Abstract

Introduction

The reorganization of the Brazilian healthcare system in conjunction with the population’s current epidemiological profile, with reduction of the birth rate, aging of the population and increasing prevalence of chronic diseases and health complaints due to external causes, has led to a need for studies on the quality of actions within the healthcare services¹1 . Moretto LC, Longo GZ, Boing AF, Arruda MP. Prevalência da utilização de serviços de fisioterapia entre a população adulta urbana de Lages, Santa Catarina. Braz J Phys Ther. 2009; 13(2): 130-5..

Different approaches have been used, and assessments made by users are one of the methods used. This has the advantage of showing the opinions of users of the healthcare services or actions. Since these users are protagonists of the process, ascertaining their opinions about the quality of care becomes essential in order to implement actions that improve the effectiveness of care, with lower costs²2 . Gonçalves JR, Vera FEL, Matos ACM, Lima ISA. Avaliação da satisfação dos pacientes submetidos à intervenção fisioterapêutica no município de Campo Maior, PI. Fisioter Mov. 2011; 24(1):47-56.

3 . Fréz AR, Nobre MIRS. Satisfação dos usuários dos serviços ambulatoriais de fisioterapia da rede pública. Fisioter Mov. 2011; 24(3):419-28.

4 . Rodrigues RM, Raimundo CB, Silva KC. Satisfação dos usuários dos serviços privados de Fisioterapia do município de Campos dos Goytacazes/RJ. Perspect Online [Internet]. 2010 [acesso 2012 Dez 7]; 4(14):163-80. Disponível em: http://www.perspectivasonline.com.br/revista/2010vol4n14/volume4(14)artigo15.pdf
http://www.perspectivasonline.com.br/rev...

5 . Machado NP, Nogueira LT. Avaliação da satisfação dos usuários de serviços de Fisioterapia. Braz J Phys Ther. 2008; 12(5):401-8.^-66 . Mendonça KMPP, Guerra RO. Desenvolvimento e validação de um instrumento de medida da satisfação do paciente com a fisioterapia. Braz J Phys Ther. 2007; 11(5):369-76.. 

Users’ perceptions are a direct measurement of how their needs have been attended to and are related to expectations regarding healthcare⁷7 . Murray CJL, Kawabata K, Valentine N. People’s experience versus people’s expectations. Health Aff (Millwood) 2001; 20(3):21-4. doi: 10.1377/hlthaff.20.3.21.
https://doi.org/10.1377/hlthaff.20.3.21... . In evaluating the services, users take into account issues relating to professional-patient relationships, access, quality, physical structure and organizational structure⁵5 . Machado NP, Nogueira LT. Avaliação da satisfação dos usuários de serviços de Fisioterapia. Braz J Phys Ther. 2008; 12(5):401-8.^,88 . Esperidião M, Trad LAB. Avaliação de satisfação de usuários. Cienc. Saude Colet. 2005; 10 Supl:303-12.. Monitoring users’ satisfaction is also important for evaluating the quality of attendance, considering that this perception may influence changes in work processes and in the capacity of healthcare treatments to resolve problems⁹9 . Geitona M, Kyriopoulos J, Zavras D, Theodoratouum T, Alexopoulos EC. Medication use and patient satisfaction: a population-based survey. Fam Pract. 2008; 25(5):362-9.^,1010 . Ramos DD, Lima MADS. Acesso e acolhimento aos usuários em uma unidade de saúde de Porto Alegre, Rio Grande do Sul, Brasil. Cad Saude Publica. 2003; 19(1):27-34..

Studies on the quality of physiotherapeutic care and users’ satisfaction have been conducted over recent years. In Brazil, studies of this nature are still sparse and limited to quantitative analyses on users’ satisfaction²2 . Gonçalves JR, Vera FEL, Matos ACM, Lima ISA. Avaliação da satisfação dos pacientes submetidos à intervenção fisioterapêutica no município de Campo Maior, PI. Fisioter Mov. 2011; 24(1):47-56.

3 . Fréz AR, Nobre MIRS. Satisfação dos usuários dos serviços ambulatoriais de fisioterapia da rede pública. Fisioter Mov. 2011; 24(3):419-28.

4 . Rodrigues RM, Raimundo CB, Silva KC. Satisfação dos usuários dos serviços privados de Fisioterapia do município de Campos dos Goytacazes/RJ. Perspect Online [Internet]. 2010 [acesso 2012 Dez 7]; 4(14):163-80. Disponível em: http://www.perspectivasonline.com.br/revista/2010vol4n14/volume4(14)artigo15.pdf
http://www.perspectivasonline.com.br/rev...

5 . Machado NP, Nogueira LT. Avaliação da satisfação dos usuários de serviços de Fisioterapia. Braz J Phys Ther. 2008; 12(5):401-8.^-66 . Mendonça KMPP, Guerra RO. Desenvolvimento e validação de um instrumento de medida da satisfação do paciente com a fisioterapia. Braz J Phys Ther. 2007; 11(5):369-76.. Even though such analyses make it possible to reach a more representative sample, at lower cost, anonymously and sometimes using self-applicable instruments, there are authors who consider that quantitative evaluations are a reductionist and limited method. For this reason, and because of the high satisfaction levels identified in different studies within healthcare, there is concern with regard to establishing new methodological strategies that would investigate users’ opinions in a more trustworthy manner¹¹11 . Keith RA. Patient satisfaction and rehabilitation services. Arch Phys Med Rehabil. 1998; 79(9):1122-8..

Qualitative studies are important because they make it possible for subjects to truly express their feelings and perceptions relating to their health conditions¹²12 . Shimizu HE, Rosales C. A atenção à saúde da família sob a ótica do usuário. Rev Latino-am Enferm. [Internet]. 2008 [acesso 2012 Dez 6]; 16(5):87-93. Disponível em: http://www.scielo.br/pdf/rlae/v16n5/pt_14.pdf
http://www.scielo.br/pdf/rlae/v16n5/pt_1... . In addition to focusing on the players’ interactions, qualitative studies also take into account beliefs, lifestyles and other conceptions of the health-disease process, and enable spontaneous expression by the interlocutor, without directing the discussion⁸8 . Esperidião M, Trad LAB. Avaliação de satisfação de usuários. Cienc. Saude Colet. 2005; 10 Supl:303-12..

Healthcare evaluations should be composed not only of perceptions based on individual experiences, but also on what is happening more broadly in the healthcare system¹³13 . Blendon RJ, Kim M, Benson JM. The public versus the World Health Organization on Health. System Performance. Health Aff (Willwood) 2001; 20(3):10-20. doi: 10.1377/hlthaff.20.3.10.
https://doi.org/10.1377/hlthaff.20.3.10... . From this perspective, by not only ascertaining users’ perceptions regarding the quality and problem-solving capacity of the care received, but also finding out about how the healthcare system that physiotherapists form part of functions, access to information is expanded and actions can be proposed in accordance with the realities of the population and what can be provided for it.

As mentioned earlier, there are no studies in the literature with a qualitative approach towards the quality of physiotherapeutic care. Taking the view that stronger data regarding the problem-solving capacity of care might be revealed through qualitative research, the objective of this study was to ascertain users’ perceptions regarding physiotherapy services, within the sphere of the problem-solving capacity of care and the difficulties faced in using outpatient physiotherapeutic services within the Brazilian National Health System (SUS) in the municipality of Campo Grande, Mato Grosso do Sul (MS), Brazil.

Methodology

This was a qualitative study of descriptive and exploratory nature that was conducted among users of outpatient physiotherapy services within SUS, in the municipality of Campo Grande, MS. Users aged over 18 years who were already undergoing physiotherapeutic treatment through SUS and who had so far fulfilled a minimum attendance of 80% of the scheduled sessions were included.

Initially, information was sought regarding the physiotherapy clinics and hospitals that provide outpatient care within SUS, by means of a list supplied by the Municipal Public Health Department (SESAU) of the municipality of Campo Grande, MS. Following this, the professionals responsible for each service were contacted and a visit was arranged. After presentation of the project and acceptance of participation, the administration of each clinic supplied a list of users who met the inclusion criteria for this study, and 20% of this total were randomly selected for interviewing.

The users were approached in the waiting room of the physiotherapy service itself, where they received explanations about the study. Those who agreed to participate were interviewed. The first part of the interview consisted of gathering personal data such as gender, age, schooling level, family income, occupation and type of health assistance used (SUS, private healthcare plan or contracted services). The second part sought data relating to the physiotherapeutic care used: reason for seeking physiotherapy services; time that had elapsed between referral and attendance; means of transport used to go to the physiotherapy sessions; and whether the sessions were conducted individually or in groups. The third part of the interview was composed of two questions: “What is your opinion regarding the problem-solving capacity of physiotherapy within SUS?” and “What are your main difficulties relating to attendance?” The questions were guided and the interviewer was free to ask questions and stimulate the users to participate or express their opinions, using neutral expressions such:  “tell us more about this” or “could you explain this better?” without inducing any type of response.

The interviews were audio-recorded and then transcribed, which made it possible to have a reliable record of the information supplied by the users. After transcription, the material underwent transverse horizontal reading in order to observe the entirety of each interview and to identify the central ideas found in the users’ declarations.

The responses to the open questions were analyzed by means of the technique of collective subject discourse (CSD)¹⁴14 . Lefévre F, Lefévre AMC. Pesquisa de representação social: um enfoque qualiquantitativo - a metodologia do Discurso do Sujeito Coletivo. 2a ed. Brasília: Liber Livro Editora; 2012., which is a way of organizing data of verbal nature that was obtained through individuals’ declarations, through which the set of individual thoughts expresses the collective thinking. For this, the individual responses to each question put forward were analyzed and, from this, the methodological concepts of key expression (KE), central idea (CI) and anchorage were extracted. These were used for processing the declarations, thus originating the CSD.

The research project was submitted to the Ethics Committee for Research on Human Beings of the Federal University of Mato Grosso do Sul (UFMS, and all the participants signed a free and informed consent statement.

Results

Interviewees’ characteristics

In the municipality of Campo Grande, MS, there are 135 physiotherapy clinics that are registered with the Regional Council for Physiotherapy and Occupational Therapy of the 13^th Region¹⁵15 . Conselho Regional de Fisioterapia e Terapia Ocupacional da 13ª Região - CREFITO13. Quantitativo de inscrições de empresas de Fisioterapia no Município de Campo Grande – MS no ano de 2012. Campo Grande; 2012.. According to the list of physiotherapy services supplied by SESAU, at the time of this study, outpatient physiotherapeutic care through SUS in this municipality in provided in supplementary form by ten clinics with service agreements. Of these, seven participated in the study, two were no longer functioning as physiotherapeutic care clinics and one did not agree to take part in the study.

Taking the inclusion criteria into consideration, 45 users were interviewed at the seven clinics. The interviewee profile was characterized as 60% male (n = 27) and 40% female (n = 18). The interviewees’ mean age was 49.18 ± 16.79 years, with a minimum age of 18 years and maximum of 86 years. With regard to schooling level, 13.3% (n = 6) had attended school until completing elementary education; 37.8% (n = 17) had not completed elementary education; 24.5% (n = 11) had attended school until completing high school education; 11.1% (n = 5) had not completed high school education; 6.7% (n = 3) had completed an undergraduate university-level course; 4.4% (n = 2) had not completed the undergraduate course; and 2.2% (n = 1) had completed a specialization course. The mean family income was 1,475.02 ± 1,062.24 reais, with a range from 624.00 to 4,500.00 reais. Regarding occupation, 11.1% (n = 5) did not have formal employment and did not have income of their own, including four housewives (80%) and one student (20%). The other 88.9% (n = 40) had income: 15% (n = 6) were civil construction workers; 7.5% (n = 3) production assistants; 7.5% (n = 3) shop assistants; 5% (n = 2) self-employed; 5% (n = 2) drivers; 5% (n = 2) nurses; 2.5% (n = 1) retired; 2.5% (n = 1) administrative assistant; 2.5% (n = 1) petrol/gasoline pump attendant; 2.5% (n = 1) foreman; 2.5% (n = 1) cook; 2.5% (n = 1) caregiver for elderly people; 2.5% (n = 1) driving school instructor; 2.5% (n = 1) maid; 2.5% (n = 1) agricultural/livestock technician; 2.5% (n = 1) barman; 2.5% (n = 1) commercial representative; 2.5% (n = 1) seamstress; 2.5% (n = 1) lathe operator; 2.5% (n = 1) mechanic; 2.5% (n = 1) teacher; and 2.5% (n = 1) welder. Among all the users, 60% (n = 27) had some other form of healthcare assistance, supplementary to SUS, but had not used the physiotherapeutic services that were available through their service agreements because of the need to pay the fees charged for each physiotherapy session.

The main complaints that led to seeking physiotherapy through SUS were bone-muscle-joint disorders, which accounted for 93.3% (n = 42) of the cases. These resulted from work-related accidents and injuries (26.2%; n = 11), vehicle accidents (23.8%; n = 10), back pain (19.1%; n = 8); shoulder injuries (9.5%; n = 4); ankle injuries (9.5%; n = 4); knee injuries (7.2%; n = 3); and osteoporosis (4.7%; n = 2). The remaining users presented neurological dysfunctions (6.7%; n = 3). The mean time that elapsed between the referral and the first physiotherapy consultation through SUS was 21.38 ± 39.7 days, with a range from one to 210 days after the referral. The majority of the users (51.1%; n = 23) traveled to the physiotherapy sessions by public transport; 37.8% (n = 17) went by car; 6.7% (n = 3) used a bicycle; and 4.4% (n = 2) walked. All the users stated that they were treated individually at the sessions.

To make their physiotherapy appointments, the users reported that they took their medical referral to the healthcare unit closest to their homes and, from there, through the regulation center, they were referred to one of the physiotherapy clinics linked to SUS that had slots available. If the users wished to choose a specific clinic among the SUS service providers, they would have to wait until slots became available at the desired clinic.

Interviewees’ perceptions

In relation to the open questions, we identified two categories among the responses: problem-solving capacity of care and barriers against using the services, which are presented below.

Problem-solving capacity of care

The declarations showed the users’ perceptions regarding the problem-solving capacity of outpatient physiotherapy through SUS from two main angles. From the responses to the question “What is your opinion regarding the problem-solving capacity of physiotherapy within SUS?” two central ideas (CI) were identified and the respective collective subject discourse (CSD) relating to each CI was compiled.

Central idea A (CIA) was that physiotherapy is not a full solution, based on the responses of six users, whose complaints consisted of bone-muscle-joint dysfunctions resulting from shoulder injuries (n = 3), ankle injury (n = 1), back pain (n = 1) and a vehicle accident (n = 1). The CSD for this is represented in Box 1.

“I see physiotherapy more as palliative, for alleviating pain. It provides some degree of solution. It works for a certain time. I came here because I was in great pain. Well, it got much better. But it’s for a short time, not for a long time. So much so that if I do 10 applications, I expect that in around 15 days, it starts to hurt again. It depends on the place, because I went to one physiotherapy clinic and had 20 sessions, just with shocks. That’s not right.”

Central idea B (CIB) – physiotherapy through SUS is a solution and works well – was reported by 39 users who correlated physiotherapy with improvement of function and of the symptoms presented. This group was composed of users who presented neurological dysfunctions (n = 3) and bone-muscle-joint dysfunctions resulting from work-related accidents and injuries (n = 11); vehicle accidents (n = 9); back pain (n = 7); osteoporosis (n = 2); shoulder injuries (n = 3); ankle injury (n = 1); and knee injuries (n = 3). Box 2 demonstrates the CSD.

Barriers against using the services

According to the declarations in the interviews in response to the second question – “What are your main difficulties relating to attendance?” – two groups of barriers against outpatient physiotherapy through SUS could be identified. The first barrier, which related to the patients, was physical and financial difficulty in accessing the services. The other, which related to the services, was difficulty in relation the continuity of treatment. From the declarations of five users, central idea C (CIC) was created: the notion that distance hindered access to physiotherapy. The CSD for this is demonstrated in Box 3.

Central idea D (CID) was formed from another 14 declarations – bureaucracy hampers continuity of care, and consequently its problem-solving capacity – as demonstrated in the corresponding CSD (Box 4).

Discussion

This study was based on the assumption that healthcare is a universal right and on recognition that functional health is an important part of Brazilians’ health. Specifically in this study, evaluation of outpatient physiotherapeutic care from service users’ perspectives positioned knowledge of the realities as a strategy for making advances regarding the quality of care.

Although healthcare services are not the main determinants in the health-disease process, the existence of such services and ensured access to them for the population may have an impact on the population’s health¹⁶16 . Goes PSA, Figueiredo N, Neves JC, Silveira FMM, Costa JFR, Pucca-Júnior GA, et al. Avaliação da atenção secundária em saúde bucal: uma investigação nos centros de especialidades do Brasil. Cad Saude Publica. 2012; 28 Supl:81-9.. Outpatient physiotherapeutic attendance provided as early as possible through a functional kinesiological diagnosis, and treatment provided immediately and continuously that resolves the problem will consequently limit the damage, enable rehabilitation and have positive repercussions of the health of individuals who are vulnerable and/or have some degree of functional incapacity.

In analyzing the profile of physiotherapeutic service users, we found that the largest percentages were adult males, with income of their own, low schooling level and low family income. With regard to traveling to the physiotherapy clinics, the majority of the users arrived at the clinics by means of public transport.

With the exception of gender, other studies have identified similar characteristics among outpatient physiotherapy users²2 . Gonçalves JR, Vera FEL, Matos ACM, Lima ISA. Avaliação da satisfação dos pacientes submetidos à intervenção fisioterapêutica no município de Campo Maior, PI. Fisioter Mov. 2011; 24(1):47-56.^,44 . Rodrigues RM, Raimundo CB, Silva KC. Satisfação dos usuários dos serviços privados de Fisioterapia do município de Campos dos Goytacazes/RJ. Perspect Online [Internet]. 2010 [acesso 2012 Dez 7]; 4(14):163-80. Disponível em: http://www.perspectivasonline.com.br/revista/2010vol4n14/volume4(14)artigo15.pdf
http://www.perspectivasonline.com.br/rev... . The users of public services present lower schooling and family income levels than the users of private services³3 . Fréz AR, Nobre MIRS. Satisfação dos usuários dos serviços ambulatoriais de fisioterapia da rede pública. Fisioter Mov. 2011; 24(3):419-28.^,55 . Machado NP, Nogueira LT. Avaliação da satisfação dos usuários de serviços de Fisioterapia. Braz J Phys Ther. 2008; 12(5):401-8.. Adults are more exposed to risk factors such as traffic and work-related accidents, chronic diseases and stress¹⁷17 . Lima-Costa MF, Loyola Filho AI. Fatores associados ao uso e à satisfação com os serviços de saúde entre usuários do Sistema Único de Saúde na Região Metropolitana de Belo Horizonte, Estado de Minas Gerais, Brasil. Epidemiol Serv Saude. 2008; 17(4):247-57.. These factors are even more evident among men, who in the present study represented the majority of the users undergoing physiotherapeutic treatment. In comparison with women, men consume more alcohol and drugs, are more susceptible to accidents due to external causes (such as traffic accidents and violence and, depending on their occupational activity, may be more exposed to risky situations in the workplace¹⁸. Another characteristic relating to male gender is that men consider themselves to be invulnerable, with low adherence to preventive practices, and do not seek attendance at primary healthcare level, Rather, they enter the healthcare system at institutions providing services of medium and high levels of complexity, when illnesses occur^19,20.

All these characteristics explain the results relating to the main reasons for seeking physiotherapy services, reported by users in this and other studies in the literature³3 . Fréz AR, Nobre MIRS. Satisfação dos usuários dos serviços ambulatoriais de fisioterapia da rede pública. Fisioter Mov. 2011; 24(3):419-28.^,55 . Machado NP, Nogueira LT. Avaliação da satisfação dos usuários de serviços de Fisioterapia. Braz J Phys Ther. 2008; 12(5):401-8., i.e. bone-muscle-joint complaints, especially due to traffic and work-related accidents. It was therefore noted that most of the users sought physiotherapeutic care because of an acute event that left them temporarily with some degree of functional incapacity and impaired their productive lives and working activities.        

Through these results, together with the fact that physiotherapeutic care provided by primary healthcare teams in Brazil is a process under construction²¹21 . Neves LMT, Acioli GG. Challenges of integrality: revisiting concepts about the physical therapist’s role in the Family Health Team. Interface (Botucatu). 2011; 15(37):551-661., and that this is not yet the reality in Campo Grande or in most other municipalities in Brazil, it can be inferred that individuals with mild complaints due to disorders that still are not imposing significant limitations on functional health are at the mercy of the natural evolution of the disease. This situation may, over the medium to long term, have the repercussion of conditions of greater severity and less chance of being resolved, thereby imposing hefty physical, psychological, social and economic costs²²22 . Borges AMP, Gonçalves MANB, Lovato M, Salício VAMM. A contribuição do fisioterapeuta para o Programa de Saúde da Família – uma revisão da literatura. Uni Cienc. 2010; 14(1):69-82.^,2323 . Rezende M, Moreira MR, Amâncio-Filho A, Tavares MFL. A equipe multiprofissional da ‘Saúde da Família’: uma reflexão sobre o papel do fisioterapeuta. Cienc. Saude Colet. 2009; 14 Supl 1:1403-10..

Also in relation to the reasons for seeking outpatient physiotherapeutic care, it was notable that only a small percentage of the users identified within the municipality’s outpatient physiotherapy network presented neurological problems. These results were similar to those reported by some other authors³3 . Fréz AR, Nobre MIRS. Satisfação dos usuários dos serviços ambulatoriais de fisioterapia da rede pública. Fisioter Mov. 2011; 24(3):419-28.^,55 . Machado NP, Nogueira LT. Avaliação da satisfação dos usuários de serviços de Fisioterapia. Braz J Phys Ther. 2008; 12(5):401-8., and were possibly related to the difficulties in physical locomotion among users with neurological disorders. The interviewees reported that they traveled to the physiotherapy clinics by means of public transport, car, bicycle or on foot, which indicated  that patients with locomotion difficulties and who were not in a financial position to fund a car that could transport them to the clinic did not have the possibility of using the public physiotherapy services.

According to the demographic census results from 2010 for this municipality, there were 150,191 inhabitants with some form of motor deficiency, who were classified as follows: 98,410 people with motor deficiency “with some difficulty”; 42,895 people “with great difficulty”; and 8,886 people who “were totally unable” to perform motor tasks²⁴24 . Instituto Brasileiro de Geografia e Estatística. Cidades. Censo Demográfico 2010 [Internet]. 2010 [acesso 2012 Nov 30]. Disponível em: http://www.ibge.gov.br/estadosat/temas.php?sigla=ms&tema=censodemog2010_defic
http://www.ibge.gov.br/estadosat/temas.p... . Considering that the majority of the population was using the public healthcare network, it can be affirmed that there was a large number of people with motor deficiency, with a need for physiotherapeutic treatment, who did not have access to rehabilitation services. This repressed demand can be explained by the fact that healthcare transportation for these users to travel to the respective services is not made available by SESAU, nor has any home care network been instituted, either in the municipality studied or in most other municipalities in Brazil. This reality has also been identified in other studies, which demonstrated that limitations relating to traveling to the physiotherapy location can be considered to be an obstacle to access. Adequate physical and financial conditions are required, given the regularity and frequency that such treatments demand⁴.

Because healthcare is a constitutional right and universality of access at all levels of care is one of the principles of the Brazilian National Health System (SUS)²⁵25 . Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União. 1990 Set 19., it is a matter for concern that lack of access to rehabilitation services is imposed on these citizens. Individuals with moderate and severe degrees of motor deficiency who are unable to move around remain restricted to their homes and, without access to rehabilitation services, remain exposed to evolution of their conditions. These citizens are denied the possibility of recovering the functional health and, in many cases, denied working and social lives.

With regard to users’ perceptions of the problem-solving capacity of the physiotherapeutic care received, we identified from their responses that this perception was linked specifically to functional recovery and pain improvement. Other studies have demonstrated that users also qualify their satisfaction with care and the problem-solving capacity of care by correlating these with the physical environment and the therapist/patient relationship³3 . Fréz AR, Nobre MIRS. Satisfação dos usuários dos serviços ambulatoriais de fisioterapia da rede pública. Fisioter Mov. 2011; 24(3):419-28.^,44 . Rodrigues RM, Raimundo CB, Silva KC. Satisfação dos usuários dos serviços privados de Fisioterapia do município de Campos dos Goytacazes/RJ. Perspect Online [Internet]. 2010 [acesso 2012 Dez 7]; 4(14):163-80. Disponível em: http://www.perspectivasonline.com.br/revista/2010vol4n14/volume4(14)artigo15.pdf
http://www.perspectivasonline.com.br/rev... ,⁶6 . Mendonça KMPP, Guerra RO. Desenvolvimento e validação de um instrumento de medida da satisfação do paciente com a fisioterapia. Braz J Phys Ther. 2007; 11(5):369-76.^,1111 . Keith RA. Patient satisfaction and rehabilitation services. Arch Phys Med Rehabil. 1998; 79(9):1122-8..

Although a significant group of respondents considered that the care received was a solution for the problem, even if the treatment was still in progress, there was another group that considered that the care received did not produce a full solution, since the symptoms returned at some time after the treatment ceased. Several factors may be linked to the limited problem-solving capacity of physiotherapeutic care and among these is discontinuity of treatment. This was also reported in the present study as a difficulty faced by users. The efficacy of the therapeutic care may be deferred, interrupted or abolished over the course of the period over which the patient remains without assistance or guidance²⁶26 . Beattie P, Dowda M, Turner C, Michener L, Nelson R. Longitudinal continuity of care is associated with high patient satisfaction with physical therapy. Phys Ther [Internet]. 2005 [acesso 2012 Dez 4]; 85(10):1046-52. Disponível em: http://ptjournal.apta.org/content/85/10/1046
http://ptjournal.apta.org/content/85/10/... .

Recognizing the relationship between problem-solving capacity and users’ satisfaction is important for evaluating the quality and performance of healthcare services. Location and the costs involved are factors that influence users’ satisfaction and adherence²⁷27 . Roush SE, Sonstroem RJ. Development of the Physical Therapy Outpatient Satisfaction Survey (PTOPS). Phys Ther [Internet]. 1999 [acesso 2012 Dez 6]; 79(2):159-70. Disponível em: http://ptjournal.apta.org/content/79/2/159
http://ptjournal.apta.org/content/79/2/1... . In the present study, the difficulties that were mentioned related to physical-financial access and bureaucracy, even among users who considered that physiotherapy provided a solution. Regarding the different dimensions of the barriers to access, Assis and Jesus (2012)²⁸28 . Assis MM, Jesus WIA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cienc Saude Colet. 2012; 17(11):2865-75. identified and described the political, technical, symbolic, physical-social and organizational barriers. The last two of these were reported by the individuals analyzed in this study.

These results reinforce the previous discussion regarding lack of access to physiotherapy services, which remain restricted to individuals who, in some manner, are capable of traveling to the treatment location. Even those who were able to undergo physiotherapy complained about having to travel long distances, which required time, physical effort and financial expenditure. This reality was also found in the study by Machado and Nogueira (2008)⁵5 . Machado NP, Nogueira LT. Avaliação da satisfação dos usuários de serviços de Fisioterapia. Braz J Phys Ther. 2008; 12(5):401-8., in which the users who reported that access was difficult considered that the following were obstacles to treatment: the time taken to travel to the attendance location; the lack of closer physiotherapy services; locomotion problems; financial difficulty; and the distance to their homes. We agree with Ramos and Lima (2003)¹⁰10 . Ramos DD, Lima MADS. Acesso e acolhimento aos usuários em uma unidade de saúde de Porto Alegre, Rio Grande do Sul, Brasil. Cad Saude Publica. 2003; 19(1):27-34., regarding the need for investigations that survey the demand among users who do not have access to physiotherapy and identify these individuals’ healthcare needs. Through this, there may be a repercussion on their day-to-day lives.

Other factors that have been mentioned as obstacles to using physiotherapy services within the public network are the bureaucratic processes of referral and making appointments. Although the paths for physiotherapeutic care are well defined in this municipality, with appointments put into operation through a slot regulation system, at primary healthcare units, there is great variability in the length of time between referral and the start of physiotherapeutic treatment. While some people report that before finishing the sessions envisaged, they seek a medical consultation to request and arrange new sessions (thereby providing an example of how the population actively seeks alternatives in relation to the bureaucracy), others wait for weeks or even for months to continue with the treatment, thus compromising access to and equity of treatment.

Currently, it is recommended that 10 sessions should be made available for every referral, with a need to return to the doctor to obtain new requests for subsequent sessions. However, the time that it takes to make appointments for medical consultations does not follow the timetable for scheduling physiotherapy, which delays the continuity of care. As already discussed, the possibility of longitudinal continuity of treatment may positively influence users’ perceptions regarding satisfaction with and problem-solving capacity of the actions implemented²⁶26 . Beattie P, Dowda M, Turner C, Michener L, Nelson R. Longitudinal continuity of care is associated with high patient satisfaction with physical therapy. Phys Ther [Internet]. 2005 [acesso 2012 Dez 4]; 85(10):1046-52. Disponível em: http://ptjournal.apta.org/content/85/10/1046
http://ptjournal.apta.org/content/85/10/... . As identified in the present study, discontinuity of treatment with the same physiotherapist not only interferes with the establishment of professional-user linkage, but also directly influences the problem-solving capacity relating to the main complaint. These comments highlight how important it is for professional physiotherapists to have autonomy for evaluating, discerning and deliberating in relation to the need for individualized interventions for each user.

There is therefore a need to make actions uniform and to achieve greater agility so that users can gain continuity of treatment more rapidly. Moreover, it is important to improve the information and publicize the paths that users need to follow through the system in order to benefit from physiotherapeutic services.

Thus, it was possible to observe that the complaints relating to outpatient physiotherapeutic care through SUS were more related to difficulties in accessing these services. It should be emphasized that even with all the difficulties reported, most of the patients considered that the physiotherapy service provided a solution. We cannot avoid reflecting on the possibility that the lack of criticism of the services may have been due to fear of harming the care provided, or due to a relationship of dependency with the healthcare professionals, which was previously broached by Fréz and Nobre (2011)³3 . Fréz AR, Nobre MIRS. Satisfação dos usuários dos serviços ambulatoriais de fisioterapia da rede pública. Fisioter Mov. 2011; 24(3):419-28..

Another factor that may have contributed towards the lack of stronger criticism may have been the low schooling level of the interviewees. The lower the schooling level is, the greater the difficulty that these individuals have in presenting a critical view regarding the services provided⁵5 . Machado NP, Nogueira LT. Avaliação da satisfação dos usuários de serviços de Fisioterapia. Braz J Phys Ther. 2008; 12(5):401-8.. The National Committee on Health Determinants (CNDSS; 2008)²⁹29 . Comissão Nacional sobre Determinantes Sociais da Saúde - CNDSS. As causas sociais das iniquidades em saúde no Brasil. Rio de Janeiro: Ed. Fiocruz; 2008. discussed the effects of schooling levels on the health of populations, such as in relation to their perception of healthcare problems, their capacity to understand information about healthcare and their consumption and use of healthcare services. Thus, it has increasingly been shown necessary to improve access to information among SUS users, regarding quality healthcare as a constitutional right³⁰30 . Constituição. Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988.. In addition to the benefits for users themselves, in the sense of strengthening their critical opinions and providing empowerment and autonomy, this also favors the flow of care provision and a healthcare network that is more responsive and resolutive.

From the same perspective, due to low numbers of years in formal education, we found that the majority of the interviewees were in occupations at technical level. These individuals’ economic limitations due to their placement in the labor market had an impact on their family incomes and consequently on their access to healthcare. Assis and Jesus²⁸28 . Assis MM, Jesus WIA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Cienc Saude Colet. 2012; 17(11):2865-75. correlated low income with difficulty in accessing healthcare services and claimed that individuals belonging to economically impaired social classes sought such services less or presented greater difficulty in benefiting from them. It is possible that the association between these factors and the users’ lower critical capacity led them to identify approaches of questionable quality as good.

Even though the majority of the users spoke positively of the problem-solving capacity of physiotherapy, the opinions of those who did not consider that physiotherapy provided a solution, along with the difficulties reported by all the interviewees, are of fundamental importance for reorganizing the public healthcare services.

Managers and teams of workers should also consider the possibility of accepting unqualified and overestimated offers from users, given that autonomy, empowerment and participation by this segment in controlling services is still at an initial stage in most healthcare networks.

Final remarks

The profile of outpatient physiotherapy users served by SUS in Campo Grande, MS, is characterized by male individuals of low schooling level who are at an economically active age, and who are in a position to travel by means of public transport or car to receive physiotherapeutic care. The main reasons for referral for outpatient physiotherapy through SUS found in this study related to bone-muscle-joint disorders. Thus, it can be understood that users with neurological disorders or disorders of other nature, with difficulties relating to physical and financial access, or without a medical referral, were not receiving physiotherapeutic attention at outpatient level.

Most of the interviewees considered that the outpatient physiotherapy available through SUS in this municipality provided a solution, since it reduced the pain symptoms and improved functionality. The difficulties in using the physiotherapy services that were mentioned related to the distance from users’ homes to the clinics and the bureaucracy involved in making appointments. The distance limited the physical-financial access and the bureaucracy interfered with the continuity and consequently the problem-solving capacity of the treatment.

For better physiotherapeutic care with greater problem-solving capacity, the care network needs to be reorganized with regard to bureaucratic issues, such as the need to return to the doctor solely with the aim of ensuring referral, and the need to expand the physiotherapy services in different regions of the municipality and the number of physiotherapists for secondary care within SUS. Moreover, it can be understood that these measures do not benefit users requiring physiotherapy who are not in a condition to travel to the clinics, or are restricted to their homes or are bedridden. Thus, it is important to establish home care services, instituted by SUS³¹31 . Portaria nº 2.029 de 24 de agosto de 2011. Institui a Atenção Domiciliar no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 2011 Ago 24. and to introduce physiotherapists into these settings. It is recommended that studies should be conducted to survey the demand among users who are not in a condition to travel to physiotherapy clinics and who remain without access to physiotherapeutic care through SUS, given that this was not taken into consideration through the methodology of the present study.

Finally, it can be understood that simply improving access and the availability of slots within the system is insufficient for ensuring problem-solving care. For this, the professionals should be qualified to promote functional health among users requiring physiotherapeutic services, and users need to develop autonomy, social participation and commitment to care for their own health.

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