding the advances and challenges for the insertion of Speech, Language and Hearing Sciences in this field of performance. For Nóbrega-Therrien & Therrien (2004, p.7)¹¹, "the finality of the state of the question is to lead the researcher to record, from rigorous bibliographic analysis, how the theme or the object of its investigation in the current state of science within its reach stands".

Methods

We performed a search in the Virtual Health Library (VHL), including abstracts from studies published in the last 20 years (from 1993 to 2013), being either from free access journals or not. The following keywords combinations were used for the search in the database: "Speech, Language and Hearing Sciences and Public Health", "Speech, Language and Hearing Sciences and Family Health", "Speech, Language and Hearing Sciences and Family Health Strategy", and "Speech, Language and Hearing Sciences and Primary Health Care". Keywords in other languages were not included, since the VHL includes searches in Spanish and Portuguese automatically, through the use of Medical Subject Headings (MeSH). Inclusion criteria adopted for the selection of bibliographic materials was limited to those focusing on Speech, Language and Hearing Sciences in the Family Health Strategy. Studies that did not address the theme were excluded.

From this search, 124 studies were selected for subsequent analysis of the full text, according to the following criteria: a) insertion of Speech, Language and Hearing Sciences in the Family Health Strategy; and b) advances and/or challenges of Speech, Language and Hearing Sciences in the Family Health Strategy. Studies were excluded which a) were duplicated in the searches with keywords; and b) studies that did not address Speech, Language and Hearing Sciences in the Family Health Strategy. From these, 21 complete articles were selected, and the instruments used in the studies are presented in this review. The flow for article selection can be seen in Figure 1.

Figure 1:
Analysis flow of summaries/abstracts and full texts selected in the Virtual Health Library (VHL) database

Grey literature was also searched including annals, dissertations and theses on the theme. The summaries/abstracts from the dissertation and theses were analyzed in the Brazilian Digital Library of Theses and Dissertations (BDLTD). The following keyword associations were used in the database search: "Speech, Language and Hearing Sciences" and "Family Health". Inclusion criteria adopted for the selection of bibliographic material were: a) insertion of Speech, Language and Hearing Sciences in the Family Health Strategy; b) advances and/or challenges of Speech, Language and Hearing Sciences in the Family Health Strategy; and c) theses and dissertations with free online access to the full text. Studies were excluded that did not address the theme and those that did not have access to full text online.

From this search 6 theses and 33 dissertations were found, from which the full texts were further analyzed to include those that met the following criteria: a) insertion of Speech, Language and Hearing Sciences in the Family Health Strategy; b) Speech, Language and Hearing Sciences performance in the Family Health Strategy. Theses and dissertations were excluded that: a) did not address Speech, Language and Hearing Sciences in the Family Health Strategy. From these, 8 dissertations were selected, and no theses met the selection criteria of this search. The flow for the selection of studies can be seen in Figure 2.

Figure 2:
Analysis flow of summaries/abstracts and full texts selected in the Brazilian Digital Library of Theses and Dissertations (BDLTD) database

The bibliographic survey of scientific studies published in annals from the Brazilian Congresses of Speech, Language and Hearing Sciences was conducted online on the Brazilian Society of Speech, Language and Hearing Sciences website, on which only annals from 2008 to present date were available for access. Studies from poster presentations were searched, in the area of Collective Health, Management in Collective Health and Health Care. Inclusion and exclusion criteria were the same as those used in the search for theses and dissertations. From this search 133 studies concerning the theme in the last 6 years were found. From these, 76 studies were selected; the instruments used in these studies are presented in this review. The flow for the selection of scientific studies can be seen in Figure 3.

Figure 3:
Analysis flow of summaries/abstracts and full texts from scientific studies published in the annals from the Brazilian Congress of Speech, Language and Hearing Sciences conducted on-line on the Brazilian Society of Speech, Language and Hearing Sciences page

Literature Review

Figure 4:
Picture containing information on the studies selected from the Virtual Health Library

Figure 5:
Picture containing information on the dissertations selected from the Brazilian Digital Library of Theses and Dissertations (BDLTD)

Figure 6:
Picture containing information on the studies found in the annals from the Brazilian Congresses of Speech, Language and Hearing Sciences

1. Insertion of Speech, Language and Hearing Sciences in the FHS - Advances

Among the positive changes, the authors agreed that the main transformation in the performance of this category in this scenario was the organization of actions according to the needs of the community¹². Many studies showed concern and effort from speech, language and hearing therapists in performing actions intrinsically linked to the needs of their territory of performance¹³.

From this, the insertion of the territorialization process in the work of Speech, Language and Hearing Sciences enabled knowledge on some determining factors in the health-sickness process of the population that reflect on the planning of actions in health^{13 15}, other than promoting an approximation of the category with the community¹⁶.

Work with epidemiological concepts, with the objective of mapping the most common sicknesses that affect communication health and their characteristics was another significant milestone^{17 19}.

The studies also showed greater understanding from the speech, language and hearing therapist regarding their role in the FHS⁶, with their main role being that of health promotion¹³. Moreover, integration with other categories and knowing how to perform interdisciplinarily was another lesson learnt in Primary Health Care^{13 20 22}.

Participation from the Speech, Language and Hearing Therapist in instances of social control guarantees greater zeal for the quality of assistance of users, strengthening the category and enhancing their performance in face of public policies, and also their conquered space²³.

All these changes have promoted a deconstruction of speech, language and hearing knowledge and a reconstruction of a new profile for performance in this context^{11 21}. This new performance has been shown to be effective for the population, as there has been an integration of the category with the professional staff at the Family Health Support Nucleus (FHSN)²⁴.

The Speech, Language and Hearing Therapist, together with FHSN, went on to develop matrix support, together with territorial organization and permanent education with professionals from family health. All these efforts, enabled the detection of early speech, language and hearing alterations in the territory, and it trained the health teams on the provision of health care for human communication^{22 25}.

Facing so many transformations, there was a need to adequate the training of the speech, language and hearing therapists according to the principles and guidelines from the UHS^{17 21 26}. Insertion of the category in the Multi-professional Residency in Family Health (MRFH) programs contributed significantly to the construction of work and conduct of Speech, Language and Hearing Sciences in Primary Health Care, as well as strengthening them in this performance scenario²⁰. MRFH enabled speech, language and hearing therapists to develop activities in the territories covered such as: situational and institutional diagnosis, reception, home visits, assistance at the nucleus, inter- and transdisciplinary (individual and/or in groups), education in health within (waiting rooms) and/or around the health units (groups for physical activity, care in health and conviviality, mental health, art [singing, dance, theater, craft], among others), and elaborating activities that involve the organization of services. Such activities are fundamental for the logical comprehension of the UHS, as most graduation courses do not fully prepare professionals with competencies, skills and attitudes for work in the UHS. The program enables unique experiences in team work (inter- or transdisciplinary) allowing each area of expertise to contribute with their knowledge, simplifying the exercise of reciprocity, and favoring integral assistance to health service users^{14 23 25}.

Concerning the performance of this category in the FHS, the authors emphasize that, the speech, language and hearing therapist may perform directly or indirectly with the population, preparing guidance programs on the development of language and hearing, on the importance for the development of neuro-vegetative functions in the production of sounds of speech, language, adequate use of voice, modifications that occur in language, and in neuro-vegetative functions and their interference in speech, language and hearing, other than conducting early diagnosis and treatment. Also, it is up to the speech, language and hearing therapists to diagnose environmental problems and detect alterations, develop activities for the promotion and protection of health in general (breastfeeding, hearing and vocal care, among others); conduct home visits, visit schools and crèches, offering advice and guidance; organize groups for health promotion and prevention (for newly-born, hypertensive individuals, elderly, and children); attend the demand of those referred to workshops and group therapy, discuss cases with the health team, contributing to the diagnosis of health situations in the area of coverage, including aspects that may interfere in human communication (noise, air pollution, lack of vaccination, prenatal care, presence of bad oral habits, oral respiration, etc.); train, guide and accompany actions conducted by the community health agents, seeking quality in the collection of data, in the guidance provided to the community and in the detection of possible human communication disorders; propose assessment instruments for the actions of speech, language and hearing therapists in consonance with FHS guidelines; and conduct and disclose studies on the performance of the speech, language and hearing therapists in the FHS^{6 27}.

Study has shown that the performance of the speech, language and hearing therapists, in a Primary Health Care Unit, together with the Observation Program for the Development of Language and Visual Function in Infants was important for the early detection of sickness, in breastfeeding support and in the reduction of vicious habits²⁸. Furthermore, the population that attended the program recognized the speech, language and hearing professional and their importance in the prevention and promotion of health. Therefore, the insertion of this category in the Primary Health Care Units, demonstrates a new management model, valuing promotion and prevention activities as part of a process of work in health and encouraging the humanization of services²⁸.

In a municipality in Maceió, 86% of the people, who went through screening at the Primary Health Care Units, presented a speech, language and hearing finding. These findings had predominance in the area of language and in the 0 to 6-year age range¹². Another study presented similar data, in which children up to the age of 10 years presented more speech, language and hearing findings, with language and speech disorders being most prevalent, as also the use of a pacifier and/or feeding bottle after the age of 24 months²⁹. This reflects in the probable alterations in communication health, demonstrating the need for performance in Speech, Language and Hearing Sciences together with the health teams from the Primary Health Care Units¹².

The main methods of performance for Speech, Language and Hearing Sciences for language disorders, in primary health care, occur through the use of games, shared reading, group workshops and home visits, among other approaches. In this manner, intervention with the parents results in the improved development of children, especially in the area of language, in groups either with or without risk factors. These are actions with children up to the age of 3 years, since early implemented intervention is decisive especially when hoping to obtain beneficial effects for them and their families. They also highlight that the work conducted with language inter-disciplinarily covered complete infant development³⁰.

One study demonstrated that speech, language and hearing work with children aged between 2 and 11 years was fundamental for the elimination of bad oral habits. Activities were conducted in a Primary Health Care Unit, in which the speech, language and hearing therapists used a ludic approach to make children and parents aware of the damage caused by the prolonged use of feeding-bottles, pacifiers and finger sucking. This study was conducted during a period of 30 days, and the strategies employed in this study were able to cease all the types of bad habits presented³¹.

The presence of the speech, language and hearing therapist in courses for pregnant women to provide guidance on care with hearing is fundamental; demonstrated through a significant increase in the number of referrals for the newborn hearing test and tests performed after the insertion of Speech, Language and Hearing Sciences in the FHS. In this manner, it is believed that the presence of the speech, language and hearing therapists in primary health care is fundamental for follow-up care and monitoring for the early diagnosis of hearing alterations, in order to improve the quality of life of children in the municipality³².

The study detected that the Community Health Agents had limited knowledge on the work of the Speech, Language and Hearing Sciences category, especially in the territories where the speech, language and hearing therapists were not present in the FHSN and in the Multi-professional Residency in Family Health, and after a moment of permanent education that addresses what Speech, Language and Hearing Sciences is, its actions in Primary Health Care and its areas of performance, it became evident that the Community Health Agents were able to perceive the problems in the community, although, quite often, they did not know how to act when faced with speech, language and hearing needs. This showed the need for the continued work of the speech, language and hearing therapist together with the FHS teams⁴.

2. Insertion of Speech, Language and Hearing Sciences in the FHS - Challenges

The most recurrent reason for restriction in the speech, language and hearing therapist's work was the lack of training for this professional to perform in primary health care. The professional speech, language and hearing therapist has been included in the FHS and the FHSN; however, quite often without due preparation, since their training, most of the time, is clinical and individual²³. Therefore, inserting them in the territories, reflects the clinical model on which they were trained, centering their performance quite often restricted to the patient, favoring the conception of sickness while producing singular actions for strictly personal phenomenon, without a binding process, dismissing the need for the professional and the importance of their follow-up^{6 11 22 33}. Other than this, the speech, language and hearing therapists present difficulties in conceptualizing the FHSN and Collective Health, fact which may imply in a work process detached from the conception of health promotion³⁴.

Some programs are being developed to reduce this gap, such as the Educational Program for Health Work, in which participation from Speech, Language and Hearing Sciences undergraduates occurs²⁵, and inclusion in the graduation curriculum framework of theoretical and practical disciplines developed at the Primary Health Care Units^{13 22 23}. However, studies affirm that this experience occurs during a short period of time, not causing an effective impact in the training of the professionals^{13 23}.

The result of this is a small number of speech therapists performing in the area of primary health care²⁴, which may come from students' prejudice caused by an "erroneous" conception of professional performance in this field during their training process³⁵. One study conducted in the Southern region of the country showed a lack of speech therapists in Public Health, as most of the professionals tend to perform curative and individualized actions, fact which restricts access to the area and, consequently, in the social recognition of Speech, Language and Hearing Sciences¹³.

Studies have signaled that the speech, language and hearing therapist has found few legal bases to perform in this context⁷. There is still the stereotyped opinion that Speech, Language and Hearing Sciences, have limited performance in rehabilitation²², with a large demand for specialized assistance²². It is mistakenly seen as a specialized care profession, reducing performance possibilities within the FHS¹³.

This distancing generates incipient knowledge for managers on the importance of Speech, Language and Hearing Sciences in primary health care, entailing few job opportunities in this scenario^{25 33 34}.

Another difficulty faced is that of integration with the multi-disciplinary team. Even though they are not incorporated in the multi-disciplinary and inter-disciplinary teams at the Primary Health Care Units, many professionals perceive the need for a speech, language and hearing therapist's work for users, but few link the insertion of this service as a contribution and complementation to their work process⁶.

The lack of knowledge on the role of the speech, language and hearing therapists by health teams and users, also, implies negatively on the inclusion of the category in the FHS. Other than this, studies on the theme identified that the professionals in this context (physician, nurse, nursing auxiliary, community agent) do not sufficiently investigate or address questions on the acquisition of oral language, oral habits, development of hearing, or mother-baby bond demonstrating a lack of knowledge and deficient co-responsibility regarding speech, language and hearing questions¹³.

There is a high degree of misinformation within the population concerning speech, language and hearing alterations, and in the knowledge and duties of the professional speech, language and hearing therapist²². One study described that some parents, even those aware that their child had some kind of speech, language or hearing disorder, did not seek professional help. This demonstrates that those who are responsible do not know the importance of the speech, language and hearing therapists' work²³. High demand was also signaled by the authors as a factor that hampers the work of the speech, language and hearing therapists in the FHS. To reduce high demand, it is necessary to adequate services to reality, to hire a greater number of speech, language and hearing therapists prepared to work in Public Health and get more attention from the government regarding public policies in Speech, Language and Hearing Sciences²⁴.

The absence of adequate physical space, lack of educational and informational materials in the Primary Health Care Units are also considered as limiting factors in the performance of Speech, Language and Hearing Sciences^{23 34 36}.

Furthermore, there is little scientific production that may fundament the importance of speech, language and hearing therapists in this field of performance. Scientific production in the Brazilian Congresses of Speech, Language and Hearing Sciences regarding health practices of the speech, language and hearing therapists in the FHS are still quite incipient²⁴ and the number of publications related to the theme is still scarce in 2012. Researchers believe that the time has come for us to conduct a survey on what is being done for the promotion and prevention of communication disorders²⁴, since research in this area may overcome the limited opinion concerning Speech, Language and Hearing Sciences in primary health care¹⁷.

Final Considerations

Most of the studies witnessed deficiencies that need to be corrected to increase the quality of care provided by the Speech, Language and Hearing Sciences in the FHS. There was an agreement, among the studies, regarding deficiency in the training of the speech, language and hearing therapists working in the FHS as the main limiting factor for the insertion and performance of these professionals. The graduation process is also flawed as the graduation curriculum framework is centered on the biomedical technique approach, with emphasis on clinical procedures, not favoring the development of competencies for performance in primary health care.

Furthermore, the structural aspect does not favor the development of the speech, language and hearing therapists' work, since there is a lack of materials, physical space and a restricted number of speech, language and hearing therapists working together with the communities.

The findings of the studies also show that few publications address this theme, witnessing the need to invest in research in this area in order to fundament the importance of speech, language and hearing actions in the FHS. Moreover, they signal that the Multi-professional Residency in Family Health has become essential to reduce the gap in the speech, language and hearing therapists' training in Primary Health Care.

Nevertheless, the small number of studies found on this theme showed that there are many challenges for the category of Speech, Language and Hearing Sciences to consolidate their performance in this scenario; however, their work together with the community promotes quality care that propitiates more quality of life and health in these people.

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  Oliveira IC, Rocha RM, Cutolo LRA. Algumas palavras sobre o Nasf: Relatando uma Experiência Acadêmica. Revista Brasileira de Educação Médica. 2012;36(4):574-80.
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  Soleman S. O trabalho do Fonoaudiólogo no Nucleos de Apoio à Saúde da Família (NASF): compreendendo as práticas a partir da composição dos processos de trabalho [dissertação]. São Paulo (SP): Universidade de São Paulo Faculdade de Saúde Pública; 2012.

Publication Dates

• Publication in this collection
  Oct 2015

History

• Received
  17 July 2014
• Accepted
  27 Apr 2015