ABSTRACT:

Introduction:

Primary care is considered a gateway to other levels of care, however, men seek mainly specialized or emergency services, especially when they already have some affection.

Objective:

the objective was to verify how male users evaluate first contact access in primary care.

Methodology:

Cross-sectional study, conducted in Campina Grande/PB, from October 2016 to February 2017, with 384 men. A sociodemographic form and the Primary Care Assessment Tool (PCATool) were used.

Results:

There was an association between service use and age (p = 0.001), income (p = 0.036), creed (p = 0.018) and knowledge of the National Men’s Health Policy (p = 0.007); The components of first contact access (utilization and accessibility) obtained a score of 5.79 and 2.7 respectively, being this attribute considered by users as poorly oriented to primary care. Ensuring accessibility and reception in primary care is critical. The service must be organized to have the ability to receive and respond positively to the health demands of the population, to have resoluteness and ability to link the service with the user.

Conclusion:

Users do not perceive primary care as a gateway to the health system, and efforts should be made to ensure first contact access.

Keywords:
Health services accessibility; Primary health care; Health services evaluation; Health evaluation; Health policy

INTRODUCTION

In 2008, the high morbidity and mortality rates among the male population led the Ministry of Health, following other health policies, to formulate the National Men’s Health Policy (Política Nacional de Assistência Integral à Saúde do Homem - PNAISH) to bring men closer to the health service, focusing on primary care¹1. Duarte S, Oliveira J, Souza R. A Política Saúde do Homem e sua operacionalização na Atenção Primária à Saúde. Gestão Saúde 2012; 3(1): 308-17.^,22. Moura EC, Santos W, Neves ACM, Gomes R, Schwarz E. Atenção à saúde dos homens no âmbito da Estratégia de Saúde da Família. Ciênc Saúde Coletiva 2014; 19(2): 429-38. https://doi.org/10.1590/1413-81232014192.05802013
https://doi.org/https://doi.org/10.1590/... ^,33. Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde do Homem (princípios e diretrizes). Brasília: MS; 2008.^,44. Ramalho MNA, Albuquerque AM, Maia JKF, Pinto MB, Santos NCCB. Dificuldades na implantação da política nacional de atenção integral à saúde do homem. Ciênc Cuid Saúde 2014; 13(4): 642-9. https://doi.org/10.4025/cienccuidsaude.v13i4.18420
https://doi.org/https://doi.org/10.4025/... .

To ensure the active participation of individuals, PNAISH combines efforts with the National Primary Health Care Policy (Política Nacional de Atenção Básica - PNAB), whose guideline proposes encouraging people’s participation, autonomy, and the capacity to build care, seeking to mitigate inequalities and prevent social exclusion. In this scenario, the National Policy of Health Promotion also has among its guidelines social participation as an essential instrument to achieve health promotion and individual empowerment results⁵5. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília: MS; 2012.^,66. Brasil. Portaria nº 2.446, de 11 de novembro de 2014. Redefine a Política Nacional de Promoção da Saúde (PNPS). Diário Oficial da União. 2014..

Despite the rights and guarantees provided by the policies mentioned above, the small demand for primary care services by male users is evident, demonstrating the need of reinforcing to this population the idea that primary care is the first level of the health system and can satisfy their needs, in order to prioritize health promotion and disease prevention actions, as well as assistance with their problems⁷7. Codogno JS, Turi BC, Fernandes RA, Monteiro HL. Comparação de gastos com serviços de atenção básica à saúde de homens e mulheres em Bauru, São Paulo, 2010. Epidemiol Serv Saúde 2015; 24(1): 115-22. https://doi.org/10.5123/S1679-49742015000100013
https://doi.org/https://doi.org/10.5123/... ^,88. Starfield B. Atenção Primária: equilíbrio entre necessidade de saúde, serviços e tecnologia. Brasília: Ministério da Saúde; 2002..

This awareness is necessary for men to see primary care as an opportunity of using the services offered in the first assistance level. Such understanding, associated with the capacity of the service in satisfying this demand, can result in a lower concentration of health conditions and diseases and increased utilization of services available in primary health care (PHC)⁹9. Sanchez RM, Ciconelli RM. Conceitos de acesso à saúde. Rev Panam Salud Publica 2012; 31(3): 260-8..

In Brazil, PHC operationalization follows the Starfield model⁸8. Starfield B. Atenção Primária: equilíbrio entre necessidade de saúde, serviços e tecnologia. Brasília: Ministério da Saúde; 2002., which classifies the essential PHC attributes - first-contact care, longitudinality, comprehensiveness, and coordination of care -, in addition to three derivative attributes - family-centeredness, community orientation, and cultural competence. Thus, first-contact care is regarded as the ability of the subject to access the health service and using it as a source of care whenever they have a new problem or episode⁸8. Starfield B. Atenção Primária: equilíbrio entre necessidade de saúde, serviços e tecnologia. Brasília: Ministério da Saúde; 2002.^,1010. Harzheim E, Gonçalves MR, Oliveira MMC, Trindade TG, Agostinho MR, Hauser L. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool PCATool - Brasil. Brasília: Ministério da Saúde ; 2010.^,1111. Brasil. Conselho Nacional de Secretários de Saúde. Atenção Primária e Promoção da Saúde. Brasília: Conselho Nacional de Secretários de Saúde; 2011..

Starfield⁸8. Starfield B. Atenção Primária: equilíbrio entre necessidade de saúde, serviços e tecnologia. Brasília: Ministério da Saúde; 2002. divides first-contact care in accessibility and utilization. Accessibility is understood as a structural care element because the service must be accessible when the individual needs it, be it regarding its working hours, location, or the possibility of treatment through planned or scheduled appointments⁸8. Starfield B. Atenção Primária: equilíbrio entre necessidade de saúde, serviços e tecnologia. Brasília: Ministério da Saúde; 2002.^,1212. Assis MMA, Jesus WLA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Ciênc Saúde Coletiva 2012; 17(11): 2865-75. https://doi.org/10.1590/S1413-81232012001100002
https://doi.org/https://doi.org/10.1590/... .

Utilization is considered a combination of the subject’s direct contact and the service provided, which, together with the means available to the user for accessing the service and their perceived health, will facilitate solving their problems, verifying the effectiveness of the actions performed and, consequently, their satisfaction with care¹³13. Travassos C, Castro MSM. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI. Políticas e Sistemas de Saúde no Brasil. 2ª ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 183-206.^,1414. Reis RS, Coimbra LC, Silva AAM, Santos AM, Alves MTSS, Lamy ZC, et al. Access to and use of the services of the family health strategy from the perspective of managers, professionals and users. Ciênc Saúde Coletiva 2013; 18(11): 3321-31. https://doi.org/10.1590/S1413-81232013001100022
https://doi.org/https://doi.org/10.1590/... .

However, a better understanding of men’s health is necessary, particularly concerning the access to and utilization of health services so as to analyze and plan actions that meet the demands of this population¹⁵15. Silva PLN, Maciel MM, Carfesan CS, Santos S, Souza JR. A Política de Atenção à Saúde do homem no Brasil e os desafios da sua implantação: uma revisão integrativa. Enferm Glob 2013; 12(32): 414-443.. Therefore, conducting a study to provide support to PNAISH, and consequently, help improve care for these users is necessary¹⁶16. Martins AM, Malamut BS. Análise do discurso da política nacional de atenção integral à saúde do homem. Saúde Soc 2013; 22(2): 429-40. https://doi.org/10.1590/S0104-12902013000200014
https://doi.org/https://doi.org/10.1590/... .

To this end, adopting tools capable of evaluating actions in the context of men’s health is essential. This assessment acts as an instrument to obtain a value judgment, be it about an intervention or its components, as well as assist in decision making¹⁷17. Contandriopoulos A-P, Champagne F, Denis J-I, Pineault R. A avaliação na área da saúde: conceitos e métodos. In: Hartz ZMA, organizador. Avaliação em Saúde: dos modelos conceituais à prática na análise da implantação de programas. Rio de Janeiro: Editora Fiocruz ; 1997. p. 29-47.. The assessment focuses on reducing decision-related uncertainties, creating a new perspective about possible consequences and effects of policy implementation¹⁸18. Novaes HMD. Avaliação de programas, serviços e tecnologias em saúde. Rev Saúde Pública 2000; 34(5): 547-9. https://doi.org/10.1590/S0034-89102000000500018
https://doi.org/https://doi.org/10.1590/... ^,1919. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Coordenação de Acompanhamento e Avaliação. Avaliação na atenção básica em saúde: caminhos da institucionalização. Brasília: MS , 2005..

Hence, this study is justified, as it aims to contribute to knowledge production targeted at the male population, especially concerning primary care, given that this issue still needs further investigation. In this context, we sought to determine how male users evaluate first-contact primary care.

METHODS

This is a quantitative analytical cross-sectional study performed in the city of Campina Grande, Paraíba, Brazil, from October 2016 to February 2017. The study sample consisted of men registered in Basic Health Units (Unidades Básicas de Saúde - UBS).

The adult male population of Campina Grande comprises 101,459 men aged 20 to 59 years²⁰20. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico 2010. Características gerais da população, religião e pessoas com deficiência. Rio de Janeiro: IBGE; 2012.. In order to estimate a representative sample, we used the formula expressed by Equation 1 ²¹21. Luiz RR, Magnanini MM. A lógica da determinação do tamanho da amostra em investigações epidemiológicas. Cad Saúde Coletiva 2000; 8(2): 9-28.:

In which:

• n = sample value;
• Z = confidence interval (1.96);
• N = population;
• P = prevalence;
• e = tolerable error (0.05).

This study adopted a prevalence of 0.5. After the calculation, we obtained n = 384. The municipality has 80 UBS, distributed into eight health districts. We chose to conduct the research in the urban area, excluding all other administrative districts and rural areas that constitute the municipality, resulting in 62 units in six districts.

A simple random draw was carried out to operationalize the research process, with probability proportional to the number of UBS in each health district, totaling 12 units. Inclusion criteria were: participants aged 20 to 59 years - target age group of PNAISH - and registered in the UBS for at least six months.

The strategy used to approach the subjects for data collection was a household visit, with the presence of the community health agent (agente comunitário de saúde - ACS) responsible for the microarea of the corresponding Family Health Strategy (Estratégia Saúde da Família - ESF). To that end, we surveyed houses registered in the household and territorial record of e-SUS, as well as a draw of households. If no men aged 20 to 59 years lived in the household, the next record was selected.

Data were collected with an instrument aimed at investigating demographic and socioeconomic variables, in addition to questions from the Primary Care Assessment Tool (PCATool) and about their knowledge of PNAISH.

Validated for Brazil, PCATool is considered the closest instrument to the ESF proposal, being, therefore, suitable for this evaluation²²22. Harzheim E, Oliveira MMC, Agostinho MR, Hauser L, Stein AT, Gonçalves MR, et al. Validação do instrumento de avaliação da atenção primária à saúde: PCATool-Brasil adultos. Rev Bras Med Fam Comunidade 2013; 8(29): 274-84. https://doi.org/10.5712/rbmfc8(29)829
https://doi.org/https://doi.org/10.5712/... ^,2323. Fracolli LA, Gomes MFP, Nabão FRZ, Santos MS, Cappellini VK, Almeida ACC de. Primary health care assessment tools: a literature review and metasynthesis. Ciênc Saúde Coletiva 2014; 19(12): 4851-60. https://doi.org/10.1590/1413-812320141912.00572014
https://doi.org/https://doi.org/10.1590/... . The tool allows measuring the presence and extent of PHC essential and derivative attributes. The adult version of PCATool has 87 items divided into 10 components related to PHC attributes:

Each attribute can be evaluated separately. This study assessed first-contact care (utilization and accessibility)¹⁰10. Harzheim E, Gonçalves MR, Oliveira MMC, Trindade TG, Agostinho MR, Hauser L. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool PCATool - Brasil. Brasília: Ministério da Saúde ; 2010..

PCATool is an instrument with a Likert scale, with responses ranging from 1 to 4:

We added the option 9, which corresponds to I do not know/do not remember.

The answers to the items allowed us to calculate a score for each PHC attribute and their components, as well as the essential and general score. Scores for each attribute and component were obtained by the arithmetic average of responses related to the respective item, as follows (Equation 2):

In order to achieve the objective of this study, we transformed the scores of components of the first-contact care attribute, as well as the utilization component (Equation 3) and the accessibility component (Equation 4), as follows:

Next, we transformed the score into a 0-10 scale using Equation 5:

Score was considered high or primary care-oriented when the result was greater than or equal to 6.6 and low or poorly oriented to primary care when the result was lower than 6.6¹⁰10. Harzheim E, Gonçalves MR, Oliveira MMC, Trindade TG, Agostinho MR, Hauser L. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool PCATool - Brasil. Brasília: Ministério da Saúde ; 2010.^,2424. Hauser L, Castro RCL, Vigo A, Trindade TG, Gonçalves MR, Stein AT, et al. Tradução, adaptação, validade e medidas de fidedignidade do Instrumento de Avaliação da Atenção Primária à Saúde (PCATool) no Brasil: versão profissionais de saúde. Rev Bras Med Fam 2013; 8(29): 244-55. https://doi.org/10.5712/rbmfc8(29)821
https://doi.org/https://doi.org/10.5712/... .

Data were entered into Excel 2016 and exported to the Statistical Package for Social Sciences (SPSS), version 20., for analysis. As with most studies that adopt the PCATool, the findings were expressed as mean and standard deviation²⁵25. Brunelli B, Gusso GDF, Santos IS, Benseñor IJM. Avaliação da presença e extensão dos atributos de atenção primária em dois modelos coexistentes na rede básica de saúde do Município de São Paulo. Rev Bras Med Fam Comunidade 2016; 11(38): 1-12. https://doi.org/10.5712/rbmfc11(38)1241
https://doi.org/https://doi.org/10.5712/... , including the 95% confidence interval (95%CI), minimum and maximum scores, and median.

Results related to demographic profile were expressed as absolute and relative frequencies of the items, mean, median, minimum and maximum scores, standard deviation, and 95%CI. The independent variables used to test the association were: age, creed, ethnicity, marital status, schooling, number of people living with the subject, household and per capita income, in addition to knowledge about PNAISH. The utilization and accessibility components were assessed as dependent variables.

We verified the association using the χ² test. When more than 20% of the expected frequencies were lower than 5, we performed Fisher’s exact test or the likelihood ratio test. Data are presented in tables.

The study complied with the ethical precepts listed in Resolution no. 466/12 of the National Health Council (NHC) and is registered in the Research Ethics Committee of Universidade Estadual da Paraíba (UEPB).

We declare that we respected ethical aspects when conducting this research since it involved human beings. The Research Ethics Committee previously approved this research, under the Certificate of Presentation for Ethical Consideration (Certificado de Apresentação para Apreciação Ética - CAAE): 56386516.3.0000.5187.

RESULTS

Table 1 presents the sociodemographic profile of participants. When questioned about PNAISH, 70.3% (n = 270) of interviewees reported not knowing the policy, while 29.7% (n=114) declared knowing it.

Table 2 shows the item scores of the utilization component. Item B1 - When you need a return visit, do you go to UBS before going to another health service? - had a mean score of 6.78, followed by item B3 - Is UBS your only means of referral to a specialized service? -, with 5.48, while item B2 - When you have a new health problem, is UBS the first service you seek? - presented the lowest score: 5.12.

In the accessibility component (Table 3), all items had scores below recommended levels. The worst scores were identified in items C1 - UBS opens on Saturdays or Sundays; C2 - UBS opens some evenings until 8 p.m.; C6 - UBS provides support on weekends if the patient is sick; and C7 - UBS provides care even at night if the patient is sick; all with mean scores below 1.

Table 4 presents the association of the utilization and accessibility components and the first-contact care attribute with sociodemographic and PNAISH knowledge variables. Thus, we can infer 53.4% (n = 205) of users evaluated the utilization component as greater than or equal to 6.6; however, the mean score was 5.79, making it not primary care-oriented. The accessibility component was assessed by 99.7% (n = 383) of users as not primary care-oriented, with a mean score of 2.7. We found an association between the utilization component and age (p = 0.02), income (p = 0.036), creed (p = 0.018), and PNAISH knowledge (p = 0.007).

DISCUSSION

Access to primary care is an essential tool for reducing morbidity and mortality rates, particularly when it promotes the subject’s first proper contact with the service⁸8. Starfield B. Atenção Primária: equilíbrio entre necessidade de saúde, serviços e tecnologia. Brasília: Ministério da Saúde; 2002.. Moreover, a health system based on primary care must have a series of structural and process elements aimed at promoting and ensuring adequate coverage for the population and universal access to services, as well as equality growth²⁶26. Oliveira BR, Viera CS, Collet N, Lima RA. Access first contact in primary health attention for children. Rev Rene 2012; 13(2): 332-42..

The findings of this study show men’s negative evaluation of first-contact care, as the components of this attribute obtained scores below recommended levels, demonstrating that male subjects considered the service poorly oriented to primary care in these aspects.

When assessing the utilization component according to frequency, the study revealed that approximately half of the men evaluated the item positively, with a higher percentage among those older than 40 years, evidencing an association between age and service utilization. This finding corroborates those of investigations that indicate a higher demand for health services among men, especially in the public system, with 57% prevalence, as well as increased demand for services with age²⁷27. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003-2008. Ciênc Saúde Coletiva 2011; 16(9): 3807-16. https://doi.org/10.1590/S1413-81232011001000016
https://doi.org/https://doi.org/10.1590/... ^,2828. Arruda GO, Mathias TAF, Marcon SS. Prevalência e fatores associados à utilização de serviços públicos de saúde por homens adultos. Ciênc Saúde Coletiva 2017; 22(1): 279-90. https://doi.org/10.1590/1413-81232017221.20532015
https://doi.org/https://doi.org/10.1590/... .

Studies suggest both income and creed are associated with the utilization component among men and creed could positively influence health conditions and the adoption of healthy behaviors by the subject²⁷27. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003-2008. Ciênc Saúde Coletiva 2011; 16(9): 3807-16. https://doi.org/10.1590/S1413-81232011001000016
https://doi.org/https://doi.org/10.1590/... ^,2929. Arruda GO, Marcon SS. Survey on the use of health services by adult men: prevalence rates and associated factors. Rev Latino-Am Enfermagem 2016; 24: e2685. https://doi.org/10.1590/1518-8345.0296.2685
https://doi.org/https://doi.org/10.1590/... .

The utilization item best evaluated by men addressed whether the service is the first they seek for a return visit, revealing men usually access the service for consultations, corroborating a study developed in Southern Brazil, which reached a prevalence of medical visits in health services of 45.6% with no difference between genders. Among the services analyzed, the most used for medical visits was UBS (49.5%)³⁰30. Bastos GAN, Duca GFD, Hallal PC, Santos IS. Utilização de serviços médicos no sistema público de saúde no Sul do Brasil. Rev Saúde Pública 2011; 45(3): 475-84. https://doi.org/10.1590/S0034-89102011005000024
https://doi.org/https://doi.org/10.1590/... ; however, this use was mainly for established diseases or morbidities, as preventive visits still present low demand among men²⁸28. Arruda GO, Mathias TAF, Marcon SS. Prevalência e fatores associados à utilização de serviços públicos de saúde por homens adultos. Ciênc Saúde Coletiva 2017; 22(1): 279-90. https://doi.org/10.1590/1413-81232017221.20532015
https://doi.org/https://doi.org/10.1590/... ^,2929. Arruda GO, Marcon SS. Survey on the use of health services by adult men: prevalence rates and associated factors. Rev Latino-Am Enfermagem 2016; 24: e2685. https://doi.org/10.1590/1518-8345.0296.2685
https://doi.org/https://doi.org/10.1590/... ^,3131. Oliveira MM, Daher DV, Silva JLL, Andrade SSCA. Men’s health in question: seeking assistance in primary health care. Ciênc Saúde Coletiva 2015; 20(1): 273-8. https://doi.org/10.1590/1413-81232014201.21732013
https://doi.org/https://doi.org/10.1590/... .

When assessing whether UBS is the first service the user seeks in case of a new health issue, episode, or condition, the mean score was low, showing men do not see primary care as the first health care option. The literature demonstrates that men judge the service unable to meet their demands, especially in a timely manner, complaining of the wait to receive medical care. Also, men believe seeking a health service is an expression of weakness and feel ashamed in doing so²2. Moura EC, Santos W, Neves ACM, Gomes R, Schwarz E. Atenção à saúde dos homens no âmbito da Estratégia de Saúde da Família. Ciênc Saúde Coletiva 2014; 19(2): 429-38. https://doi.org/10.1590/1413-81232014192.05802013
https://doi.org/https://doi.org/10.1590/... ^,3232. Storino LP, Souza KV, Silva KL. Men’s health needs in primary care: user embracement and forming links with users as strengtheners of comprehensive health care. Esc Anna Nery 2013; 17(4): 638-45. https://doi.org/10.5935/1414-8145.20130006
https://doi.org/https://doi.org/10.5935/... ^,3333. Cavalcanti JRD, Ferreira JA, Henriques AHB, Morais GSN, Trigueiro JVS, Torquato IMB. Integral Assistance to Men’s Health: needs, barriers and coping strategies. Esc Anna Nery 2014; 18(4): 628-34. https://doi.org/10.5935/1414-8145.20140089
https://doi.org/https://doi.org/10.5935/... . The fact that men do not consider the service effective can discourage access and utilization.

As to whether UBS is the only means of referral to a specialist, the mean score was below recommended levels. Study conducted in Paraíba based on data from the National Program for Improving Access and Quality of Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ) identified users leave the health unit with an appointment in 10.2% of family health teams, while 47.2% of appointments are scheduled by UBS and only latter the date is informed to the user, leading to prolonged wait and, consequently, user dissatisfaction³⁴34. Protasio APL, Silva PB, Lima EC, Gomes LB, Machado LS, Valença AMG. Avaliação do sistema de referência e contrarreferência do estado da Paraíba segundo os profissionais da Atenção Básica no contexto do 1o ciclo de Avaliação Externa do PMAQ-AB. Saúde em Debate 2014; 38(Núm. Esp.): 209-20. https://doi.org/10.5935/0103-1104.2014S016
https://doi.org/https://doi.org/10.5935/... .

We found no study in the literature indicating an association between PNAISH knowledge and utilization; however, the PNAB guideline states the importance of user participation in increasing their autonomy and the capacity of building care for individuals and communities. Therefore, encouraging users to access the service to which they are registered becomes important. That way, they can be informed about policies and participate in discussions for their implementation and quality improvement⁵5. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília: MS; 2012..

With respect to the accessibility component, most subjects evaluated this component as poorly oriented to primary care with a low mean score. Study conducted in Recife³⁵35. Santiago RF, Mendes ACG, Miranda GMD, Duarte PO, Furtado BMASM, Souza WV. Qualidade do atendimento nas Unidades de Saúde da Família no município de Recife: a percepção dos usuários. Ciênc Saúde Coletiva 2013; 18(1): 35-44. https://doi.org/10.1590/S1413-81232013000100005
https://doi.org/https://doi.org/10.1590/... also detected dissatisfaction among UBS users in this respect, reporting that impairment in this component compromises one of the main UBS goals - be the entry point into an effective and universal health system.

A non-accessible service creates a barrier, preventing it from being used by potential users. Accessibility is directly connected to what the population expects from the service, representing the main issue to be overcome by the user¹²12. Assis MMA, Jesus WLA. Acesso aos serviços de saúde: abordagens, conceitos, políticas e modelo de análise. Ciênc Saúde Coletiva 2012; 17(11): 2865-75. https://doi.org/10.1590/S1413-81232012001100002
https://doi.org/https://doi.org/10.1590/... ^,1313. Travassos C, Castro MSM. Determinantes e desigualdades sociais no acesso e na utilização de serviços de saúde. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI. Políticas e Sistemas de Saúde no Brasil. 2ª ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 183-206.. However, according to PNAB, primary care should be the preferred contact by users, the main entry point into the health care system. It should be guided by principles, such as accessibility, and have mechanisms to ensure their full application⁵5. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília: MS; 2012..

When evaluating accessibility items, the elements UBS opens on weekends and UBS opens some evenings until 8 p.m. had scores below recommended levels. In this regard, study conducted in Paraíba suggests the need for restructuring UBS working hours, especially the night shift, given that this population has rigid schedules due to their participation in the labor market³³33. Cavalcanti JRD, Ferreira JA, Henriques AHB, Morais GSN, Trigueiro JVS, Torquato IMB. Integral Assistance to Men’s Health: needs, barriers and coping strategies. Esc Anna Nery 2014; 18(4): 628-34. https://doi.org/10.5935/1414-8145.20140089
https://doi.org/https://doi.org/10.5935/... .

Schedule-related issues were evidenced when users were questioned about the need to miss work or school to be able to visit the health service, in addition to the difficulty in scheduling an appointment when necessary. Moreover, men’s aversion to the service can be explained by the difficulty of the service in solving problems when required, the waiting period longer than 30 minutes to consult a professional, the hardship of scheduling appointments, and the lack of medical care, as well as the ineffectiveness of the service in satisfying health demands from this population, the struggle to have access to tests and exams, and the prolonged care, motivating evasion³³33. Cavalcanti JRD, Ferreira JA, Henriques AHB, Morais GSN, Trigueiro JVS, Torquato IMB. Integral Assistance to Men’s Health: needs, barriers and coping strategies. Esc Anna Nery 2014; 18(4): 628-34. https://doi.org/10.5935/1414-8145.20140089
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In addition, a concerning fact is the obstacles faced by users when it comes to getting phone advice in case of doubts about their health, communication when the UBS is closed, and support by UBS professionals when the user gets ill on weekends or evenings. This concern is related to reports from the literature that indicate the connection between users and primary care staff as an important tool to promote the construction of new relations, allowing a closer interaction of the user with UBS and favoring the adherence to health services as the user starts believing in them³³33. Cavalcanti JRD, Ferreira JA, Henriques AHB, Morais GSN, Trigueiro JVS, Torquato IMB. Integral Assistance to Men’s Health: needs, barriers and coping strategies. Esc Anna Nery 2014; 18(4): 628-34. https://doi.org/10.5935/1414-8145.20140089
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Considering what has been described in the literature, our findings reinforce the idea of a differentiated service for this population, either by having special working hours at night, at least on some days of the week, or by opening on weekends, with the purpose of eliminating barriers to primary care access among men. To this end, implementing pilot units could be a strategy to assess if the night service is effective.

Ensuring accessibility and user embracement in primary care is crucial. Therefore, the service must prepare to receive the population, respond positively to their health demands, be effective and capable of connecting service and users, as well as solve their problems. These aspects are essential to establish primary care as the contact and entry point into other health levels⁵5. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília: MS; 2012..

A limitation of this investigation was evaluating only one PHC attribute, and we emphasize the need for studies to verify the remaining attributes and provide a better understanding of men’s evaluation of the service. Despite the limitation mentioned, the many barriers related to men’s health became evident, with access being one of the most important to overcome. Therefore, we suggest further studies to expand knowledge that could promote men’s access to primary care, especially to monitor the social determinants of health.

CONCLUSION

The study showed male users evaluate first-contact care negatively and consider the service as poorly oriented to primary care. Despite the efforts made by the public sector, including the formulation of PNAISH, men still do not see primary care as the entry point into health services. Thus, efforts are necessary to ensure the first contact-care in particular, making this population realize the importance of primary care and use the services provided. One of PNAISH priorities is to strengthen ESF, allowing men’s full access to health with one of the actions targeted at access and embracement of this demand. Although the policy is recent - less than ten years -, we underline the negative evaluation of primary care by the men in this study, which suggests PNAISH still has not reached full effectiveness in these components.

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