Abstract

The objective was to confront the view of users and health professionals about the satisfaction with the public dental service. Interviews were conducted with users, professionals considered directly (ESB) and indirectly (ACS) involved in oral health. Variables were evaluated individually and grouped into domains. A score was created for the analysis and the Kruskal-Wallis test was applied. The respondents positively assessed the quality of the dental services. The ACS demonstrated less satisfaction compared to users regarding general satisfaction in the Physical Structure and Medical Care domains and the variables: quality of clinical care; guidance to the patient after treatment performed in the specialty; and period of dental care. The ESB professionals expressed greater satisfaction than the users in the Medical Care domain and in the variables related to the provision of guidance, answering questions, attention solvability and consultation scheduling. It is concluded that the ESB professionals demonstrated a high degree of similarity to the satisfaction displayed by users, although positively expanded, and the ACS expressed more critically discrepant opinions in relation to users.

Key words
Evaluation of health services; Health staff; Patient satisfaction; Primary Health Care; Oral health

Introduction

The evaluation of health services has been a widely discussed necessity for global health policies, considered one of the paths for management to pursue the quality of services provided¹1. Brasil. Ministério da Saúde (MS). Portaria nº 1.654, de 19 de julho de 2011. Institui, no âmbito do Sistema Único de Saúde, o Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB) e o Incentivo Financeiro do PMAQ-AB, denominado Componente de Qualidade do Piso de Atenção Básica Variável - PAB Variável. Diário Oficial da União 2011; 20 jul.

2. Serapioni M, Silva MGC. Evaluation of the quality of Family Healthcare program in municipalities of Ceará: a multidimensional approach. Cien Saude Colet 2011; 16(11):4315-4326.

3. Bjertnaes OA, Sjetne IS, Iversen HH. Overall patient satisfaction with hospitals: effects of patient-reported experiences and fulfilment of expectations. BMJ Qual Saf 2012; 21(1):39-46.

4. Sobreira PGP, Vasconcellos MTL, Portela MC. Avaliação do processo de aconselhamento pré-teste nos Centros de Testagem e Aconselhamento (CTA) no Estado do Rio de Janeiro: a percepção dos usuários e profissionais de saúde. Cien Saude Colet 2012; 17(11):3099-3113.

5. Saliba NA, Nayme JGR, Moimaz SAS, Cecilio LPP, Garbin CAS. Organization of the demand for a Centre of Dental Specialties. Rev Odontol UNESP 2013; 42(5):317-323.^-66. Paddison CAM, Abel GD, Roland MO, Elliott MN, Lyratzopoulos G, Campbell JL. Drivers of overall satisfaction with primary care: evidence from the English General Practice Patient Survey. Health Expect 2015; 18(5):1081-1092.. An important component of this evaluation process is the apprehension of user satisfaction. It offers support for the reorganization of services through relevant and reliable information, as well as being a popular participation tool in health management⁷7. Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114.^,88. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JAG, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413..

Despite the increasing use of user satisfaction as a sensitive indicator of quality of health services²2. Serapioni M, Silva MGC. Evaluation of the quality of Family Healthcare program in municipalities of Ceará: a multidimensional approach. Cien Saude Colet 2011; 16(11):4315-4326.^,44. Sobreira PGP, Vasconcellos MTL, Portela MC. Avaliação do processo de aconselhamento pré-teste nos Centros de Testagem e Aconselhamento (CTA) no Estado do Rio de Janeiro: a percepção dos usuários e profissionais de saúde. Cien Saude Colet 2012; 17(11):3099-3113., it is accessed concisely and in isolation, without the desired articulation between the opinions of those involved in the production of care.

To seize and expand the understanding of the multiplicity of factors affecting user satisfaction, it is necessary to initially have a thorough understanding of their needs. Studies have shown discrepancies between analyses of users and professionals regarding the quality and prioritization of health services²2. Serapioni M, Silva MGC. Evaluation of the quality of Family Healthcare program in municipalities of Ceará: a multidimensional approach. Cien Saude Colet 2011; 16(11):4315-4326.^,88. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JAG, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413.^,99. Sonneveld RE, Wensing M, Bronkhorst EM, Truin GJ, Brands WG. The estimation of patients’ views on organizational aspects of a general dental practice by general dental practitioners: a survey study. BMC Health Services Research 2011; 11:263.. While users tend to value relational aspects of the work process, health workers attach more importance to the technical skills of health care¹⁰10. Ronzani TM, Silva CM. O Programa Saúde da Família segundo profissionais de saúde, gestores e usuários. Cien Saude Colet 2008; 13(1):23-34. and tend to present, in different evaluative contexts, higher satisfaction levels²2. Serapioni M, Silva MGC. Evaluation of the quality of Family Healthcare program in municipalities of Ceará: a multidimensional approach. Cien Saude Colet 2011; 16(11):4315-4326.^,88. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JAG, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413.^,99. Sonneveld RE, Wensing M, Bronkhorst EM, Truin GJ, Brands WG. The estimation of patients’ views on organizational aspects of a general dental practice by general dental practitioners: a survey study. BMC Health Services Research 2011; 11:263..

Therefore, it is important to develop listening strategies, integrated or minimally, for a gradual approximation between the different opinions. The first step in this direction is the promotion of innovative assessment practices within teams and government health management²2. Serapioni M, Silva MGC. Evaluation of the quality of Family Healthcare program in municipalities of Ceará: a multidimensional approach. Cien Saude Colet 2011; 16(11):4315-4326.. The present study provides an opportunity to align the expression of workers and users on the same study subject: the satisfaction with public dental services, believing that their results can drive improvements in labor relations, in decision-making and exercising control of public health management.

Based the above, the present study sought to compare the user view with the professionals involved directly or indirectly with oral health with regards to satisfaction with aspects related to the public dental service.

Methodology

Type of study, sample and sampling

The present is a transversal research, developed in the urban area of a medium-sized municipality in Paraná, with an estimated population of 311,611 inhabitants, predominantly urban and of a young adult profile¹¹11. Instituto Brasileiro de Geografia e Estatística (IBGE). Dados censitários de 2011. [acessado 2013 nov 10]. Disponível em: http://cidades.ibge.gov.br/xtras/perfil.php?lang=&codmun=411990
http://cidades.ibge.gov.br/xtras/perfil.... . The study population was composed of users and dental service professionals in the field of primary health care, distributed in 27 regular health clinics in the urban area of the city, divided into 14 basic health units and 13 family health units.

In the field of professionals, the total of subjects in the working hours during this evaluated period were included, linked to the study scenarios, namely: 40 dentists, 06 technicians in oral health, 21 auxiliary oral health care assistants and 159 community health workers. For the purposes of the survey, all categories mentioned above were considered to be “involved directly or indirectly with oral health”.

Faced with the infeasibility of collecting information together from the total number of users ascribed in the study areas, a sample calculation was performed. A representative sample was then given with the use of the Epi.Info 7.1.4 software, considering the estimated adult population in the city studied (172, 600 inhabitants) with an accuracy of 5%, confidence interval of 95% and design effect 1, for a prevalence of 50% of adults satisfied with the quality of dental services. This prevalence was used in an attempt to get the highest possible sample. The calculated total (384) was increased by 20% in order to enhance the results, resulting in a final sample of 461 adults.

Users were randomly selected and stratified in the various health units in the days and alternating periods of operation in order to access the multitude of views and enhance the representativeness of the sample.

The eligibility criteria for users were: user of Brazilian public dental network of the primary health care; have received dental care in a referral center for a maximum of one year from the interview; present an age less than 18 years; or the under-aged were accompanied to the dental appointment on the day of the interview.

The professional eligibility criteria were: be part of the framework of the previously guided professions and health units involved in the study, and being in the profession.

Data collection

Two structured forms were developed to obtain the information, one for users and one for professionals, addressing issues related to the objective of the study, represented by the variables shown in Chart 01, with response patterns: happy, more or less satisfied and dissatisfied. Note that both forms investigated the same variables, but with a written arrangement appropriate for each research group.

The forms were adapted from protocols for assessing user satisfaction of the PNASS (National Program for Health Services Review)¹²12. Brasil. Ministério da Saúde (MS). Programa Nacional de Avaliação de Serviços de Saúde: Edição 2004-2005. Brasília: MS; 2004. and PMAQ (National Program for Improving Access and Quality of Primary Care)¹³13. Brasil. Ministério da Saúde (MS). Instrumento De Avaliação Externa Do Saúde Mais Perto De Você – Acesso E Qualidade Programa Nacional De Melhoria Do Acesso E Da Qualidade Da Atenção Básica (PMAQ). Brasília: MS; 2012. Série A. Normas e Manuais Técnicos., nationally based instruments proposed by the Ministry of Health to evaluate the quality of health services and support for SUS management (Health System). The adjustment was made in order to adapt these instruments which are essentially aimed at the medical health field to tackle specific aspects of dental reality. To ensure the understanding of the instrument regarding the text, the vocabulary used and the sensitivity of the responses, a pilot study was carried out to quantify the internal consistency among the questions through the Cronbach's α (α = 0.70), with users from the urban area and professionals from the health units in the rural area of the municipality. The data obtained in this stage were not part of the sample.

Data collection was conducted through individual interviews, conducted by a trained investigator to gather the necessary information and welcome any questions without influencing the answers. This step took place in a private environment within the health units. The average time of the interview lasted fifteen minutes and, at its end, the respondent received oral hygiene kits and a printed information sheet, designed specifically for the study, containing information on the rights and duties of the SUS and oral health care for the different life cycles.

Processing and data analysis

Prior to the actual examination, the sample of professionals was divided into two groups: group of professionals considered “indirectly involved with oral health”, made up of community health agents (CHA); and the group of professionals “directly involved with oral health”, made up of dentists, oral health technicians and oral health assistants, which together make up an oral health team (OHT).

For the first analysis, the variables of interest were grouped into domains. The formation of these areas was initially decided by the use of factor analysis, through diagnosis with orthogonal rotation, which seeks to identify similarities between variables that allow the grouping, usually by a linear relationship of the responses of individuals with latent traits¹⁴14. Pasquali L. Psicometria. Rev Esc Enferm USP 2009; 43(Spec.):992-999.. However, the factor analysis creates some strong postulations that do not always match the reality of the facts¹⁴14. Pasquali L. Psicometria. Rev Esc Enferm USP 2009; 43(Spec.):992-999., especially when it comes to a very homogeneous sample, similar to those studied. In applying the test, one group was proposed, thus opting for the use of conceptual analysis for creating the domains, which took place from a literature review and in-depth analysis about the dimensional concepts routinely used in the evaluation of health services¹⁵15. Fernandes MGM, Nóbrega MML, Garcia TR, Macêdo-Costa KNF. Análise Conceitual: Considerações Metodológicas. Rev Bras Enferm 2011; 64(6):1150-1156..

The variables were then grouped by the researchers according to proximity to the basic dimensions of evaluation of public health services in Brazil, namely: Medical Care, Information and Support, Organization of Services and Physical Structure, which proved to be in line with the groupings adopted in equivalent studies⁷7. Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114.^,1616. Donabedian A. The quality of care: how can it be assessed? JAMA 1988; 260(12):1743-1748.

17. Wensing M, Baker R, Vedsted P, Heje H, Klingenberg A, Broge B, Kersnik J, Seuntjens L, Künzi B, Milano M, Mola E, Elwyn G, Gro R. Revised Europep instrument and user manual 2006. [acessado 2013 nov 10]. Disponível em: http://www.topaseurope.eu/files/Europep%202006rapport_0.pdf
http://www.topaseurope.eu/files/Europep%... ^-1818. Priporas CV, Laspa C, Kamenidou I. Patient satisfaction measurement for in-hospital services: a pilot study in Greece. J Med Mark 2008; 8(4):325-340. (Chart 1).

To obtain the overall satisfaction level in every domain, a 0-1 index was created, calculated by using the average of their forming variables, assigning values to possible answers, namely: satisfied (value 1), more or less (value 0.5) and dissatisfied (value 0).

In order to better exploit the results, as well as the analysis by areas, a second analysis was conducted, where the forming variables in each domain were evaluated individually. Only the number of individuals satisfied in each evaluative variable was considered in the data exposure. The percentage content was calculated according to the total number of individuals responding to each variable, because some evaluative variables were different from the total number of the study sample.

The normality test (Kolmogorov-Smirnov) was used to define the use of parametric or non-parametric analyses. The data were not normally distributed, thus the nonparametric Kruskal-Wallis with the post Dunn's test at a significance level of 5% were applied.

Research ethics

All subjects were informed about the purpose of the research, their character and willingness of non-identification, as well as how to collect, analyze and destinate the data. Those who acquiesced to their participation did so by signing a free and informed consent. The study was approved by the Ethics Committee in Research with Human Beings of Araçatuba Dental School - UNESP and the State University of Ponta Grossa – UEPG, respecting the dictates of Resolution 466/12 of the Brazilian National Council of Health.

Results

The final sample was consisted of 461 members, 133 professionals indirectly involved with oral health (CHA) and 52 professionals directly involved with oral health (30 dentists, five oral health technicians and 17 oral health assistants). The loss of subjects occurred by the absence of the professional in the days of the interview, because of vacation or sick leave. Figure 1 shows the evaluation results of the users and professionals by dissociation in domains.

The overall satisfaction rate of users was 0.8 and the CHA was 0.75, with a significant difference (p < 0.05). The overall satisfaction expressed by the OHT (0.80) showed no significant difference when compared to the user group (p > 0.05).

Individually analyzing the fields, the CHA group had values of satisfaction below those expressed by users in all domains evaluated, with a significant difference for the Physical Structure (p < 0.05) and Medical Care (p < 0.05). When comparing the OHT to the users, greater satisfaction was presented by the OHT group in all domains, with significant differences only for the Medical Care (p < 0.05). All categories of the subjects investigated attributed the Service Organization domain as the lowest level of satisfaction, however, the values were not significantly different (p > 0.05).

Table 1 shows the percentage of the satisfaction of users and professionals in each variable formed by the domains, and the statistical values resulting from the comparison of satisfaction among users and the CHA and between users and the OHT.

Overall, users reported being satisfied with the public dental services offered. The CHA group exhibited lower satisfaction than the users, presenting a significant difference for the variables: “quality of clinical care offered by the oral health team” (p < 0.001); “orientation to the patient after treatment used in the specialty” (p < 0.01); “dental care period at the clinic unit” (p < 0.01); and for all the variables of the Physical Structure domain (p < 0.001).

Professionals in the OHT expressed high satisfaction, statistically higher than that of users for the variables “capacity to resolve all oral health problems” (p < 0.05); “answering questions, oral health concerns and problems by the dental team” (p < 0.01); “guidance during the consultation on the prevention of oral diseases by the dental team” (p < 0.01); and “time to schedule a dental appointment at the health clinic” (p < 0.01).

Discussion

The first aspect to be highlighted from the results of the present study was the high degree of satisfaction indicated by users in relation to public dental services investigated. This finding corroborates satisfaction surveys found in the national and international literature⁴4. Sobreira PGP, Vasconcellos MTL, Portela MC. Avaliação do processo de aconselhamento pré-teste nos Centros de Testagem e Aconselhamento (CTA) no Estado do Rio de Janeiro: a percepção dos usuários e profissionais de saúde. Cien Saude Colet 2012; 17(11):3099-3113.^,77. Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114.^,88. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JAG, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413.^,1818. Priporas CV, Laspa C, Kamenidou I. Patient satisfaction measurement for in-hospital services: a pilot study in Greece. J Med Mark 2008; 8(4):325-340.^,1919. Goetz K, Szecsenyi J, Klingenberg A, Brodowski M, Wensing M, Campbell SM. Evaluation of patient perspective on quality of oral health care in Germany – an exploratory study. Int Dent J 2013; 63(6):317-323..

However, these results should be analyzed with caution, since Brazilian health users tend to exhibit some conformity in relation to serviçes², low critical content and vindicating²2. Serapioni M, Silva MGC. Evaluation of the quality of Family Healthcare program in municipalities of Ceará: a multidimensional approach. Cien Saude Colet 2011; 16(11):4315-4326.^,77. Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114. and even a mistaken view in the recognition of health care as a benefit and not as a right, which may lead to a false high quality of health services researched⁷7. Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114.. In this sense, it is important to build a space in which users can understand their rights and feel encouraged to develop a critical and reflective vision about their needs and the work process in the health units²⁰20. Reis RS, Coimbra LC, Silva AAM, Santos AM, Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MSA, Silva RA. Acesso e utilização dos serviços na Estratégia Saúde da Família na perspectiva dos gestores, profissionais e usuários. Cien Saude Colet 2013; 18(11):3321-3331..

Despite the close proximity to the user and indirect involvement in oral health, community health workers, when compared to users, showed greater dissatisfaction with the public dental services. These findings reflect the importance of rethinking of the managers and trainers of evaluation policies on the inclusion of this group of professionals in the planning of health services, a fact which would allow the view of the same object under investigation by another lens and certainly the enrichment of the whole process.

The fact that community health workers do not act directly in dental services, one can get them to present a more critical view, demanding and less prone to conflicts of interest than those directly involved subjects (OHT), exposing a larger perception of rights and duties of citizenship, fundamental conditions for there to be progress in action planning and improvements in the quality of health services. Another proposition is the close relationship established between the CHA and users with alleged apprehension and exposure of yearnings and aspirations of users, which remain often veiled when investigated by researchers. It is inferred that the reasons that lead users to not express themselves properly may be related to users’ fear of losing the right to service and being perceived negatively by professionals⁴4. Sobreira PGP, Vasconcellos MTL, Portela MC. Avaliação do processo de aconselhamento pré-teste nos Centros de Testagem e Aconselhamento (CTA) no Estado do Rio de Janeiro: a percepção dos usuários e profissionais de saúde. Cien Saude Colet 2012; 17(11):3099-3113..

Studies show a recurring factor of dissatisfaction among users and health professionals is the precariousness of the physical structure of the health units⁴4. Sobreira PGP, Vasconcellos MTL, Portela MC. Avaliação do processo de aconselhamento pré-teste nos Centros de Testagem e Aconselhamento (CTA) no Estado do Rio de Janeiro: a percepção dos usuários e profissionais de saúde. Cien Saude Colet 2012; 17(11):3099-3113.^,2121. Nora CRD, Jungles JR. Política de humanização na atenção básica: revisão sistemática. Rev Saude Publica 2013; 47(6):1186-1200.. However, for users of the present study, these conditions were quite satisfactory, a result that diverges significantly from the perception of the investigated CHA. This discrepancy of opinions may suggest different levels of expectations among subjects⁸8. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JAG, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413., considering the various aspects of the physical area and the regulatory systems of health units, and even a supposed lack of user knowledge about the technical aspects (hard technology) of services²⁰20. Reis RS, Coimbra LC, Silva AAM, Santos AM, Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MSA, Silva RA. Acesso e utilização dos serviços na Estratégia Saúde da Família na perspectiva dos gestores, profissionais e usuários. Cien Saude Colet 2013; 18(11):3321-3331., causing them to more positively evaluate the structure of the units.

The domain holder of criticism among users and health professionals is the Organization of Services⁴4. Sobreira PGP, Vasconcellos MTL, Portela MC. Avaliação do processo de aconselhamento pré-teste nos Centros de Testagem e Aconselhamento (CTA) no Estado do Rio de Janeiro: a percepção dos usuários e profissionais de saúde. Cien Saude Colet 2012; 17(11):3099-3113.^,77. Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114.^,88. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JAG, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413.^,2020. Reis RS, Coimbra LC, Silva AAM, Santos AM, Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MSA, Silva RA. Acesso e utilização dos serviços na Estratégia Saúde da Família na perspectiva dos gestores, profissionais e usuários. Cien Saude Colet 2013; 18(11):3321-3331.

21. Nora CRD, Jungles JR. Política de humanização na atenção básica: revisão sistemática. Rev Saude Publica 2013; 47(6):1186-1200.^-2222. Van Stralen CJ, Belisário SA, Van Stralen TBS, Lima AMD, Massote AW, Oliveira CL. Perceptions of primary health care among users and health professionals: a comparison of units with and without family health care in Central-West Brazil. Cad Saude Publica 2008; 24(Supl. 1):148-158., which reached the lowest level of satisfaction among the investigated. Studies have reported high dissatisfaction with the long waiting time to schedule a consultation, inefficient organization of the flow for the host and also the insufficient period of dental services⁴4. Sobreira PGP, Vasconcellos MTL, Portela MC. Avaliação do processo de aconselhamento pré-teste nos Centros de Testagem e Aconselhamento (CTA) no Estado do Rio de Janeiro: a percepção dos usuários e profissionais de saúde. Cien Saude Colet 2012; 17(11):3099-3113.^,77. Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114.^,88. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JAG, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413.^,2020. Reis RS, Coimbra LC, Silva AAM, Santos AM, Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MSA, Silva RA. Acesso e utilização dos serviços na Estratégia Saúde da Família na perspectiva dos gestores, profissionais e usuários. Cien Saude Colet 2013; 18(11):3321-3331.

21. Nora CRD, Jungles JR. Política de humanização na atenção básica: revisão sistemática. Rev Saude Publica 2013; 47(6):1186-1200.^-2222. Van Stralen CJ, Belisário SA, Van Stralen TBS, Lima AMD, Massote AW, Oliveira CL. Perceptions of primary health care among users and health professionals: a comparison of units with and without family health care in Central-West Brazil. Cad Saude Publica 2008; 24(Supl. 1):148-158.. These factors constitute a challenge in the search for completeness and solvability of attention regarding the approach of the relationship between the actions of network services at different levels of complexity and skills. Reorganization initiatives of work processes as well as optimization of internal flows can also contribute to improve the quality of services and thus the satisfaction of users⁷7. Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114. and should, therefore, enable the organization of services and health practices to carry out an expanded grasp of the needs of the population under their responsibility.

In the Medical Care domain, the opinion among the OHT and CHA users was divergent. The CHA presented lower satisfaction and professionals in the OHT, the highest satisfaction when compared to users, both with significant values. This difference of opinion suggests the need for closer ties between professionals and users, as well as strengthening monitoring and site assessment activities so that weaknesses and new possibilities in the production process of public health services are identified²⁰20. Reis RS, Coimbra LC, Silva AAM, Santos AM, Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MSA, Silva RA. Acesso e utilização dos serviços na Estratégia Saúde da Família na perspectiva dos gestores, profissionais e usuários. Cien Saude Colet 2013; 18(11):3321-3331..

To individually analyze the evaluative variables, differences were also observed among the views of users and the OHT group of professionals for the variable “quality of clinical care offered by the oral health team”. The study by Reis et al.²⁰20. Reis RS, Coimbra LC, Silva AAM, Santos AM, Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MSA, Silva RA. Acesso e utilização dos serviços na Estratégia Saúde da Família na perspectiva dos gestores, profissionais e usuários. Cien Saude Colet 2013; 18(11):3321-3331. converges with the present study, since the professionals investigated in these studies were more likely to positively evaluate the quality of services in health when confronted by users.

The variable “orientation to the patient after treatment performed in the specialty” was assessed by the CHA group with satisfaction values significantly below those expressed by users. This low satisfaction may be related to the interpretation of professionals to consider the existing barriers in the process of referrals and counter-references, which hinder the return of the user and its access to guidelines. Examples of these obstacles are the difficulties encountered in many services in the scheduling of consultations for specialized care, non-cordial treatment in reference services and the absence of counter references⁴4. Sobreira PGP, Vasconcellos MTL, Portela MC. Avaliação do processo de aconselhamento pré-teste nos Centros de Testagem e Aconselhamento (CTA) no Estado do Rio de Janeiro: a percepção dos usuários e profissionais de saúde. Cien Saude Colet 2012; 17(11):3099-3113.. Still, the significant dissatisfaction expressed by the CHA, when compared to users, may be related to the development of numerous extra functional activities performed by this category, such as scheduling outpatient visits to the clinic, which would give them an even closer look at the existing difficulties.

Still confronting the opinions of users and the CHA, the satisfaction in relation to the dental care period at the clinic was significantly lower for the CHA. It is possible that this more critical view from the CHA is related to the fact that they know the community's desires as a whole, especially the formal workers, who often have difficulties in gaining access to the units and health services due to the layout of their work schedules²³23. Castro RCL, Knauth DR, Harzheim E, Hauser L, Duncan BB. Avaliação da qualidade da atenção primária pelos profissionais de saúde: comparação entre diferentes tipos de serviços. Cad Saude Publica 2012; 28(9):1772-1784., and that at the time of the interview, these aspects were taken into consideration. The expansion of the health unit service office hours beyond the working hours and weekends might be a strategy for facilitating access to the use of health services²⁰20. Reis RS, Coimbra LC, Silva AAM, Santos AM, Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MSA, Silva RA. Acesso e utilização dos serviços na Estratégia Saúde da Família na perspectiva dos gestores, profissionais e usuários. Cien Saude Colet 2013; 18(11):3321-3331..

In the comparison of opinions between the users and OHT, it was verified that professionals showed significantly greater satisfaction in the variables related to the provision of guidance, doubts clarification and attention resolution. The most favorable view of the OHT in relation to these labor factors, which directly reflect the activities that are developed at the facility level, can be explained by the natural tendency of individuals to issue a favorable value judgment of their relationship with their own actions and behaviors. Moreover, it can be related to a low criticality and high receptivity expressed by users for the provision of public services and non-performing formal complaints¹⁰10. Ronzani TM, Silva CM. O Programa Saúde da Família segundo profissionais de saúde, gestores e usuários. Cien Saude Colet 2008; 13(1):23-34..

The time to schedule an appointment at the health center is a source of high dissatisfaction for users of the health service in general⁴4. Sobreira PGP, Vasconcellos MTL, Portela MC. Avaliação do processo de aconselhamento pré-teste nos Centros de Testagem e Aconselhamento (CTA) no Estado do Rio de Janeiro: a percepção dos usuários e profissionais de saúde. Cien Saude Colet 2012; 17(11):3099-3113.^,77. Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114.^,88. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JAG, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413.^,2020. Reis RS, Coimbra LC, Silva AAM, Santos AM, Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MSA, Silva RA. Acesso e utilização dos serviços na Estratégia Saúde da Família na perspectiva dos gestores, profissionais e usuários. Cien Saude Colet 2013; 18(11):3321-3331.

21. Nora CRD, Jungles JR. Política de humanização na atenção básica: revisão sistemática. Rev Saude Publica 2013; 47(6):1186-1200.^-2222. Van Stralen CJ, Belisário SA, Van Stralen TBS, Lima AMD, Massote AW, Oliveira CL. Perceptions of primary health care among users and health professionals: a comparison of units with and without family health care in Central-West Brazil. Cad Saude Publica 2008; 24(Supl. 1):148-158.. This finding converges with the data expressed by the users of the present study, albeit on a less stricter view of the OHT. In the study by Reis et al.²⁰20. Reis RS, Coimbra LC, Silva AAM, Santos AM, Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MSA, Silva RA. Acesso e utilização dos serviços na Estratégia Saúde da Família na perspectiva dos gestores, profissionais e usuários. Cien Saude Colet 2013; 18(11):3321-3331., a more condescending perception by professionals regarding the scheduling of time was verified. This vision of professionals draws attention to the need for active categories in services, being more attentive to the barriers of the public health system and community aspirations.

Sonneveld et al.⁹9. Sonneveld RE, Wensing M, Bronkhorst EM, Truin GJ, Brands WG. The estimation of patients’ views on organizational aspects of a general dental practice by general dental practitioners: a survey study. BMC Health Services Research 2011; 11:263. also found significant differences between the views of users and professionals in various organizational aspects of dental services. The findings also showed that oral health professionals were able to correctly estimate the user´s point of view only half the time they were questioned. The authors suggest greater attention to the priorities of users and the channels of communication with the team.

With the findings herein, emerge the appreciation of different subjects involved in the health production process, with a view for the execution and expansion of humanization in public services. Thus, the present study contributes to the understanding of satisfaction with public dental services, through the perspective of users and different health professionals, an approach not yet sufficiently explored in the scientific field.

The development of different apprehension technologies for the awareness of health workers and users of health services is suggested, in scenarios of different practices, as a complementary method to pre-established government instruments. It is important that the managers launch methodological assessment innovations to expand communication between different perceptions, fostering theoretical knowledge and design to contribute to a better quality of health services. As suggestions, in addition to the inclusion of community workers in the evaluation process, the use of concomitant qualitative methods with quantitative methods may be a useful strategy to managers because it allows for the deeper issues and points more clearly to the reasons that infer the quality of services.

Final considerations

The results presented by users revealed high levels of satisfaction with the various aspects related to public dental services. Overall, the CHA exposed the most critical views on these services, compared to users. The professionals directly involved with oral health (OHT), for the most part, expressed satisfaction similar to the users, and in a few situations, expressed a positively larger view.

Despite the high parity between the users’ opinions and the OHT, it is deemed important to devote attention to the discrepancies found. It is then suggested that the public practices of oral health in the municipality can be improved and are linked to sensitive and periodic evaluations, aiming to deepen the quality of the relationship between the professionals and users; and still be able to respond positively to the Primary Health Care in Brazil for the dental area.

Acknowledgements

We would like to thank the Brazilian National Council for Scientific and Technological Development (CNPq) for providing funding for this work.

References

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