Community health workers: mapping of knowledge before and aftertraining workshops

Abstracts

OBJETIVOS:

mapear o conhecimento de agentes comunitários de saúde antes e após participação em oficinas de instrumentalização sobre aspectos fonoaudiológicos e verificar as mudanças de percepção segundo o tempo de trabalho na Estratégia de Saúde da Família.

MÉTODOS:

o estudo foi realizado em um município a 170 km da capital de Minas Geraise com 74.409 habitantes. A rede de Atenção Primária a Saúde do município é composta por 10 unidades de Estratégia de Saúde da Família que alocam 60 agentes de saúde. Os dados foram coletados em todas as unidades e consistiu em três etapas: a) aplicação de questionário auto-aplicável acerca de aspectos fonoaudiológicos; b) processo de instrumentalização; c) reaplicação do questionário.

RESULTADOS:

participaram do estudo 51 agentes de saúde. Após a instrumentalização, tornou-se maior o número de agentes de saúde que deram relevância a fatores que sugerem a ocorrência de distúrbio da comunicação nas diferentes faixas etárias e que passaram a conhecer as quatro áreas que englobam a atuação fonoaudiológica. Não houve relação estatística entre o desempenho dos agentes nas respostas e a unidade de trabalho. Quanto ao tempo de trabalho Estratégia de Saúde da Família, na pré-instrumentalização, o melhor desempenho nas respostas foi dos agentes que trabalham há menos de um ano na atenção primária.

CONCLUSÃO:

ainstrumentalização favoreceu as respostas dos agentes comunitários de saúde. Houve relação entre o processo de instrumentalização e o tempo de atuação no Programa de Saúde da Família.

Estratégia de Saúde da Família; Sistema Único de Saúde; Capacitação em Serviço; Atenção Primária à Saúde; Fonoaudiologia; Agentes Comunitários de Saúde

Introduction

The Primary Health Care is characterized as the foundation of the health care network and by the expanded and general assistance based on comprehensive care. The services based on this practice are configured in an integrated manner, so as to employ curative and rehabilitative actions, promote health and take preventive actions, based on teamwork, coordinated and articulated with public policies, aiming at the provision of comprehensive care to individuals and their families¹.

Through the implementation of the Family Health Strategy, the Brazilian government sought to carry out health activities in primary care and to realize the essence of the Single Health System: comprehensiveness, universality and equity².

The Family Health Strategy seeks to expand coverage and access of the population to services and health actions, mainly due to active search, health care planning and logic related to the territory and its features. Among the consolidation factors of this health care mode, the proximity of the residence of the service users, the territorial coverage process and the interdisciplinary and interprofessional teamwork, through home visits in direct contact with families and comunities³ are highlighted.

In a proposal of actuation focused on family and on its context, the health team inserts itself in the social environment, knows it and undertakes to change it⁴. It also searches to conduct health surveillance and to create a connection between the team and the population, fostering an organization of Primary Health Care³ more suitable to the problems and health needs of the population and to the principles of the Single Health System.

Home visits allow a connection between the professionals and the population, including health practices in the daily life of the users in order to ensure the education process and health intervention⁵. This strategy favors the construction of a dialogue and therefore, a comprehensive care, which becomes more human, since the health professional becomes aware of the family situation of the individual⁶.

The Family Health Strategy has a comprehensive and multidisciplinary character, therefore the health workers, in a primary contact with the population, should be prepared to observe the individuals in their entirety, seeking to understand beyond the complaint and signs presented by the assisted population⁷. It is worth noting that like other professionals, community health workers should participate in activities that ensure the joint assessment of the situation of the territory, agreement on the development of the work process and goals, and construction of the interdisciplinary context of health care².

Communication is among the attention or observation aspects of the family health team; this condition and human skill enable the individuals to place themselves as agents of transformation of the society and their reality⁸. Thus, to be aware of the process of communication development and other phonological aspects in all cycles of life should be the focus of the actions of the family health team and therefore be included in the training process of the staff,especially health workers.

When inserted in the training process of the health worker, the Speech Therapy seeks to offer a more qualified assistance to the target population of the Family Health Strategy. The discussion of the knowledge of health care, rehabilitation and impact of physical, hearing, mental and visual impairments and the provision of dietary and nutrition guidelines is an opportunity for the effective contribution to the improvement of the life conditions of the population⁹. The Speech Therapy in the APS (Primary Health Care), through care to individuals and social groups at risk and of social vulnerability, gives a chance to people who previously had no access to this medical specialty⁹.

The Speech Therapy must be included in the Family Health Strategy in a general way, able to identify the most important issues in its community, to elaborate and to carry out actions aimed at a solution, adopting preventive measures whenever possible⁸. It is necessary to monitor and systematize the limits and potentials of this model, aiming at its development and appropriation as comprehensive care strategy, to include Speech Therapy in the Single Health System (SUS), creating interdisciplinary and interprofessional care networks⁹.

The purpose of this study was to map the knowledge of community health workers before and after the participation in training workshops on phonoaudiological aspects and to verify changes in the perception according to the working time in the Family Health Strategy.

Methods

It is a pre-experimental exploratory study using non-probabilistic sample approved under Opinion No. 677/07 by the Research Ethics Committee of the Federal University of Minas Gerais and conducted in a municipality located in the central region of Minas Gerais, 170 km from the capital Belo Horizonte. The municipality has 74,219 inhabitants according to data estimated by IBGE¹⁰, and presents Human Development Index of 0.755 according to data released by the United Nations Development Program in 2.000¹¹. The Primary Care network of the municipality was composed of 10 units of the Family Health Strategy that allocated 60 health workers. The Municipal Health Department and the Coordination of the Family Health Strategy of the municipality authorized the research by signing the letter of agreement.

For the study, a self-applicable form was used as instrument, which was elaborated by the researchers (Figure 1), containing closed questions that corresponded to areas of phonoaudiology, to actuation forms in different life cycles, communication disorders, assistance needs and guidance offered to the community. The purpose of these questions was to determine whether health workers had the ability to recognize complaints and demands for the speech therapy service.

Figure 1:
Form used for data collection

The following inclusion criteria were established to define the sample: be a health worker of a Family Health Strategy unit of the municipality and have agreed to participate by signing the Free and Cleared Term of Consent. The exclusion criteria were: to leave the training workshop; be unable to perform the duties for any reason during the study period, for example, be on leave at the time of data collection; and fill less than 80% of the survey form in the initial or final data collection.

The data collection was performed in all basic health units in the municipality and consisted of three stages, namely:

a) Stage I: Characterization of the knowledge of the health workers. A questionnaire was applied to each team of health workers in their unit of origin. All health workers filled individually and simultaneously the data collection form in a closed and silent room. Also in this stage the workshop schedule was presented and the doubts of the health workers about the activities to be performed were clarified.

b) Stage II: Training workshops. Each team of health workers participated in two workshops lasting four hours each. Group activities, situational games, analysis of problem situations and dialogue based presentation were used as a methodology of training, with the main themes: Role of the Speech Therapist in the Single Health System; Acquisition and development of human communication and its disorders; Guidance and referral to a speech therapy service. Each workshop lasted an hour and the health workers received a workbook containing theoretical bases about the covered subjects and clarification about the purposes, duration and description of the activities.

c) Stage III: Reapplication of the questionnaire. A questionnaire was applied again to each team of health workers in their unit of origin. All health workers filled individually and simultaneously the data collection form in a closed and silent room.

A descriptive analysis of their answers to the closed questions of the form was performed, considering, in a distinct way, the questions with only one answer option and those with more possibilities. For questions that presented only one answer option, a statistical analysis using Fisher's exact test was performed. For questions that presented more answer options, a statistical analysis using the paired t-test was performed. Frequency tables were used for categorical variables and graphical visualization of the main findings. The data analysis related to the variables "health unit of origin" and "working time as a family health worker" took place in a qualitative way. The significance level of 5% (0.05) was considered in all analyses.

The statistical program SPSS version 18 was used for processing and statistical analysis of the data.

Results

Fifty one health workers with a mean age of 32.71 years participated in the study, 86.3% have completed Secondary School. Regarding the working time in the Family Health Strategy, the average was 3.45 years, between six months and 10 years, 25.5% less than one year and 21.6% five years of work. Regarding the work routine, each health worker of the municipality visited in average 15.53 families per day at the time of data collection.

Another important fact to be considered for the characterization of the participants is that 98% of the health workers who participated in the study reported to have never worked with a speech therapist and 2% reported not to know if they have worked with this kind of professional.

Table 1 shows the data related to the questions with more than one answer option. It is worth clarifying that only the correct answers that were marked were considered correct.

Table 1:
Distribution of answers to questions with more than one possible answer

• Legend:Paired t-test
• N - Number* value with statistical significance.

Table 2 describes the results of the questions with only one correct answer possible.

Table 2:
Distribution of answers to questions with two possible answers (yes or no)

• Legend:N - Number Fisher Exact Test

Tables 3 and 4 describe the results of the questions regarding the referral of children and adolescents with complaints of reading and writing and voice alteration, respectively. It is noteworthy that only professionals available in the municipality were listed in the question concerning reading and writing.

Table 3:
Distribution of answers about the professional to be sought in cases of difficulties in reading and writing

• p = 0.443 Paired t-test
• Legend= N - Number

Table 4:
Distribution of answers about how to proceed before a patient with voice alteration

• p = 0.436 Paired t-test
• Legend= N - Number

Table 5 shows the distribution of answers concerning the working areas of the speech therapist. It is noteworthy that four areas of actuation (hearing, language, voice and speech) and other areas that could be mentioned as correspondents were listed in the questionnaire (Figure 1).Only the marks in the areas of speech therapy were considered for analysis.

Table 5:
Distribution of answers about the knowledge of the working areas of the speech therapist

• p = 0.001*Paired t-test
• Legend= N - Number

Table 6 presents the data related to the distribution of the correct answers according to the working time in the Family Health Program in stages I and II of the study. It should be considered that only the forms with correct answers were considered in the analysis of each question.

Table 6:
Distribution of frequency of correct answers according to the stage of collection and working time in the Family Health Program

• Legend; N= number PSF=Family Health Program

Discussion

The analysis of the data revealed changes in the answers of the community health workers in stages I and III (Tables 1 to 6). However, it is necessary to check the detailed analysis of each question to understand the dimension and more relevant aspects. An important fact was that the instrument used to collect the data made it possible to raise fundamental issues in the discussion on the communicative development in the different life cycles¹² and the role of the speech therapist in the care network^{13 - 18}.

By comparing the answers of the stages I and III of the form regarding the behavior of an infant that needs care (Table 1), it was observed that, after the training, the number of health workers that noted that a baby was not scared by loud noises such as shutting of doors became greater. Although there were no statistically significant differences, a greater number of community health workers began to consider the relevance of the observation of the hearing of infants or consider the complaints from parents about hearing issues. It is worth noting that it is essential to think about the relevance of this concept in the performance of the health workers, once hearing is essential for the acquisition and overall development of children, mainly of language¹⁹.

Regarding the behavior of children and adolescents, when comparing the performance of health workers after the workshops, a statistical significance was observed related to myofunctional disorders such as the presence of deleterious oral habits - nail biting, thumb sucking, mouth breathing - complaints about articulation disorders and alterations of the temporomandibular joint; and issues related to language delay, as children that communicate only by gestures and screams (Table 1). It is noteworthy that normally patients with such alterations are referred to speech therapy services in all cycles of life, therefore, they must be recognized in the primary care. These data corroborate the literature²⁰ by stating that training provides the recognition of the population needs by health workers. The findings also corroborate with previous study, which highlights that the majority of the guidelines and advices offered by health workers needs theoretical basis²¹.

When considering the questions related to language delay concerning the occurrence of reading and writing disorders, all workers in both stages (I and III), answered that this is a worrying condition (Table 1 and 3).

Regarding the presence of dysphonia in children and adolescents, no statistically significant difference between the answers of the health workers was observed before and after the training, since it was already a constant concern of the teams (Tables 2 and 4). There were also no statistically significant differences in the questions concerning the behavior in such cases relative to the search for an evaluation by otolaryngologist and speech therapist. These data do not corroborate the literature²² according to which training allows people to identify the determinants of the health-disease process and favors the modification of how they act in the reality of the population. However, it must be highlighted that in this study only two training workshops, which addressed the entire scope of the communication development in all cycles of life and the role of speech therapist in the health care network, were performed. In addition, the community health workers that participated of the study had no previous contact with the speech therapist.

Also in relation to matters concerning the health of children and adolescents, the literature has demonstrated the importance of qualification actions of the assistance in this life cycle and the high prevalence of alterations raised by studies in the area demonstrate the importance of planning and implementation of promotional activities of healthy communication^{23 , 24}. Thus, to talk to health workers about such elements may have been essential to awaken in them the condition for further observations of health demands and needs of the population.

The analysis of the questions related to the need for follow up of the elderly by speech therapists has demonstrated the association, with statistical significance, between the number of health workers that began to consider characteristic clinical signs of alterations of the vestibular system, aphasia, occurrence of dysphagia, dysphonia and hearing impairments. The literature⁷ shows that health workers must be able to observe the individuals in their entirety.It is also worth remembering the importance of the investment in human resources to ensure the effectiveness of the current health care model²⁵.

In the questions related to knowledge and access of workers to Speech Therapy, over 90% of the participants answered that they have never worked with a speech therapist. Considering the working areas of the speech therapist in the stages of the study, the health workers first associated phonoaudiology to speech. After the training process, a difference with statistical significance was observed in the number of health workers that marked the four areas included by phonoaudiology, and hearing became the most frequent response.

It is noteworthy that health workers related hearing only to otolaryngologists and during the training process they revealed to be surprised to know the role of the speech therapist in this field. No statistical significance was observed in the increasing number of health workers who reported to know the way of working of a speech therapist after the training, and there was no changes in the answers of the participants regarding knowledge of all areas of activity of this professional. It can be explained by the fact that the workers report that even with training they did not feel safe in saying that they quite knew the way of working and the scope of work of the speech therapist. These findings corroborate the literature²⁶ which showed that health workers did not always present technical training in health, and their knowledge was acquired through practice and discussion with other professionals. Studies show the positive relationship between community health workers and speech therapists, whether in research²⁷, training²⁵ and health planning¹⁸.

The health workers believe that there is a demand for speech therapy services in the areas covered by the Family Health Strategy in the municipality, since during the training workshops many reported clinical cases that demanded attention. The analyses of the statistical data of the stages I and III have enabled to verify that the training process contributed to the perception and ability of health workers to recognize communication disorders. These data corroborate the literature⁵ that states that health professionals involved in primary care, must be submitted to a continuous education process.

The analysis related to the "working time in the Family Health Strategy" has demonstrated that, in the step I, the performance of health workers who work for less than a year in the Family Health Program (PSF) was better as compared to workers with longer working time (Table 6), which may suggest that the professionals that were recently included in the program were more up to date. After the training process, there is a deconcentration of health workers who answered correctly to the questions of this group, indicating that the training consisted of an update strategy of the professionals that integrated the Family Health Program for longer. These data corroborate the literature^{28 , 29} that emphasizes the importance of continuous education in the field of health²⁹ and reports that for a good performance of the Family Health teams it is necessary to promote training and upgrading of the profissionals²⁸.This factor also corroborates previous studies^{18 , 30} that state that experienced health community workers can make a deeper reflection of the issues addressed in the education processes¹⁸. They also report that the working time in the Family Health Strategy does not influence the knowledge of the community health workers³⁰, since only the practice is not enough, being necessary to offer training for these professionals.

In this study the mapping of the knowledge about the working areas of speech therapists by health workers and their training are relevant points and show the possibility of realization of a joint work between speech therapists and health workers contributing to the concretion of the Speech Therapy as health promoter. During the primary contact with the community, the health worker, aware of the work of speech therapy in the primary care, can correctly assess the needs of the assisted population, and support the prevention process and treatment of communication disorders. For that, it is necessary to increase the contact of these workers with speech therapists and to carry out a continuous process of guidance and training of these workers, which are the main connection between the community and the health care network.

It is noteworthy that the overall analysis of the form revealed changes in the profile of correct answers in all questions when comparing the answers of the first (stage I) with the answers of the second form (stage III).In all cases there was an increase in the number of correct answers after the training. This data may indicate that the training workshops provided perception changes in the short term. However, it is not possible to assert that these changes will persist or become behavioral or attitudinal changes.

This study also presented some limitations that should be considered. The form used in the research is an instrument developed by the researchers, therefore without validation in the national literature. The fact that it is a self-applicable form may have generated differences or even confusion in the interpretation of the questions by the participants of the study. Furthermore, it is noteworthy that the training of the health workers was performed in only two meetings lasting four hours each.

In the present study, the pre-experimental exploratory design was adequate to characterize the data presented here, because the workshops were an educational action for community health workers and as such it carries all the difficulty of control of the variables and biases that must be ensured in experimental studies. However, the results of this study should be viewed with caution as the social, health, human, territorial and economic reality of the municipality that hosted the study is unique and therefore unrepeatable.

Conclusion

Before the analyzed results it can be concluded that the participants demonstrated partial knowledge of communication aspects and of the demand for speech therapy. In addition, the training workshops produced changes in the perception of the community health workers about demands and phonoaudiologic alterations related to the cycles of life of children and elderlies. It was also observed an association between the participation in the training workshops and working time in the Family Health Strategy.

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Publication Dates

• Publication in this collection
  June 2015

History

• Received
  14 Oct 2013
• Accepted
  26 Apr 2014