The quality of primary care from the perspective of older adults: the reality of a city in Central BrazilAbstract
Objective To evaluate the quality of Primary Health Care from the perspective of elderly users in Rio Brilhante,MS, Brazil.
Method Cross-sectional research cross-sectional with quantitative analysis and a representative sample from Central Brazil (n= 345 elderly people). Date were collected using the questionnaire from the PCATool-Brasil instrument (Primary Care Assessment Tool), validated nationally by the Ministry of Health. For data analysis, a descriptive analysis procedure was used with presentation of results through absolute and relative frequencies for the categorical variables, and through measures of central tendency and variability, standard deviation for continuous variables. The inferential analysis was carried out using the logistic regression test with the presentation of the Odds Ratio, with a value of p>0,20.
Results A greater user of the services offered by female users was found to be 69,7%. The essential scores of APS in the municipality, evaluating the assistance offered at the primary level, obtained average an average of 6.94, above the cutoff score of 6.6, classified as high quality. The overall score was evaluated at 6.27, but considered low by the instrument.
Conclusion The quality of PHC according to the general scores is low. The essential score is high, indicating that the municipality’s APS health services are guided by their attributes, promoting greater user satisfaction with a positive impact on the population’s health status.
Keywords
Delivery of health care; Primary Health Care; Health Services for the Elderly; Quality Indicators in Health Care; Health Unic System; Family Health
Resumo
Objetivo Avaliar a qualidade da Atenção Primária à Saúde na perspectiva dos usuários idosos de Rio Brilhante, MS, Brasil.
Método Pesquisa de delineamento transversal de análise quantitativa e amostra representativa do Brasil Central (n= 345 pessoas idosas). Os dados foram coletados utilizando o questionário do instrumento PCATool-Brasil (Primary Care Assesment Tool), validado nacionalmente pelo Ministério da Saúde. Para análise de dados, foram utilizados procedimentos de análise descritiva com apresentação dos resultados por meio das frequências absolutas e relativas para as variáveis categóricas e através das medidas de tendência central e variabilidade, desvio padrão, para as variáveis contínuas. A análise inferencial foi realizada por meio do teste de regressão logística com apresentação da Odds Ratio, com valor de p<0,20.
Resultados Constatou-se maior utilização dos serviços oferecidos pelos usuários do sexo feminino de 69,7%. O escore essencial da APS no município, avaliação da assistência oferecida no nível primário, obteve média 6,94 acima da nota de corte de 6,6, classificado como qualidade alta. O escore geral foi avaliado em 6,27, porém, considerado baixo pelo instrumento.
Conclusão A qualidade da APS segundo o escore geral é baixa, O escore essencial é alto, indicando que os serviços de saúde da APS do município são orientados por seus atributos promovendo maior satisfação dos usuários com impacto positivo no estado de saúde da população.
Palavras-Chave:
Atenção à Saúde; Atenção Primária à Saúde; Serviços de Saúde para Idosos; Indicadores de Qualidade em Assistência à Saúde; Sistema Único de Saúde; Saúde da Família
INTRODUCTION
According to the National Policy on Basic Care1, Primary Care plays a key role in promoting healthy aging, given its active contribution in managing the health of older adults, as well as to the diagnosis and prevention of risk factors for diseases.
Primary Care has a strategic position within the Brazilian National Health System (SUS) as an important place for identifying the health needs of the population, providing support for the care delivered, implementing health promotion and prevention actions, besides offering treatment within this level of care complexity1.
According to the Brazilian Institute of Geography and Statistics (IBGE),2 the city of Rio Brilhante has been an independent entity for 92 years and is situated in the interior of the state of Mato Gross do Sul, 160 km from the state capital of Campo Grande. In 2020, the IBGE estimated the city´s population at 38,186 people. The older population represents 7.15% of the total population and the mortality rate from diseases in general over the past 3 years of study is higher in older individuals aged > 60 years.
The projected growth in the older population, a stratum more naturally vulnerable than other age groups due to the aging process, coupled with the lack of specific care programs for older residents of the city, prompted the present study assessing the quality of health care for older individuals. Owing to their more advanced age, these individuals require more effective and adequate healthcare across all levels, particularly within primary care 3.
There are scant studies assessing the quality of actions in primary care and their impact on the health of older adults amid the challenge posed by population aging. Therefore, the objective of the present study was to assess the quality of Primary Care, as perceived by older adult users, in the city of Rio Brilhante (Mato Grosso do Sul state, Brazil). The study results can help inform actions to improve the quality of health services.
METHOD
A cross-sectional quantitative study of primary data was carried out at the Primary Care facilities of the city of Brilhante (Mato Grosso do Sul state, Brazil).
The study population comprised older adults. Inclusion criteria were being an actively enrolled older user of the SUS at urban primary care clinics in the city of Rio Brilhante, constituting a sample of 3,409 people.
Based on this total, a representative sample of 345 older individuals was calculated, drawn using stratified sampling according to the population of the health clinics. Sample size was calculated using the formula n=[DEFF*Np(1-p)] / [(d2/Z21-α/2*(N-1)+p*(1-p)], based on a population of 3,409 older adults, a 5% absolute margin of error, 95% confidence interval and hypothetical outcome rate of 50%.
The exclusion of older individuals exhibiting any limitation which precluded interview was envisaged, such as cognitive deficits, memory or speech impairments, among others. However, when applying the criteria, none of the selected participants displayed these characteristics.
Study participants were selected from the 8 primary care clinics situated in the urban area of the city. The users invited to take part in the study were selected using simple random selection drawing on the registry of users of the clinics. Each user registered at the health clinics was assigned an identification number which was placed in a box and the drawn randomly, according to the size of the sample at each unit. Data collection took place between July and October 2021.
Data collection was carried out by the principal investigator at participants´ homes, dispensing with the need for a trained team. At the visits, the risks and benefits of the study were explained to respondents, who also read the Free and Informed Consent form. After the participants had agreed to take part, data collection interviews were conducted, whose duration averaged 20 minutes. All potential respondents selected met the inclusion criteria and the full sample required was attained. Participants were told they could discontinue the interview at any time.
Given the target audience of the survey were older adults, and the fact that data collection took place during the COVID-19 pandemic, the biosafety protocol recommended by the World Health Organization was followed, involving measures for protection and prevention of COVID-194.
Following approval, a pilot test with 5 older subjects was performed to assess comprehension regarding the clarity of the questions and response options allowed within the range of possible answers for the tool (definitely yes, probably yes, probably not, definitely not, don´t know/can´t remember). No difficulties using or understanding the tool were reported and, therefore, no changes were deemed necessary.
Data collection was broken down into two blocks. The first block contained structured questions designed to characterize participants, probing age, sex, education, occupation and living arrangement. The second block drew on the short version of the Primary Care Assessment Tool (PCATool-Brasil)5 for adult patients, whose validity and reliability have been validated for Brazil. The PCATool-Brasil comprises 26 items across 10 components related to the theme of interest. The researcher read out the questions of the survey and noted down information according to responses given by participants using a printed answer card with the following response options: “definitely yes”, “probably yes”, “probably not”, “definitely not”, “don´t know/can´t remember” used to record answers for all items.
The PCATool-Brasil assessment questionnaire has been validated by the Ministry of Health as a tool for assessing the quality of primary care services with measurement of aspects related to the structure, process and outcomes of health services. The instrument measures the 4 key domains of primary care: first-contact care, longitudinality, comprehensiveness and coordination of care; and 3 derived attributes qualifying the actions and services of primary care, namely: family-centeredness, community orientation, and cultural competence. The components related to the attributes include: affiliation, use, accessibility, longitudinality, integration of care, information systems, services available, services delivered, family-centeredness and community orientation, where a score of 0 to 10 is assigned to each individual attribute and an overall score derived from mean value of attributes5.
The values ranging from 1 to 4 for each response are used to calculate the overall score for primary care, derived from the mean of the responses, where the options include “definitely yes” (4); “probably yes“ (3); “probably not” (2) “definitely not” (1); and “don´t know/can´t remember” (9), with this last item regarded as a missing value. The score ranges from 1 to 4 points, with higher values indicating service characteristics more well-oriented to primary care. The overall score was transformed on a scale ranging from 0 to 10 to facilitate reading of results. This conversion was performed using the formula given below, contained in the manual for the original instrument, in which “Score obtained” corresponds to the score originally on a 1-4 scale and requiring transformation to values between 0 and 10.
The overall score and mean of the 7 attributes, ranging from 0 to 10, has a cut-off of 6.6, representing the minimum “probably yes” responses a health service must have in order for the presence of attributes of primary care to be recognized. Hence, a high classification (score ≥6.6) denotes services that are better oriented toward these attributes, whereas a low classification (score <6.6) indicates services with low presence of these attributes”.
The essential score was obtained by calculating the mean of the essential attributes (affiliation, access, longitudinality, care coordination and comprehensiveness). The overall score was derived from the sum of the values of the items from the survey divided by 23, the number of items making up the survey, encompassing the essential and derived attributes.
The values of the items C11 and C14 were inverted (4=1; 3=2; 2=3; 1=4) on the scale to reflect the presence of the characteristics of the services, given these were formulated such that higher values on the scale suggest non-delivery of the service. Item E1 indicates whether patients were attending a consultation with a specialist or at a specialized service (Yes, No, Don´t know/Can´t remember), and Item E1 was therefore not included in the score calculation.
Descriptive analyses of data were first carried out for frequencies, percentages, means, standard deviations, quartiles and 95% confidence intervals. One participant was excluded from the analyses because 57.0% of their data was missing. In the remaining cases, scores of 2 were assigned for instances of missing values as per manual instructions. The scores of the attributes, essential and overall, were classified into low or high scores, using a cutoff of 6.6, as per manual directions. The percentages of low and high scores for each attribute in the essential and overall score were then calculated.
Categorization of variables was performed for the analysis of sociodemographic characteristics. Age was stratified into 60-69, 70-79 and ≥80 years age groups. The items indicating marital status (married/partner, single, widowed, separated/divorced) were grouped into “without partner” and “with partner”. The items regarding occupational status were categorized into “retired/pensioner”, “homemaker” and “working out of home”, with the last item sub-grouped into the professions cited. Education was grouped into two levels, those who studied “up to complete primary” and those who studied to “secondary or higher level”. And the variable “living arrangement” was grouped into “alone”, “with spouse” and “with family”.
Logistic regression models were estimated for associations between each independent variables (sex, age, marital status, education and living arrangement) and the outcome overall score (dichotomized as per manual for the instrument). Variables with p-value <0.20 on bivariate analyses were entered into a multiple logistic regression model, where the final model comprised the variable which remained significant when analyzed together with the others. The goodness-of-fit of the model was assessed by the Akaike Information Criteria (AIC). Odds Ratios, along with the respective 95% confidence intervals, were estimated from the regression models. A 5% level of significance was adopted for all analyses.
The proportion of female versus male participants in the sample was determined using the binomial test (p<0.001).
This study reported in the present article was conducted in compliance with the precepts established in Resolution 466/2012 and Resolution 510/2016 and approved by the Research Ethics Committee of the Universidade Federal de Mato Grosso do Sul, under permit no. 4.702.978.
RESULTS
Data for a sample of 345 older adults were analyzed, comprising 67% females and 33% males, with all participants aged ≥60 years, and most aged 60-69 years.
The demographic and socioeconomic characteristics of participants are presented in Table 1.
Sociodemographic characteristics of participants, Rio Brilhante, Mato Grosso do Sul state, 2022 (N=344).
The results for scores on each attribute, the essential score and overall score are given in Table 2.
Descriptive analysis of scores on attributes of primary care assessment (PCATool), for older adults, Rio Brilhante, Mato Grosso do Sul state, 2022 (n=344).
On a scale of 0 to 10, the mean overall score was 6.27 (95%CI: 6.17-6.37). The essential score (Affiliation; First-contact care: Use and Accessibility; Longitudinality; Coordination: Integration of Care and Information Systems; Comprehensiveness: Services Available and Services Delivered), attained a mean of 6.94 (95%CI: 6.86-7.02).
Mean scores for the attributes Coordination – Information Systems (Mean=3.78; 95%CI: 3.57-3.99), Comprehensiveness – Services Available (Mean=4.62; 95%CI: 4.42-4.83), Family-centeredness (Mean=3.71; 95%CI: 3.53-3.88) and Community Orientation (Mean=2.31; 95%CI: 2.02-2.61) were below 5 points on a scale of 0 to 10, and below the score considered low (<6.6) by the tool.
The distribution of frequencies of classification of the scores for each attribute, essential and overall, as per the Manual for the tool, is presented in Table 3. Most of the older adults attributed low scores to Coordination – Information Systems (77.0%), Comprehensiveness – Services Available (76.4%), Family-centeredness (93.6%) and Community Orientation (89.8%). Likewise, overall score was low for most respondents (65.1%), whereas essential score was high for 70.6% of the older adults.
Descriptive analysis of scores on attributes of primary care assessment (PCATool) for older adults, Rio Brilhante, Mato Grosso do Sul state, 2022, according to cutoff point (n=344).
The results on the crude analyses of the association of variables with the score showed a p-value <0.20 for age group, marital status and occupation. Thus, these variables were subsequently entered into the multiple regression model. However, only the occupation variable remained significant when these variables were analyzed together. Therefore, the final model comprised the occupation variable. The results revealed that 62.9%, 60.3% and 76.5% of the respondents who were retired/pensioners, homemakers and worked out of home, respectively, gave a low score on the primary care assessment. Individuals that worked out of home had a greater chance of giving a low rating on the primary care assessment (OR=1.92; 95%CI: 1.02-3.58, p<0.05) Table 4.
Analysis of associations with overall score on primary care assessment (PCATool). for older adults, Rio Brilhante, Mato Grosso do Sul state, 2022 (n=344).
DISCUSSION
This study showed that, from the perspective of the older adults surveyed, the primary care system had worse performance in terms of overall score (6.27) but better performance for essential score (6.94). The attributes first-contact care (use and accessibility), longitudinality, coordination (care integration) and comprehensiveness (services delivered) were rated as having good performance, while attributes including coordination (information systems), comprehensiveness (services available), family-centeredness and community orientation were rated as low performance.
With regard to overall score, the older adults surveyed gave a low rating for primary care in the city, revealing a weak orientation of the local primary care services towards the attributes of primary care, corroborating the findings of previous studies in Brazil involving the same age group and assessment tool6-8.
The main perceived issues underpinning the low scores were: little or no running of satisfaction surveys with users, failing to raise community problems, low orientation with regard to the comprehensiveness of services in relation to provision of information on healthy diet, good hygiene, adequate sleep, recommended physical exercises, medication, or falls prevention, and lack of family planning with reference to the way to convene family members when necessary and discuss treatment and care plans with users or a family member.
The analysis of participant characteristics and their association with the assessment of performance of the primary care service revealed that most respondents of both genders gave a low score (<6.6).
In the present study, females made up over 60% of the total sample surveyed, mirroring the results of previous studies assessing the quality of primary care in Macaíba/Rio Grande do Norte9 and Porto Alegre/Rio Grande do Sul10, confirming that women tend to be the main users of health services in Brazil11.
The present study found that, across the age strata investigated, only those aged 80 years or older predominantly assessed the primary care system with a high score. This same trend had been observed in other Brazilian studies of young and older adults, such as the investigations by Perillo et. al.6,Carvalho et al.7 and Carvalho et al.8, in which the assessment of performance was more favorable among the oldest old. This phenomenon might be explained by the fact that the older population is more prone to multiple comorbidities and thus seeks health services and care more often. Moreover, the current results show the older adults working out of home were more likely to rate the primary care performance with a low score, where the times of operation of the services, typically limited to weekdays and business hours, hampers access to the primary care service. As reported in a previous study12, factors such as greater frequency and regularity of health service utilization were associated with better perceived performance of the primary care service by users.
There are scant studies in the literature comparing primary care quality assessments exploring care models from a user´s perspective, making the present study pioneering in the state by addressing the older population. The lack of studies renders it hard to measure the degree of success of different types of services and establish a definition of what is closest to the ideal according to the principles of primary care, a barrier also reported by previous studies carried out in the states of Minas Gerais13 and Paraíba14.
These results differ to the findings of a study performed in Minas Gerais9, but are similar to those of studies in João Pessoa and Belo Horizonte14,15. The authors of the study conducted in Belo Horizonte15 used the same instrument with a similar survey, allowing assessment of the same primary care attributes measured in the present investigation.
A limitation of the present study was the fact it was conducted in a relatively small town, where results may have differed if performed in a large city. Also, the analysis of the quality of primary care in Rio Brilhante was based solely on the perceptions of the users surveyed.
CONCLUSION
Based on the overall score, it was concluded that the quality of primary care in the city was low, suggesting there is room for improvement in the quality of these services. The essential score was rated as high, showing that the health services in the city´s primary care system are well-oriented to their attributes, promoting greater user satisfaction and positively impacting the health status of the population.
As evidenced by the good rating for longitudinality and comprehensiveness, there is care continuity and a good relationship of this provision with the population, reflecting a bond of trust between users and health professionals. Users can readily access services when required and there is good capacity to ensure care continuity via the health teams.
Further studies involving larger samples should be performed to address the lack of research using the PCATool-Brasil (Primary Care Assessment Tool), a factor limiting more meaningful discussion of the results found, which is essential given the need to conduct increase studies assessing the quality of services in primary care.
-
This study received no external funding.
-
DATA AVAILABILITY
The complete anonymized dataset underpinning the results of the present study are available on the Figshare repository and can be accessed at https://figshare.com/s/4887bb5c5b09cda4682f or 10.6084/m9.figshare.27617505.
References
- 1 Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União, Brasília, seção 1, p. 68, 21 set. 2017
-
2 Instituto Brasileiro de Geografia e Estatística. Cidades/Rio Brilhante: panorama, 2020. Disponível em: https://cidades.ibge.gov.br/brasil/ms/rio-brilhante/panorama Acesso em: 28 ago. 2023
» https://cidades.ibge.gov.br/brasil/ms/rio-brilhante/panorama - 3 Veras RP. Doenças crônicas e longevidade: desafios futuros. Rev. Bras. Geriat. Geront. 2023; 26:e230233. 10.1590/1981-22562023026.230233.pt
-
4 Brasil. Ministério da Saúde. Plano de Contingência Nacional para Infecção Humana pelo novo Coronavírus Covid-19. Brasília; 2020. Disponível em: https://portalarquivos2.saude.gov.br/images/pdf/2020/fevereiro/13/plano-contingenciacoronavirus-COVID19.pdf
» https://portalarquivos2.saude.gov.br/images/pdf/2020/fevereiro/13/plano-contingenciacoronavirus-COVID19.pdf - 5 Ministério da Saúde. Secretaria de Atenção Primária à Saúde. PCAtool Brasil/2020. Manual do Instrumento de Avaliação da Atenção Primária à Saúde. Brasília, DF: Ministério da Saúde; 2020
- 6 Perillo R, Bernal P, Duarte EC, Mala DC. Fatores associados à avaliação da Atenção Primária à Saúde na perspectiva do usuário: resultados do inquérito telefônico Digitel. Cienc. Saúde Colet. 2021: 23(3):961-974. 10.1590/1413-81232021265.07062021.
- 7 Carvalho FCHS, Rossato SL, Fuchs FD, Harzheim E, Fuchs SC, Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study. BMC Puyblic Health 2013;13:art. 605. 10.1186/1471-2458-13-605.
- 8 Carvalho, FC, Bernal RTI, Perillo RD, Malta DC. Association between positive assessment of Primay Healath Care, sociodemographic characteristics and comorbidities in Brazil. Rev. Bras. Epidemiol 2022:25:e220023. 10.1590/1980-549720220023.
-
9 Araújo L, Gama Z, Nascimento F, Oliveira H, Azevedo W, Almeida JH. Avaliação da qualidade da atenção primária à saúde sob a perspectiva do idoso. Cien. Saúde Colet. 2014; 19(8):3521-3532. Disponível em: https://doi.org/10.1590/1413-81232014198.21862013.
» https://doi.org/10.1590/1413-81232014198.21862013 - 10 Dotto J, Ávila G, Martins A, Hugo F, D’avila O, Hilgert J. Avaliação da qualidade dos serviços de atenção primária à saúde acessados por idosos em dois distritos de Porto Alegre, RS, Brasil. RFO UPF 2016; 21(1)23-30. Disponível em: http://revodonto.bvsalud.org/scielo.php?script=sci_arttext&pid=S1413-40122016000100004. 10.5335/rfo.v21i1.5385.
-
11 Levorato CD, Mello L M, Silva AS, Nunes AP, Fatores associados à procura por serviços de saúde numa perspectiva relacional de gênero. Cienc. Saúde Colet. 2014; 19(4):1263-1274. Disponível em: https://doi.org/10.1590/1413-81232014194.01242013.
» https://doi.org/10.1590/1413-81232014194.01242013 -
12 Silva AN, Silva SA, Silva ARV, Araújo TME, Rebouças CBA, Nogueira LT. A avaliação da atenção primária a saúde na perspectiva da população masculina. Rev Bras Enferm 2018; 71(2): 236-43. https://doi.org/10.1590/0034-7167-2016-0651.
» https://doi.org/10.1590/0034-7167-2016-0651 - 13 Garcia LAA, Nardeli GG, Oliveira AFM, Casaburi LE, Camargo FC, Santos AS. Satisfação dos idosos octogenários com os serviços de Atenção Primária à Saúde. Rev. Bras. Geriat. Gerontol. 2022; 23(1)e-180195. 10.1590/1981-22562020023.190235.
-
14 Lubenow JAM, Silva AO. O que os idosos pensam sobre o atendimento nos serviços de saúde. Rev. Bras. Geriat. Gerontol 2019; 22(2):e180195. Disponível em: https://doi.org/10.1590/1981-22562019022.180195.
» https://doi.org/10.1590/1981-22562019022.180195 -
15 Perillo R,Bernal RTI, Poças KC, Duarte EC, Malta DC. Avaliação da Atenção Primária na ótica dos usuários: reflexões sobre o uso do Primary Care Asessment Tool-Brasil versão reduzida nos inquéritos telefônicos. Rev. Bras. Epidemiol. 2020; 23(supl.1):e200013. Disponível em: https://doi.org/10.1590/1980-549720200013.supl.1.
» https://doi.org/10.1590/1980-549720200013.supl.1
Edited by
-
Edited by: Camila Alves dos Santos
The complete anonymized dataset underpinning the results of the present study are available on the Figshare repository and can be accessed at https://figshare.com/s/4887bb5c5b09cda4682f or 10.6084/m9.figshare.27617505.
