Performance of primary health care according to PCATool instrument: a systematic review

Prates, Mariana Louzada; Machado, Juliana Costa; Silva, Luciana Saraiva da; Avelar, Patrícia Silva; Prates, Luciana Louzada; Mendonça, Erica Toledo de; Costa, Glauce Dias da; Cotta, Rosângela Minardi Mitre

doi:10.1590/1413-81232017226.14282016

Abstract

This study aims to analyze studies that evaluated the performance of Primary Health Care (PHC) services by using the Primary Care Assessment Tool (PCATool) under a worldwide user perspective. This is a systematic review that implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model, from the following databases: Lilacs, Medline, SciELO, PubMed and the Coordination for the Improvement of Higher Education Personnel (CAPES) Journals Website, using descriptors Primary Care Assessment Tool and PCATool. Considering inclusion and exclusion criteria, we analyzed 22 research papers published from 2007 to 2015. The best-evaluated attributes were cultural competence, first contact use and longitudinality. On the other hand, the worst evaluated were first contact accessibility, family orientation, community orientation and comprehensiveness. Most of the health services evaluated were from Brazil, applied to “traditional” primary care clinic (UBS) and the Health Family Strategy (FHS). Services evaluated should strengthen structure and process components to achieve a better performance in PHC.

Primary care assessment tool; Primary Health Care; PCATool; Systematic review; Health evaluation

Introduction

In 1978, with the Alma-Ata International Conference¹1. Organização Pan-Americana da Saúde. Declaração de Alma-Ata. In: ConferênciaInternacional Sobre Cuidados Primários de Saúde;1978, Alma Ata., Primary Health Care (PHC) gains momentum as a strategy to be implemented in the operationalization of health services (HS) under ongoing health care that provides prevention, promotion, treatment and rehabilitation at affordable costs¹1. Organização Pan-Americana da Saúde. Declaração de Alma-Ata. In: ConferênciaInternacional Sobre Cuidados Primários de Saúde;1978, Alma Ata.

2. Organização Mundial da Saúde (OMS). Relatório mundial de saúde 2008: Atenção Primária em Saúde. Agora mais do que nunca. Genebra: OMS; 2008.

3. Fracolli LA, Gomes MFP, Nabão FRZ, Santos MS, Cappellini VK, Almeida ACC. Instrumentos de avaliação da Atenção Primária à saúde: revisão de literatura e metassíntese. Cien Saude Colet 2014; 19(12):4851-4860.-⁴4. Mendes EV. Uma agenda para a saúde. São Paulo: Hucitec; 1996..

Based on the assumptions defined in Alma-Ata¹1. Organização Pan-Americana da Saúde. Declaração de Alma-Ata. In: ConferênciaInternacional Sobre Cuidados Primários de Saúde;1978, Alma Ata., Starfield⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002. codified PHC into four essential attributes and three derivatives, which qualify services as PHC and increase their interaction power with users and communities. The essential attributes are first contact access, access and use of HS whenever necessary; longitudinality, understood as a professional-subject-of-care temporal relationship, leading to the establishment of a strong mutual trust; coordination, understood as the integration of all the care that the user receives and needs with the other HS; comprehensiveness, represented by actions of promotion, prevention, treatment and rehabilitation appropriate to the PHC context, recognizing the biopsychosocial character of the health-disease-illness process⁶6. Cotta RMM, Campos AOC, Mendonça EO, Costa GD, Machado JC, Silva LS, Siqueira RL, Leão RT, Reis RS. Políticas de saúde: desenhos, modelos e paradigmas. Viçosa: UFV, Abrasco; 2013.. Derivative attributes include family orientation, which is the knowledge of family factors that interfere in the health-disease-illness process by the health team, considering the family as the subject of care; community orientation, understood as the recognition of community health needs, guiding services for their benefit and, finally, cultural competence, which means adapting the HS to the cultural specificities of the community served⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002..

According to Fracolli et al.³3. Fracolli LA, Gomes MFP, Nabão FRZ, Santos MS, Cappellini VK, Almeida ACC. Instrumentos de avaliação da Atenção Primária à saúde: revisão de literatura e metassíntese. Cien Saude Colet 2014; 19(12):4851-4860. and Ibanez et al.⁷7. Ibañez N, Rocha JSY, Castro PC, Ribeiro MCSA, Forster AC, Novaes MHD, Viana ALd’A. Avaliação do desempenho da atenção básica no Estado de São Paulo. Cien Saude Colet 2006; 11(3):683-703., due to the lack of research to evaluate the performance of PHC, the Primary Care Assessment Tool (PCATool)⁸8. Shi L, Starfield B, Xu J. Validating the adult primary care assessment tool. J Fam Pract 2001; 50(2):161-175.,⁹9. Cassady CE, Starfield B, Hurtado MP, Berk R, Nanda JP, Friedenberg LA. Measuring consumer experiences with primary care. Pediatrics 2000; 105(4 Pt 2):998-1003. was based on Donabedian¹⁰10. Donabedian A. The quality of care: How can it be assessed? JAMA 1988; 260(12):1743-1748. theory on the evaluation quality of HS structure, process and results.

The publicly-owned instrument implemented by the World Health Organization (WHO) consists of a structured questionnaire that empirically measures the essential PHC attributes and derivatives through the evaluation of users⁸8. Shi L, Starfield B, Xu J. Validating the adult primary care assessment tool. J Fam Pract 2001; 50(2):161-175.,⁹9. Cassady CE, Starfield B, Hurtado MP, Berk R, Nanda JP, Friedenberg LA. Measuring consumer experiences with primary care. Pediatrics 2000; 105(4 Pt 2):998-1003., managers and health professionals¹¹11. Brasil. Ministério da Saúde (MS). Manual do Instrumento de Avaliação da Atenção Primária à Saúde. Brasilia: MS; 2008. (Primary Care Assessment Tool. PCATool-Brasil)., which has been adapted and validated in different countries, namely, Brazil¹¹11. Brasil. Ministério da Saúde (MS). Manual do Instrumento de Avaliação da Atenção Primária à Saúde. Brasilia: MS; 2008. (Primary Care Assessment Tool. PCATool-Brasil).,¹²12. Almeida C, Macinko J. Validação de uma metodologia de avaliação rápida das características organizacionais e do desempenho dos serviços de atenção básica do Sistema Único de Saúde (SUS) em nível local. Brasília: Organização Pan-Americana da Saúde (OPAS); 2006. (Série técnica desenvolvimento de sistemas e serviços de saúde)., South Korea¹³13. Lee JHO, Choi YJ, Sung NJ, Kim SY, Chung SH, Kim J, Jeon TH, Park K. Development of the Korean primary care assessment tool - measuring user experience: tests of data quality and measurement performance. Int J Qual Health Care 2009; 21(2):103-111. and Catalonia-Spain¹⁴14. Berra S, Rocha KB, Rodríguez-Sanz M, Pasarín I, Rajmil L, Borrell C, Starfield B. Properties of a short questionnaire for assessing primary care experiences for children in a population survey. BMC Public Health 2011; 11:285..

According to Donabedian¹⁰10. Donabedian A. The quality of care: How can it be assessed? JAMA 1988; 260(12):1743-1748., the quality component of the structure corresponds to the characteristics of the service; the process refers to actions by health professionals and populations; and results reflect the health status achieved. Regarding the PCATool⁸8. Shi L, Starfield B, Xu J. Validating the adult primary care assessment tool. J Fam Pract 2001; 50(2):161-175.,⁹9. Cassady CE, Starfield B, Hurtado MP, Berk R, Nanda JP, Friedenberg LA. Measuring consumer experiences with primary care. Pediatrics 2000; 105(4 Pt 2):998-1003. instrument, the attributes enable the evaluation of services’ structure and process. Longitudinality and coordination attributes involve both structure and process characteristics, while the structure aspect of services is strongly linked to the first contact access/sub-item accessibility and comprehensiveness/sub-item available services, whereas the process category is more involved in first contact access/sub-item use and comprehensiveness/sub-item services provided⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002..

To this end, this study aims to analyze the performance of PHC services worldwide, through studies available in the national and international literature in relation to the attributes originally proposed by Starfield⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002. in the PCATool instrument.

Methods

This is a systematic review built on the recommendations proposed in the Guide Preferred Reporting Items for Systematic Reviews and Meta-Analyzes - PRISMA¹⁵15. Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009; 339:b2535., based on studies that used the PCATool instrument to evaluate SH’s performance.

The PCATool appears as a questionnaire divided into sections by evaluated attribute, which are divided into essential attributes and their sub-items: first contact access, with sub-items accessibility and use; longitudinality; coordination, with sub-items integrated care and information system; and comprehensiveness, with sub-items available services and services provided.

The identification and selection of studies occurred from June to October 2015, independently by two trained researchers, through the guiding question: “Which studies evaluated the performance of PHC services worldwide using the PCATool instrument, from the user’s perspective?”

The main health databases consulted were the Latin American and Caribbean Health Sciences Literature (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE), CAPES Journals Website, Scientific Electronic Library Online (SciELO), PubMed (US National Library of Medicine National Institutes of Health). The Pan American Health Organization (PAHO) and WHO databases were also included. Descriptors used in the search were “primary care assessment tool” and “PCATool” and in their Spanish and Portuguese versions.

Secondary data qualitative papers were excluded from the study whose evaluated users were tuberculosis patients, since in order to cover this condition, the PCATool instrument underwent considerable adaptations, theses, manuals, editorials and studies that exclusively evaluated professionals and managers. The inclusion criteria were original studies that applied the PCATool to target users, which evidenced defined performance classification criteria, i.e. a cut-off point from which the evaluated service could be classified as adequate to PHC principles.

In total, 466 papers were identified, of which 311 were excluded due to duplication within and between the databases, leaving out 155 papers, which were analyzed. Then, applying the exclusion criteria, 83 studies were fully analyzed. In the end, applying the inclusion criteria, we analyzed 22 original papers that implemented the PCATool to users which included, at least, an essential or derivative attribute in the instrument and that defined a minimum value for the performance of the evaluated PHC services.

Regarding the services’ performance assessment, studies evaluated used different methods, and 19 studies used the Likert-type scale with an adjusted score from zero to ten. Of these, one paper¹⁶16. Araújo LUA, Gama ZAS, Nascimento FLA, Oliveira HFV, Azevedo WM, Almeida Júnior HJB. Avaliação da qualidade da atenção primária à saúde sob a perspectiva do idoso. Cien Saude Colet 2014; 19(8):3521-3532. considered satisfactory performance values above 7.0; 11 papers¹⁷17. Leão CDA, Caldeira AP. Avaliação da associação entre qualificação de médicos e enfermeiros em atenção primária em saúde e qualidade da atenção. Cien Saude Colet 2011; 16(11):4415-4423.

18. Araújo JP, Viera CS, Toso BRGO, Collet N, Nassar PO. Avaliação dos atributos de orientação familiar e comunitária na saúde da criança. Acta Paul Enferm 2014; 27(5):440-446.

19. Berra S, Rodríguez-Sanz M, Rajmil L, Pasarín MI, Borrell C. Experiences with primary care associated to health, socio-demographics and use of services in children and adolescentes. Cad Saude Publica 2014; 30(12):2607-2618.

20. Carneiro MSM, Melo DMS, Gomes JM, Pinto FJM, Silva MGC. Avaliação do atributo coordenação da Atenção Primária à Saúde: aplicação do PCATool a profissionais e usuários. Saúde Debate 2014; 38(n. esp.):279-295.

21. Carvalho VCHS, Rossato SL, Fuchs FD, Harzheim, Fuchs SC. Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study. BMC Public Health 2013, 13:605.

22. Mesquita-Filho M, Luz BSR, Araújo CS. A Atenção Primária à Saúde e seus atributos: a situação das crianças menores de dois anos segundo suas cuidadoras. Cien Saude Colet 2014; 19(7):2033-2046.

23. Leão CDA, Caldeira AP, Oliveira MMC. Atributos da atenção primária na assistência à saúde da criança: avaliação dos cuidadores. Rev. Bras. Saúde Matern. Infant 2011; 11(3):323-334.

24. Lima EFA, Sousa AI, Primo CC. Avaliação dos atributos da atenção primária na perspectiva das usuárias que vivenciam o cuidado. Rev. Latino-Am. Enfermagem 2015; 23(3):559-559.

25. Marques AS, Freitas DA, Leão CDA, Oliveira SKM, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saude Colet 2014; 19(2):365-371.

26. Oliveira VBCA, Veríssimo MLOR. Assistência à saúde da criança segundo suas famílias: comparação entre modelos de atenção primária. Rev Esc Enferm USP 2015; 49(1):30-36.

27. Reis RS, Coimbra LC, Silva AAM, Santos AM, Britto e Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MAS, 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.

28. Silva OCS, Fonseca ADG, Souza e Souza LP, Siqueira LG, Belasco AGS, Barbosa DA. Integralidade e Atenção Primária à Saúde: avaliação sob a ótica dos usuários. Cien Saude Colet 2014; 19(11):4407-4415.-²⁹29. Silva AS, Fracolli LA. Avaliação da Estratégia Saúde da Família: perspectiva dos usuários em Minas Gerais, Brasil. Saúde Debate 2014; 38(103):692-705., values equal to or above 6.6; one paper²⁷27. Reis RS, Coimbra LC, Silva AAM, Santos AM, Britto e Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MAS, 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., values above 4 and 6 papers¹⁹19. Berra S, Rodríguez-Sanz M, Rajmil L, Pasarín MI, Borrell C. Experiences with primary care associated to health, socio-demographics and use of services in children and adolescentes. Cad Saude Publica 2014; 30(12):2607-2618.,³⁰30. Furtado MCC, Braz JC, Pina JC, Mello DF, Lima RAG. A avaliação da atenção à saúde de crianças com menos de um ano de idade na Atenção Primária. Rev. Latino-Am. Enfermagem 2013, 21(2):554-561.

31. Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Room for improvement: Patients’ experiences of primary care in Quebec before major reforms. Can Fam Physician 2007; 53(6):1056-1057.

32. Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Practice features associated with patient reported accessibility, continuity, and coordination of primary health care. Ann Fam Med 2008, 6(2):116-123.

33. Jeon KY. Cross-cultural adaptation of the US consumer form of the short Primary Care Assessment Tool (PCAT):the Korean consumer form of the short PCAT (KC PCAT) and the Korean standard form of the short PCAT (KS PCAT). Qual Prim Care 2011;19(2):85-103.-³⁴34. Tourigny A, Aubin M, Haggerty J, Bonin L, Morin D, Reinharz D, Leduc Y, St-Pierre M, Houle N, Giguère A, Benounissa Z, Carmichael PH. Patients’ perceptions of the quality of care after primary care reform: Family medicine groups in Quebec. Can Fam Physician 2010; 56(7):273-282., values above 3.0. Another 3 papers adjusted the Likert scale from 0 to 100, and 2 studies³⁵35. Sung NJ, Suh SY, Lee DW, Ahn HP, Choi YJ, Lee JH. Patient’s assessment of primar y care of medical institutions in South Korea by structural type. Int J Qual Health Care 2010; 22(6):493-499.,³⁶36. Wang HHX, Wong SYS, Wong MCS, Wang JJ, Wei JL, Li DKT, Tang JL, Griffiths SM. Attributes of primary care in community health centres in China and implications for equitable care: a cross-sectional measurement of patients’ experiences. QJM 2014; 108(7):549-560. evaluated the performance of services according to the percentile achieved by the attribute and one study³⁷37. Pereira MJB, Abrahão-Curvo P, Fortuna CM, Coutinho SS, Queluz MC, Campos LVO, Fermino TZ, Santos CB. Avaliação das características organizacionais e de desempenho de uma unidade de Atenção Básica à Saúde. Rev Gaúcha Enferm 2011; 32(1):48-55. classified values of 50% or greater as satisfactory. In this study, as a form of standardization, attributes related to the performance of services were classified as adequate and inadequate, according to the papers evaluated.

Results

Chart 1 lists 22 studies published between 2007 and 2015, of which 15 (68.20%) are Brazilian¹⁶16. Araújo LUA, Gama ZAS, Nascimento FLA, Oliveira HFV, Azevedo WM, Almeida Júnior HJB. Avaliação da qualidade da atenção primária à saúde sob a perspectiva do idoso. Cien Saude Colet 2014; 19(8):3521-3532.

17. Leão CDA, Caldeira AP. Avaliação da associação entre qualificação de médicos e enfermeiros em atenção primária em saúde e qualidade da atenção. Cien Saude Colet 2011; 16(11):4415-4423.-¹⁸18. Araújo JP, Viera CS, Toso BRGO, Collet N, Nassar PO. Avaliação dos atributos de orientação familiar e comunitária na saúde da criança. Acta Paul Enferm 2014; 27(5):440-446.,²⁰20. Carneiro MSM, Melo DMS, Gomes JM, Pinto FJM, Silva MGC. Avaliação do atributo coordenação da Atenção Primária à Saúde: aplicação do PCATool a profissionais e usuários. Saúde Debate 2014; 38(n. esp.):279-295.

21. Carvalho VCHS, Rossato SL, Fuchs FD, Harzheim, Fuchs SC. Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study. BMC Public Health 2013, 13:605.

22. Mesquita-Filho M, Luz BSR, Araújo CS. A Atenção Primária à Saúde e seus atributos: a situação das crianças menores de dois anos segundo suas cuidadoras. Cien Saude Colet 2014; 19(7):2033-2046.

23. Leão CDA, Caldeira AP, Oliveira MMC. Atributos da atenção primária na assistência à saúde da criança: avaliação dos cuidadores. Rev. Bras. Saúde Matern. Infant 2011; 11(3):323-334.

24. Lima EFA, Sousa AI, Primo CC. Avaliação dos atributos da atenção primária na perspectiva das usuárias que vivenciam o cuidado. Rev. Latino-Am. Enfermagem 2015; 23(3):559-559.

25. Marques AS, Freitas DA, Leão CDA, Oliveira SKM, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saude Colet 2014; 19(2):365-371.

26. Oliveira VBCA, Veríssimo MLOR. Assistência à saúde da criança segundo suas famílias: comparação entre modelos de atenção primária. Rev Esc Enferm USP 2015; 49(1):30-36.

27. Reis RS, Coimbra LC, Silva AAM, Santos AM, Britto e Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MAS, 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.

28. Silva OCS, Fonseca ADG, Souza e Souza LP, Siqueira LG, Belasco AGS, Barbosa DA. Integralidade e Atenção Primária à Saúde: avaliação sob a ótica dos usuários. Cien Saude Colet 2014; 19(11):4407-4415.

29. Silva AS, Fracolli LA. Avaliação da Estratégia Saúde da Família: perspectiva dos usuários em Minas Gerais, Brasil. Saúde Debate 2014; 38(103):692-705.-³⁰30. Furtado MCC, Braz JC, Pina JC, Mello DF, Lima RAG. A avaliação da atenção à saúde de crianças com menos de um ano de idade na Atenção Primária. Rev. Latino-Am. Enfermagem 2013, 21(2):554-561.,³⁷37. Pereira MJB, Abrahão-Curvo P, Fortuna CM, Coutinho SS, Queluz MC, Campos LVO, Fermino TZ, Santos CB. Avaliação das características organizacionais e de desempenho de uma unidade de Atenção Básica à Saúde. Rev Gaúcha Enferm 2011; 32(1):48-55. , 3 (13.63%) are Canadian³¹31. Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Room for improvement: Patients’ experiences of primary care in Quebec before major reforms. Can Fam Physician 2007; 53(6):1056-1057.,³²32. Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Practice features associated with patient reported accessibility, continuity, and coordination of primary health care. Ann Fam Med 2008, 6(2):116-123.,³⁴34. Tourigny A, Aubin M, Haggerty J, Bonin L, Morin D, Reinharz D, Leduc Y, St-Pierre M, Houle N, Giguère A, Benounissa Z, Carmichael PH. Patients’ perceptions of the quality of care after primary care reform: Family medicine groups in Quebec. Can Fam Physician 2010; 56(7):273-282., 2 (9,09%) Korean³³33. Jeon KY. Cross-cultural adaptation of the US consumer form of the short Primary Care Assessment Tool (PCAT):the Korean consumer form of the short PCAT (KC PCAT) and the Korean standard form of the short PCAT (KS PCAT). Qual Prim Care 2011;19(2):85-103.,³⁵35. Sung NJ, Suh SY, Lee DW, Ahn HP, Choi YJ, Lee JH. Patient’s assessment of primar y care of medical institutions in South Korea by structural type. Int J Qual Health Care 2010; 22(6):493-499., one (4,54%) is Spanish¹⁹19. Berra S, Rodríguez-Sanz M, Rajmil L, Pasarín MI, Borrell C. Experiences with primary care associated to health, socio-demographics and use of services in children and adolescentes. Cad Saude Publica 2014; 30(12):2607-2618. and one (4,54%) Chinese³⁶36. Wang HHX, Wong SYS, Wong MCS, Wang JJ, Wei JL, Li DKT, Tang JL, Griffiths SM. Attributes of primary care in community health centres in China and implications for equitable care: a cross-sectional measurement of patients’ experiences. QJM 2014; 108(7):549-560.. Only one (4.54%) study was implemented in two stages, before the health reform in Quebec and then³⁴34. Tourigny A, Aubin M, Haggerty J, Bonin L, Morin D, Reinharz D, Leduc Y, St-Pierre M, Houle N, Giguère A, Benounissa Z, Carmichael PH. Patients’ perceptions of the quality of care after primary care reform: Family medicine groups in Quebec. Can Fam Physician 2010; 56(7):273-282., all the others were applied in a single stage. Four (18.2%) studies were applied in different PHC services to compare them to each other²¹21. Carvalho VCHS, Rossato SL, Fuchs FD, Harzheim, Fuchs SC. Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study. BMC Public Health 2013, 13:605.,²⁶26. Oliveira VBCA, Veríssimo MLOR. Assistência à saúde da criança segundo suas famílias: comparação entre modelos de atenção primária. Rev Esc Enferm USP 2015; 49(1):30-36.,²⁸28. Silva OCS, Fonseca ADG, Souza e Souza LP, Siqueira LG, Belasco AGS, Barbosa DA. Integralidade e Atenção Primária à Saúde: avaliação sob a ótica dos usuários. Cien Saude Colet 2014; 19(11):4407-4415.,³⁵35. Sung NJ, Suh SY, Lee DW, Ahn HP, Choi YJ, Lee JH. Patient’s assessment of primar y care of medical institutions in South Korea by structural type. Int J Qual Health Care 2010; 22(6):493-499..

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Chart 1
Matrix analyzing studies included in the systematic review on the use of the PCATool instrument in the evaluation of the performance of Primary Health Care services worldwide.

Regarding the studied population, 8 (36.36%) studies addressed only the child user population¹⁷17. Leão CDA, Caldeira AP. Avaliação da associação entre qualificação de médicos e enfermeiros em atenção primária em saúde e qualidade da atenção. Cien Saude Colet 2011; 16(11):4415-4423.

18. Araújo JP, Viera CS, Toso BRGO, Collet N, Nassar PO. Avaliação dos atributos de orientação familiar e comunitária na saúde da criança. Acta Paul Enferm 2014; 27(5):440-446.-¹⁹19. Berra S, Rodríguez-Sanz M, Rajmil L, Pasarín MI, Borrell C. Experiences with primary care associated to health, socio-demographics and use of services in children and adolescentes. Cad Saude Publica 2014; 30(12):2607-2618.,²²22. Mesquita-Filho M, Luz BSR, Araújo CS. A Atenção Primária à Saúde e seus atributos: a situação das crianças menores de dois anos segundo suas cuidadoras. Cien Saude Colet 2014; 19(7):2033-2046.,²³23. Leão CDA, Caldeira AP, Oliveira MMC. Atributos da atenção primária na assistência à saúde da criança: avaliação dos cuidadores. Rev. Bras. Saúde Matern. Infant 2011; 11(3):323-334.,²⁵25. Marques AS, Freitas DA, Leão CDA, Oliveira SKM, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saude Colet 2014; 19(2):365-371.,²⁶26. Oliveira VBCA, Veríssimo MLOR. Assistência à saúde da criança segundo suas famílias: comparação entre modelos de atenção primária. Rev Esc Enferm USP 2015; 49(1):30-36.,³⁰30. Furtado MCC, Braz JC, Pina JC, Mello DF, Lima RAG. A avaliação da atenção à saúde de crianças com menos de um ano de idade na Atenção Primária. Rev. Latino-Am. Enfermagem 2013, 21(2):554-561., through the application of PCATool to caregivers, 6 (27.27%) papers covered the adult population²⁰20. Carneiro MSM, Melo DMS, Gomes JM, Pinto FJM, Silva MGC. Avaliação do atributo coordenação da Atenção Primária à Saúde: aplicação do PCATool a profissionais e usuários. Saúde Debate 2014; 38(n. esp.):279-295.,²⁸28. Silva OCS, Fonseca ADG, Souza e Souza LP, Siqueira LG, Belasco AGS, Barbosa DA. Integralidade e Atenção Primária à Saúde: avaliação sob a ótica dos usuários. Cien Saude Colet 2014; 19(11):4407-4415.,²⁹29. Silva AS, Fracolli LA. Avaliação da Estratégia Saúde da Família: perspectiva dos usuários em Minas Gerais, Brasil. Saúde Debate 2014; 38(103):692-705.,³³33. Jeon KY. Cross-cultural adaptation of the US consumer form of the short Primary Care Assessment Tool (PCAT):the Korean consumer form of the short PCAT (KC PCAT) and the Korean standard form of the short PCAT (KS PCAT). Qual Prim Care 2011;19(2):85-103.,³⁴34. Tourigny A, Aubin M, Haggerty J, Bonin L, Morin D, Reinharz D, Leduc Y, St-Pierre M, Houle N, Giguère A, Benounissa Z, Carmichael PH. Patients’ perceptions of the quality of care after primary care reform: Family medicine groups in Quebec. Can Fam Physician 2010; 56(7):273-282.,³⁶36. Wang HHX, Wong SYS, Wong MCS, Wang JJ, Wei JL, Li DKT, Tang JL, Griffiths SM. Attributes of primary care in community health centres in China and implications for equitable care: a cross-sectional measurement of patients’ experiences. QJM 2014; 108(7):549-560., 5 (22,73%) evaluated services in the adult and child population²⁷27. Reis RS, Coimbra LC, Silva AAM, Santos AM, Britto e Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MAS, 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.,³¹31. Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Room for improvement: Patients’ experiences of primary care in Quebec before major reforms. Can Fam Physician 2007; 53(6):1056-1057.,³²32. Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Practice features associated with patient reported accessibility, continuity, and coordination of primary health care. Ann Fam Med 2008, 6(2):116-123.,³⁵35. Sung NJ, Suh SY, Lee DW, Ahn HP, Choi YJ, Lee JH. Patient’s assessment of primar y care of medical institutions in South Korea by structural type. Int J Qual Health Care 2010; 22(6):493-499.,³⁷37. Pereira MJB, Abrahão-Curvo P, Fortuna CM, Coutinho SS, Queluz MC, Campos LVO, Fermino TZ, Santos CB. Avaliação das características organizacionais e de desempenho de uma unidade de Atenção Básica à Saúde. Rev Gaúcha Enferm 2011; 32(1):48-55., 2 (9,1%) targeted the elderly population¹⁶16. Araújo LUA, Gama ZAS, Nascimento FLA, Oliveira HFV, Azevedo WM, Almeida Júnior HJB. Avaliação da qualidade da atenção primária à saúde sob a perspectiva do idoso. Cien Saude Colet 2014; 19(8):3521-3532.,²¹21. Carvalho VCHS, Rossato SL, Fuchs FD, Harzheim, Fuchs SC. Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study. BMC Public Health 2013, 13:605. and 1 (4.54%) focused on adult women as the research subject²⁴24. Lima EFA, Sousa AI, Primo CC. Avaliação dos atributos da atenção primária na perspectiva das usuárias que vivenciam o cuidado. Rev. Latino-Am. Enfermagem 2015; 23(3):559-559..

Regarding the type of services evaluated, eight studies exclusively evaluated Family Health Strategy (FHS)¹⁶16. Araújo LUA, Gama ZAS, Nascimento FLA, Oliveira HFV, Azevedo WM, Almeida Júnior HJB. Avaliação da qualidade da atenção primária à saúde sob a perspectiva do idoso. Cien Saude Colet 2014; 19(8):3521-3532.,¹⁷17. Leão CDA, Caldeira AP. Avaliação da associação entre qualificação de médicos e enfermeiros em atenção primária em saúde e qualidade da atenção. Cien Saude Colet 2011; 16(11):4415-4423.,²⁰20. Carneiro MSM, Melo DMS, Gomes JM, Pinto FJM, Silva MGC. Avaliação do atributo coordenação da Atenção Primária à Saúde: aplicação do PCATool a profissionais e usuários. Saúde Debate 2014; 38(n. esp.):279-295.,²⁴24. Lima EFA, Sousa AI, Primo CC. Avaliação dos atributos da atenção primária na perspectiva das usuárias que vivenciam o cuidado. Rev. Latino-Am. Enfermagem 2015; 23(3):559-559.,²⁵25. Marques AS, Freitas DA, Leão CDA, Oliveira SKM, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saude Colet 2014; 19(2):365-371.,²⁷27. Reis RS, Coimbra LC, Silva AAM, Santos AM, Britto e Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MAS, 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.,²⁹29. Silva AS, Fracolli LA. Avaliação da Estratégia Saúde da Família: perspectiva dos usuários em Minas Gerais, Brasil. Saúde Debate 2014; 38(103):692-705.,³⁰30. Furtado MCC, Braz JC, Pina JC, Mello DF, Lima RAG. A avaliação da atenção à saúde de crianças com menos de um ano de idade na Atenção Primária. Rev. Latino-Am. Enfermagem 2013, 21(2):554-561., one exclusively addressed “traditional” primary care clinic (UBS)³⁷37. Pereira MJB, Abrahão-Curvo P, Fortuna CM, Coutinho SS, Queluz MC, Campos LVO, Fermino TZ, Santos CB. Avaliação das características organizacionais e de desempenho de uma unidade de Atenção Básica à Saúde. Rev Gaúcha Enferm 2011; 32(1):48-55., two jointly evaluated FHS and UBS¹⁸18. Araújo JP, Viera CS, Toso BRGO, Collet N, Nassar PO. Avaliação dos atributos de orientação familiar e comunitária na saúde da criança. Acta Paul Enferm 2014; 27(5):440-446.,²²22. Mesquita-Filho M, Luz BSR, Araújo CS. A Atenção Primária à Saúde e seus atributos: a situação das crianças menores de dois anos segundo suas cuidadoras. Cien Saude Colet 2014; 19(7):2033-2046., two evaluated comparatively FHS versus UBS²¹21. Carvalho VCHS, Rossato SL, Fuchs FD, Harzheim, Fuchs SC. Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study. BMC Public Health 2013, 13:605.,²⁶26. Oliveira VBCA, Veríssimo MLOR. Assistência à saúde da criança segundo suas famílias: comparação entre modelos de atenção primária. Rev Esc Enferm USP 2015; 49(1):30-36., two evaluated FHS in comparison with other PHC services (Health Center and Community Health Worker Program - PACS)²³23. Leão CDA, Caldeira AP, Oliveira MMC. Atributos da atenção primária na assistência à saúde da criança: avaliação dos cuidadores. Rev. Bras. Saúde Matern. Infant 2011; 11(3):323-334.,²⁸28. Silva OCS, Fonseca ADG, Souza e Souza LP, Siqueira LG, Belasco AGS, Barbosa DA. Integralidade e Atenção Primária à Saúde: avaliação sob a ótica dos usuários. Cien Saude Colet 2014; 19(11):4407-4415.. In relation to Canadian studies, one evaluated only the services provided by the Family Medicine Group³⁴34. Tourigny A, Aubin M, Haggerty J, Bonin L, Morin D, Reinharz D, Leduc Y, St-Pierre M, Houle N, Giguère A, Benounissa Z, Carmichael PH. Patients’ perceptions of the quality of care after primary care reform: Family medicine groups in Quebec. Can Fam Physician 2010; 56(7):273-282. and two evaluated several PHC services: Group practice, Solo practice, Stand-alone walk-in clinic and Community Health Centers (CHCs)³¹31. Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Room for improvement: Patients’ experiences of primary care in Quebec before major reforms. Can Fam Physician 2007; 53(6):1056-1057.,³²32. Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Practice features associated with patient reported accessibility, continuity, and coordination of primary health care. Ann Fam Med 2008, 6(2):116-123.. With regard to Korean studies, one evaluated services from CHCs and private clinics offering general practice, general surgery, family medicine, gynecology and obstetrics services³³33. Jeon KY. Cross-cultural adaptation of the US consumer form of the short Primary Care Assessment Tool (PCAT):the Korean consumer form of the short PCAT (KC PCAT) and the Korean standard form of the short PCAT (KS PCAT). Qual Prim Care 2011;19(2):85-103. and the other evaluated PHC services in private clinics, school hospitals, public health centers and clinical cooperatives³⁵35. Sung NJ, Suh SY, Lee DW, Ahn HP, Choi YJ, Lee JH. Patient’s assessment of primar y care of medical institutions in South Korea by structural type. Int J Qual Health Care 2010; 22(6):493-499.. One Chinese study evaluated only CHCs³⁶36. Wang HHX, Wong SYS, Wong MCS, Wang JJ, Wei JL, Li DKT, Tang JL, Griffiths SM. Attributes of primary care in community health centres in China and implications for equitable care: a cross-sectional measurement of patients’ experiences. QJM 2014; 108(7):549-560. and the Spanish study assessed the Catalan population ascribed to Arees Integrals de Salut¹⁹19. Berra S, Rodríguez-Sanz M, Rajmil L, Pasarín MI, Borrell C. Experiences with primary care associated to health, socio-demographics and use of services in children and adolescentes. Cad Saude Publica 2014; 30(12):2607-2618.. Two studies jointly evaluated urban and rural population³¹31. Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Room for improvement: Patients’ experiences of primary care in Quebec before major reforms. Can Fam Physician 2007; 53(6):1056-1057.,³²32. Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Practice features associated with patient reported accessibility, continuity, and coordination of primary health care. Ann Fam Med 2008, 6(2):116-123., and one study exclusively evaluated the rural population²⁵25. Marques AS, Freitas DA, Leão CDA, Oliveira SKM, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saude Colet 2014; 19(2):365-371.(Table 2).

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Table 2
Performance of attributes according to studies that used the PCATool instrument.

The most evaluated attributes were longitudinality (24), first contact access/sub-item accessibility (19), community orientation (18) and family orientation (15). The least evaluated were cultural competence (2) and comprehensiveness (7).

Regarding the performance of services, derivative attribute cultural competence achieved the highest percentage of adequate performance (100%); first contact access attribute showed a low adequate performance (33.33%), as well as its sub-item accessibility (15.78%), while sub-item use showed a high adequate performance (71.42%); essential attribute longitudinality showed an adequate performance (62.50%); attribute coordination showed a lower performance than its sub-item integrated care (35.71% and 54.54%, respectively); finally, attribute comprehensiveness showed a lower performance than its sub-item services provided (50%) and higher performance than its sub-item available services (25%).

Discussion

The PCATool instrument is recent in the evaluation of PHC services, which justifies the publication period of the studies found (2007 and 2015). Its first version was shown in 2000 to evaluate services provided to the child user⁹9. Cassady CE, Starfield B, Hurtado MP, Berk R, Nanda JP, Friedenberg LA. Measuring consumer experiences with primary care. Pediatrics 2000; 105(4 Pt 2):998-1003., followed by the mirrors instruments for the evaluation of services by adult users⁸8. Shi L, Starfield B, Xu J. Validating the adult primary care assessment tool. J Fam Pract 2001; 50(2):161-175., by professionals and by health service providers¹¹11. Brasil. Ministério da Saúde (MS). Manual do Instrumento de Avaliação da Atenção Primária à Saúde. Brasilia: MS; 2008. (Primary Care Assessment Tool. PCATool-Brasil).. In Brazil, the original version of the instrument was adapted and validated for existing PHC services in the country by Almeida and Macinko¹²12. Almeida C, Macinko J. Validação de uma metodologia de avaliação rápida das características organizacionais e do desempenho dos serviços de atenção básica do Sistema Único de Saúde (SUS) em nível local. Brasília: Organização Pan-Americana da Saúde (OPAS); 2006. (Série técnica desenvolvimento de sistemas e serviços de saúde)., conducted in the city of Petrópolis, and by Harzheim et al., applied to PHC services in Porto Alegre, Rio Grande do Sul.

This study evidenced that most of the studies listed were performed in Brazil. This is due to the following reasons: a) in 2010, the Ministry of Health launched/introduced the PHC Evaluation Instrument Manual (PCATool-BR)¹¹11. Brasil. Ministério da Saúde (MS). Manual do Instrumento de Avaliação da Atenção Primária à Saúde. Brasilia: MS; 2008. (Primary Care Assessment Tool. PCATool-Brasil)., an adaptation of the original instrument made by Harzheim et al.³⁹ for the evaluation of PHC services from the perspective of adult and child users, health professionals and managers; b) in the manual, the Ministry of Health recommends that the instrument be used for the evaluation and monitoring of PHC quality as a routine of the Family Health teams, at various levels of management and for academic use; c) Brazil, as well as Canada, which presented the second largest representation in the sample, have PHC-oriented health systems. Thus, an instrument for evaluating the performance of health services is very useful in feeding and feeding back policies geared to the sector³3. Fracolli LA, Gomes MFP, Nabão FRZ, Santos MS, Cappellini VK, Almeida ACC. Instrumentos de avaliação da Atenção Primária à saúde: revisão de literatura e metassíntese. Cien Saude Colet 2014; 19(12):4851-4860..

In relation to the evaluation of attributes, cultural competence had the best performance, however, it appeared only twice in the papers analyzed, which does not allow us to infer that this attribute is strongly incorporated in PHC services. One of the factors that may explain the low frequency found may be the non-inclusion of this attribute in the PCATool-BR¹¹11. Brasil. Ministério da Saúde (MS). Manual do Instrumento de Avaliação da Atenção Primária à Saúde. Brasilia: MS; 2008. (Primary Care Assessment Tool. PCATool-Brasil). instrument, although it is included in the original version for the assessment of adults⁸8. Shi L, Starfield B, Xu J. Validating the adult primary care assessment tool. J Fam Pract 2001; 50(2):161-175. and its evaluation encouraged in later publications⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002..

The first contact access attribute and its sub-item accessibility had poor performance, both making up part of the evaluation of HS structure according to the Donabedian model⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002.,¹⁰10. Donabedian A. The quality of care: How can it be assessed? JAMA 1988; 260(12):1743-1748.. The low performance found may reflect geographical and organizational barriers to PHC services, such as reduced facility working hours, difficulties faced in scheduling appointments, and waiting time at the facility in order to be serviced. This low percentage impairs individual comprehensive health care, since, when faced with access barriers, health care tends to be postponed, hampering the impact of possible prevention actions, incurring future additional expenses⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002.. However, first contact access attribute’s sub-item use, corresponding to Donabedian¹⁰10. Donabedian A. The quality of care: How can it be assessed? JAMA 1988; 260(12):1743-1748. process category, had a high performance, suggesting that the user seeks health services whenever necessary¹¹11. Brasil. Ministério da Saúde (MS). Manual do Instrumento de Avaliação da Atenção Primária à Saúde. Brasilia: MS; 2008. (Primary Care Assessment Tool. PCATool-Brasil)., before visiting a service of greater specialization²2. Organização Mundial da Saúde (OMS). Relatório mundial de saúde 2008: Atenção Primária em Saúde. Agora mais do que nunca. Genebra: OMS; 2008.,⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002.. Thus, its high performance may indicate that, while there are structural hurdles in accessing the evaluated services, users recognize PHC services as their primary source of health care.

The longitudinality attribute, belonging to process category¹⁰10. Donabedian A. The quality of care: How can it be assessed? JAMA 1988; 260(12):1743-1748., had the third best evaluation in this review. Longitudinality is not an exclusive PHC attribute, but is essential to it. It develops insofar as users identify the location or provider of PHC services as their usual source of health care⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002.. In this respect, the definition of an ascribed population, a PHC⁴4. Mendes EV. Uma agenda para a saúde. São Paulo: Hucitec; 1996. characteristic, and the universal access to healthcare in Brazil through expanded FHS²⁴24. Lima EFA, Sousa AI, Primo CC. Avaliação dos atributos da atenção primária na perspectiva das usuárias que vivenciam o cuidado. Rev. Latino-Am. Enfermagem 2015; 23(3):559-559.can be variables that explain the good performance found.

The essential attribute coordination and its sub-items integrated care and information system had low adequate performance. To achieve a satisfactory coordination, PHC and subspecialty care must be closely linked through appropriate communication and a strengthened referral and counter-referral system. The low performance of the attribute may show flaws in this interrelationship, which evidences the need for greater integrated and articulated PHC in the HS⁴4. Mendes EV. Uma agenda para a saúde. São Paulo: Hucitec; 1996..

In the same perspective, the essential attribute comprehensiveness and its sub-item available services had inadequate performance, below sub-item services provided. The low performance found can show the critical difficulty of assessed HS in PHC in offering a complete range of individual health-related needs and in making available the resources needed to include them⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002.. Comprehensiveness requires different levels of complexity in health promotion, prevention, recovery and rehabilitation services⁶6. Cotta RMM, Campos AOC, Mendonça EO, Costa GD, Machado JC, Silva LS, Siqueira RL, Leão RT, Reis RS. Políticas de saúde: desenhos, modelos e paradigmas. Viçosa: UFV, Abrasco; 2013.,²²22. Mesquita-Filho M, Luz BSR, Araújo CS. A Atenção Primária à Saúde e seus atributos: a situação das crianças menores de dois anos segundo suas cuidadoras. Cien Saude Colet 2014; 19(7):2033-2046. from health counseling to small surgeries⁸8. Shi L, Starfield B, Xu J. Validating the adult primary care assessment tool. J Fam Pract 2001; 50(2):161-175.. The good performance of comprehensiveness demands constant investments in physical, material and human resources, which requires assigning to PHC its real significance and not to be characterized as a service of low complexity and requiring low investment⁴4. Mendes EV. Uma agenda para a saúde. São Paulo: Hucitec; 1996.. However, comprehensiveness sub-item services provided had a better performance, evidencing a greater capacity of the facility to provide services well rather than to supply a greater variety of these services.

With the exception of cultural competence, the attributes community orientation and family orientation evidenced the worst performance rates of the entire study. According to Starfield⁵5. Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002., a high level of achievement of the exclusive and fundamental qualities of PHC results in these three derivative attributes. The low performance achieved by family orientation and community orientation may be associated with a difficulty in PHC services evaluated to provide comprehensive care geared to family and community, being still far from the of Social Production of Health model⁶6. Cotta RMM, Campos AOC, Mendonça EO, Costa GD, Machado JC, Silva LS, Siqueira RL, Leão RT, Reis RS. Políticas de saúde: desenhos, modelos e paradigmas. Viçosa: UFV, Abrasco; 2013..

However, some limitations should be pointed out: the difficulty of finding studies that presented a defined and standardized classification of adequate performance of PHC services; studies that evaluated, in a limited way, only some attributes; the non-homogeneity of PHC services; the limitations of the PCATool itself, considering that all the attributes showed the same weight in the orientation of PHC services, as well as, the conception that the quality of PHC services are included in the attributes of the instrument.

Conclusion

This review shows an overview of the performance of PHC services worldwide based on studies that have used PCATool as an assessment tool. We found that some attributes of assessed PHC services – cultural competence, service use and longitudinality – were well evaluated. However, other attributes – first contact access, first contact access/accessibility, comprehensiveness, family orientation and community orientation – evidenced weaknesses. It was observed that most of the evaluated services are Brazilian and represented by UBS and FHS, whose performance still requires improvement. Therefore, considering the PHC model addressed in the PCATool, the need to strengthen the process and structure components for better PHC performance is highlighted.

Acknowledgment

This work was performed with the support of the Coordination for the Improvement of Higher Education Personnel (CAPES), a Brazilian Government body geared to the training of human resources.

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¹⁷
Leão CDA, Caldeira AP. Avaliação da associação entre qualificação de médicos e enfermeiros em atenção primária em saúde e qualidade da atenção. Cien Saude Colet 2011; 16(11):4415-4423.
¹⁸
Araújo JP, Viera CS, Toso BRGO, Collet N, Nassar PO. Avaliação dos atributos de orientação familiar e comunitária na saúde da criança. Acta Paul Enferm 2014; 27(5):440-446.
¹⁹
Berra S, Rodríguez-Sanz M, Rajmil L, Pasarín MI, Borrell C. Experiences with primary care associated to health, socio-demographics and use of services in children and adolescentes. Cad Saude Publica 2014; 30(12):2607-2618.
²⁰
Carneiro MSM, Melo DMS, Gomes JM, Pinto FJM, Silva MGC. Avaliação do atributo coordenação da Atenção Primária à Saúde: aplicação do PCATool a profissionais e usuários. Saúde Debate 2014; 38(n. esp.):279-295.
²¹
Carvalho VCHS, Rossato SL, Fuchs FD, Harzheim, Fuchs SC. Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study. BMC Public Health 2013, 13:605.
²²
Mesquita-Filho M, Luz BSR, Araújo CS. A Atenção Primária à Saúde e seus atributos: a situação das crianças menores de dois anos segundo suas cuidadoras. Cien Saude Colet 2014; 19(7):2033-2046.
²³
Leão CDA, Caldeira AP, Oliveira MMC. Atributos da atenção primária na assistência à saúde da criança: avaliação dos cuidadores. Rev. Bras. Saúde Matern. Infant 2011; 11(3):323-334.
²⁴
Lima EFA, Sousa AI, Primo CC. Avaliação dos atributos da atenção primária na perspectiva das usuárias que vivenciam o cuidado. Rev. Latino-Am. Enfermagem 2015; 23(3):559-559.
²⁵
Marques AS, Freitas DA, Leão CDA, Oliveira SKM, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saude Colet 2014; 19(2):365-371.
²⁶
Oliveira VBCA, Veríssimo MLOR. Assistência à saúde da criança segundo suas famílias: comparação entre modelos de atenção primária. Rev Esc Enferm USP 2015; 49(1):30-36.
²⁷
Reis RS, Coimbra LC, Silva AAM, Santos AM, Britto e Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MAS, 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.
²⁸
Silva OCS, Fonseca ADG, Souza e Souza LP, Siqueira LG, Belasco AGS, Barbosa DA. Integralidade e Atenção Primária à Saúde: avaliação sob a ótica dos usuários. Cien Saude Colet 2014; 19(11):4407-4415.
²⁹
Silva AS, Fracolli LA. Avaliação da Estratégia Saúde da Família: perspectiva dos usuários em Minas Gerais, Brasil. Saúde Debate 2014; 38(103):692-705.
³⁰
Furtado MCC, Braz JC, Pina JC, Mello DF, Lima RAG. A avaliação da atenção à saúde de crianças com menos de um ano de idade na Atenção Primária. Rev. Latino-Am. Enfermagem 2013, 21(2):554-561.
³¹
Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Room for improvement: Patients’ experiences of primary care in Quebec before major reforms. Can Fam Physician 2007; 53(6):1056-1057.
³²
Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Practice features associated with patient reported accessibility, continuity, and coordination of primary health care. Ann Fam Med 2008, 6(2):116-123.
³³
Jeon KY. Cross-cultural adaptation of the US consumer form of the short Primary Care Assessment Tool (PCAT):the Korean consumer form of the short PCAT (KC PCAT) and the Korean standard form of the short PCAT (KS PCAT). Qual Prim Care 2011;19(2):85-103.
³⁴
Tourigny A, Aubin M, Haggerty J, Bonin L, Morin D, Reinharz D, Leduc Y, St-Pierre M, Houle N, Giguère A, Benounissa Z, Carmichael PH. Patients’ perceptions of the quality of care after primary care reform: Family medicine groups in Quebec. Can Fam Physician 2010; 56(7):273-282.
³⁵
Sung NJ, Suh SY, Lee DW, Ahn HP, Choi YJ, Lee JH. Patient’s assessment of primar y care of medical institutions in South Korea by structural type. Int J Qual Health Care 2010; 22(6):493-499.
³⁶
Wang HHX, Wong SYS, Wong MCS, Wang JJ, Wei JL, Li DKT, Tang JL, Griffiths SM. Attributes of primary care in community health centres in China and implications for equitable care: a cross-sectional measurement of patients’ experiences. QJM 2014; 108(7):549-560.
³⁷
Pereira MJB, Abrahão-Curvo P, Fortuna CM, Coutinho SS, Queluz MC, Campos LVO, Fermino TZ, Santos CB. Avaliação das características organizacionais e de desempenho de uma unidade de Atenção Básica à Saúde. Rev Gaúcha Enferm 2011; 32(1):48-55.

Publication Dates

Publication in this collection
June 2017

History

Received
28 Dec 2015
Reviewed
19 July 2016
Accepted
21 July 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Berra S, Rocha KB, Rodríguez-Sanz M, Pasarín I, Rajmil L, Borrell C, Starfield B. Properties of a short questionnaire for assessing primary care experiences for children in a population survey. BMC Public Health 2011; 11:285.

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[16] ¹⁶
Araújo LUA, Gama ZAS, Nascimento FLA, Oliveira HFV, Azevedo WM, Almeida Júnior HJB. Avaliação da qualidade da atenção primária à saúde sob a perspectiva do idoso. Cien Saude Colet 2014; 19(8):3521-3532.

[17] ¹⁷
Leão CDA, Caldeira AP. Avaliação da associação entre qualificação de médicos e enfermeiros em atenção primária em saúde e qualidade da atenção. Cien Saude Colet 2011; 16(11):4415-4423.

[18] ¹⁸
Araújo JP, Viera CS, Toso BRGO, Collet N, Nassar PO. Avaliação dos atributos de orientação familiar e comunitária na saúde da criança. Acta Paul Enferm 2014; 27(5):440-446.

[19] ¹⁹
Berra S, Rodríguez-Sanz M, Rajmil L, Pasarín MI, Borrell C. Experiences with primary care associated to health, socio-demographics and use of services in children and adolescentes. Cad Saude Publica 2014; 30(12):2607-2618.

[20] ²⁰
Carneiro MSM, Melo DMS, Gomes JM, Pinto FJM, Silva MGC. Avaliação do atributo coordenação da Atenção Primária à Saúde: aplicação do PCATool a profissionais e usuários. Saúde Debate 2014; 38(n. esp.):279-295.

[21] ²¹
Carvalho VCHS, Rossato SL, Fuchs FD, Harzheim, Fuchs SC. Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study. BMC Public Health 2013, 13:605.

[22] ²²
Mesquita-Filho M, Luz BSR, Araújo CS. A Atenção Primária à Saúde e seus atributos: a situação das crianças menores de dois anos segundo suas cuidadoras. Cien Saude Colet 2014; 19(7):2033-2046.

[23] ²³
Leão CDA, Caldeira AP, Oliveira MMC. Atributos da atenção primária na assistência à saúde da criança: avaliação dos cuidadores. Rev. Bras. Saúde Matern. Infant 2011; 11(3):323-334.

[24] ²⁴
Lima EFA, Sousa AI, Primo CC. Avaliação dos atributos da atenção primária na perspectiva das usuárias que vivenciam o cuidado. Rev. Latino-Am. Enfermagem 2015; 23(3):559-559.

[25] ²⁵
Marques AS, Freitas DA, Leão CDA, Oliveira SKM, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saude Colet 2014; 19(2):365-371.

[26] ²⁶
Oliveira VBCA, Veríssimo MLOR. Assistência à saúde da criança segundo suas famílias: comparação entre modelos de atenção primária. Rev Esc Enferm USP 2015; 49(1):30-36.

[27] ²⁷
Reis RS, Coimbra LC, Silva AAM, Santos AM, Britto e Alves MTSS, Lamy ZC, Ribeiro SVO, Dias MAS, 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.

[28] ²⁸
Silva OCS, Fonseca ADG, Souza e Souza LP, Siqueira LG, Belasco AGS, Barbosa DA. Integralidade e Atenção Primária à Saúde: avaliação sob a ótica dos usuários. Cien Saude Colet 2014; 19(11):4407-4415.

[29] ²⁹
Silva AS, Fracolli LA. Avaliação da Estratégia Saúde da Família: perspectiva dos usuários em Minas Gerais, Brasil. Saúde Debate 2014; 38(103):692-705.

[30] ³⁰
Furtado MCC, Braz JC, Pina JC, Mello DF, Lima RAG. A avaliação da atenção à saúde de crianças com menos de um ano de idade na Atenção Primária. Rev. Latino-Am. Enfermagem 2013, 21(2):554-561.

[31] ³¹
Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Room for improvement: Patients’ experiences of primary care in Quebec before major reforms. Can Fam Physician 2007; 53(6):1056-1057.

[32] ³²
Haggerty JL, Pineault R, Beaulieu MD, Brunelle Y, Gauthier J, Goulet F, Rodrigue J. Practice features associated with patient reported accessibility, continuity, and coordination of primary health care. Ann Fam Med 2008, 6(2):116-123.

[33] ³³
Jeon KY. Cross-cultural adaptation of the US consumer form of the short Primary Care Assessment Tool (PCAT):the Korean consumer form of the short PCAT (KC PCAT) and the Korean standard form of the short PCAT (KS PCAT). Qual Prim Care 2011;19(2):85-103.

[34] ³⁴
Tourigny A, Aubin M, Haggerty J, Bonin L, Morin D, Reinharz D, Leduc Y, St-Pierre M, Houle N, Giguère A, Benounissa Z, Carmichael PH. Patients’ perceptions of the quality of care after primary care reform: Family medicine groups in Quebec. Can Fam Physician 2010; 56(7):273-282.

[35] ³⁵
Sung NJ, Suh SY, Lee DW, Ahn HP, Choi YJ, Lee JH. Patient’s assessment of primar y care of medical institutions in South Korea by structural type. Int J Qual Health Care 2010; 22(6):493-499.

[36] ³⁶
Wang HHX, Wong SYS, Wong MCS, Wang JJ, Wei JL, Li DKT, Tang JL, Griffiths SM. Attributes of primary care in community health centres in China and implications for equitable care: a cross-sectional measurement of patients’ experiences. QJM 2014; 108(7):549-560.

[37] ³⁷
Pereira MJB, Abrahão-Curvo P, Fortuna CM, Coutinho SS, Queluz MC, Campos LVO, Fermino TZ, Santos CB. Avaliação das características organizacionais e de desempenho de uma unidade de Atenção Básica à Saúde. Rev Gaúcha Enferm 2011; 32(1):48-55.

Author	Objective	Study population	Location
Araújo et al., 2014¹⁶	Identifying the extent of attributes of family and community orientation in child health care in PHC^a.	548 caregivers of children under 12 years of age of the 24 health facilities (23 UBS^b and 2 FHS^c).	Brazil
Araújo et al., 2014¹⁸	Assessing the quality of PHC from the perspective of the elderly.	Interview with 100 elderly enrolled in 10 FHS teams of the 20 municipal primary health care facilities.	Brazil
Berra et al., 2014¹⁹	Evaluating the health perceptions of the child user.	2,196 caregivers of children under 15 years of age in all 36 health areas called “Arees Integrals de Salut” according to the National Health System in the region of Catalonia.	Espanha
Carneiro et al., 2014²⁰	Evaluating the quality of PHC by verifying the coordination attribute.	607 adult users of the 48 FHS facilities of the municipality. FHS professionals.	Brazil
Carvalho, et al., 2013²¹	Evaluating the PHC orientation level with regard to the quality of life of the elderly attended.	509 elderly (> 60 years) coming from 21 municipal PHCs, 13 of the 33 FHSs and 8 of the 23 UBS	Brazil
Mesquito-Filho et al. 2014²²	Evaluating the attributes of primary health care for children from zero to two years of age	343 caregivers of children aged 0 to 2 years attended at the municipal PHC services	Brazil
Furtado et al., 2013³⁰	Analyzing the existence and extent of PHC attributes and the level of user enrollment vis-à-vis the FHS.	44 mothers of children under one year of age monitored at an FHS.	Brazil
Haggerty, et al., 2007³¹	Evaluating Quebec primary care services from patients’ care experiences in PHC.	3,441 patients and caregivers of 100 primary care services (Group practice, Solo practice, Stand-alone, walk-in clinic, Community Health Center) in urban and rural areas.	Canada
Autor	Appropriate	Performance Inappropriate
Araújo et al., 2014¹⁶	_________	Family Orientation Community Orientation
Araújo et al., 2014¹⁸	First Contact sub-item Use Coordination sub-item Information System	First Contact First Contact sub-item Accessibility Coordination Coordination sub-item Integrated Care Comprehensiveness Comprehensiveness sub-item Services Provided Comprehensiveness sub-item Available Services Community Orientation Family Orientation
Berra et al., 2014¹⁹	First Contact Longitudinality Coordination Comprehensiveness sub-item Available Services Comprehensiveness sub-item Services Provided Cultural Competence	_________
Carneiro et al., 2014²⁰	_________	Coordination
Carvalho, et al., 2013²¹	First Contact sub-item Use (FHS)	First Contact sub-item Use (UBS) First Contact sub-item Accessibility (UBS) (FHS) Longitudinality (UBS) (FHS) Coordination (UBS) (FHS) Comprehensiveness (UBS) (FHS) Family Orientation (UBS) (FHS)
Mesquito-Filho et al. 2014²²	Longitudinality	First Contact sub-item Accessibility Coordination Comprehensiveness sub-item Available Services Comprehensiveness sub-item Services Provided Family Orientation Community Orientation
Furtado et al., 2013³⁰	First Contact sub-item Accessibility First Contact sub-item Use Longitudinality Coordination sub-item Integrated Care Coordination sub-item Information System Comprehensiveness sub-item Available Services Family Orientation Community Orientation	Comprehensiveness sub-item Services Provided
Haggerty, et al., 2007³¹	First Contact sub-item Accessibility Longitudinality Coordination	_________
Author	Objective	Study population	Location
Haggerty et al., 2008³²	Identifying the characteristics of clinical organization and professional practice in the prediction of accessibility, longitudinality and coordination of care.	2,725 patients from 100 PHC services (10 Community Health Centers, 57 private clinics, 16 private physician offices, 10 Walk in Clinics) in rural and urban areas.	Canadá
Jeon, 2011³³	Adapting and validating the short version of the US Consumer Primary Care Assessment Tool in primary care in the Republic of Korea.	606 users over the age of 17 were interviewed from 245 rural and urban Community Health Centers as well as from private clinics providing general practice, general surgery, family medicine, gynecology and obstetrics services.	South Korea
Leão e Caldeira, 2011¹⁷	Verifying the association between PHC attributes and the professional qualification promoted by the Family and Community Medicine Residency and by the Family Health Multidisciplinary Residency.	Caregivers of children from 0 to less than 2 years of age of 350 families enrolled and monitored in 43 of the 44 FHSs located in urban area. The sample was divided into children from FHSs with professionals with family medicine and related areas residency (RF) and those without residency in the area (sRF).	Brazil
Leão et al., 2011²³	Comparing PHC in child health care in the family health teams with that of other childcare services at the municipal level from the viewpoint of caregivers.	Caregivers of children from 0 to less than 2 years of age of 350 families enrolled and accompanied in 43 of the 44 FHSs located in urban areas.	Brazil
Lima et al., 2015²⁴	Evaluating FHS quality from the perspective of female users and verifying the association between PHC attributes.	215 female users aged 20 to 49 years from the FHS services of the municipality of Serra, ES.	Brasil
Marques et al., 2014²⁵	Evaluating PHC attributes focusing on child health.	Caregivers of children from 0 to 5 years of age from the 76 families enrolled in the FHS of the quilombola rural community Buriti do Meio in the North of Minas Gerais.	Brazil
Oliveira e Veríssimo, 2015²⁶	Comparing the existence and extent of PHC attributes to child health between the traditional municipal FHS and UBS facilities.	482 caregivers of children over one year of age (247 children in UBS and 235 in FHS) from the 21 municipal health facilities.	Brazil
Autor	Appropriate	Performance Inappropriate
Haggerty et al., 2008³²	Longitudinality Coordination sub-item Integrated Care	First Contact sub-item Accessibility
Jeon, 2011³³	First Contact sub-item Use Comprehensiveness Cultural Competence	First Contact sub-item Accessibility Longitudinality Coordination Community Orientation
Leão e Caldeira, 2011¹⁷	Longitudinality (RF) (sRF) Coordination (sRF) Comprehensiveness sub-item Services Provided (RF) (sRF)	First Contact (RF) (sRF) Coordination (RF) Comprehensiveness sub-item Available Services (RF) (sRF) Family Orientation (RF ) (sRF) Community Orientation (RF) (sRF)
Leão et al., 2011²³	Longitudinality (FHS) (OS) Coordination (OS) Comprehensiveness sub-item Services Provided (FHS) (OS)	First Contact (FHS) (OS) Coordination (FHS) Comprehensiveness sub-item Available Services (FHS) (OS) Community Orientation (FHS) (OS)
Lima et al., 20 1 5²⁴	First Contact sub-item Use	First Contact sub-item Accessibility Longitudinality Coordination sub-item Integrated Care Coordination sub-item Information System Comprehensiveness sub-item Available Services Comprehensiveness sub-item Services Provided Family Orientation Community Orientation
Marques et al., 2014²⁵	First Contact sub-item Use Coordination sub-item Information System	First Contact sub-item Accessibility Longitudinality Coordination sub-item Integrated Care Comprehensiveness sub-item Services Provided Comprehensiveness sub-item Available Services Family Orientation Community Orientation
Oliveira e Veríssimo, 2015²⁶	First Contact sub-item Use (FHS) Coordination sub-item Integrated Care (FHS)	First Contact sub-item Accessibility (FHS) (UBS) First Contact sub-item Use (UBS) Longitudinality (FHS) (UBS) Coordination sub-item Integrated Care (UBS) Coordination sub-item Information System (FHS) (UBS) Comprehensiveness (FHS) (UBS) Family Orientation (FHS) (UBS) Community Orientation (FHS) (UBS)
Author	Objective	Study population	Location
Pereira et al., 2011³⁷	Evaluating organizational and performance characteristics from users.	55 users (adults and companions of children under 14 years) from a UBS of the 14 PHC services facilities of a municipality in rural São Paulo.	Brazil
Reis et al., 2013²⁷	Evaluate the access and use of the FHS as the gateway to the SUS, identifying the structural and procedural elements that strengthen or hamper the accomplishment of this role.	882 users (adults and children caregivers) enrolled and monitored in 44 of the 89 FHS teams.	Brazil
Silva et al., 2014²⁸	Evaluating the PHC Comprehensiveness process from the users’ viewpoint.	373 adult users, 124 (33.6%) covered by the FHS and 249 (66.4%) by other services – Health Center and Community Health Worker Program as the main source of PHC.	Brazil
Silva e Fracolli, 2014²⁹	Evaluating attributes of first contact access, comprehensiveness, care coordination, longitudinality, family orientation and community orientation, FHS attributes from the perspective of users.	527 adults over 18 years of age enrolled in 33 municipal FHS facilities.	Brazil
Sung, et al., 2010³⁵	Comparing different PHC services from the perspective of patients.	602 patients enrolled in different PHC care services (private clinics, school hospitals, public health centers and clinical cooperatives).	South Korea
Tourigny et al., 2010³⁴	Assessing how primary care reform affects patients’ experience with regard to the essential realms of PHC.	1,046 adult users interviewed in 5 of the 13 Family Medicine Group at the onset of implementation and after 18 months of operation.	Canada
Wang et al., 2014³⁶	Evaluate PHC attributes in CHC through user evaluation.	3,360 adult PHC users serviced at the Community Health Center.	China
Autor	Appropriate	Performance Inappropriate
Pereira et al., 2011³⁷	First Contact Longitudinality Comprehensiveness Coordination	Family orientation Community orientation
Reis et al., 2013²⁷	___________	First Contact First Contact sub-item Use First Contact sub-item Accessibility
Silva et al., 2014²⁸	First Contact sub-item Use (FHS) Longitudinality (FHS)	First Contact sub-item Use (OS) First Contact sub-item Accessibility (FHS/ OS) Longitudinality (OS)
Silva e Fracolli, 2014²⁹	First Contact sub-item Use Longitudinality	First Contact sub-item Accessibility Coordination sub-item Integrated Care Coordination sub-item Information System Comprehensiveness sub-item Available Services Comprehensiveness sub-item Services Provided Community Orientation
Sung, et al., 20 1 0³⁵	First Contact Longitudinality	Coordination Community/Family Orientation
Tourigny et al., 2010³⁴	Coordination sub-item Integrated Care (AR / DR) Longitudinality (AR/ DR)	First Contact sub-item Accessibility (AR / DR)
Wang et al., 20 1 4³⁶	First Contact sub-item Accessibility First Contact sub-item Use Coordination Service Integration System Longitudinality Coordination sub-item Information System Comprehensiveness sub-item Available Services Comprehensiveness sub-item Services Provided Family Orientation Community Orientation	___________

	Total number of evaluations	Good performance

	N	N	%
Essential attributes
First Contact	9	3	33,33
FC Accessibility	19	3	15,78
FC Use	14	10	71,42
Longitudinality	25	16	64
Coordination	14	5	35,71
Coord. Integrated Care	11	6	54,54
Coord. Information System	8	3	37,5
Comprehensiveness	7	2	28,57
Comp. Available Services	12	3	25
Comp. Services Provided	12	6	50
Derivative attributes
Family Orientation	15	2	13,33
Community Orientation	18	2	11,11
Cultural competence	2	2	100

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