User satisfaction with primary health care by region in Brazil: 1<sup>st</sup> cycle of external evaluation from PMAQ-AB

Protasio, Ane Polline Lacerda; Gomes, Luciano Bezerra; Machado, Liliane dos Santos; Valença, Ana Maria Gondim

doi:10.1590/1413-81232017226.26472015

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ARTICLE • Ciênc. saúde colet. 22 (6) • June 2017 • https://doi.org/10.1590/1413-81232017226.26472015 copy

User satisfaction with primary health care by region in Brazil: 1^st cycle of external evaluation from PMAQ-AB

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The National Program for Access and Quality Improvement in Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, PMAQ-AB) aimed to improve healthcare public service quality and satisfaction of health service users. This study’s objective was to identify the main factors influencing user satisfaction with primary care (PC) services by region in Brazil. Using secondary data from the 1st Cycle of PMAQ-AB, logistic regression models were developed by region, with user satisfaction as the dependent variable, as defined by cluster analysis. Based on the obtained models, the health unit’s ability to solve users’ problems and feeling respected by the health providers were the most important factors for user satisfaction in all regions in Brazil. However, other important factors by region included the following: the health unit’s hours of operation meeting the user’s needs (Northeast); providers asking about family members (North); providers asking about other health needs (Midwest); users being seen without an appointment (South); and users asking questions after the appointment (Southeast). In conclusion, the factors influencing user satisfaction with PC vary according to region and are mainly associated with access quality, meeting users’ needs, and work process organization.

Primary health care; Health evaluation; User satisfaction

Variables	Reclassification (1 = satisfied and 2 = dissatisfied)
If, when the user seeks assistance at this unit, lack of materials or equipment usually hinders care delivery	1 (Never)
	2 (Yes, Always; Yes, Sometimes)
If, when a health provider prescribes a drug, the medication is available at this health unit	1 (Yes, Always; Yes, Sometimes)
	2 (This unit does not provide drugs; Never)
Opinion of the user on the care he/she receives from the health team	1 (Very Good; Good)
	2 (Fair; Poor; Very poor)
Opinion of the user on the care his/her relatives receive from the health team	1 (Very Good; Good)
	2 (Fair; Poor; Very poor)
If the user would change teams or health units if he/she had that option	1 (No)
	2 (Yes)
If the user would recommend this health unit to a friend or relative	1 (Yes)
	2 (No)
Score from zero to ten that the user assigns to his/her satisfaction with the care received at the unit	Not dichotomized

Independent Variables
1.	Gender
2.	Age
3.	If the user can read and write
4.	If the user is retired
5.	Currently a paid worker
6.	Opinion in regard to distance from user’s home to this health unit
7.	If the user thinks the signs identifying different areas within the unit make it easier to find them (office rooms, restrooms, vaccination room, etc.)
8.	If the health unit operates five days a week
9.	Operation time and days of the health unit
10.	If the hours of operation of this health unit meet the user’s needs
11.	Method for making an appointment at the health unit
12.	Schedule for making appointments at the health unit
13.	If the user is able to make an appointment for the same day
14.	How the appointment is made (scheduled for a specific time, at defined times or periods of the day, on a first-come, first-served basis, seen between appointments, other(s))
15.	The user is seen to solve any problem
16.	If the user feels he/she is respected by the health professionals in regard to his/her cultural customs, practices, religion
17.	If when the user is seen at this health unit, he/she thinks that the team makes an effort to solve his/her needs/problems
18.	If the office room provides privacy
19.	If the health providers ask questions about other health needs that the user has or may have besides those related to the reason for the appointment
20.	Opinion of the user if, during the appointment, the team’s providers suggest solutions adequate to his/her reality
21.	If, during the appointment at the health unit, the doctor allows enough time for the user to talk about his/her concerns or problems
22.	If the user is seen by the same doctor at the health unit
23.	If the health providers of this unit usually ask about the users’ relatives
24.	If the health providers recall what happened in the last user’s appointments
25.	If, when the user has questions after the appointments, it is easy for him/her to talk with the providers who assisted him/her
26.	If, when the user interrupts treatment for some reason or misses her/his appointment at the health unit, the providers try to find out what happened and resume care
27.	If the user is comfortable talking with the team about his/her concerns, social problems, relatives, or other questions
28.	If, when the user needs it, the team providers are able to make an appointment with other providers or specialists
29.	If it is easy for the user to obtain information about his/her test results at the health unit
30.	If the user’s health community agent (HCA) visits his/her home
31.	If other health provider teams visit the user’s home
32.	If the user can make a complaint or suggestion at the health unit

Variable	NORTHEAST		NORTH		MIDWEST		SOUTH		SOUTHEAST

	p-value	OR (95 % CI)	p-value	OR (95 % CI)	p-value	OR (95 % CI)	p-value	OR (95 % CI)	p-value	OR (95 % CI)
Intercept	< 0.0001*	13.67(10.63-17.63)	< 0.0001*	15.01(11.24-20.27)	< 0.0001*	9.69(6.52-14.57)	< 0.0001*	32.92(22.31-49.21)	< 0.0001*	18.65(15.21-22.92)
III.4.6- Gender
Male (reference)		1
Female	0.0002*	1.27(1.12-1.44)
III.4.7- How old are you?
	< 0.0001*	1.01(1.01-1.01)			0.0003*	1.01(1.01-1.02)			< 0.0001*	1.01(1.01-1.01)
III.5.2- What do you think about the distance from your home to this health unit?
Close (reference)										1
Reasonable	< 0.0001*	0.72(0.64-0.80)					< 0.0001*	0.64(0.54-0.76)	< 0.0001*	0.67(0.60-0.75)
Far	0.1822	0.92(0.81-1.04)					0.0041*	0.74(0.60-0.91)	< 0.0001*	0.71(0.62-0.80)
III.5.3- Do you think the signs identifying different areas within the unit make it easier to find them? (e.g., office rooms, restrooms, vaccination rooms, etc.).
Yes (reference)										1
No									0.0001*	0.72(0.61-0.85)
Yes, some signs									0.6635	1.05(0.86-1.28)
I did not see or there are no signs in the unit									< 0.0001*	0.70(0.60-0.83)
III.5.4- Does the health unit operate five days a week?
Yes (reference)
No	< 0.0001*	0.70(0.59-0.83))
III.5.7- Do the hours of operation of this unit meet your needs?
Yes (reference)										1
No	< 0.0001*	0.50(0.44-0.57)	< 0.0001*	0.42(0.32-0.55)	< 0.0001*	0.51(0.39-0.67)	< 0.0001*	0.40(0.34-0.48)	< 0.0001*	0.55(0.49-0.62)
III.6.2- In general, can an appointment for this health unit can be made every day of the week?
Yes (reference)										1
No			0.0017*	0.73(0.60-0.89)					0.0005*	1.19(1.08-1.31)
III.6.3- When you are able to make an appointment, is it for the same day?
Yes (reference)										1
No	< 0.0001*	0.81(0.74-0.88)							< 0.0001*	0.80(0.73-0.88)
III.6.4.2- When you are able to make an appointment, is your appointment at defined times or periods of the day?
Yes (reference)								1
No							0.0007*	1.52(1.19-1.93)
III.7.1- When you go to the health unit to solve a problem without a scheduled appointment, are you seen?
Yes (reference)		1				1		1		1
No	< 0.0001*	0.53(0.47-0.59)	< 0.0001*	0.47(0.37-0.60)	< 0.0001*	0.41(0.32-0.52)	< 0.0001*	0.48(0.40-0.58)	< 0.0001*	0.62(0.56-0.70)
Never had to go to the health unit without an appointment	0.0185*	0.86(0.76-0.98)	0.0167*	0.71(0.53-0.94)	0.0008*	0.63(0.48-0.83)	0.0731	0.81(0.64-1.02)	0.0278*	0.85(0.74-0.98)
III.7.6- Do you feel that the providers respect your cultural customs, practices, and religion?
Yes, always (reference)								1		1
Yes, sometimes	< 0.0001*	0.41(0.35-0.48)	< 0.0001*	0.49(0.35-0.67)			< 0.0001*	0.43(0.33-0.57)	< 0.0001*	0.49(0.42-0.57)
No	< 0.0001*	0.46(0.35-0.62)	0.0011*	0.39(0.22-0.68)			< 0.0001*	0.38(0.24-0.60)	< 0.0001*	0.37(0.28-0.48)
III.8.1- When you are seen at this health unit, do you think the team tries to solve your needs/problems at the health unit itself?
Yes, always (reference)		1				1		1		1
Yes, sometimes	< 0.0001*	0.54(0.48-0.59)	< 0.0001*	0.44(0.34-0.55)	< 0.0001*	0.56(.,44-0.72)	< 0.0001*	0.55(0.47-0.65)	0.0001*	0.52(0.46-0.57)
No	< 0.0001*	0.39(0.32-0.47)	< 0.0001*	0.34(0.23-0.49)	< 0.0001*	0.31(0.22-0.45)	< 0.0001*	0.39(0.28-0.54)	< 0.0001*	0.31(0.26-0.36)
III.8.2- Does the office room provides privacy?
Yes (reference)		1								1
No	< 0.0001*	0.57(0.48-0.68)	0.0001*	0.47(0.32-0.67)			0.0016*	0.60(0.44-0.83)	< 0.0001*	0.58(0.48-0.70)
III.8.7 – Do the health providers ask questions about other health needs that you may have besides those related to the reason for the appointment?
Always (reference)						1				1
Most of the time					0.0010*	0.59(0.43-0.81)	0.1915	0.86(0.69-1.08)	0.124	0.90(0.78-1.03)
Almost never					0.0001*	0.45(0.31-0.67)	0.0014*	0.65(0.50-0.85)	< 0.0001*	0.55(0.47-0.66)
Never					< 0.0001*	0.54(0.42-0.69)	< 0.0001*	0.60(0.51-0.72)	0.0001*	0.71(0.63-0.80)
III_8_8- In your opinion, during the appointments, do the team’s providers suggest solutions that are adequate when compared to your reality?
Always (reference)										1
Most of the time	0.0099*	0.85(0.76-0.96)							0.9101	1.01(0.89-1.15)
Almost never	0.0001*	0.72(0.61-0.84)							0.0583	0.85(0.72-1.01)
Never	< 0.0001*	0.64(0.57-0.71)							< 0.0001*	0.73(0.65-0.82)
III.9.1- During the appointments at this health unit, does the doctor allow enough time for you to talk about your concerns or problems?
Yes (reference)						1		1
Yes, sometimes	< 0.0001*	0.68(0.59-0.79)			0.6183	0.92(0.66-1.28)	0.0019*	0.71(0.57-0.88)
No	< 0.0001*	0.72(0.64-0.82)			< 0.0001*	0.50(0.37-0.68)	0.0004*	0.66(0.52-0.83)
III.9.7- At this health unit, are you seen by the same doctor?
Always (reference)
Most of the time
Almost never
Never
III.9.12- Do the providers of this unit usually ask about your relatives?
Always (reference)		1								1
Most of the time	0.5112	0.95(0.82-1.10)	0.4951	0.89(0.64-1.25)	0.0507	1.49(1.00-2.24)	0.1632	1.21(0.93-1.57)	0.4159	1.07(0.92-1.24)
Almost never	0.0002*	0.72(0.60-0.86)	0.234	0.79(0.54-1.17)	0.0287*	0.60(0.39-0.95)	0.0197*	0.72(0.55-0.95)	0.0422*	0.83(0.70-0.99)
Never	< 0.0001*	0.56(0.50-0.63)	< 0.0001*	0.49(0.37-0.64)	0.0003*	0.59(0.45-0.79)	< 0.0001*	0.55(0.45-0.68)	< 0.0001*	0.71(0.63-0.80)
III.9.13- Do the providers recall what happened in your last appointments?
Yes (reference)		1		1		1				1
Yes, sometimes	0.0164*	0.86(0.76-0.97)	0.3173	0.85(0.63-1.16)	0.3293	0.85(0.62-1.18)			0.5603	0.96(0.84-1.10)
No	< 0.0001*	0.65(0.59-0.73)	0.0001*	0.64(0.51-0.80)	< 0.0001*	0.59(0.46-0.75)			0.0001*	0.70(0.63-0.78)
III.9.14- When you have questions after the appointments, is it easy for you to talk with the providers who assisted you?
Always (reference)										1
Most of the time									0.0427*	0.86(0.75-0.99)
Almost never									< 0.0001*	0.66(0.55-0.79)
You never had to ask questions									0.0255*	0.87(0.77-0.98)
III.9.16- When you interrupt treatment for some reason or you miss an appointment at this health unit, do the providers seek you to find out what happened and resume care?
Always (reference)		1								1
Yes, sometimes	0.7799	0.97(0.77-1.22)	0.9357	1.02(0.61-1.76)			0.7744	1.08(0.66-1.83)	0.0385*	0.76(0.58-0.99)
Almost never	< 0.0001*	0.70(0.61-0.80)	< 0.0001*	0.55(0.41-0.73)			< 0.0001*	0.59(0.46-0.75)	< 0.0001*	0.64(0.56-0.73)
Never interrupted treatment or missed an appointment	0.7911	1.02(0.90-1.16)	0.3757	0.88(0.66-1.17)			0.8574	0.98(0.78-1.23)	0.0351*	0.87(0.76-0.99)
III.9.18- Do you feel comfortable talking with the team about your concerns, social problems, relatives or other questions?
Always (reference)		1				1				1
Most of the time	0.0031*	0.82(0.72-0.93)	0.9548	1.02(0.60-1.74)	0.0026*	0.61(0.44-0.84)	0.1937	0.87(0.70-1.08)	0.1348*	0.90(0.78-1.03)
Almost never	< 0.0001*	0.68(0.57-0.81)	< 0.0001*	0.55(0.41-0.72)	0.1367	0.76(0.53-1.10)	< 0.0001*	0.57(0.44-0.74)	0.0014*	0.76(0.65-0.90)
Never	< 0.0001*	0.61(0.55-0.68)	0.5974	0.93(0.70-1.23)	< 0.0001*	0.54(0.42-0.69)	< 0.0001*	0.58(0.48-0.69)	< 0.0001*	0.64(0.57-0.72)
III.9.19- When you need it, are the team’s providers able to make an appointment with other provides or specialists?
Yes, always (reference)										1
Yes, sometimes									0.0001*	0.73(0.64-0.82)
No									0.0001*	0.65(0.56-0.76)
Never needed it									0.997	1.00(0.89-1.13)
III.9.22- Is it easy for you to obtain information about the results of your tests at this health unit?
Yes, always (reference)										1
Yes, sometimes	0.0008*	0.82(0.73-0.92)							< 0.0001*	0.76(0.67-0.86)
No	< 0.0001*	0.77(0.69-0.85)							< 0.0001*	0.64(0.57-0.73)
III.9.23- Does your health community agent (HCA) visit you at home?
Yes (reference)										1
No	< 0.0001*	0.76(0.67-0.85)							< 0.0001*	0.64(0.56-0.72)
There is no HCA at this health unit or in the neighborhood	0.1223	0.71(0.46-1.10)							0.084	0.55(0.29-1.12)
III.9.24- Do other health providers visit you at home?
Yes, always (reference)
Yes, sometimes	0.9256	0.99(0.83-1.19)					0.7131	0.93(0.64-1.37)
No	< 0.0001*	0.69(0.60-0.79)					< 0.0001*	0.53(0.40-0.69)
III.19.1- When you want to make a complaint or suggestion at the health units, are you able to?
Yes (reference)		1				1		1		1
Yes, but with difficulty	< 0.0001*	0.49(0.39-0.61)			0.0068*	0.45(0.25-0.80)	0.0001*	0.53(0.39-0.73)	0.0001*	0.64(0.51-0.80)
No	0.0024*	0.79(0.67-0.92)			0.9527	1.01(0.71-1.44)	< 0.0001*	0.41(0.32-0.52)	0.0386*	0.86(0.75-0.99)
Never needed to	< 0.0001*	1.29(1.14-1.46)			< 0.0001*	2.07(1.55-2.76)	0.0061*	1.29(1.07-1.54)	0.0001*	1.57(1.40-1.77)

Model quality	NORTHEAST	NORTH	MIDWEST	SOUTH	SOUTHEAST
Sample n	15324	2544	2941	7671	18511
Significant variables	20	10	10	15	21
Analysis of deviance	Accepted	Accepted	Accepted	Accepted	Accepted
AUC of ROC curve	0.845	0.820	0.823	0.847	0.856
Sensitivity	0.762	0.741	0.746	0.770	0.775
Specificity	0.761	0.736	0.746	0.767	0.775
Estimate of accuracy *	0.808	0.756	0.818	0.864	0.855
Risk estimate*	0.190	0.245	0.182	0.136	0.149

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E-mail: cienciasaudecoletiva@fiocruz.br

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[1] Collaborations

APL Protasio, LB Gomes, LS Machado and AMG Valença contributed in the design, analysis and interpretation of the data, writing of the article and approval of the version to be published.

Brasil

Brasil

User satisfaction with primary health care by region in Brazil: 1st cycle of external evaluation from PMAQ-AB

Abstract

User satisfaction with primary health care by region in Brazil: 1^st cycle of external evaluation from PMAQ-AB