Satisfaction of patients attended in physical therapy in the community curriculum training

Endereço para correspondência: Vanessa Lôbo de Carvalho – Rua Professor Lourenço Peixoto, 31 – CEP: 57035-640 – Maceió (AL), Brasil – E-mail: carvalhovanessa@hotmail.com Apresentação: fev. 2013 – Aceito para publicação: out. 2013 – Fonte de financiamento: nenhuma – Conflito de interesses: nada a declarar. Resumo | A inserção do fisioterapeuta na atenção básica é uma realidade que necessita de avaliação, no que se refere à satisfação dos usuários nos serviços de saúde. Os questionários tornam-se instrumentos auxiliadores e contribuem para o conhecimento sobre a relevância do serviço de Fisioterapia, no contexto da saúde pública, para o planejamento e a avaliação dos serviços prestados à população. O objetivo deste trabalho foi mensurar a satisfação dos pacientes atendidos no estágio curricular de Fisioterapia na Comunidade, em um dos 50 bairros do município de Maceió (AL). Para isso, foi realizado um estudo descritivo, transversal e quantitativo, com uma amostra de 15 pacientes, onde foi utilizada — como instrumento de coleta — uma adaptação do questionário “Instrumento para aferir a satisfação do paciente com a assistência fisioterapêutica na rede pública de saúde”. Para análise estatística, foi realizado o teste de normalidade de Shapiro-Wilk, complementado pelo teste não paramétrico de Friedman — na comparação das dimensões — e, em seguida, o teste não paramétrico de Wilcoxon, para verificar entre quais dimensões as diferenças foram significativas. As informações obtidas nesta pesquisa demonstraram um alto nível de satisfação geral e foi observada a diferença significativa entre os domínios relação terapeuta/paciente e satisfação; higiene e satisfação; acesso e satisfação (p<0,05). Por meio da análise realizada, foi possível constatar que os pacientes, em sua maior parte, mostraram-se satisfeitos com o serviço oferecido.


INTRODUCTION
In Brazil, the first Physical Therapy technician course was created in Santa Casa de Misericórdia, in São Paulo, in 1929 1 .This course was created to meet the need of patients with sequels resulting from poliomyelitis and occupational accidents 2 .The epidemiological profile of this population was mainly composed of infectious diseases 3 .
From 1969 on, with the Decree-Law n. 938/69, Physical Therapy was established in Brazil as a higher education profession, with the objective of executing methods and physical therapy techniques in order to restore, develop and maintain the physical skills of the client 4 .Resolution COFFITO-10 (Federal Council of Physical Therapy and Occupational Therapy) of 1978 created the Code of Professional Ethics for Physical Therapy and Occupational Therapy, which led to changes in the profile of the physical therapists and extended their work to the actions of health promotion 5 .
Facing this reality, the physical therapist should work on prevention, thus preventing possible complications 6 , besides treating the diseases and their sequels.Group physical therapy involves the development of physical therapy aiming at damage and risk control, without compromising the rehabilitating physical therapy.In this case, the professional will be in the primary health care, aiming at full assistance 7 .
The Unified Health System (Sistema Único de Saúde -SUS) was created by the Federal Constitution and regulated by the Organic Law of Health 8 .This system is ruled by the principles: of Universality, which establishes that the health is a common right and duty of the State; of Integrality; and Equality.
The latter aims at reducing social and regional differences in the country, and searches for the harmonization and integrality of care 9 .
Basic Care (BC) in Brazil functions with high decentralization levels, guided by the principles of universality, accessibility, connection, continuity, care, full attention, responsibilization, humanization, equity and social participation 10 .
In 1994, the Family Health Program (Programa de Saúde da Família) was created, and has recently been called Family Health Strategy (Estratégia da Saúde da Família -ESF), which looks to readdress the basic health care and the individualized assistance in the family context, be it in individual and/or collective dimensions 6 .Each ESF team assists an average of 600 and 1,000 families 11 .Teams are comprised of at least one doctor, one nurse, one nursing assistant and six community health agents, and at times oral health is included 12 .In Maceió there are currently 72 ESF teams divided in eight Sanitary Districts, and three of these teams are located in the analyzed neighborhood 13 .We analyzed one of the 50 neighborhoods of the city of Maceió, where socioeconomic vulnerability is presented as one of its main features.
The physical therapist, among other health professionals, was officially included in BC after the Ministerial Order 154, from 2008, in the Ministry of Health, which created the Family Health Support Center (Núcleo de Apoio à Saúde da Família) 14 .This fact raised concerns about the quality of formation of health professionals, in terms of BC 15 .The stage of this study, called Physical Therapy in Community, occurs during the entire school year with five weekly meetings, when group promotion and prevention activities take place, as well as home care individual resumen | La inserción del fisioterapeuta en la atención básica es una realidad que necesita evaluación, en lo que se refiere a la satisfacción de los usuarios en los servicios de salud.Los cuestionarios se vuelven instrumentos auxiliadores y contribuyen al conocimiento de la relevancia del servicio de Fisioterapia, en el contexto de la salud pública, para el planeamiento y la evaluación de los servicios prestados a la población.El objetivo de este trabajo fue medir la satisfacción de los pacientes atendidos en la pasantía de Fisioterapia en la Comunidad, en uno de los 50 barrios del municipio de Maceió (AL).Para eso, fue realizado un estudio descriptivo, transversal y cuantitativo, con una muestra de 15 pacientes, donde fue utilizada -como instrumento de recolecciónuna adaptación del cuestionario "Instrumento para medir la satisfacción del paciente con la asistencia fisioterapéutica en la red pública de salud".Para análisis estadístico, fue realizado el test de normalidad de Shapiro-Wilk, complementado por el test no paramétrico de Friedman -en la comparación de las dimensionesy, enseguida, el test no paramétrico de Wilcoxon, para verificar entre cuales dimensiones las diferencias fueron significativas.Las informaciones obtenidas en esta investigación demostraron un alto nivel de satisfacción general y fue observada la diferencia significativa entre los dominios relación terapeuta/paciente y satisfacción; higiene y satisfacción; acceso y satisfacción (p<0,05).Por medio del análisis realizado, fue posible constatar que los pacientes, en su mayor parte, se mostraron satisfechos con el servicio ofrecido.
Palabras clave | Fisioterapia; Salud Pública; Satisfacción del Paciente treatments.The study was conducted with home care patients, and the sample consisted of 15 people.
Considering that the profile of the health professional should be related to BC, the internship of the analyzed Higher Education Institution (HEI) assists the community of a socially and economically vulnerable neighborhood.The physical therapy treatments provided by the internship are conducted by senior graduate students, under the supervision of a professor.Besides the professor of the HEI, who works as the internship supervisor, there is no other physical therapist in the analyzed municipal service.
The quality of the health service is related to the satisfaction of the patients with regard to meeting their needs.Therefore, it is essential to develop satisfaction analyses with the users in order to adapt the services to their needs 16 .Even though such analyses are associated with personal and social values, they consist of an important instrument to assess such services 17 .
The Ministry of Health created the Development Index of SUS in order to verify the performance of the services and access to basic care and to hospital and ambulatory services.According to this Ministry, the city of Maceió, in the State of Alagoas, was graded 5.03 in this assessment of 2011 18 .
The objective of this study was to measure the satisfaction of patients assisted in a socially and economically vulnerable neighborhood of Maceió (Alagoas, BR), assisted by students in the 10 th period of the Physical Therapy course during the curricular internship in the community.

METHODOLOGY
This is a descriptive, observational, cross-sectional and quantitative study.As an instrument for data collection, the questionnaire "Instrumento para aferir a satisfação do paciente com a assistência fisioterapêutica na rede pública de saúde", (Instrument to assess patient satisfaction regarding physical therapy care in public health), proposed by Moreira et al. 19 in 2007 was used.The questionnaire consists of 31 questions, being 9 socioeconomic descriptive ones; 22 are objective and divided into 5 domains: therapist/patient relationship (14), access (3), satisfaction (3) hygiene (1) and the importance of the service (1).
Home care patients who had at least 10 sessions from the physical therapy curricular internship in the community were included, without distinction of gender or age limit.All of the 15 subjects were invited, and none of them refused to participate.They all signed the informed consent form, which guaranteed the confidentiality and the anonymity of responses.Users were approached at their houses and the questionnaire was applied by trained researchers, after the signature of the informed consent form.
The therapist/patient relationship was analyzed with the following items: explanations, security, attention, respect, kindness, opportunity to express one's opinion, privacy, language and skills of the interns.Concerning the access, the analysis observed how easy it was to schedule an appointment, to start it and available hours.As to satisfaction, the following matters were analyzed: number of appointments, follow up and service recommendation.
After the responses were analyzed, the following values were attributed to them: 1=terrible/never; 2=poor/ no; 3=good/maybe; 4=great/yes; 5=excellent/definitely.The same values referring to the descriptor of the questionnaire were used to describe satisfaction (Table 1).
For the descriptive statistical analysis, the Shapiro-Wilk normality test was used and showed there was no normal distribution for any of the studied dimensions.
Therefore, in order to compare the distributions of the values attributed to the dimensions, the non-parametric Friedman test was used and showed p=0.02, which indicates there is significant difference between the distributions of values (p<0.05).Afterwards, the non-parametric Wilcoxon test was performed in order to check for the differences: if they were significant and between which dimensions they occurred.The GraphPAD Instat software was used.

RESULTS
The sample was composed of 15 patients, with mean age of 56,7 years old and standard deviation of 23.2.Out of this total, 10 participants (66.7%) were female and 5 (33.3%) were male patients.From the users of the research, 86.7% knew about their clinical diagnosis, and 66.7% reported it was their first contact with physical therapy.As to the medical specialties from which patients were referred to physical therapy care: 53% of these referrals came from neurology, 26%, from rheumatology and orthopedics, 16%, from respiratory illnesses, and 5%, from angiology.In relation to time of treatment, 86.7% of the sample has been on physical therapy treatment for more than 1 year; and 13.3%, for less than 1 year.All of the components of the sample were submitted to more than 10 physical therapy sessions.The analysis of the time of treatment in the physical therapy service presented more patients who had been treated for more than one year, maybe because these people suffer from chronic pathologies, which require longer treatments, and this profile was prevalent in our sample.
Concerning the objective part, the dimensions presented the (Md) from three to five, which indicate good, great and excellent (Table 2).
In this study, there was a significant statistical difference when comparing the therapist/patient relationship and hygiene/access domains with satisfaction (p<0.05)(Table 3).
Concerning the distribution of answers, the therapist/patient, hygiene and satisfaction domains presented variation from three to five.As to access and importance, the interval of answers was larger, ranging from two to five (Figure 1).

DISCUSSION
In the analyzed study, it was observed that most assisted patients submitted to the research had neurological conditions, unlike the study by Matias et al. 20 .In the mentioned study, the assessment was conducted in a school clinic, where most appointments occurred in the orthopedics/traumatology specialty.Therefore, the differences between frequencies in this study and in the one by Matias et al. 20 may be due to the different research locations and difficulties in physical access.Many of the assessed patients live in areas with geographical accidents, which raise difficulties concerning the accessibility to the rehabilitation center, especially because the dislocation of patients with neurological deficit, who represented most of the cases, is more critical and usually requires more care and assistance.
Matias et al. 20 states that most users were referred by the medical service.The results in this study show that most users were referred by the ESF team, without discriminating the professional field they came from.The analyzed territory has three teams, and most referrals were made by the nurses in the teams.
In relation to schooling, more than half of the patients (53.3%) claimed to have concluded elementary   20 (47.2%), which involved more patients with incomplete elementary school.Low schooling may have interfered with the assessment criteria in this study as to the level of demand and criticality.
In accordance with the studies by Suda et al. 21, Matias et al. 20 and Gonçalves et al. 22 , we found a high level of satisfaction in the studied sample.The result presented satisfaction in the studied sample.It is important to think about and criticize the fact that the users did not have physical therapy services available in the Basic Health Unit, and they reported having low schooling and vulnerable socioeconomic condition.
In the domain concerning importance of physical therapy for recovery, 53% of the sample considered it to be very important.Even though the treatment was conducted by graduate interns, the users understood the importance of the profession.
According to Moreira et al. 19 , the therapist/patient relationship domain presents the highest correlation with user satisfaction in relation to the service.These theoreticians have been discussing why the communication between therapist and patient is one of the most important aspects when satisfaction is being assessed.In this study, the satisfaction of the therapist/patient relationship was considered as great.
In the comparison of access to physical therapy care in relation to satisfaction, a largest interval was observed between the lowest and the highest value of the questions, which was also brought up by the result of the study by Fréz and Nobre 17 .On the other hand, the study by Moreira et al. 19 contradicts such observation by affirming the access to the physical therapy service is less related to user satisfaction.
In the study by Suda et al. 21, the research was conducted with users of a physical therapy school clinic and presented high level of general satisfaction.This study also presented high level of general satisfaction, even though it analyzed home care patients.They reported to have considered the potential of the household as a positive aspect for their recovery.

CONCLUSION
Facing the analyzed and discussed topics, the conclusion is that the users are satisfied with the services carried out by the interns in the Physical Therapy Course considering these services to be excellent.

Table 1 .
Relation between the descriptor of the questionnaire, value attributed to the descriptor and satisfaction descriptor

Table 3 .
Comparison between the dimensions of the questionnaire 21ignificant statistical difference school, unlike the studies from Suda et al.21(49%) andMatias et al.