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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.22 no.3 Rio de Janeiro Mar. 2017 


The use of the Primary Care Assessment Tool (PCAT): an integrative review and proposed update

Otávio Pereira D’Avila1 

Luiz Felipe da Silva Pinto2 

Lisiane Hauser1 

Marcelo Rodrigues Gonçalves1 

Erno Harzheim1 

1 Projeto TelessaúdeRS, Fundação de Apoio à Universidade Federal do Rio Grande do Sul. R. Dona Laura 320/11º, Rio Branco. 90000-035 Porto Alegre RS Brasil.

2 Departamento de Medicina de Família e Comunidade, Faculdade de Medicina. Universidade Federal do Rio de Janeiro. Rio de Janeiro RJ Brasil.


This study proposes an integrative review of the literature based on articles and publications on the use of the Primary Care Assessment Tool (PCAT) as a tool for evaluating these services, discussing the results found in Brazil and in other countries of the world, from the initial matrix conceived by Professor Barbara Starfield’s team and proposing updates for the Brazilian version. We identified 124 studies, of which 42 were selected after full reading and according to the established inclusion criteria. Of this subtotal, 17 (40.5%) were Brazilian studies. There is a need to update items of each tool’s attribute, in particular “access – first contact”, including new forms of doctor-patient communication such as: email, mobile application messages, use of videoconference software for communication and even use of telemedicine, among others. PCAT’s use, application and calculation of scores is simple, which makes it useful and suitable for use in the local management of services, especially in its short version.

Key words: Primary Health Care; Health evaluation; Health care; Health services; Outcome assessment


Este estudo propõe a realização de uma revisão integrativa da literatura a partir de artigos e publicações sobre o uso do “Primary Care Assessment Tool (PCAT)” como instrumento de avaliação desses serviços, discutindo os resultados encontrados no Brasil e em outros países do mundo, a partir da matriz inicial concebida pela equipe da Professora Bárbara Starfield e propor atualizações para a versão brasileira. Identificaram-se 124 trabalhos; porém, após a leitura dos mesmos, foram selecionados 42, de acordo com os critérios de inclusão estabelecidos. Deste subtotal, 17 (40,5%) foram estudos brasileiros. Sugere-se a necessidade da atualização de itens de cada atributo do instrumento, em particular do “acesso – primeiro contato”, incluindo novas formas de comunicação médico-paciente como: e-mail, mensagens por aplicativos em dispositivos móveis, uso de software de transmissão de vídeo para comunicação e mesmo utilização de telemedicina, entre outros. O PCAT apresenta simplicidade quanto ao uso, aplicação e cálculo dos escores, o que o torna útil e adequado para uso na gestão local dos serviços, especialmente em suas versões reduzidas em número de itens.

Palavras-Chave: Atenção Primária à Saúde, Avaliação em saúde; Assistência à saúde; Serviços de saúde; Avaliação de resultados


In the late 1990s and early 2000s, tools were developed in several countries to assess the quality of Primary Health Care through the experience of users, professionals and/or managers in the daily services. Among these resources are the Components of Primary Care Instrument (CPCI)1, Primary Care Assessment Survey (PCAS)2, EUROPEP questionnaire3, Primary Care Assessment Tool (PCAT)4, Interpersonal Processes of Care5 and Qualicopc6. PCATool was proposed and validated in the USA by Cassady et al.7, led by Professor Barbara Starfield, as a psychometric scale that covers scores for all PHC attributes, as well as two summary measures. Authors compared two national PHC models with samples conducted by phone and e-mail interviews, calculating statistics called “scores” for each of the characteristics that formed a search group of items: (i) extension of affiliation with a service; (ii) first contact access – use; (iii) first contact access – accessibility; (iv) longitudinality; (v) coordination – integration of care; (vi) comprehensiveness – available services, (vii) comprehensiveness – services provided; (viii) family orientation, (ix) community orientation. Initially, the attribute “coordination” contemplated only the perspective of the integration of care, leaving aside the measurement of information systems. This tool has a version for adult and children users, health professionals and managers.

In Brazil, Harzheim et al.8 were the first to adapt the PCATool – children’s version, analyzing their validity and reliability by means of a cross-sectional study in the city of Porto Alegre, performing reverse translation, adaptation, pre-test, construct validity, internal consistency and reliability analysis. Oliveira9 and Trindade10 used the same databases of Porto Alegre to develop comparative evaluations between different health care models, associating with the quality of management of hypertension in adults. Simultaneously, in Petrópolis, a highland city in the state of Rio de Janeiro, Macinko et al.11 compared facilities with family health teams x facilities with traditional care, validating a version for adult users with small differences in the composition of the items and in the response scale. In 2010, some of these versions were endorsed by the Ministry of Health with the publication of a Manual of said tool12. Subsequently, a team of researchers linked to the Epidemiology Graduate Program, Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS) validated the versions for adult users13, professionals14 and the short versions for adults15 and children16.

Since then, several Brazilian authors have started to use PCATool as a resource for the evaluation of Primary Health Care from the perspective of users responsible for children, adolescents and also adult users, in municipalities and cities of different population sizes, combining and complementing, sometimes, with clinical outcomes and use of other questionnaires / protocols in the health area and adapting the local culture to its items. At the global level, researchers from several countries worked on the adaptation and validation of PCATool versions appropriate to their social and health contexts, with increasing use of the tool in several parts of the world.

This study aims to present an integrative review of papers, theses and dissertations available on the internet on the use of PCAT as a tool for evaluating primary health care services through users’ perceptions, discussing the results found in Brazil and in the versions adapted and validated in other countries, from the initial matrix conceived by professor Barbara Starfield’s team, as well as to propose updates for the Brazilian version.


The integrative literature review synthesizes information over a specific period on a specific topic. Its main advantage over the revision of the traditional bibliography is that there is a strict method in the selection of papers, with well-defined inclusion and exclusion criteria, period, pre-established languages, bibliographic databases of public domain used and, sometimes, book repositories or theses and dissertations consulted. Its elaboration presupposes detailing to the reader all these choice criteria.

For the review, we consulted Pubmed databases of the National Library of Medicine of the United States, Lilacs (Latin American and Caribbean Literature in Health Sciences), SciELO (Scientific Electronic Library Online), as well as the institutional repositories of scientific production The Sergio Arouca National School of Public Health / Oswaldo Cruz Foundation (ENSP/Fiocruz), the Federal University of Rio Grande do Sul (UFRGS) and the University of São Paulo (USP), as well as research reports with random samples of users, available on the internet. We selected studies published between January 1, 2000 and June 1, 2016. For the search, keywords used were ‘PCATool’ and associations between “PCAT” and “Primary Care Assessment”.

The collection identified 124 papers on the subject. However, after reading them, 42 were selected according to the inclusion criteria: articles published in the period; languages: English, Portuguese and Spanish; types of study: cross-sectional study with results from samples of children or adults users. In a second reading, we searched for publications that listed more than one Primary Health Care attribute and PCAT scores, both for the essential and the derivative characteristics, totaling the same 42 studies. At the end of literature review, scores whose articles were not shown on a scale of 0 to 10 were transformed into this metric in order to standardize the analysis of the observed results. The included studies were characterized by author (s), country / region / city, target audience, data collection period and PCAT calculated scores.


Chart 1 shows the distribution of the 42 national and international studies, all with a cross-sectional design and with the respective attribute scores, retrieved in databases or repositories. Of this total, 17 (40.5%) are from Brazil, four each from Canada and China, three from Argentina, two each from the United States and Hong Kong and one each from South Africa, Colombia, South Korea, Spain, Japan, Paraguay, New Zealand, Thailand, Tibet and Uruguay (Figure 1).

Source: Elaboration by authors from the integrative literature review.

Figure 1 Map of PCAT studies (user’s version) included in the integrative literature review – 2000-2016. 

Chart 1 Characteristics of publications on the use of the Primary Care Assessment Tool (PCAT) among primary health care users 

Nº of study Author(s)/year Country/Region /Federal Unit City(ies) n Target Audience Data collection period
01 Cassady et al. (2000)7 United States Washington D.C. 450 Children and adolescents 1998/1999
02 Harzheim et al. (2010)12 Brazil/ Distrito Federal Brasília - - 2010
03 Berra et al. (2011)19 Argentina/ Province of Córdoba Córdoba - - From June 2009 to June 2010
04 Shi et al. (2001)4 .United States/ Carolina do Sul Columbia 892 adults 1999
05 Ibañez et al. (2006)25 Brazil/ São Paulo 62 rural municipalities of São Paulo with more than 100 thousand inhabitants 2923 adults and children 2005
06a Harzheim et al. (2015)17 Brazil/ Rio de Janeiro Rio de Janeiro 3.145 children January-June 2014
06b Harzheim et al. (2015)17 Brazil/ Rio de Janeiro Rio de Janeiro 3.530 adults January-June 2014
07 Ferrer (2013)26 Brazil/ São Paulo São Paulo – west region 501 children January-December 2011
08 Macinko et al. (2007)11 Brazil/ Rio de Janeiro Petrópolis 468 adults January-February 2004
09 Elias et al. (2006)27. Brazil/ São Paulo São Paulo - total municipality divided into three strata 1.117 adults Not informed
10 Silva (2014)28 Brazil/ Minas Gerais Micro-Region of Alfenas (11 municipalities) 527 adults June-July 2012
11 van Stralen et al. (2008)29 Brazil/Goiás, Mato Grosso do Sul Seven municipalities of Goiás and two municipalities of Mato Grosso do Sul. 623 adults and children 2006-2007.
12 Leão (2010)30. Brazil/ Minas Gerais Montes Claros 350 children January-February 2009
13 Carvalho et al. (2013)31 Brazil/ Bahia Ilhéus 509 elderly August 2010 - August 2011
14 Oliveira (2012)32 Brazil/Paraná Colombo, metropolitan region of Curitiba (with more than 200 thousand inhabitants) 482 children June-July 2012
15 Braz (2012)33 Brazil/Bahia Vitória da Conquista 271 children January-June 2012
16 Pieri (2013)34 Brazil/Paraná Londrina 119 adults 2009-2012.
17 Wolkers (2014)35 Brazil/Minas Gerais Uberlândia 64 children July 2013
18 Mesquita Filho et al. (2014)36 Brazil/ Minas Gerais Pouso Alegre 419 children January-December 2009
19 Oliveira (2007)9 Brazil/ Rio Grande do Sul Porto Alegre 1184 adults July 2006-August 2007.
20 Trindade (2007)10 Brazil/ Rio Grande do Sul Porto Alegre 588 adults July 2006-August 2007.
21 Harzheim et al. (2013)13 Brazil/ Rio Grande do Sul Porto Alegre 1484 Female adults July 2006-August 2007.
22 Gómez et al. (2012)37 Argentina/ Province of Buenos Aires Lunús 161 adults 2011
23 Rodríguez-Riveros et al. (2012)38 Paraguay/ Urban fringe of Asunción Asunción, region of Bañado Sur (urban area) 360 adults April-July 2011
24 Berterretche & Sollazzo (2012)39 Uruguay/ Province of Montevideo Montevideo 178 adults August-October 2011

Chart 1 continuation 

Mean scores (transformed for scale from 0 to 10)
Nº of study A B C D E F G H I J Ess Ger
01 - - - - - - - - - - - -
02 - - - - - - - - - - - -
03 - - - - - - - - - - - -
04 - 8,52 7,57 7,35 6,53 - 7,73 3,52 6,96 3,52 6,96 6,63
05 - 8,50 5,00 7,80 4,00 4,00 5,50 5,50 4,20 3,50 5,76 5,33
06a 7,54 7,88 4,72 6,14 6,01 6,63 5,76 5,44 5,43 5,09 6,30 6,09
06b 7,05 7,96 4,19 6,27 6,57 6,63 5,00 3,99 5,08 4,74 5,93 5,73
07 - - 4,97 4,93 6,61 6,61 6,11 6,11 4,19 4,21 5,64 5,33
08 - 8,01 3,96 8,90 7,49 7,49 7,86 7,86 5,69 5,84 7,37 7,01
09 - 7,62 4,03 7,78 7,80 7,80 8,11 8,11 2,68 3,02 7,32 6,33
10 3,67 8,59 3,21 7,26 6,10 6,41 5,22 4,92 5,69 5,88 5,64 5,67
11 - 8,58 2,74 6,98 6,13 6,13 7,09 7,09 1,73 2,26 6,39 5,41
12 5,42 8,16 6,61 6,61 5,17 7,96 4,12 4,64 6,65 6,09
13 5,84 2,83 4,95 3,56 3,56 3,13 3,13 2,07 3,87 3,86 3,66
14 5,26 6,48 3,82 4,38 6,63 5,74 5,43 5,52 4,96 3,65 5,41 5,19
15 7,40 7,20 4,80 6,90 4,03 7,43 6,10 6,03 3,43 5,97 5,30 5,07
16 - 6,33 4,95 7,60 6,35 6,35 4,33 4,33 3,68 2,15 5,75 5,12
17 7,97 6,00 4,97 7,37 3,10 6,70 2,13 5,43 3,87 0,80 5,50 4,83
18 - - 4,70 7,80 5,00 5,00 4,25 - 4,70 5,40 5,35 5,26
19 6,07 8,75 2,69 5,87 5,01 5,01 5,69 3,56 3,46 4,98 5,33 5,11
20 6,58 8,49 2,84 6,85 4,95 4,95 5,63 4,18 4,12 4,89 5,56 5,35
21 7,44 4,64 6,74 4,43 6,06 4,79 3,77 5,59 3,55 5,41 5,22
22 - 6,40 4,80 8,10 6,00 6,00 6,00 6,00 7,20 3,60 6,19 6,01
23 - 6,80 2,60 7,60 4,80 4,80 5,80 5,80 5,00 6,80 5,46 5,56
24 - 8,00 4,80 8,60 7,40 7,40 8,20 8,20 5,20 4,60 7,51 6,93

Chart 1 continuation 

Nº of study Author(s)/year Country/Region /Federal Unit City(ies) n Target Audience Data collection period
25 Berra et al. (2013)20 Argentina/ Province of Córdoba Córdoba 296 adults 2010
26 Rodriguez-Villamizar et al. (2013)40 Colombia/ Dept of Santander Six municipalities with rural profile 3.011 adults and children June-October 2010
27 Lee et al. (2009)18 South Korea/ Seoul metropolitan region Seoul and nearby small towns. 722 adults April-June 2007
28 Yang et al. (2013)41 China/ Province of Hunan Changsha 2.532 adults March-August 2009
29 Haggerty et al. (2007)42 Canada/ Province of Québec Five district of Québec: Montreal, Montérégie, Bas-Saint-Laurent, Côte-Nord, Gaspésie 3.441 adults December 2001-October 2002
30 Rocha et al. (2012)43 Spain/ Region of Catalonia Region of Catalonia 12.933 adults 2006
31 Wang et al. (2015)44 China/ South China, Region of Pearl River Delta (urban areas) Province of Guangdong (seven geographical regions) 3.360 adults November 2010-February 2011
32 Wong et al. (2010)45 Hong Kong Three regions of Hong Kong 1.000 adults November 2010-February 2011
33 Tsai et al. (2010)46 Taiwan Taichung 271 adults April-September 2008
34 Wang et al. (2014)47. Tibet Regions of Shigatse and Linzhi 1386 adults September-October 2013
35 Wei et al. (2015)48 China Shanghai 725 adults October-November 2011
36 Wei et al. (2015)48 Hong Kong Hong Kong 391 adults October-November 2011
37 Tourigny et al. (2010)49 Canada/ Province of Québec Not specified 1.275 adults Before-and-after sample type. Before (n1): June-September 2004
38 Tourigny et al. (2010)49 Canada/ Province of Québec Not specified 1046 adults Before-and-after sample type. After (n2): December 2006-March 2007
39 Aoki et al. (2015)21 Japan/ Region of Tokyo Kita 204 adults September-October 2014
40 Carroll et al. (2016)50 Canada/ Province of Ontario Toronto 1.026 adults 2015 ( ? )
41 Mei et al. (2016)51 China / Province of Guangdong Three cities: Guangzhou, Dongguan and Shenzhen 1.465 adults June-August 2014
42 Bresick et al. (2016)24 South Africa/ Province of Western Cape Six urban districts of Cape Town and four rural districts and Cape Winelands 1.432 adults 2013

Chart 1 continuation 

Mean scores (transformed for scale from 0 to 10)
Nº of study A B C D E F G H I J Ess Ger
25 - 7,00 6,00 6,67 6,33 7,00 6,33 5,33 5,00 4,00 6,38 5,96
26 - 9,50 4,81 5,40 9,00 9,00 8,60 8,60 4,20 3,79 7,84 6,99
27 - 8,88 9,05 9,01 5,99 - 5,24 - 6,50 - 7,63 7,45
28 5,82 7,56 6,89 6,56 6,21 - - 6,75 6,73 - 6,63 6,65
29 8,13 7,22 4,03 7,53 7,40 7,60 5,64 - - - 6,79 -
30 - - 7,59 6,89 7,50 - 5,33 - - - - 7,14
31 - 6,32 5,93 6,23 6,17 6,42 6,92 5,97 6,41 4,38 6,28 5,90
32 - 6,82 3,41 5,83 4,69 5,61 5,31 3,79 5,56 2,30 5,07 4,81
33 - 6,47 5,17 5,53 5,73 5,67 5,40 5,93 5,90 4,27 5,70 5,56
34 - - 5,66 8,39 7,72 - 7,66 - 8,22 6,78 7,36 7,41
35 5,33 4,00 7,00 4,67 9,00 7,67 4,67 6,50 3,50 6,05 5,81
36 7,33 2,00 4,67 5,33 6,00 4,67 3,67 5,00 3,00 4,81 4,63
37 - 7,06 5,02 8,03 7,12 - - - - - - -
38 - 7,02 5,13 8,30 7,18 - - - - - - -
39 - - 4,14 6,91 6,16 - 6,46 3,81 - 5,28 - 5,47
40 - 9,00 4,27 7,70 7,83 5,57 6,10 4,53 6,40 -
41 - 6,10 2,19 5,10 2,61 2,62 - - - 3,72 -
42 - 7,00 5,00 6,67 7,33 7,33 7,00 5,67 6,00 4,33 6,57 6,43

Caption: A - attribute “extension of affiliation with a health service”, B - attribute “first contact access – use”, C - attribute “first contact access – accessibility”, D - attribute “longitudinality”, E - attribute “coordination – integration of care”, F - attribute “coordination - information system”, G - attribute “comprehensiveness - services available”, H - attribute “comprehensiveness - services provided”, I – attribute “family orientation”, J – attribute “community orientation”. Ess – “Essential Attributes Score”, Ger – “Score of all measured attributes”. Source: Prepared by authors from reading and analysis of publications.

The geographic distribution of the works shows concentration of studies in the American and Asian continents. The target audience consisted mostly of adults and/or children living in urban areas of cities of countries studied. Only one was conducted in rural cities. Of the 42 surveys, 35 (83.3%) had a cross-sectional study design. Two were before-and-after type and six more were tool validation in the country or region. Among the works geared to the evaluation of services from population samples, the study developed in the city of Rio de Janeiro using PCAT user version17 was the one with the largest sample recorded in a single city in the world, both for children (n = 3,145) and for adults (n = 3,530).


As can be seen in Figure 1, PCAT is a tool for assessing PHC services used in various locations worldwide. In order to meet the objectives of measuring different realms of PHC in services with heterogeneous characteristics, it was adapted and validated in different regions, always achieving acceptable psychometric properties4,8,17-21. This gives PCAT an advantageous international comparability feature.

Within the observed period, Brazil was the country that most published studies evaluating services using PCAT. Studies showed as essential scores of PHC – first contact access, longitudinality, comprehensiveness and coordination of care – low values ranging from 3.86 in Ilhéus, Bahia, to 7.37 in the city of Rio de Janeiro. Regarding the general score, which includes the already described family and community orientation attributes, we observed a similar range of values: 3.66 in Ilhéus and 7.01 in Rio de Janeiro. The result may be related to the choice made by the municipality of Rio de Janeiro of scaling-up expansion of PHC services, which increased population coverage from 3.5% in 2008 to 70% in 201622. It also established a family and community medicine residency program, which increased municipal PHC capacity17,23.

International studies have shown that, in relation to the essential / general attributes with a history of investment in PHC, the following locations performed well: Montevideo (7.51 / 6.93), Seoul and metropolitan region (7.63 / 7.45), Department of Santander in Colombia (7.84 / 6.99), Shigatse and Linzi in Tibet (7.36 / 7.41) and Columbia in the USA (6.99 / 6.63). The first study to analyze a city in South Africa also showed essential and general scores close to 6,624.

Despite being culturally and organizationally different models, these locations, together with the municipality of Rio de Janeiro, Brazil, evidenced scores that demonstrate that their own health services are PHC-oriented. However, scores enable us to affirm that services listed above are organized from a structured health care network with established flows. The portfolio of services meets the needs of the population and care continuity and facilitated access is in place. As shown in Chart 1, study by Harzheim et al.17 obtained a sample for the city of Rio de Janeiro, of 3,145 children and 3,530 adults, totaling 6,675 individuals interviewed in field work in the first half of 2014, with a sub-municipal representative for the so-called “health planning area”, and also for the two types of facilities that provided primary health care at the time. This was the largest sample ever performed in a single city that we located in our research until 2015.

Nevertheless, the large sample, for example, enabled authors of this study to stratify the results of attribute scores in subsamples, according to some complementary variables searched in the tool, such as: “administrative areas of the city”, “social class” , “team implantation time”, “elderly users - people over 60 years”. Authors found higher scores in health facilities with a longer time of implantation of their family health teams (primary care teams in Brazil) and did not find differences between social classes and the subgroup of adult users older than 60 years.

Some studies in Canada and Spain have used part of the PCAT or short version adapted and validated to their reality43,49, especially in the realm of “comprehensiveness”, in which the list of items that compose it is very specific in each country. This data collection tool allows the researcher to use part of the tool as specific items to use as a proxy for a particular outcome, or only items that make up the realms for an attribute of interest. In addition, short versions have been developed with the objective of optimizing the collection of information and pointing out ways from evaluations that can be routine32,43.

Issues to be incorporated into an upcoming version of the tool

After reviewing the literature and fifteen years after its initial proposal, the application and analysis of the observed results suggest the need to update items of each attribute of the tool. This applies in particular to the attribute “First contact access”, which could be tested to evaluate the possibility of including / adapting new items, such as the inclusion of new forms of doctor-patient communication, such as e-mail messages, mobile device applications messages, use of video broadcasting software for communication and even use of telemedicine, among others. In addition, the use of electronic information systems replacing paper medical records has brought to care not only a technological substitute, but also several possibilities for improving the coordination of care that must be incorporated into new versions of the tools. Likewise, change in the epidemiological context raises the need to include new items in the realm of comprehensiveness.

Final considerations

PCAT enables the evaluation of health services from the user’s perspective, observing the extent of PHC attributes in the evaluated services. This tool has been used around the world from different versions validated for local contexts that allow the comparability of findings. In addition, it is simple to use / apply and calculate scores, even when there is a need to impute data16, which makes it useful and suitable for use in the local management of services. Short PCAT versions have been shown to be competent to evaluate particular aspects of PHC attributes and are yet another important tool for local management.


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Received: November 15, 2016; Revised: December 05, 2016; Accepted: December 07, 2016


OP D’Ávila and LFS Pinto collected and read the review papers and wrote the text. L Hauser, MR Gonçalves and E Harzheim developed the analysis and critical review structure of the final version of the paper.

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