Abstract

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

Primary health care; Health evaluation; User satisfaction

Introduction

There is clear evidence that national health systems that prioritize primary actions as the organizing axis of health practices achieve better health indicators, lower costs, and greater user satisfaction¹1. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002.[acessado 2013 nov 23]. Disponível em: http://pesquisa.bvsalud.org/portal/resource/pt/sus-5656
http://pesquisa.bvsalud.org/portal/resou... . Therefore, the institutionalization of primary care (PC) assessment in Brazil has gained momentum with the new National Primary Care Assessment Policy in the country.

The most recent health assessment program conducted in Brazil is the National Program for Access and Quality Improvement in Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, PMAQ-AB), which aims, among other things, to improve healthcare services according to user need and satisfaction. PMAQ-AB has a phase called External Evaluation that evaluates the access to and quality of the health services in the municipalities and in the teams registered in the program through monitoring of contracted indicators and assessment of the teams’ quality standards. In this evaluation, one of the questions raised was user satisfaction and perception of the Primary Health Care (PHC) services in regard to access and usage²2. Brasil. (MS). Saúde mais perto de você – acesso e qualidade. Programa nacional de melhoria do acesso e da qualidade da atenção Básica (PMAQ-AB). Documentos. Brasília: Departamento de atenção Básica; 2012. [acessado 2013 nov 2]. Disponível em: http://dab.saude.gov.br/sistemas/pmaq/documentos.php
http://dab.saude.gov.br/sistemas/pmaq/do... .

User satisfaction evaluation is included in studies of interpersonal relationships in health services, strengthening community participation in the planning and evaluation processes³3. Esperidião MA, Trad LAB. Avaliação de satisfação de usuários: considerações teórico-conceituais. Cad Saude Publica 2006; 22(6):1267-1276.. Moreover, the importance of users in this evaluation process makes them real evaluators, amplifies their rights as citizens, and establishes shared accountability for health care production, which may influence the way care is provided and enable improved quality and effectiveness⁴4. Pinheiro R, Martins PH. Avaliação em saúde na perspectiva do usuário: abordagem multicêntrica . CEPESC; 2009. Recuperado de: http://www.nucleodecidadania.org/nucleo/extra/2011_05_13_00_31_16_apresentacao_livro_avaliacao_em_saude.pdf
http://www.nucleodecidadania.org/nucleo/... . Consequently, obtaining a statistically based evaluation of the interaction between health services and their users may contribute to the development of joint alternatives for more adequate interventions to solve daily routine problems with the services, favoring advances in health service production and management⁵5. Brandão, 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..

It is worth noting that the interventions must thoroughly consider the large geographic, environmental, social, cultural, and economic diversity of the five macro regions of Brazil, whose disparities are reflected in unequal access to basic life conditions, availability of public services, life expectancy at birth, institutional capacity of the state governments, and development opportunities, all of which cause an unequal geographic distribution of work and income and, consequently, unequal living and health conditions⁶6. Brasil. Ministério da Integração Nacional (MIN). Política Nacional de Desenvolvimento Regional - PNDR. Brasília: MIN; 2004.

7. Brasil. Ministério da Integração Nacional (MIN). A PNDR em dois tempos: A experiência apreendida e o olhar pós 2010. Brasília: MIN; 2010.^-88. Amparo PP. Os desafios a uma política nacional de desenvolvimento regional no Brasil. Interações Campo Gd 2014; 15(1):175-192.. At the macro regional scale, the socio-economic indicators for the North and Northeast regions are considerably below the national average, where the living conditions are far different from those found in the Midwest and especially from those in the South and Southeast⁹9. Daros ELR, Albernaz LR. Desenvolvimento Regional e Sustentabilidade do Crescimento. Rev TCU 2012; (124):82-124.. Given these inequalities, which are the target of public policies, the regions in Brazil have very different epidemiologic and health service access profiles in regard to both geographic characteristics and health services organization¹⁰10. Guimarães RM, Andrade SSCA, Machado EL, Bahia CA, Oliveira MM, Jacques FVL. Diferenças regionais na transição da mortalidade por doenças cardiovasculares no Brasil, 1980 a 2012. 2015. [acessado 2013 nov 11]. Disponível em: http://iris.paho.org/xmlui/handle/123456789/9337
http://iris.paho.org/xmlui/handle/123456... . Thus, the different regions have different needs that must be met to achieve health equality in Brazil.

In this context and using the data obtained in the 1^st external evaluation cycle from the PMAQ-AB as the basis of this study, this article primarily aimed to identify the main factors influencing user satisfaction with Primary Care Services (USat-PC), taking into account Brazilian regional inequalities.

Methods

In this study, secondary data were obtained with the External Evaluation Tool “Health Closer to You,” which was implemented by the Ministry of Health in Brazil in the 1^st of External Evaluation of the PMAQ-AB conducted between 2012 and 2013 in 17,203 contracted Primary Health Care Teams referring to 3,944 Brazilian municipalities. In particular, the answers of 65,392 users interviewed in Brazil during Module III – Interview with the User at the Health Unit were analyzed; the interview aimed to assess user satisfaction with access to and usage of health services. For a better analysis of the data, two criteria were used: 1 - Variable selection criteria: the variables with a maximum of 10% of absent data were included; and 2 - Case inclusion criteria: users who had complete data for the variables selected by criterion 1 were included.

Therefore, from the 91 pre-selected variables, the study analyzed 39 variables. Of the 65,392 users interviewed, 46,991 were included in the study, of whom 15,324 (of 21,556) were from the Northeast, 2,941 (of 4,337) from the Midwest, 18,511 (of 25,406) from the Southeast, 7,671 (of 10,364) from the South, and 2,544 (of 3,728) from the North.

Logistic regression models were fitted for each region in Brazil. All models used the same independent variables and outcomes: satisfaction (Y = 1) and dissatisfaction (Y = 0). To obtain the dichotomized dependent variable “user satisfaction,” the multivariate technique Two-Step Cluster Analysis was used, and the variables about user satisfaction that met the variable selection criteria were reclassified as satisfied and dissatisfied. The quality of the clustering obtained was analyzed with the Silhouette coefficient (SC). The pre-selected variable set is described in Chart 1.

Once the variables used to obtain the dependent variable were removed, the variables from Module III, which met the selection criteria and could influence USat-PC, were pre-selected to be the explanatory or independent variables. The pre-selected variable set is described in Chart 2.

In the development of each logistic model, the steps described below were taken for each region. Initially, bivariate analyses (each independent variable and the outcome) were conducted using the chi-square test and adopting a significance level of 20%. Next, the model was fitted with the Stepwise Forward method, using the Bayesian Information Criterion (BIC), and the final model was obtained assuming a statistical significance level of 5%. The goodness of fit of the final model was analyzed through deviance analysis and the receiver operating characteristic (ROC) curve, and cross validation was used for analyzing the predictive power of the resulting models.

The statistical analyses were performed using R software, except for the Two-Step Cluster analysis, which was performed with the statistical software SPSS version 20.0 (IBM). The study was submitted to and approved by the research ethics committee of Federal University of Rio Grande do Sul (Universidade Federal do Rio Grande do Sul, UFRGS).

Results

The cluster analysis used to obtain the variable user satisfaction had a Silhouette coefficient of 0.5, indicating a good result¹¹11. Mooi E, Sarstedt M. A Concise Guide to Market Research: The Process, Data, and Methods Using IBM SPSS Statistics. Berlin: Springer Science & Business Media; 2011.. This analysis enabled identifying two groups in regard to perceived satisfaction with care: 36,027 (76.7%) users classified as satisfied and 10,964 (23.3%) users classified as dissatisfied in Brazil. The results by region were as follows: Midwest, 661/22.5% dissatisfied and 2,280/77.5% satisfied; Northeast, 4,374/28.5% dissatisfied and 10,950/71.5% satisfied; North, 936/36.8% dissatisfied and 1,608/63.2% satisfied; Southeast, 3,679/19.9% dissatisfied and 14,832/80.1% satisfied; and South, 1,314/17.1% dissatisfied and 6,357/82.9% satisfied.

Table 1 shows the logistic model fitted for each region in Brazil, including the significant variables, p-value, odds ratio (OR), and confidence interval at 95%.

Table 2 shows the data obtained in the quality assessment of the model generated.

Discussion

In this study, being a female user in the Northeast increased the likelihood of achieving USat-PC by 1.27-fold over males. This result corroborates the findings of Nigenda-López et al.¹²12. Nigenda-López G, Salinas-Rodríguez A, Gómez-Camponovo M, Manrique-Espinoza B, Ruiz-Larios JA, Trejo-Rosales A. Identificação dos usuários segundo nível de satisfação nos módulos gerontológicos empregando a análise de conglomerados. Rev Esc Enferm U P 2013; 47(2):421-425., who found an association between satisfaction with geriatric care and female gender in Mexico (OR = 2.86). In other regions, the variable gender was not significant in the models, corroborating several studies¹³13. Bastos GAN, Fasolo LR, Bastos GAN, Fasolo LR. Factors that influence outpatient service user satisfaction in a low-income population: a population-based study. Rev Bras Epidemiol 2013; 16(1):114-124.^,1414. Castro HCO, Machado LZ, Walter MIMT, Ranincheski SM, Schmidt BV, Marinho DNC, Campos TMA. A Satisfação dos Usuários com o Sistema Único de Saúde (SUS). Soc Em Debate 2012; 14(2):113-134..

Age positively influenced user satisfaction in some regions in the country (Northeast, Southeast, Midwest). For each 10-year increase in age, there was an 11% increase in the likelihood of achieving USat-PC. Confirming this result, other studies have observed a statistically significant association between USat-PC and age¹⁵15. Arain M, Nicholl J, Campbell M. Patients’ experience and satisfaction with GP led walk-in centres in the UK; a cross sectional study. BMC Health Serv Res 2013; 13(1):142.

16. Assefa F, Mosse A, H/Michael Y. Assessment of Clients’ Satisfaction with Health Service Deliveries at Jimma University Specialized Hospital. Ethiop J Health Sci 2011; 21(2):101-110.

17. Drakopoulou M, Roka V, Apostolara P, Bucaj A, Skafidakis D, Kalokerinou A. Correlates of Health Services Users’ Satisfaction Provided by the First Urban Type Health Center in Greece. Balk Mil Med Rev 2012; 15(1):2-14.

18. Nguyen Thi PL, Briançon S, Empereur F, Guillemin F. Factors determining inpatient satisfaction with care. Soc Sci Med 2002; 54(4):493-504.^-1919. Santiago RF, Mendes ACG, Miranda GMD, Duarte PO, Furtado BMASM, Souza WV. Quality of care in the family healthcare units in the city of Recife: user perception. Cien Saude Colet 2013; 18(1):35-44.. However, neither Kamhawi et al.²⁰20. Kamhawi S, Underwood C, Murad H, Jabre B. Client-centered counseling improves client satisfaction with family planning visits: evidence from Irbid, Jordan. Glob Health Sci Pract 2013; 1(2):180-192. in Jordan nor Gouveia et al.²¹21. Gouveia GC, Souza WV, Luna CF, Souza-Júnior PRB, Szwarcwald CL. User satisfaction in the Brazilian health system: associated factors and regional differences. Rev Bras Epidemiol 2009; 12(3):281-296. in Pernambuco (Brazil) observed this association, which is in agreement with the models for the South and North regions in this study.

Moreover, in this study, the distance from the user’s home to the health units was an important factor to achieve USat-PC in the Northeast, Southeast, and South. This result corroborates the study by Perez et al.²²22. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JA, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413. in Vespasiano in the state of Minas Gerais (Brazil), who observed that difficulty in accessing the Family Health Strategy (FES) services decreased the likelihood of achieving user satisfaction with the services by 80%. In the study by Santos et al.²³23. Santos SMS, Oliveira VAC, Oliveira RAC, Guimarães EAA. Estratégia saúde da família: qualidade da assistência sob a perspectiva da satisfação do usuário. Rev Min Enferm 2010; 14(4):499-508. in Santo Antônio do Monte in the state of Minas Gerais, the users indicated the following as reasons for their satisfaction: good location of the FES, short distance from home to the family health unit (FHU), short period of time spent travelling to the FHU, and the possibility to walk to the FHU. In Pernambuco, Albuquerque et al.²⁴24. Albuquerque MSV, Farias SF, Mendes MFM, Martelli PJL, Lyra TM. Accessibility to health services: an analysis of the Primary Care in the state of Pernambuco. Saúde em Debate 2014; 38(spe):182-194. considered that the obstacles related to distance were associated with secondary care level because the FES must be located close to the users’ homes.

With regard to signaling of different areas in the FHU in order for the user to feel comfortable with the environment, this aspect was important only in the Southeast; when the signs identifying different areas inside the unit did not facilitate the dynamics within the primary health unit (PHU), the likelihood of achieving USat-PC decreased 1.4-fold. Fixed work elements, such as signs, leaflets, regulations, routines, and instructions, must be taken into account because they are needed in the structuring of the care relationship. In addition, they must be easily visible, indicating the location of the different rooms and departments²⁵25. Matumoto S, Mishima SM, Pinto IC. Collective health: a challenge for nursing. Cad Saude Publica fevereiro de 2001; 17(1):233-241..

With regard to the hours of operation, the likelihood of achieving USat-PC decreased 1.4-fold in the Northeast if the unit did not operate five days a week. Furthermore, if the hours of operation did not meet the users’ needs, USat-PC decreased in all regions, mainly in the South (2.5 times) and the North (2.4 times). Santos et al.²³23. Santos SMS, Oliveira VAC, Oliveira RAC, Guimarães EAA. Estratégia saúde da família: qualidade da assistência sob a perspectiva da satisfação do usuário. Rev Min Enferm 2010; 14(4):499-508. also observed that hours of operation is one of the organizational aspects that leads to dissatisfaction, impairing access to the service. These results may be explained by the fact that most users work during business hours and need extended hours of operation to facilitate their access to PC services, which is the gateway to the system. However, several studies with PMAQ data in Pernambuco and in Brazil revealed that most users considered the hours of operation to be satisfactory²⁴24. Albuquerque MSV, Farias SF, Mendes MFM, Martelli PJL, Lyra TM. Accessibility to health services: an analysis of the Primary Care in the state of Pernambuco. Saúde em Debate 2014; 38(spe):182-194.^,2626. Fausto MCR, Giovanella L, Mendonça MHM, Seidl H, Gagno J. The position of the Family Health Strategy in the health care system under the perspective of the PMAQ-AB participating teams and users. Saúde em Debate 2014; 38(spe):13-33..

In the North, being unable to make an appointment every day of the week influenced USat-PC. In the South, it was important that appointments were not made at defined times or periods of the day. In the Southeast, not having to make appointments only at specific times increased the likelihood of achieving USat-PC. These results corroborate those by Bastos et al.¹³13. Bastos GAN, Fasolo LR, Bastos GAN, Fasolo LR. Factors that influence outpatient service user satisfaction in a low-income population: a population-based study. Rev Bras Epidemiol 2013; 16(1):114-124. in Porto Alegre in the state of Rio Grande do Sul (Brazil), who observed that the ease of making an appointment increased the likelihood of being satisfied with the last medical appointment by 40%. Moreover, scheduling appointments in advance organizes and humanizes care, effectively facilitates access, and enables prioritization of risk cases, altering the exclusive model of emergency care²⁷27. Ramos DD, Lima MADS. Health care access and receptivity to users in a unit in Porto Alegre, Rio Grande do Sul, Brazil. Cad Saude Publica 2003; 19(1):27-34..

In the Northeast and Southeast, it was observed that the likelihood of achieving USat-PC decreased when the user was able to make an appointment but not for the same day. Moreover, when the user could not be seen at the health unit without an appointment, the likelihood of achieving USat-PC decreased in all regions. Never needing to go to the unit without an appointment, compared to those who were able to be seen most of the time, also influenced USat-PC in all regions, except in the South. It is possible that this aspect can be solved with a welcoming approach, valuing complaints and searching for possible solutions for the user’s problem, even if they cannot receive care. To be welcoming does not mean that the users’ demands are fully resolved but instead that attention is given to the professional-user relationship, which involves listening, valuing complaints, and identifying needs²⁸28. Medeiros FA, Araújo-Souza GC, Albuquerque-Barbosa AA, Clara-Costa IC. Basic health unit embracement: focusing on user satisfaction. Rev Salud Pública 2010; 12(3):402-413.. A welcoming reception takes place with the involvement of all staff at the PHU in order to combine different approaches and explanations about the diseases, demands, and needs²⁴24. Albuquerque MSV, Farias SF, Mendes MFM, Martelli PJL, Lyra TM. Accessibility to health services: an analysis of the Primary Care in the state of Pernambuco. Saúde em Debate 2014; 38(spe):182-194.. Notably, when Alves et al.²⁹29. Alves MGM, Casotti E, Oliveira LGD, Machado MTC, Almeida PF, Corvino MPF, Marin J, Flauzino RF, Montenegro LAA. Factors affecting access to the Family Health Strategy teams in Brazil. Saúde em Debate 2014; 38(spe):34-51. analyzed access to HFS with PMAQ-AB data, they observed that the Southeast region showed greater access potential among the regions through the influence of increased welcoming reception and resource availability at the contracted PHU. By contrast, the North region had a negative influence on access.

This study also showed that solving the users’ needs/problems at the health unit itself was associated with USat-PC in all regions. The user, when he/she seeks the health unit, expects that his/her problem will be solved individually or collectively, that the set of health actions will be beneficial, and that the actions will be effective and satisfactory²⁸28. Medeiros FA, Araújo-Souza GC, Albuquerque-Barbosa AA, Clara-Costa IC. Basic health unit embracement: focusing on user satisfaction. Rev Salud Pública 2010; 12(3):402-413.. This result is in agreement with a study by Bernhart et al.³⁰30. Bernhart MH, Wiadnyana IGP, Wihardjo H, Pohan I. Patient satisfaction in developing countries. Soc Sci Med 1999; 48(8):989-996. conducted in Indonesia, which found that the main determinant of satisfaction with the services is the user feeling that his/her problem was solved. From this perspective, the Ministry of Health claims that the FHS is a place for screening and referral as well as a place with capacity to solve approximately 80% of the health problems of the population³¹31. Brasil. Portaria No 2.027, de 25 de agosto de 2011. Dispõe sobre a carga horária dos profissionais médicos que compõem as Equipes de Saúde da Família (ESF) e na parte que dispõe sobre a suspensão do Piso de Atenção Básica (PAB Variável). Diário Oficial da União 2011; 26 ago.. However, it requires structural resources and compatible equipment for enabling health providers to make this commitment³²32. Figueiredo EN. Estratégia Saúde da Família e Núcleo de Apoio à Saúde da Família: diretrizes e fundamentos. Módulo Político Gestor. 2010. [acessado 2013 nov 23]. Disponível em: http://www.unasus.unifesp.br/biblioteca_virtual/esf/1/modulo_politico_gestor/Unidade_5.pdf
http://www.unasus.unifesp.br/biblioteca_... . It is important to highlight that the high prevalence of resolved demands also contributes to building confidence and increasing the relationship between users and services.

With regard to privacy, users from all regions mentioned that the lack of an office room that provided privacy decreased the likelihood of achieving USat-PC, confirming the work of Villadsen et al.³³33. Villadsen SF, Tersbol BP, Negussie D, GebreMariam A, Tilahun A, Friis H, Rasch V. Antenatal Care Strengthening in Jimma, Ethiopia: A Mixed-Method Needs Assessment. J Environ Public Health 2014; 2014:945164. conducted in Ethiopia. This variable had the greatest influence in the North (2.1-fold decrease in USat-PC). It is necessary to emphasize that the space for treatment must preserve privacy, promoting communication without interruptions, in addition to being the most comfortable place possible³⁴34. Lloyd M, Bor R. Communication skills for medicine. Amsterdam: Elsevier Health Sciences; 2009.. Some authors have considered that the lack of adequate physical space at the PHU has led to lack of privacy during conversations with the users³⁵35. Freire LAM, Storino LP, Horta NC, Magalhães RP, Lima T. O acolhimento sob a ótica de profissionais da equipe de saúde da família. Rev Min Enferm 2008; 12(2):271-277.^,3636. Guedes CR, Pitombo LB, Barros MEB. Formation processes within the National Humanization Politics: the experience of a course for managers and workers in primary health care. Physis 2009; 19(4):1087-1109..

In this study, in all regions except the Midwest, the likelihood of achieving satisfaction decreased more than 2-fold when the user did not feel that his/her cultural customs, practices, or religion were respected by the health providers, or were only respected sometimes, compared with users who always felt respected by the providers. Data from Southeast users stood out in this regard because feeling disrespected resulted in a 2.7-fold decrease in the likelihood of achieving USat-PC. This corroborates the work of Mendoza Aldana et al.³⁷37. Mendoza Aldana J, Piechulek H, al-Sabir A. Client satisfaction and quality of health care in rural Bangladesh. Bull World Health Organ 2001; 79(6):512-517. in Bangladesh, who observed that respect from providers towards users was the main factor influencing user satisfaction, followed by satisfaction with the providers, respect for privacy, waiting time, and duration of the appointment.

In the Midwest and Southeast, there was an association between USat-PC and providers asking questions about other needs besides those related to the reason for the appointment. These results show a need for a more open communication between health providers and patients, allowing for shared health production, which enables inclusion of the individual in the therapeutic process and promotion of self-care³⁸38. Clementino FS, Gomes LB, Vianna RPT, Marcolino EC, Araújo JP, Chaves TV. Acolhimento na Atenção Básica: análise a partir da avaliação externa do programa de melhoria do acesso e da qualidade (PMAQ-AB). Rev Saúde Ciênc Online 2015; 4(1):62-80..

Regarding the health provider/user relationship, the model developed for the Northeast and Southeast shows that providing solutions that are adequate to the users’ reality influences USat-PC. It is important to highlight that knowing the users’ reality, considering the cultural diversity of Brazil, is important for FHS professionals to establish the provider-user relationship. This diversity requires that health professionals be capable of learning new values and developing other health-disease perceptions³⁹39. Caprara A, Rodrigues J. Asymmetric doctor-patient relationship: rethinking the therapeutic bond. Cien Saude Colet 2004; 9(1):139-146., removing all their preconceptions, prejudices, and traditional knowledge, in order to recognize the limits of each family and provide treatment according to the reality of the user of the local health services, with the aim of ensuring treatment adherence⁴⁰40. Ilha S, Dias MV, Backes DS, Backes MTS. Professional-patient bond in a team of Family Health Strategy. Ciênc Cuid E Saúde. 29 de maio de 2014; 13(3):556-62..

In the Northeast, the likelihood of achieving USat-PC decreased when the doctor only sometimes allowed or did not allow, enough time for the user to talk about his/ her concerns or problems during the appointment. Other studies have confirmed the existence of a significant association between appointment duration and user satisfaction¹³13. Bastos GAN, Fasolo LR, Bastos GAN, Fasolo LR. Factors that influence outpatient service user satisfaction in a low-income population: a population-based study. Rev Bras Epidemiol 2013; 16(1):114-124.^,3737. Mendoza Aldana J, Piechulek H, al-Sabir A. Client satisfaction and quality of health care in rural Bangladesh. Bull World Health Organ 2001; 79(6):512-517.. Caprara and Rodrigues³⁹39. Caprara A, Rodrigues J. Asymmetric doctor-patient relationship: rethinking the therapeutic bond. Cien Saude Colet 2004; 9(1):139-146. identified an association between a longer appointment and improved quality of care because it enables improved medical history taking, a better explanation of the problem and of the diagnostic and therapeutic procedures, as well as the verification (by the doctor) of the patient’s understanding and participation in the appointment.

Nevertheless, it is also necessary that the user feel comfortable to express himself/herself; when the user feels welcome by the team and finds openness to report his/her needs, there is a strengthening of the relationship and joint development of the therapeutic plan in accordance with the reality of the individuals, therefore increasing the chances of adherence to treatment. This aspect was important in all regions of Brazil because there was an association between the user feeling comfortable enough to talk with the team about his/her concerns, social problems, family problems, or other issues and USat-PC, mainly in the South and North regions.

According to the study by Perez et al.²²22. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JA, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413., those citing a good provider-patient relationship as beneficial showed a 4.8-fold higher likelihood of achieving satisfaction versus those who did not cite it. Moreover, health production shared between providers and users is necessary for achieving a welcoming reception, an important factor for strengthening the role of PC in healthcare system³⁸38. Clementino FS, Gomes LB, Vianna RPT, Marcolino EC, Araújo JP, Chaves TV. Acolhimento na Atenção Básica: análise a partir da avaliação externa do programa de melhoria do acesso e da qualidade (PMAQ-AB). Rev Saúde Ciênc Online 2015; 4(1):62-80..

It was also observed that the practice of asking about relatives of the users influenced user satisfaction in all regions, mainly in the North, South, and Northeast. This result shows the importance that the user attributes to the relationship between the providers and the family; this represents an active segment in the healthcare process, with its own representations and strategies that should not be disregarded by the providers. Moreover, the literature shows that medical knowledge of the patient, interpersonal communication, and valuing treatment continuity and care coordination affect the user’s assessment of health services⁴¹41. Cunha EM, Giovanella L. Longitudinalidade/continuidade do cuidado: identificando dimensões e variáveis para a avaliação da Atenção Primária no contexto do sistema público de saúde brasileiro. Cien Saude Colet 2011; 16(1):1029-1042.^,4242. Nutting PA, Goodwin MA, Flocke SA, Zyzanski SJ, Stange KC. Continuity of primary care: to whom does it matter and when? Ann Fam Med 2003; 1(3):149-155.. This humanization is as important or more important for user satisfaction than the technical skills of the provider or the final result of the treatment or procedure, such as relief of unpleasant or painful symptoms and cure⁴³43. Passero LG. Insatisfação do usuário da atenção básica com o Sus: análise multinível da pesquisa da ouvidoria [tese]. Porto Alegre: UFRGS; 2013..

Cunha and Giovanella⁴¹41. Cunha EM, Giovanella L. Longitudinalidade/continuidade do cuidado: identificando dimensões e variáveis para a avaliação da Atenção Primária no contexto do sistema público de saúde brasileiro. Cien Saude Colet 2011; 16(1):1029-1042. consider that one of the essential aspects for the longitudinality and continuity of care is the information chain. In this context, this study found that providers recalling previous appointments influenced user satisfaction in all regions, except in the South. Moreover, to achieve USat-PC, it is important that the providers seek the user to learn what happened and resume care whenever treatment is interrupted or the user misses an appointment. This shows how much patients value care continuity, corroborating many authors who claim that care continuity is an essential aspect of primary care that must be ensured⁵5. Brandão, 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.^,4141. Cunha EM, Giovanella L. Longitudinalidade/continuidade do cuidado: identificando dimensões e variáveis para a avaliação da Atenção Primária no contexto do sistema público de saúde brasileiro. Cien Saude Colet 2011; 16(1):1029-1042.^,4444. Veras RP, Caldas CP, Motta LB, Lima KC, Siqueira RC, Rodrigues RTSV, Santos LM, Guerra AC. Integration and continuity of Care in health care network models for frail older adults. Rev Saude Publica 2014; 48(2):357-365..

Importantly, another part of continued care is the provider answering questions from the user after the appointments using a welcoming approach, valuing complaints, and searching for potential solutions for the problem²⁸28. Medeiros FA, Araújo-Souza GC, Albuquerque-Barbosa AA, Clara-Costa IC. Basic health unit embracement: focusing on user satisfaction. Rev Salud Pública 2010; 12(3):402-413.. In this study, answering questions from users after the appointments influenced USat-PC in the Northeast. These data show the importance assigned by users to having questions answered by health providers who assisted them, and the relationship established is thus essential.

In this aspect, home visits created an opportunity for dialogue between health providers and the individual under care as well as his/her family, favoring care production through a relationship of confidence and shared commitments⁴⁰40. Ilha S, Dias MV, Backes DS, Backes MTS. Professional-patient bond in a team of Family Health Strategy. Ciênc Cuid E Saúde. 29 de maio de 2014; 13(3):556-62.. In the Southeast and Northeast, the home visits conducted by the health community agents influenced the USat-PC. Home visits by the health providers were an influencing factor in the Northeast and South regions. In agreement with this study, Perez et al.²²22. Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JA, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saude Publica 2013; 47(2):403-413. and Mues et al.⁴⁵45. Mues KE, Resende JC, Santos OC, Perez LG, Ferreira JA, Leon JS. User satisfaction with the Family Health Program in Vespasiano, Minas Gerais, Brazil. Rev Panam Salud Pública 2012; 31(6):454-460. also observed that the users in the state of Minas Gerais considered home visits to be a satisfaction-influencing factor. Albuquerque and Bosi⁴⁶46. Albuquerque ABB, Bosi MLM. Home visits as a component of the Family Health Program: user’s perceptions in Fortaleza, Ceará State, Brazil. Cad Saude Publica 2009; 25(5):1103-1112., in Fortaleza in the state of Ceará (Brazil), noted that from the user’s point of view, home visits from the health providers were a way to ensure rights, such as comprehensiveness, humanization, and care centered in the user and his/her family.

With regard to access to secondary services, only the Southeast region associated the ability make an appointment with other professionals or specialists with USat-PC. Several other studies¹⁹19. Santiago RF, Mendes ACG, Miranda GMD, Duarte PO, Furtado BMASM, Souza WV. Quality of care in the family healthcare units in the city of Recife: user perception. Cien Saude Colet 2013; 18(1):35-44.^,4747. Conill EM, Giovanella L, Almeida PF. Waiting lists in public systems: from expanding supply to timely access? Reflections on Spain’s National Health System. Cien Saude Colet 2011; 16(6):2783-2794.

48. Cunha ABO, Vieira-da-Silva LM. Acessibilidade aos serviços de saúde em um município do Estado da Bahia, Brasil, em gestão plena do sistema Health services accessibility in a city of Northeast Brazil. Cad Saude Publica 2010; 26(4):725-737.

49. Marin MJS, Marchioli M, Moracvick MYAD. Fortalezas e fragilidades do atendimento nas unidades básicas de saúde tradicionais e da estratégia de saúde da família pela ótica dos usuários. Texto Contexto Enferm 2013; 22(3):780-788.^-5050. Valius L, Rastenytė D, Malinauskienė V, Krančiukaitė-Butylkinienė D. Evaluation of the quality of services in primary health care institutions. Med Kaunas 2011; 47(1):57-62. have also reported difficulty in accessing specialized services as the most frequent complaint by users, which is in agreement with this study. These results can be attributed to the existence of flow problems in the services network due to the lack of planning and organization, which results in relatively high average waiting times for making an appointment for secondary services and, consequently, leads to user dissatisfaction⁵¹51. Protasio APL, Silva PB, Lima EC, Gomes LB, Machado LS, Valença AMG, Gomes LB. Evaluation of the reference and counter-reference system based on the responses of the Primary Care professionals in the first External Evaluation cycle of PMAQ-AB in the state of Paraíba. Saúde Debate 2014; 38(spe):209-220..

It was also observed that difficulty in obtaining test results at the health unit decreased the likelihood of achieving USat-PC in the Northeast and Southeast regions. In agreement with these results, Santiago et al.¹⁹19. Santiago RF, Mendes ACG, Miranda GMD, Duarte PO, Furtado BMASM, Souza WV. Quality of care in the family healthcare units in the city of Recife: user perception. Cien Saude Colet 2013; 18(1):35-44. identified great dissatisfaction among FHS users with waiting times to be seen and to receive test results. These findings must be taken into consideration by the managers in these regions because the identification of a non-effective health network points to the need to review the organization strategies of the services. Moreover, it is important that the secondary healthcare level ensures access to appointments and specialized tests that are essential for the confirmation of diagnoses obtained in PHC⁵²52. Serra CG, Rodrigues PHA. Avaliação da referência e contrarreferência no Programa Saúde da Família na Região Metropolitana do Rio de Janeiro (RJ, Brasil). Cien Saude Colet 2010; 15(3):3579-3586..

Another relevant aspect to achieve USat-PC in all regions, except the North, was to be able to make a complaint or suggestion at the health unit. Therefore, the ability to make a complaint is essential for the user because this is an essential factor in the process of evaluation of the services provided by the units¹⁹19. Santiago RF, Mendes ACG, Miranda GMD, Duarte PO, Furtado BMASM, Souza WV. Quality of care in the family healthcare units in the city of Recife: user perception. Cien Saude Colet 2013; 18(1):35-44..

Using decision models, this study provides scientific support for health managers in planning and decision making for improving service quality from the perspective of user satisfaction. Moreover, a regional-level analysis may be an important tool to create policies considering the specificities of the health systems of each region.

Although the results of the models differed by region, the data suggest that it is necessary to improve access quality, effectiveness, the organizational aspects of the work process, and the strengthening of the relationship between users and health professionals. Most of these improvements are feasible for the managers because they do not require large financial investment but instead involve a reorganization of work processes and flow.

The study limitations include the use of secondary data and the fact that the results presented in this study came from a first application of the 1^st cycle of external evaluation from PMAQ-AB, where team adherence was scarce and voluntary. However, because PMAQ-AB is a continuous and progressive process for the improvement of primary care access and quality, these data from the 1^st cycle may form the basis for the analysis of potential changes in the next evaluation cycle.

Conclusion

Using data obtained through the application of decision models described and developed for each region, it was possible to identify the main factors associated with user satisfaction with Primary Care services by region in Brazil. The user’s ability to solve his/her problems at the health unit itself and feeling respected by the health providers were the most important factors for all the regions in regard to user satisfaction. However, there were several noteworthy regional factors, namely:

• Northeast: the hours of operation and being able to make a complaint or suggestion at the health unit;

• North: the providers asking about relatives, hours of operation, being seen without an appointment, and the privacy of the office room;

• Midwest: interest of the providers in other health needs, being seen without an appointment, and being able to make a complaint or suggestion at the health unit;

• South: the hours of operation, being seen without an appointment, and being able to make a complaint or suggestion at the health unit;

• Southeast: ease of asking questions after the appointment and being asked by the providers about issues not related to the reason for the appointment.

Finally, the analysis conducted in this study indicates that user satisfaction with Primary Care is related to different dimensions of health care, but it is more associated with humanized care than with the structural and operational conditions of the health units. These findings may benefit health management in the planning of intervention strategies promoting better care provision and greater user satisfaction at this level of care.

References

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