Abstract

Primary health care is an essential component of effective health systems. The aim of this study aim was to evaluate the quality of primary care in a city in the state of Pernambuco, Brazil. We conducted an exploratory study with 525 service users using structured questionnaires. The quality of primary care was assessed across five dimensions: accessibility, clinical care, professional-user relations, community activities and structure. The findings point to the perpetuation of social vulnerabilities and challenges in achieving equitable universal care. Dissatisfaction rates were highest in the following categories: access to specialist appointments and exams, appointment wait time, and opportunity to make complaints. However, respondents were satisfied with medical and nursing care, particularly in relation to respect, privacy, listening and confidentiality. The findings show that, although health professionals were committed to providing humanized care, fragmentation of care is evident, hampering the provision of adequate and timely follow-up and negatively affecting the quality of care.

Key words:
Primary health care; Health services research; Patient satisfaction

Introduction

As the preferred front door to the Brazilian health system, primary health care (PHC) should welcome patients, promoting patient affiliation and co-responsibility for care. However, there are many obstacles to the provision of quality health care and this problem can have a negative effect on the continuity of care, comprehensiveness and health system efficiency¹.

Given the critical role PHC plays within the health system and its impact on the population’s health, ongoing evaluation is essential in order to strengthen outcomes and the quality of care²^,³.

Ensuring the quality of care delivered by health care facilities is therefore a technical and social imperative. The pursuit of equity of access to resources, high health care costs and new public concerns have meant that public and private health institutions have directed their efforts to evaluating quality of care and whether it is efficiently provided⁴4 Nery NG, Marcelo VC, Dantas MAA. A satisfação de idosos quanto à Estratégia Saúde da Família, a partir da atenção em Saúde Bucal. Rev Brasil Cien Saude 2010; 14 (1):43-50..

Based on the concept of quality developed by Donabedian (1984)⁵5 Donabedian A. La calidad de la atención médica - definición y métodos de evaluación. Prensa Médica Mexicana 1984., the notion of patient satisfaction has become a key element of the assessment of health services. Under this approach, patients are seen to play an active role in the assessment process and their opinions, expectations and everything they consider to be fair and equitable are legitimate elements in the definition and measurement of the quality of care⁶6 Almeida PF, Medina MG, Fausto MCR, Giovanella L, Bousquat A, Mendonça MHM. Coordenação do cuidado e Atenção Primária à Saúde no Sistema Único de Saúde. Saude Debate 2018; 42(spe. 1):244-260..

Within this context, service user satisfaction surveys are an important tool for facilitating patient participation in plans and programs aimed at improving care and supporting the construction of a new aspect of care⁷7 Callou Filho CR, Machado MFAS, Mesquita CAM, Rocha LK, Rodrigues MVS. Estratégia Saúde da Família: satisfação dos usuários no município de Fortaleza-CE. Rev Saude Pesq 2017; 10(2):339-346.^,88 Santos AL, Andrade CJN, Santos MS, Silva Neto MF, Porto TD. Percepção de usuários com diabetes acerca da assistência recebida na Atenção Primária à Saúde. Rev APS 2018; 21(2): 251-258..

Moreover, this methodology plays an important role within the Brazilian health care context because it strengthens public participation, insofar as it involves users in health service planning and evaluation processes⁹9 Esperidião MA, Viera da Silva LM. The satisfaction of the user in health services evaluation: essay on the imposition of problems. Saude Debate 2018; 42(2):331-340..

The right to health needs to be constantly defended and evaluation is an important tool. Evaluating care based on the experiences of users enables¹⁰10 Brandão ALRBS, Giovanella L, Campos CEA. Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros. Cien Saude Colet 2013; 18(1):103-114. not only the construction of a new perspective of care, but also the monitoring of service availability and strengthening of public participation.

In light of the above, this study analyzed users’ perceptions of the quality of primary health care in a municipality located in the Metropolitan Region of Recife in the state of Pernambuco.

Methods

We conducted a quantitative cross-sectional study of family health centers (FHCs) in Jaboatão dos Guararapes in the Metropolitan Region of Recife.

According to the Brazilian Institute of Geography and Statistics¹¹11 Brasil. Departamento de Informática do SUS. População residente - estimativas para o TCU - Pernambuco. [acessado 2020 ago 18]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?ibge/cnv/poptpe.def.
http://tabnet.datasus.gov.br/cgi/tabcgi.... , in 2018, Jaboatão dos Guararapes was one of the state’s five largest cities, with a population of 697,636 inhabitants. According to the Ministry of health, the city had 104 family health teams during the data collection period (July to September 2018), covering 51.43% of the population¹²12 Brasil. Cobertura da Atenção Básica. [acessado 2020 ago 18]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaAB.xhtml;jsessionid=6NmUeRNj6g6r8JTLp5WRvZAh.
https://egestorab.saude.gov.br/paginas/a... .

The sample size was calculated based on the expected satisfaction rate from studies undertaken by Gouveia (2011)¹³13 Gouveia GC, Souza WV, Luna CF, Szwarcwald CL, Souza Júnior PRB. Satisfação dos usuários com a assistência de saúde no estado de Pernambuco, Brasil, 2005 Cienc Saude Colet 2011; 16(3):1849-1862. evaluating user satisfaction with health care in the state of Pernambuco.

The number of care centers was selected using proportionate simple random sampling and adopting a 5% sampling error, 20% relative error, 65% satisfaction rate and 95% confidence level, resulting in a sample of 40 centers. A random sample of centers was selected from each health region in a number proportional to the number of health teams in each region when compared to the total number of health teams in the city. The user sample size was calculated using proportionate simple random sampling and adopting a 5% sampling error, design effect of 1.5 and 95% confidence level, resulting in a sample of 525 users.

User inclusion criteria were as follows: users registered at FHCs aged 18 years and over present at the time of interviewing who had had attended at least one appointment in the center in the six months prior to the interview.

The quality of primary care was assessed across the following five dimensions: accessibility, structure, clinical care, professional-user relations and community activities. These dimensions were defined drawing on the Health System Performance Assessment/Proadess¹⁴14 Fundação Oswaldo Cruz (Fiocruz). Projeto - Desenvolvimento de metodologia de avaliação do desempenho do sistema de saúde Brasileiro/ PRO-ADESS. Relatório Final. Rio de Janeiro: Fiocruz; 2003., quality improvement policies¹⁵15 Brasil. Ministério da Saúde (MS). Secretaria de Atenção a Saúde. Departamento de Atenção Básica. Política Nacional da Atenção Básica. Brasília: MS; 2012., Reid et al. (2002)¹⁶16 Reid R, Haggerty J, Mckendry R. Defusing the confusion: concepts and measures of continuity of healthcare. Ottawa: Canadian Health Services Research Foundation; 2002. [cited 2020 fev 24]. Available from: http://www.cfhi-fcass.ca/Migrated/PDF/ResearchReports/CommissionedResearch/cr_contcare_e.pdf and Beltran (2006)¹⁷17 Beltran TP. Coordinación entre Niveles Asistenciales. Una Propuesta para su Evaluación. Universitat Pompeu Fabra (UPF). Máster de Salud Pública; 2005-2006.. The questions relating to satisfaction had five alternative answers: terrible, poor, fair, good and very good.

We administered a 58-item structured questionnaire devised specifically for the study. The data were collected in the care centers’ waiting rooms on each day of the week and throughout all appointment scheduling times in order to ensure randomness. Service users were selected using a pre-established seating system whereby the interviewer selected the study participants by choosing previously numbered seats at random.

Considering the assumption of independence of observations, level of satisfaction was measured using the following dichotomous variable: dissatisfied (terrible, poor and fair); satisfied (good and very good).

The Friedman test was used to detect statistically significant differences between the different dimensions of satisfaction and their attributes. The results were presented as satisfaction mean rankings, where the greater the mean the higher the level of satisfaction.

It is worth noting that user satisfaction assessments can suffer from “gratitude bias”, which is a feeling that can emerge due to the fact that the service is public and the fear of losing guaranteed health care when giving a negative evaluation. This bias was minimized by explaining the study aims and ensuring the confidentiality of the information provided by the participants.

This study was part of a PhD thesis and the research protocol was approved by the research ethics committee at the Aggeu Magalhães Institute, Oswaldo Cruz Foundation, Recife, Pernambuco.

Results

The 525 respondents were predominantly female (87.4%), black/brown (77.0%), aged between 20 and 49 years (61.7%), married or living in stable union (67.0 %), and had a monthly income of up to one minimum wage (64.2%) and children (mean = 2.4 children).

With regard to education, 38.2% had not completed junior high school and 35.3% had completed high school. With regard to occupation, most of the sample were homemakers (27.4%), followed by unemployed (26.9%) and employed/self-employed (24.4%).

The analysis of user satisfaction showed statistically significant differences (p = 0.00) between the dimensions, with accessibility and structure showing the highest dissatisfaction rates and professional-user relations showing the highest satisfaction rates (81.8%) (Table 1).

The category with the highest dissatisfaction rate in the accessibility dimension was access to specialist examinations (90.8%), followed by access to specialist appointments (88.8%) and appointment wait time (69.0%), while the category that showed the highest satisfaction rate was distance from home to health center (67.3%), followed by appointment times (65.5%) (Table 2).

Table 2 shows that user dissatisfaction rates were above 60% in most of the categories within the structure dimension. The category with the highest user dissatisfaction rate was comfort of chairs (67.9%), followed by number of chairs (65.5%), ventilation and temperature (63%), and health center physical structure (62.9%). The dissatisfaction rate for the categories health center cleanliness and restroom cleanliness were 40.4% and 45.0%, respectively.

Satisfaction rates were above 70% in all categories in the clinical care dimension, except treatment provided by community health workers (CHW), where the rate was 68.2%. Likewise, satisfaction rates were above 70% in most categories in the professional-user relations dimension. The highest rating category was treated with respect by nurses (95.8%), followed by treated with respect by doctors (93.5%) and confidence in nurses (90.7%), while opportunity to make complaints and promptness of care showed lower satisfaction rates (Table 3).

Table 4 shows that satisfaction rates in the community activities dimension were below 70% in all categories except group activities (72.0%). Dissatisfaction rates in the categories directly related to CHWs varied between 44.9% and 55.7%, while 60% of the respondents reported that they were satisfied with doctor and nurse home visits.

Discussion

The evaluation of health care from the perspective of service users is a key tool for identifying aspects and situations that positively influence care delivery and the main factors that generate dissatisfaction. The lens of the service user is the best tool for evaluating care and promoting public participation in the pursuit of quality health systems that provide equal access to universal care tailored to the population’s real needs.

Most of the users were young brown or black women (aged between 20 and 39 years) with a low level of education and children. Most of the women were married and homemakers or unemployed, as found in previous studies¹⁸18 Abreu DMX, Araújo LHL, Reis CMR, Lima AMLD, Santos AF, Jorge AO, Fonseca Sobrinho D, Machado ATGM. Percepção dos usuários sobre o cuidado prestado por equipes participantes do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica no Brasil. Epidemiol Serv Saude [periódico na Internet]. 2018 [acessado 2020 jan. 12]; 27(3): e00184715. [cerca de 13p.] Disponível em: https://doi.org/10.5123/S1679-49742018000300002.
https://doi.org/10.5123/S1679-4974201800... ^,1919 Lucena LN, Melo RHV, Rodrigues MP, Andrade FB, Vilar RLA, Bosco Filho J. Avaliação da satisfação do usuário com o acolhimento na Estratégia da Saúde da Família no Recife (PE). Rev Cien Plural 2018; 4(2):21-37..

This may be explained by the fact that women tend to be more concerned about their health and accompany their children and husbands to appointments, while men seem to devote themselves more to work and consequently health becomes a secondary concern.

The findings show that most service users were outside the labor force. Respondents who reported being unemployed, homemakers or retired/living on benefits accounted for more than 70% of the sample. These findings suggest that the economically active population find it more difficult to access services.

The development of health promotion and disease prevention strategies for this group is therefore a major challenge, leading to an increase in cases of late diagnosis. This in turn can result in complications that require complex health care, the majority of which cannot be resolved in PHC.

In this regard, efforts have been made to broaden the provision of public services by extending health center opening times to the evening to facilitate access to health care among workers²⁰20 Brasil. Ministério da Saúde (MS). Gabinete do Ministro. Portaria nº 930, de 15 de maio de 2019. Institui o Programa Saúde na Hora. Brasília: MS; 2019..

The highest rating dimensions were clinical care and professional-user relations, both of which obtained satisfaction rates above 70%. In contrast, accessibility, physical structure and community activities showed dissatisfaction rates above 40%.

None of the categories in the accessibility dimension were rated as satisfactory. Dissatisfaction rates were highest in the categories access to specialist appointments and access to specialist examinations, illustrating weaknesses in access to specialist care. This is mainly due to a lack of capacity and shortage of professionals in specialist care facilities to meet the demands and needs of the population, resulting in long appointment wait times and compromising the provision of adequate and timely care and case resolvability.

Although satisfaction rates for the categories distance from home to health center and appointment times were around 60%, dissatisfaction rates were high in the categories ease of appointment scheduling, access in the case of worsening health conditions, appointment wait time and availability of medicines.

Distance from home to health center is a key element of user satisfaction. Our findings show that more than 30% of respondents were dissatisfied with this aspect. The location of FHCs should be planned considering the specific geographic characteristics of each territory in order to facilitate access. In practice, this question is often neglected by health managers, and health centers are built in hard-to-reach places. It is also common to find the same center housing various health teams, leading to large distances between services and certain areas, thus making it difficult for some patients, many of whom rely on public transport, to get to the facility.

A study conducted in Brazil²¹21 Protasio APL, Gomes LB, Machado LS, Valenca AMG. Satisfação do usuário da Atenção Básica em Saúde por regiões do Brasil: 1o ciclo de avaliação externa do PMAQ-AB. Cien Saude Colet 2017; 22(6):1829-1844. showed that living a fair distance or far from the health center reduced the chance of user satisfaction by 32% and 16%, respectively. According to Santos et al.⁸8 Santos AL, Andrade CJN, Santos MS, Silva Neto MF, Porto TD. Percepção de usuários com diabetes acerca da assistência recebida na Atenção Primária à Saúde. Rev APS 2018; 21(2): 251-258., easy geographic access is an important factor in health care seeking behavior, influencing appointment seeking, follow-up and treatment.

Dissatisfaction rates were above 50% in the categories ease of appointment scheduling, access in the case of worsening health conditions and appointment wait time. Considering that FHCs deliver services to the population within a specific territory under the responsibility of a single health team, it is necessary to rethink the planning of the actions and services necessary to meet the specific demands and needs of the population within that territory.

A study conducted in a teaching clinic²²22 Gabe MC, Rosa AMS, Garcia LSB, Ambrosio PG, Madeira K. Avaliação do grau de satisfação de pacientes atendidos no serviço de medicina de uma clínica escola. Arq Catarin Med 2018; 47(3):146-158. highlighted that difficulty scheduling initial appointments was the main complaint mentioned by patients, while Protassio et al.²³23 Protasio APL, Gomes LB, Machado LS, Valenca AMG. Factors associated with user satisfaction regarding treatment offered in Brazilian primary health care. Cad Saude Publica [periódico na Internet]. 2017 Mar. [acessado 2020 jan. 12]; 33(2): e00184715. [cerca de 13p.]. Disponível em: doi: 10.1590/0102-311 X00184715.
https://doi.org/10.1590/0102-311 X001847... reported that not receiving health care without an appointment decreased the chance of being satisfied by 42%.

Appointment wait time has also been widely associated with user dissatisfaction¹⁸18 Abreu DMX, Araújo LHL, Reis CMR, Lima AMLD, Santos AF, Jorge AO, Fonseca Sobrinho D, Machado ATGM. Percepção dos usuários sobre o cuidado prestado por equipes participantes do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica no Brasil. Epidemiol Serv Saude [periódico na Internet]. 2018 [acessado 2020 jan. 12]; 27(3): e00184715. [cerca de 13p.] Disponível em: https://doi.org/10.5123/S1679-49742018000300002.
https://doi.org/10.5123/S1679-4974201800... ^,2323 Protasio APL, Gomes LB, Machado LS, Valenca AMG. Factors associated with user satisfaction regarding treatment offered in Brazilian primary health care. Cad Saude Publica [periódico na Internet]. 2017 Mar. [acessado 2020 jan. 12]; 33(2): e00184715. [cerca de 13p.]. Disponível em: doi: 10.1590/0102-311 X00184715.
https://doi.org/10.1590/0102-311 X001847...

24 La Torre Mantilla AR, Oyola García AE, Quispe Ilanzo MP. Factores associados al grado de satisfacción del usuario del consultório externo de gastroenterología del Hospital Central de la Fuerza Aérea del Perú. Mayo, 2014. Rev Gerenc Polít Salud 2018; 17(34):1-10.^-2525 Melo DS, Martins RD, Jesus RPFS, Samico IC, Santo ACGE do. Avaliação da responsividade de um serviço de saúde público sob a perspectiva do usuário idoso. Rev Saude Publica [periódico na Internet]. 2017 [acessado 2020 jan. 12]; 51(62): [cerca de 13p.]. Disponível em: https://doi.org/10.1590/S1518-8787.2017051006854.
https://doi.org/10.1590/S1518-8787.20170... . The current study showed that mean wait times varied across health centers, with most patients having to wait up to seven days to get an appointment. However, it is worth noting that 17% of respondents got an appointment on the same day, revealing that some teams are sensitive to the need to provide adequate and timely appointments in order to identify cases that need priority treatment.

Around 60% of users were dissatisfied with availability of medicines. This may be related to deficiencies in the medication planning and distribution process, resulting in medicine shortages and affecting treatment in cases of acute and chronic conditions. This finding is particularly important given that the majority of the service users in our study are from vulnerable families.

Our findings are corroborated by a study conducted by Gabe et al.²²22 Gabe MC, Rosa AMS, Garcia LSB, Ambrosio PG, Madeira K. Avaliação do grau de satisfação de pacientes atendidos no serviço de medicina de uma clínica escola. Arq Catarin Med 2018; 47(3):146-158., who found a high level of user dissatisfaction with access to medications in a teaching clinic. In contrast, Soeiro et al.²⁶26 Soeiro OM, Tavares NUL, Nascimento Júnior JM, Guerra Junior AA, Costa EA, Acurcio FA, Guibu IA, Juliana Álvares J, Oliveira MGO Karnikowski, Leite SN, Costa KS. Satisfação dos usuários com os serviços da assistência farmacêutica na atenção básica nos municípios brasileiros. Rev Saude Publica 2017; 51(Supl. 2):21s. reported that 58.4% of users were satisfied with these services.

Our results show a high rate of dissatisfaction with physical structure, corroborating the findings of previous studies⁸8 Santos AL, Andrade CJN, Santos MS, Silva Neto MF, Porto TD. Percepção de usuários com diabetes acerca da assistência recebida na Atenção Primária à Saúde. Rev APS 2018; 21(2): 251-258.^,1919 Lucena LN, Melo RHV, Rodrigues MP, Andrade FB, Vilar RLA, Bosco Filho J. Avaliação da satisfação do usuário com o acolhimento na Estratégia da Saúde da Família no Recife (PE). Rev Cien Plural 2018; 4(2):21-37.^,2727 Silva SN, Lima MG, Ruas CM. Avaliação de Serviços de Saúde Mental Brasileiros: satisfação dos usuários e fatores associados. Cien Saude Colet 2018; 23(11):3799-3810.. Dissatisfaction rates were around 60% in all categories except those related to center cleanliness.

User dissatisfaction with physical structure can have a negative effect on processes of welcoming and meeting community demands. According to Lucena et al.¹⁹19 Lucena LN, Melo RHV, Rodrigues MP, Andrade FB, Vilar RLA, Bosco Filho J. Avaliação da satisfação do usuário com o acolhimento na Estratégia da Saúde da Família no Recife (PE). Rev Cien Plural 2018; 4(2):21-37., a quality care setting encourages reflection on practices and modes of operation, creating facilities that deliver effective health care in a functional, welcoming and comfortable environment.

Spaces should be adapted to the context in which they are located, taking into account the specific characteristics and health needs of the local population, number of expected users and services provided in order ensure the delivery of humanized and welcoming care.

Satisfaction rates in the clinical care dimension were above 70% in all categories, except treatment provided by community health workers.

The highest rating categories in this dimension were treatment provided by doctors, nurses and nurse technicians. The categories clinical examination, appointment duration, performing procedures and meeting patients’ needs were rated highly by the respondents. These findings point to service delivery that focuses on humanized care and favors patient affiliation with the care provider, resulting in better chances of success of health promotion and disease prevention actions and treatment.

Studies in Brazil and Spain showed that satisfaction rates for care provided by health teams in primary care centers were above 80%⁷7 Callou Filho CR, Machado MFAS, Mesquita CAM, Rocha LK, Rodrigues MVS. Estratégia Saúde da Família: satisfação dos usuários no município de Fortaleza-CE. Rev Saude Pesq 2017; 10(2):339-346.^,2828 Juan Fariño C, Elsa VLF, Gabriela CMA, Paola VDA, Jesus LNM, Guadalupe SJD. Satisfacción de usuarios y calidad de atención en unidades primarias de Salud de Milagro. INSPILIP 2018; 2(2):2-25..

With regard to meeting patients’ needs, the findings suggest that PHC professionals are committed to seeking effective responses to users’ health problems. Comprehensiveness of care is directly related to the health team’s capacity to resolve health problems. A national study in Brazil²¹21 Protasio APL, Gomes LB, Machado LS, Valenca AMG. Satisfação do usuário da Atenção Básica em Saúde por regiões do Brasil: 1o ciclo de avaliação externa do PMAQ-AB. Cien Saude Colet 2017; 22(6):1829-1844. showed that the fact that users are able to resolve their health problems in the health center was a key factor in patient satisfaction.

Most of the categories in the professional-user relations dimension showed high satisfaction rates, notably treated with respect by doctors and nurses, privacy, and information confidentiality. Treatment with respect, trust, privacy and confidentiality facilitates the development of a bond between the professional and patient, which in turn facilitates user affiliation, positively affecting follow-up.

Rodrigues et al.²⁹29 Rodrigues KZ, Mattos CFP, Ferreira DA, Koch LFA, Schmitt EJ, Gabardo MCL. Grau de satisfação entre os usuários de uma unidade básica de saúde no estado do Paraná, Brasil. Sci Med [periódico na Internet]. 2018 [acessado 2020 jan 12]; 28(4): [cerca de 13p.]. Disponível em:10.15448/1980-6108.2018.4.32253.
https://doi.org/10.15448/1980-6108.2018.... showed that more than 80% of PHC service users were satisfied in relation to trust in professionals, while studies with pregnant women and older persons²⁵25 Melo DS, Martins RD, Jesus RPFS, Samico IC, Santo ACGE do. Avaliação da responsividade de um serviço de saúde público sob a perspectiva do usuário idoso. Rev Saude Publica [periódico na Internet]. 2017 [acessado 2020 jan. 12]; 51(62): [cerca de 13p.]. Disponível em: https://doi.org/10.1590/S1518-8787.2017051006854.
https://doi.org/10.1590/S1518-8787.20170... ^,2727 Silva SN, Lima MG, Ruas CM. Avaliação de Serviços de Saúde Mental Brasileiros: satisfação dos usuários e fatores associados. Cien Saude Colet 2018; 23(11):3799-3810. also showed high user satisfaction rates in relation to respectful treatment by health professionals.

Corroborating the findings of the current study, other authors²⁵25 Melo DS, Martins RD, Jesus RPFS, Samico IC, Santo ACGE do. Avaliação da responsividade de um serviço de saúde público sob a perspectiva do usuário idoso. Rev Saude Publica [periódico na Internet]. 2017 [acessado 2020 jan. 12]; 51(62): [cerca de 13p.]. Disponível em: https://doi.org/10.1590/S1518-8787.2017051006854.
https://doi.org/10.1590/S1518-8787.20170... ^,3030 Hermida PMV, Nascimento ERP, Echevarría-Guanilo ME, Vituri DW, Martins SR, Barbosa SS. Responsividade do acolhimento com clasificação de risco: avaliação dos usuários em unidade de pronto atendimento. Texto Contexto Enferm [periódico na Internet]. 2019 [acessado 2020 jan 12]; 28: e20180480 [cerca de 10p.]. Disponível em: https://doi.org/10.1590/1980-265X-TCE-2017-0480.
https://doi.org/10.1590/1980-265X-TCE-20... ^,3131 Dantas RAN, Dantas DV, Nascimento JCP, Sarmento SDG, Oliveira SP. Evaluation of satisfaction of users assisted by prehospital mobile emergency care servisse. Saude Debate 2018; 42(116):191-202. have shown high satisfaction rates for privacy and confidentiality. In contrast, other studies reported that privacy during consultations was one of the main shortcomings in care delivery identified by service users²⁷27 Silva SN, Lima MG, Ruas CM. Avaliação de Serviços de Saúde Mental Brasileiros: satisfação dos usuários e fatores associados. Cien Saude Colet 2018; 23(11):3799-3810..

It is worth mentioning that studies show that listening and clarity of information during consultations, aspects related to effective communication, were highly rated¹⁹19 Lucena LN, Melo RHV, Rodrigues MP, Andrade FB, Vilar RLA, Bosco Filho J. Avaliação da satisfação do usuário com o acolhimento na Estratégia da Saúde da Família no Recife (PE). Rev Cien Plural 2018; 4(2):21-37.^,2525 Melo DS, Martins RD, Jesus RPFS, Samico IC, Santo ACGE do. Avaliação da responsividade de um serviço de saúde público sob a perspectiva do usuário idoso. Rev Saude Publica [periódico na Internet]. 2017 [acessado 2020 jan. 12]; 51(62): [cerca de 13p.]. Disponível em: https://doi.org/10.1590/S1518-8787.2017051006854.
https://doi.org/10.1590/S1518-8787.20170... ^,2929 Rodrigues KZ, Mattos CFP, Ferreira DA, Koch LFA, Schmitt EJ, Gabardo MCL. Grau de satisfação entre os usuários de uma unidade básica de saúde no estado do Paraná, Brasil. Sci Med [periódico na Internet]. 2018 [acessado 2020 jan 12]; 28(4): [cerca de 13p.]. Disponível em:10.15448/1980-6108.2018.4.32253.
https://doi.org/10.15448/1980-6108.2018.... . Effective communication is an important element of quality care, especially dialogue with patients, which should promote effective listening and a clear explanation of the health condition and/or treatment.

Satisfaction rates were low in the category opportunity to make complaints, which is a reality that has been widely discussed in both the national and international literature²¹21 Protasio APL, Gomes LB, Machado LS, Valenca AMG. Satisfação do usuário da Atenção Básica em Saúde por regiões do Brasil: 1o ciclo de avaliação externa do PMAQ-AB. Cien Saude Colet 2017; 22(6):1829-1844.^,2727 Silva SN, Lima MG, Ruas CM. Avaliação de Serviços de Saúde Mental Brasileiros: satisfação dos usuários e fatores associados. Cien Saude Colet 2018; 23(11):3799-3810.

28 Juan Fariño C, Elsa VLF, Gabriela CMA, Paola VDA, Jesus LNM, Guadalupe SJD. Satisfacción de usuarios y calidad de atención en unidades primarias de Salud de Milagro. INSPILIP 2018; 2(2):2-25.^-2929 Rodrigues KZ, Mattos CFP, Ferreira DA, Koch LFA, Schmitt EJ, Gabardo MCL. Grau de satisfação entre os usuários de uma unidade básica de saúde no estado do Paraná, Brasil. Sci Med [periódico na Internet]. 2018 [acessado 2020 jan 12]; 28(4): [cerca de 13p.]. Disponível em:10.15448/1980-6108.2018.4.32253.
https://doi.org/10.15448/1980-6108.2018.... . The lack of opportunity for patients to show their dissatisfaction and the fact that complaints that are made often go unaddressed is a concern and can lead to negative perceptions of care. This fact suggests a lack of ethical commitment on the part of professionals, illustrated by a lack of interest in resolving complaints and addressing patient demands.

With regard to community activities, the only category rated as satisfactory was group activities. More than 40% of the respondents were dissatisfied with the work of CHWs (home visits, guidance and monitoring of health status).

CHWs are recognized as playing an important role in the development of actions in the community. They experience similar situations to service users, meaning they are able to build a close relationship with the community and understand the local reality³²32 Andrade VMP, Cardoso CL. Visitas Domiciliares de Agentes Comunitários de Saúde: Concepções de Profissionais e Usuários. Psico-USF 2017; 22(1):87-98.^,3333 Kebian LVA , Acioli S. A visita domiciliar de enfermeiros e agentes comunitários de saúde da Estratégia Saúde da Família. Rev Eletr Em 2014;16(1):161-169..

However, our findings show that this bond alone is not enough to achieve user satisfaction. Although home visits encompass listening and welcoming, the frequency of visits and guidance provided fall short of expectations.

Most of the respondents were satisfied with home visits made by doctors and nurses; however, 30% were dissatisfied with this activity. These findings also illustrate a weakness in relation to access to health services by people who have mobility problems. In this regard, it is important to rethink work processes in order to ensure universal access to services.

Home visits are an important tool for understanding the social determinants of health. Home visits allow professionals to evaluate the patient’s life context, social and environmental aspects, housing conditions, etc. This information facilitates the planning and implementation of care strategies tailored to the specific reality of each case.

Investment and the development of community activities are needed to promote a shift from care models focused on disease to health promotion. To this end, activities need to be promoted that involve the whole health team, prioritizing community engagement, the inclusion of routine home visits in work processes and the development of educational activities that promote self-care and strengthen user autonomy.

Final considerations

Considering the place of speech of subjects involved in health care is fundamental to ensuring a right that has been severely threatened. This space is even more important when it depicts the vulnerability that characterizes our society. Our findings show that most users were young black or brown women with children and a low level of income and education.

With regard to inequality, important aspects of health care were characterized by dissatisfaction. The lowest-rated dimensions were accessibility, community activities and physical structure. These dimensions are essential to the welcoming process, strengthening community affiliation, and the delivery of quality comprehensive care.

On the other hand, users were satisfied with clinical care and professional-user relations, demonstrating the commitment of health professionals to promoting quality humanized care focused on affiliation, respect and confidence, despite structural problems and difficulties accessing medications and specialist consultations and examinations.

Further research investigating and reflecting upon the provision of health services and actions is essential in order to safeguard the right to health. Investment in PHC as a pivotal component of health care is essential. To this end, understanding the perspectives of service users provides important inputs to help health managers plan effective strategies aimed at defending respect for subjectivities and dignity and guaranteeing the provision of quality comprehensiveness care.

References

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