Primary health care assessment by users with and without disabilities

Accepted: November 09, 2017 Study conducted at the Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina, Universidade de São Paulo – USP São Paulo (SP), Brazil. 1 Universidade de São Paulo – USP São Paulo (SP) Brazil. Financial support: Edital PPSUS 2013 FAPESP 2014/50012-8 and Programa de Educação pelo Trabalho na Saúde-Redes de Atenção (PET/Redes 2013-2015). Conflict of interests: nothing to declare. ABSTRACT


INTRODUCTION
Primary Health Care (PHC) is an integral and strategic part of any health system.In Brazil, the development of services at this level of assistance was guided by different models, such as the Programmatic Actions in Health (1,2) and, more recently, the Family Health Strategy (FHS) (3) , with the aim of reformulating the assistance model for the implementation of the Brazilian Unified Health System (SUS).
In the Primary Health Care National Policy (3) , the essential principles for the development of PHC are indicated in the challenging perspective for universalization of health access and care for the population with equity, comprehensiveness, and participation of users, necessary to ensure the right to health.
Expansion of PHC also has the challenge to face the changes occurred in the demographic and morbimortality profile of the Brazilian population.In response to the increased prevalence of chronic non-communicable diseases, in which various types of disabilities are included, PHC is expected to act as coordinator of care and network health assistance provider (4) .
In this sense, there is need to evaluate the development of PHC to respond to these specific demands.One of the initiatives aimed at this purpose refers to the use of the Primary Care Assessment Tool (PCAT), an instrument validated in the country and recommended by the Ministry of Health since 2010 as one of the strategies for assessment and improvement of PHC services (5) .
The PCAT was developed by Starfield (6) .It is an instrument aimed at evaluating the core and derivative attributes from PHC, and it has been used in many countries, proving to be sensitive to its proposing objectives.Other instruments for evaluation of PHC have been described in the national and international literature; however, the authors of an article that compiled all the questionnaires available concluded that the PCAT is the most appropriate, because it allows assessment of health care focused on family and community (7) , in agreement with the Primary Health Care National Policy (3) .
In this evaluation process, it is fundamental to know the users' perception regarding the availability and quality of the services provided, enabling their improvement and reorientation.In this sense, several studies have addressed this issue from the perspective of different classes of users: adults, legal guardians for children, or the elderly.Other studies have established relationships between the perceptions of different populations (1,2,(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) .
However, there is only one study assessing the perception of individuals with disabilities about different attributes of PHC in the national literature (18) .Therefore, the importance of new studies addressing users with disabilities in PHC is evident due to the scarcity of research on these individuals; the history of development of specialized services for their care -closely associated with philanthropic and charitable initiatives; and the expectation and need for primary care services to identify and monitor these populations in their different health needs.
For these reasons, the objectives of this study are as follows: a) to evaluate the essential and derivative attributes of PHC based on the perception of its users, especially of those with disabilities, at Basic Health Units (BHU) in the west zone of the city of Sao Paulo which have a partnership with the University of Sao Paulo (USP) in teaching-service articulation projects and b) to learn some factors related to user perception regarding the PHC attributes.

Scenario of the research
The study was conducted in basic health units (BHU) located in the area of Technical Health Supervision of Butantã district of the Secretaria Municipal de Saúde de São Paulo.The Health Technical Supervision of the district was responsible for a population of approximately 428,217 inhabitants assisted at 14 BHUs.Five of these units were selected for this study within the partnership with the Universidade de São Paulo in teaching-service articulation projects, particularly the program PET -Saúde/Redes de Atenção.This partnership does not include the provision of human and material resources by USP, but is essential for health education because it offers practice scenarios for students to participate in activities planned for Primary Health Care (PHC) by the Secretaria Municipal da Saúde.
These BHUs presented different characteristics with respect to the assistance provided to individuals with disabilities and their families.Two of these BHUs operate exclusively within the Family Health Strategy (FHS) and three present mixed services, operating in the FHS and Traditional Care modalities.In addition to the services provided under the FHS, the BHUs also conduct other care activities, such as bodily practices and complementary approaches.Four units hold Family Health Support Centers (NASF) and one has a specific multidisciplinary team.
The development of activities under the FHS and the support by a multidisciplinary team comprised the inclusion criteria of this study.

Casuistics
Study participants were individuals with disabilities identified by the professionals of the multidisciplinary teams associated with the program PET -Saúde/Redes de Atenção.During the application of the questionnaires, a small part of this population declared not having any type of disability, being thus classified as non-disabled.The others described themselves as individuals with disabilities.Thus, the study sample was composed of individuals of different age ranges, residents of the area covered by the five participating BHUs, assisted by the health teams of these units.The participants were divided into two groups: G1 (individuals self-declared with disabilities) and G2 (individuals self-declared without disabilities).As established in the Primary Care Assessment Tool (PCAT), individuals under age and with severe mental disorders had the questionnaires completed by their caregivers.All participants signed an Informed Consent Form prior to study commencement.

Procedures
Data were collected through interviews with the application of the PCAT.This instrument assesses the following core attributes of PHC: First Contact -Accessibility, which includes accessibility to and use of the health services for each new problem or event; Longitudinality, which presupposes the existence of a regular source of care and its use over time; Comprehensiveness, which comprises an array of services available at and provided by PHC aimed at comprehensive care (including referrals to secondary, tertiary, and support services); and Coordination of Services, which requires some form of continuity, recognition of problems treated in other services, and the integration of this assistance in total patient care.The derivative attributes identified and assessed by the PCAT qualify the actions of the health services: Family Orientation, Community Orientation, and Cultural Competence or adaptation of health professionals to the cultural characteristics of a population (6) .
The PCAT establishes five possible answers with respective scores for each item that comprise the attribute or its dimensions: "certainly yes" (4 points), "probably yes" (3 points), "probably no" (2 points), "certainly no" (1 point), and "do not know/cannot remember" (9 points).The score obtained in each item is transformed into a 0 to 10 scale calculated as [(score obtained -1) × 10] / 3. Scores ≥ 6.6 are considered high and equivalent to scores ≥ 3 in the Likert scale (19) .
The score for each attribute, or its dimensions, is calculated from the mean values of the responses to the items.For some items, the higher the score assigned, the lower its PHC orientation, and vice versa.In these cases, the items must have their scores reversed.Scores are only calculated when interviewees respond to more than 50% of the items.If the sum of the blank responses is less than 50%, they must be transformed from score 9 (do not know/cannot remember) to score 2 (probably no).
As for the attribute Degree of Affiliation, the score has its own scale, with scores from 1 to 4 not transformed into a 0 to 10 scale, where score 1 represents affiliation to four different services and score 4 shows affiliation to a single service in all questions.
The PHC Essential Score is calculated by the sum of the mean score of the dimensions that belong to the core attributes and the score of the Degree of Affiliation divided by the number of dimensions.The PHC General Score is measured by the sum of the mean score of the dimensions that belong to the core attributes and that of the dimensions that belong to the derivative attributes, plus the score of the Degree of Affiliation divided by the total number of dimensions (19) .
The PCAT was complemented by a set of questions on the demographic characterization of users, presence and types of disability, and their recognition and monitoring in the service by professionals of the multidisciplinary teams (except physicians and nurses), by the socioeconomic classification of the families and schooling of the head of family of the Brazilian Association of Research Companies (20) , and by the insertion of users in school, work, and/or community groups.
The tool was applied for three typical weeks, from 45 minutes to one hour, by students of the program PET Saúde/Redes, trained by the study researchers and monitored by preceptors/service professionals.

ANALYSIS OF THE DATA
Data were expressed in mean and standard deviation.The normality distribution of each variable was evaluated using the Shapiro-Wilk test.When normal distribution of variables was not observed, the Mann Whitney test was used for comparisons between two groups and the Kruskal Wallis test was applied for comparisons between three or more groups.A type I error rate (α = 0.05) was considered in all inferential analyses.Data analyses were conducted using the SPSS 21 software (SPSS 21.0 for Windows).
Most users were single women aged >18 years (minimum age = 2 years; maximum age = 80 years).The majority of the heads of family have completed High School, and most of the working adults and elderly are full-time employees.Of the users who did not work, most were retired.Of the underage users, more than 25% did not attend school and, of those who attended, most were enrolled in public schools.Regarding participation in community groups, almost half of the users were involved in some activity (Table 1).

Assessment of the Basic Health Unit by its users
Table 2 presents the means of the scores obtained with the application of the PCAT to users with and without disabilities.No statistically significant difference was observed in the comparison between the groups for all attributes, dimensions, and general and essential scores.
When the scores were analyzed qualitatively (Table 2), the following attributes presented satisfactory (above cutoff) scores in both groups: Degree of Affiliation, First Contact -Utilization, Longitudinality, and Coordination of Services -Care Integration.The General and Essential Scores show that users in both groups assessed the BHUs positively.
As no statistically significant difference was observed in the comparison between the groups of individuals with and without disabilities, as previously shown, a comparison between the scores obtained by age range was performed including disabled and non-disabled users.Table 3 shows the means of the users' assessments by age range.Statistically significant difference was found only for the attribute First Contact -Accessibility, which was better evaluated by the parents and/or legal guardians of underage users.For this age range, a qualitative assessment (Table 3) shows that the attributes Degree of Affiliation, First Contact -Utilization, Longitudinality, and Coordination of Services -Information System were satisfactorily evaluated, as well as the Essential Score.
Tables 4 and 5 show the scores for the core and derivative attributes evaluated as unsatisfactory (below cutoff) by users.
In Table 4 (assessment by adults and elderly), it can be verified that the worst scores were given to the Accessibility dimension, with the following items receiving very low scores: not opening on weekends and at night, not providing telephone contact or access to any professional in those periods when users are ill.
As for the attribute Comprehensiveness -Services Available (Table 4), the unavailability of the following items significantly contributed to the unsatisfactory scores obtained in this dimension: splinting of sprained articulations and identification of visual and hearing impairments.Other items poorly assessed included lack of treatment/counseling about drug abuse, aging process, and family members with disabilities.
Concerning the attribute Comprehensiveness -Services Provided (Table 4), the lowest score was related to the lack of advice on firearms in the household, child safety in the car, and domestic accidents such as burns, exposure to hazardous substances, and falls.
With respect to the assessment by parents and/or legal guardians of underage users (Table 5), fewer items received below cutoff scores compared with the evaluation by adults and elderly.The item that received the lowest score from this population belonged to the Community Orientation dimension, in which users were dissatisfied with regard to surveys conducted on the community and themselves, on their health problems, and to motivating participation in Management and User Councils.Other important items which were evaluated as unsatisfactory by these users in other dimensions were First Contact -Accessibility (waiting time for consultation and availability of counseling on the phone) and Comprehensiveness -Services Provided (existence of a nutrition supplementation program; identification of visual impairments).
Regarding monitoring by PHC professionals, except physicians and nurses, on the health condition of users (Table 6), some items received unsatisfactory scores.
In relation to adults and elderly, there was greater recognition, by the multidisciplinary team, of problems that affect the users' appearance, such as lack of any part of the body, mobility impairment, and problems with moving any part of the body than of psychiatric problems and vision, hearing or speech impairments.In addition, the multidisciplinary team presented difficulties in recognizing the need for guidance to caregivers or the users themselves, who need assistance with daily activities.For the parents and/or legal guardians of underage users, the teams show greater recognition  Note: Some items could not be calculated for underage users because of the small number of participants in this age range and the impossibility of calculating the responses when interviewees answered less than 50% of the questions Captions: BHU = Basic Health Unit of problems related to mobility, speech, vision, moving any part of the body, and psychiatric disorders, and less recognition, but still on the average, of intellectual problems.

DISCUSSION
With regard to the sociodemographic profile of Primary Health Care (PHC) users, it is worth noting that, in Brazil, there is greater presence of women who seek, more frequently than men, health care services, and who are prevented from conducting daily life activities due to health reasons (21) .This study showed that the greater participation of women (11,16,17) , as well as of adults and elderly (9) , is similar to that reported in other studies.
Another characteristic of the study participants is that they belong to class C, in accordance with the income profile of the population living in the peripheral areas of the health region investigated (22) .Low income, also mentioned by participants of other studies (11,23) , coupled with low insertion in the work market and low professional qualification of the disabled participants, suggests the social vulnerability of the interviewees.Accordingly, studies have shown that disabled individuals (DI) are under-represented in the work market, occupy subordinate positions, and receive lower salaries compared with those of other workers (24)(25)(26) .The present study also highlights the low access of disabled users to Continuous Cash Benefit, which may be due to lack of information about the criteria for requesting it.
The study also reveals that the participation of PHC users in community groups is small, being more frequently indicated in the BHUs to which the interviewees are linked, which suggests a lack of partnerships between the health services and sectors of the society to foster social participation of DIs, as reported in another study (18) .
As for perception about the different PHC attributes, no statistically significant difference was observed in the comparison between users with and without disabilities.The absence of differences was also verified in a study that evaluated PHC from the perspective of parents and/or legal guardians of children and adolescents with and without physical disabilities (18) .
Degree of Affiliation received satisfactory scores in the assessment by general users (with and without disability) regarding the care provided by physicians and nurses.Overall, users seemed to recognize services or professionals as a reference in health care (11,18) .
Similarly, the attribute First Contact: Utilization was evaluated as satisfactorily by the interviewees, which corroborates the results found in other studies (16,17,27) .
The attribute First Contact: Accessibility, which marks the availability of PHC to users with receptive and humanized admission, was one of the attributes that received the lowest scores, as observed in other studies (9,16,17) .These results are due, in particular, to the very low scores obtained on items such as "not opening on weekends", "not opening on weekdays after 8 pm", and "not providing contact on the phone in these periods" (16,(28)(29)(30) , which expresses structural issues that lead users to have poor accessibility to health service.With regard to individuals with disabilities, this attribute obtained an even lower score compared with those by individuals without disabilities, although with no statistically significant difference.These data suggest that, in the case DIs, the difficulties faced in accessing health services are even clearer, emphasizing the iniquities to which these individuals are subject (23) .
As observed in other studies, the attribute Longitudinality was rated satisfactorily by users in general (16) , and underage (27) and elderly (13) users.The high mean score received by this attribute is fundamental for appropriate treatment, limiting unnecessary referrals to services of greater complexity (24) , which suggests the use of PHC as a usual source to assist with all health problems, welcoming the user holistically for years (15) .
The attribute Coordination of Services: Care Integration has received different scores in assessments reported by other authors.In the present study, this attribute obtained satisfactory scores in the evaluation by users in general and by adults and elderly, whereas it has received relatively adequate scores in a current research (27) and unsatisfactory (17) scores in a previous study.The attribute Coordination of Services: Information System has also obtained mean score above cutoff in this study when evaluated by adults, the elderly, and users in general, corroborating the finding of another study (2) .Coordination should occur along the therapeutic process and ensure continuity of care at different times, which indicates the appropriate use of information and services by users (17) .
In this study, the attribute Comprehensiveness: Services Available obtained unsatisfactory scores.Similarly, other studies have also reported the following as little available services: removal of warts (13,16) , treatment/counseling about drug abuse, splinting of sprained articulations, identification of hearing and visual impairments, counseling about the aging process, and guidance on the care for disabled family members (16) .
It is worth noting that adult and elderly users with disabilities considered that the BHUs do not recognize a large part of their specific demands, especially those not manifested in their physical appearance, such as hearing, visual and speech/voice impairments, psychiatric problems, use of the upper limbs in daily activities, or the need for guidance to caregivers.If the multidisciplinary team cannot recognize these conditions, the health service is not aware of the difficulties that DIs undergo in daily life, making it impossible to fulfill the role of PHC as a network health assistance provider, also for this populationl (3,4) .
The lowest mean score obtained by the attribute Comprehensiveness -Services Provided has also been observed in other studies, and it was associated with lack of counseling about child safety in the car, exposure to hazardous substances, and domestic accidents such burns (16,23) , falls, and firearms in the household (16) .
With respect to the derivative attributes, Community Orientation obtained below cutoff scores in the assessment by users in general, corroborating the results of other studies (1,9,16,18,28) .PHC users, as observed in other studies, were dissatisfied with the services with regard to surveys conducted on the community and themselves, on their health problems (1,28) , and to service performance and motivating participation in the Management Councils of the BHUs (28) .
The attribute Family Orientation also received unsatisfactory scores in the evaluation by users in general, specially by adults is an observational, cross-sectional study conducted between August and December 2014.This study, which is an integral part of the research "Atenção Básica como ordenadora das redes de atenção à saúde Cegonha e de Cuidados à Pessoa com Deficiência" was approved by the Human Research Ethics Committees of the Secretaria Municipal de Saúde de São Paulo (32273014.8.0000.0065)and Faculdade de Medicina da Universidade de São Paulo (process no.189/14), and was funded by FAPESP (Edital PPSUS 2014/50012-8) and Ministério da Saúde (MS) through the teaching-service integration project Programa de Educação pelo Trabalho na Saúde -PET Saúde/Redes de Atenção.This Program was a partnership between the Secretaria Municipal de Saúde de São Paulo and Universidade de São Paulo -USP (2013-2015) for the monitoring, by students, of health assistance activities specific to the daily services and research development focused on assessing and strengthening health care networks.The Program was funded by the MS by means of scholarships granted to students, preceptors, and tutors of USP.

Table 1 .
Characterization of the PHC users according to presence of disability, gender, age range, schooling, employment status, marital status, and social participation

Table 2 .
Mean and standard deviation of the scores for PCAT attributes and dimensions of users with and without disabilities; p value Mann Whitney test at 5% significance level (p<0.05)Captions: PCAT = Primary Care Assessment Tool; SD = standard deviation

Table 3 .
Mean and standard deviation of the scores for PCAT attributes and dimensions of users according to age range; p value Kruskal Wallis test at 5% significance level (p<0.05)Captions: PCAT = Primary Care Assessment Tool; SD = standard deviation

Table 4 .
Description of the PCAT attributes that received unsatisfactory (below cutoff) scores in the assessment by adults and elderly users E9 -Did your physician/nurse seem interested in the quality of care you were given (asked whether you were well or poorly assisted by this specialist or specialist service)?6.11Captions: PCAT = Primary Care Assessment Tool; BHU = Basic Health Unit Captions: PCAT = Primary Care Assessment Tool; BHU = Basic Health Unit

Table 5 .
Description of the PCAT attributes that received unsatisfactory (below cutoff) scores in the assessment by parents and/or legal guardians of underage users Changes in the growth and development of the child, that is, what you should expect at each age, for example, when the child begins to walk, urine control, etc.
Captions: PCAT = Primary Care Assessment Tool; BHU = Basic Health Unit

Table 6 .
Mean scores, according to age range, regarding the monitoring of users' disabilities by Primary Health Care professionals, except