ABSTRACT:

Objective:

Communication barriers are the main obstacle for people with sensory disabilities (visual and hearing) to access health services. This study aims to describe the presence of facilitators of communication of basic health units in Brazil and to verify its associated factors.

Methods:

Cross-sectional multilevel study, of 38,811 health units in 5,543 municipalities between 2012 and 2013, collected in the National Program for Improving Access and Quality in Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ-AB). The outcome was defined by grouping facilitators of communication (braille material; hearing resources; visual communication; accessible list of service; professionals to welcome users with sensory disabilities). The two levels were structured, using the variables: level I (contextual): macro region, population size, and GDP per capita; and level II (service): extended professional team (psychologist/social worker); service shifts; welcoming room; publishing of service hours; presence of physical access facilitators. Multilevel Poisson regression with hierarchical modeling was used in both stages.

Results:

The presence of facilitators of communication is small in Brazilian health units (32.1%). It is more frequent in the municipalities with a higher GDP (RP = 1.02, 95%CI 0.92 - 1.12) and population size (RP = 1.25, 95%CI 1.02 - 1.52).

Conclusion:

Welcoming users is the main access facilitator and should be the focus of initiatives to improve health care for disabled persons. Universal access with adequate services, removal of communication barriers and encouragement to properly welcome users must be promoted.

Keywords:
Communication barriers; Primary health care; Disabled persons; User embracement

INTRODUCTION

Physical and sensory disabilities (auditory and visual) are the most prevalent disabilities both in Brazil and in the world, and population aging is directly related to the increase in these types of disabilities, because they are mostly acquired throughout life¹1. Stevens GA, White RA, Flaxman SR, Price H, Jonas JB, Keeffe J, et al. Global Prevalence of Vision Impairment and Blindness: Magnitude and Temporal Trends, 1990-2010, Ophthalmology 2013; 120(12): 2377-84. https://doi.org/10.1016/j.ophtha.2013.05.025
https://doi.org/https://doi.org/10.1016/... ^,22. Malta DC, Stopa SR, Canuto R, Gomes NL, Mendes VL, Goulart BN, et al. Prevalência autorreferida de deficiência no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Ciên Saúde Coletiva 2016; 21(10): 3253-64. https://doi.org/10.1590/1413-812320152110.17512016
https://doi.org/https://doi.org/10.1590/... . The global prevalence of disabilities is 15.3% of the population; of serious disabilities, with a major impairment of daily skills, the percentage is 2.9%. However, among elderly individuals (over 60 years old), 10.2% report severe disabilities and need care³3. World Health Organization. Global data on visual impairments 2010. Genebra: World Health Organization; 2012.. In Brazil, the prevalence of self-reported disability was 6.2% (about 12.4 million people), increasing to 18.2% among the elderly. Visual disability was the most frequent one (3.6%), and hearing disabilities affect 1.1% of the population. The prevalence of both increases with age (11.5 and 5.2% at 60 years old, respectively)²2. Malta DC, Stopa SR, Canuto R, Gomes NL, Mendes VL, Goulart BN, et al. Prevalência autorreferida de deficiência no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Ciên Saúde Coletiva 2016; 21(10): 3253-64. https://doi.org/10.1590/1413-812320152110.17512016
https://doi.org/https://doi.org/10.1590/... . This distribution of deficiencies is similar to the figures presented in other countries, such as in China⁴4. Zheng X, Chen G, Song X, Liu J, Yan L, Du W, et al. Twenty-year trends in the prevalence of disability in China. Bull World Health Organ 2011; 89: 788-97. https://doi.org/10.2471/BLT.11.089730
https://doi.org/https://doi.org/10.2471/... and the United States⁵5. Schiller JS, Lucas JW, Peregoy JA. Summary health statistics for U.S. adults: National Health Interview Survey, 2011. Vital Health Stat 10 2012; (256): 1-218..

Disabled persons present more health needs which are not met⁶6. Casey R. Disability and unmet health care needs in Canada: A longitudinal analysis. Disabil Health J 2015; 8(2): 173-81. https://doi.org/10.1016/j.dhjo.2014.09.010
https://doi.org/https://doi.org/10.1016/... ^,77. Krahn GL, Walker DK, Correa-De-Araujo R. Persons with disabilities as an unrecognized health disparity population. Am J Public Health 2015; 105(S2): S198-S206. https://doi.org/10.2105/AJPH.2014.302182
https://doi.org/https://doi.org/10.2105/... , that is, they report greater difficulty in being able to solve health problems compared to non-disabled persons. Access to health services is also more difficult⁸8. de Vries McClintock HF, Barg FK, Katz SP, Stineman MG, Krueger A, Colletti PM, et al. Health care experiences and perceptions among people with and without disabilities. Disabil Health J 2016; 9(1): 74-82. https://doi.org/10.1016/j.dhjo.2015.08.007
https://doi.org/https://doi.org/10.1016/... . The barriers to this access can be classified into three categories: structural, financial, and personal/cultural⁹9. Institute of Medicine. Access to health care in America. Washington, D.C.: National Academy Press; 1993.. These barriers do not compromise access only for disabled persons, but they tend to be more severe for this portion of the population¹⁰10. Scheer J, Kroll T, Neri MT, Beatty P. Access barriers for persons with disabilities: the consumer’s perspective. J Disabil Policy Stud 2003; 13(4): 221-30. https://doi.org/10.1177/104420730301300404
https://doi.org/https://doi.org/10.1177/... ^,1111. Drainoni ML, Lee-Hood E, Tobias C, Bachman SS, Andrew J, Maisels L. Cross-disability experiences of barriers to health-care access: consumer perspectives. J Disabil Policy Stud 2006; 17(2): 101-15. https://doi.org/10.1177/10442073060170020101
https://doi.org/https://doi.org/10.1177/... .

People with hearing disabilities report barriers to communication as the main obstacle to health accessibility, both in relation to the interaction with health professionals and to the information available in the service¹²12. Alexander A, Ladd P, Powell S. Deafness might damage your health. Lancet 2012; 379(9820): 979-81. https://doi.org/10.1016/S0140-6736(11)61670-X
https://doi.org/https://doi.org/10.1016/... . The main complaints reported are: communication problems during clinical examination and anamnesis; difficulty in understanding the prescription, which interferes with drug safety; lack of information on the best form of non-verbal communication for deaf patients; difficulties in the waiting room and for scheduling appointments¹³13. Iezzoni LI, O’Day BL, Killeen M, Harker H. Communicating about health care: observations from persons who are deaf or hard of hearing. Ann Intern Med 2004; 140 (5): 356-62. https://doi.org/10.7326/0003-4819-140-5-200403020-00011
https://doi.org/https://doi.org/10.7326/... .

People with visual disabilities also have great difficulty in accessing health services. Barriers to communication, physical access, information (materials written in an inaccessible format) and attitudinal barriers were mentioned by blind or partially sighted people, such as lack of respect or concern in relation to the doctor’s thinking that patients are not capable of caring for their own health¹⁴14. O’Day BL, Killen M, Iezzoni LI. Improving health care experiences of persons who are blind or have low vision: suggestions from focus group. Am J Med Qual 2004; 19(5): 193-200. https://doi.org/10.1177/106286060401900503
https://doi.org/https://doi.org/10.1177/... . Elderly people with visual disabilities, when compared to elderly people with no disabilities, had more comorbidities and conditions secondary to diseases (such as diabetes, systemic arterial hypertension and stroke), greater limitation of activities of daily living, such as walking, preparing meals or taking medications, in addition to greater restriction of their social life¹⁵15. Crews J, Campbell V. Health Conditions, Activity Limitations, and Participation Restrictions Among Older People with Visual Impairments. J Vis Impair Blind 2001; 95(8): 453-67. https://doi.org/10.1177/0145482X0109500802
https://doi.org/https://doi.org/10.1177/... .

Health professionals also realize that the access of population with sensory disabilities is more complex, reporting greater difficulty when caring for people with limited communication and visual disabilities than when caring for those with reduced mobility or cognitive disability¹⁶16. Bachman SS, Vedrani M, Drainoni ML, Tobias C, Maisels L. Provider perceptions of their capacity to offer accessible health care for people with disabilities. J Disability Policy Stud 2006; 17(3): 130-36. https://doi.org/10.1177/10442073060170030101
https://doi.org/https://doi.org/10.1177/... . Both users and professionals report the need for training and continuing education of the health team to reduce barriers to communication¹⁷17. Morrison EH, George V, Mosqueda L. Primary care for adults with physical disabilities: perceptions from consumer and provider focus groups. Fam Med 2008; 40(9): 645-51., increased awareness and knowledge, the empowerment of disabled users and the creation of public policies to improve health care¹⁸18. McClintock HF, Kurichi JE, Barg FK, Krueger A, Colletti PM, Wearing KA, et al. Health care access and quality for persons with disability: Patient and provider recommendations. Disabil Health J 2018; 11(3): 382-9. https://doi.org/10.1016/j.dhjo.2017.12.010
https://doi.org/https://doi.org/10.1016/... .

The literature is very consistent in relation to the barriers to physical disabilities that hinder access to health units¹⁹19. Mudrick NR, Breslin ML, Liang M, Yee S. Physical accessibility in primary health care settings: results from California on-site reviews. Disabil Health J 2012; 5(3): 159-67. https://doi.org/10.1016/j.dhjo.2012.02.002
https://doi.org/https://doi.org/10.1016/... ^,2020. Siqueira FCV, Facchini LA, Silveira DS, Piccini RX, Thumé E, Tomasi E. Barreiras arquitetônicas a idosos e portadores de deficiência física: um estudo epidemiológico da estrutura física das unidades básicas de saúde em sete estados do Brasil. Ciên Saúde Coletiva 2009; 14(1): 39-44. https://doi.org/10.1590/S1413-81232009000100009
https://doi.org/https://doi.org/10.1590/... ^,2121. Martins KP, Costa TF, Medeiros TM, Fernandes MGM, França ISX, Costa KNFM. Estrutura interna de Unidades de Saúde da Família: acesso para as pessoas com deficiência. Ciênc Saúde Coletiva 2016; 21(10): 3153-60. https://doi.org/10.1590/1413-812320152110.20052016
https://doi.org/https://doi.org/10.1590/... . Nonetheless, there was no population-based study focusing on barriers to communication in primary health care services, which is a preferential gateway into the health care network. It is also assumed that the contextual variables, linked to the municipality in which health units of the referred studies are inserted, can influence the accessibility of services, given that primary care services are organized and offered by municipal health systems. Based on the above, the aims of the present study were to describe and analyze the facilitators of and barriers to access for using primary care services by people with sensory disabilities (hearing and visual).

METHODS

DESIGN

A cross-sectional and observational study was carried out, with a multilevel analytical approach, based on data from Cycle I of the National Program for Improving Access and Quality in Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ-AB) and contextual data from the municipalities.

SETTING

In 2011, Brazil implemented the National Program for Improving Access and Quality in Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ-AB), whose main objectives were to expand access and improve the quality of primary care²²22. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ): manual instrutivo. Brasília: Ministério da Saúde; 2012. 62 p.. The external evaluation of the PMAQ-AB was conducted in a multicenter and integrated manner by independent Education and Research Institutions, with direct monitoring by the Brazilian Ministry of Health. Cycle I of the PMAQ-AB took place between 2011 and 2013 throughout the Brazilian territory. The external evaluation instrument of the first PMAQ-AB cycle was organized into three modules:

In the present article, information from module I was used.

DATA COLLECTION

Data were collected in loco in all Brazilian UBS, between May and December 2012, with a standardized and previously tested instrument, using portable computers (tablets). The team coordinator responded to the data collection instrument, which was checked by the external evaluator. External evaluators, who collected the data, underwent a one-week training based on the field manual prepared by the Department of Primary Care (Departamento de Atenção Básica - DAB) of the Ministry of Health²³23. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Instrumento de Avaliação Externa do Saúde Mais Perto de Você - Acesso e Qualidade. Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). Brasília: Ministério da Saúde ; 2013. 126 p..

VARIABLES OF INTEREST

The variables of the block related to accessibility to users with visual and/or hearing disabilities, decreased vision and/or hearing or those who cannot read were used. The outcome was created using the variables of the question of the PMAQ external evaluation instrument: “Does the health unit guarantee accessibility to users who cannot read, have reduced vision and/or hearing or visual and/or hearing disability?” the PMAQ external evaluation instrument. The following variables were grouped: presence of material with embossed characters, braille or embossed figures; auditory resource (sound); visual communication (signage by text, drawings and figures) indicating environments or UBS services; listing (scope) of service actions so that disabled persons have access; and existence of a professional to welcome users with visual or hearing disabilities. All questions had categorical answer options “yes; no; do not know/did not answer”. After adding the facilitators, the variable was dichotomized into having no facilitator or having one or more facilitators. The choice for joint analysis of barriers to auditory and visual communication was due to the low frequency of specific facilitators for each type of sensory disability.

The exposure variables of level I related to the contextual characteristics of the municipalities were macroregion, population size and gross domestic product (GDP) per capita, which were collected in the official secondary database of the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE). The base year for information on population density, population size of the municipality and GDP per capita was 2010.

At level II, the variables related to the UBS, selected in an exploratory way, were extended professional team in Primary Care; care model (traditional and Family Health Strategy (FHS)/parameterized); service shifts; welcoming room; publishing of service hours; presence of facilitators of physical access (pavement in good conditions, non-slip floor, regular floor, access ramp, handrail and absence of carpet). The minimum professional team is comprised of a doctor, nurse and a licensed practical nurse, and the extended professional team can count on several other professionals, such as psychologists, social workers, nutritionists, physiotherapists, among others. For the present study, we considered an extended professional team with a psychologist and/or social worker. Regarding the care model, they were divided into the traditional model (UBS, with the largest population enrolled) and FHS/parameterized (units that have a FHS or are parameterized to work along the lines of this care model). All variables were collected in the external evaluation of the PMAQ-AB.

BIASES

In order to avoid information and measurement bias, the same instrument for data collection was used by all external evaluators. The evaluators also counted on the presence of a field supervisor.

STATISTICAL ANALYSIS

The data were analyzed using the Stata 11 and SPSS 20 software. Analyzes of the absolute and relative frequencies of the studied variables were performed. Multilevel Poisson regression²⁴24. Bastos LS, Oliveira RVC, Velasque LS. Obtaining adjusted prevalence ratios from logistic regression models in cross-sectional studies. Cad Saúde Pública 2015; 31(3): 487-95. https://doi.org/10.1590/0102-311X00175413
https://doi.org/https://doi.org/10.1590/... ^,2525. Spiegelman D, Hertzmark E. Easy SAS calculations for risk or prevalence ratios and differences. Am J Epidemiol 2005; 162(3): 199-200. https://doi.org/10.1093/aje/kwi188
https://doi.org/https://doi.org/10.1093/... ^,2626. Barros AJD, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3: 21. https://doi.org/10.1186/1471-2288-3-21
https://doi.org/https://doi.org/10.1186/... (xtpoisson command, with re subcommand for random effects)²⁷27. Rabe-Hesketh S, Skrondal A. Multilevel and Longitudinal Modeling Using Stata. 2ª ed. Stata Press; 2008. was used to obtain the gross and adjusted prevalence ratios with the respective 95% confidence intervals (95% CI) and 5% significance level. The modeling used was hierarchical²⁸28. Fuchs SC, Victora CG, Fachel J. Modelo hierarquizado: uma proposta de modelagem aplicada à investigação de fatores de risco para diarreia grave. Rev Saúde Pública 1996; 30(2): 168-78. https://doi.org/10.1590/S0034-89101996000200009
https://doi.org/https://doi.org/10.1590/... in two stages: Model 1 (only the contextual variables in the adjustment within the block itself); and Model 2 (the contextual variables with p < 10% of model 1, plus the UBS level variables). Deviance, Akaike information criterion (AIC) and Bayesian information criterion (BIC) parameters were used to analyze the adjustment of models. The theoretical model used was adapted from Donabedian²⁹29. Donabedian A. The quality of care. How can it be assessed? JAMA 1988; 260(12): 1743-8. https://doi.org/10.1001/jama.260.12.1743
https://doi.org/https://doi.org/10.1001/... (Figure 1).

ETHICAL ASPECTS

Research was carried out in accordance with the principles of the Declaration of Helsinki and the guidelines and standards for research involving human beings of Resolution No. 446/2012, of the Brazilian National Health Council (Conselho Nacional de Saúde - CNS). For data collection related to external evaluation, the PMAQ was submitted to the Research Ethics Committee of Universidade Federal do Rio Grande do Sul, approved on March 13, 2012, registration No. 21.904.

RESULTS

A total of 38,811 UBS from 5,543 municipalities were assessed, reaching 99.6% of Brazilian municipalities. The most prevalent facilitators of communication were professionals for welcoming users (21.1%); availability of a list of accessible services for disabled persons (10.8%); and design of health services (8.6%). Hearing aids and materials available in braille were found in less than 1% of services. Even when grouping the facilitators to create the outcome, only 32.1% of the UBS had one or more facilitators of communication (Table 1).

The Southeastern and Southern macroregions had better results (presence of at least one facilitator in 39.0 and 36.3% of the units, respectively), as well as the municipalities with the highest GDP and population size (more than 500 thousand inhabitants). In relation to health units, having a welcoming room, a psychologist and social worker and publishing of service hours were also more associated to the presence of facilitators of communication (Table 1).

In the multilevel analysis, the cities in the Southeastern region (PR = 1.67, 95%CI 1.48 - 1.89) and the Southern region (PR = 1.50, 95%CI 1.31 - 1.71) had a higher prevalence of least one facilitator to access, as well as the municipalities with the largest population size (PR = 1.32, 95%CI 1.06 - 1.65) and with the highest GDP (3^rd tertile) (PR = 1.12, 95%CI 1.01 - 1.23), when compared to the other categories (Table 2).

In relation to health units, those that published their service hours (PR = 1.56, 95%CI 1.49 - 1.63) and those that were part of the FHS (PR = 1.50, 95%CI 1.38 - 1.62) had better results. In order to have an adequate physical structure, with the five facilitators to physical access - pavement in good conditions, non-slip floor, regular floor, access ramp, handrail and absence of carpet - (PR = 1.41, 95%CI 1.19 - 1.68) and with a welcoming room (PR = 1.28, 95%CI 1.22 - 1.35) were also associated to the presence of facilitators of access to communication (Table 2).

There was an improvement in the adjustment parameters of the models: empty model (deviance = 51465.022 / AIC = 51469.02 / BIC = 51486.16), model 1 (deviance = 51270.934 / AIC = 51294.93 / BIC = 51397.73), and model 2 (deviance = 39918.484 / AIC = 39966.48 / BIC = 40167.09).

DISCUSSION

In Brazil, few UBS had facilitators of communication. Among the 38,811 health units evaluated by the study, the presence of professionals for welcoming users was an important facilitator of communication. On the other hand, hearing and material resources were available in less than 1% of health services. It is noteworthy that the best results were presented by the Southeastern and Southern regions, as well as by the municipalities with the highest GDP and the largest population. For health units, publishing service hours and the care model of the FHS remained associated to the presence of facilitators of access to communication.

In some countries, especially in Brazil, the macroregional differences in health regarding access, use and performance of health services have well-discriminated scientific evidence. Well-structured and rational health systems are expected to have primary health care as a gateway to the entire population, regardless of the economic situation. However, it is known that macroregional inequities due to socioeconomic conditions and environmental characteristics related to health systems³⁰30. Andersen RM. National health surveys and the behavioral model of health services use. Med Care 2008; 46(7): 647-53. https://doi.org/10.1097/MLR.0b013e31817a835d
https://doi.org/https://doi.org/10.1097/... also interfere with the use of health services. The Southeastern and Southern regions showed better results in the human development index³¹31. Duarte CM, Pedroso MD, Bellido JG, Moreira RD, Viacava F. Regionalização e desenvolvimento humano: uma proposta de tipologia de Regiões de Saúde no Brasil. Cad Saúde Pública 2015; 31(6): 1163-74. https://doi.org/10.1590/0102-311X00097414
https://doi.org/https://doi.org/10.1590/... and greater use of health services³²32. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CL. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saúde Pública 2017; 51(Supl. 1). http://dx.doi.org/10.1590/s1518-8787.2017051000074
https://doi.org/http://dx.doi.org/10.159... . In contrast, the Northern and Northeastern regions with the highest percentages of care provided by the Unified Health System (SUS) had worse results. This reinforces the need to adapt these services to loco-regional realities with a view to reducing inequities³³33. Viacava F, Bellido JG. Condições de saúde, acesso a serviços e fontes de pagamento, segundo inquéritos domiciliares. Ciên Saúde Coletiva 2016; 21(2): 351-70. https://doi.org/10.1590/1413-81232015212.19422015
https://doi.org/https://doi.org/10.1590/... .

There are differences between people with the same type of sensory disability, both for individual preferences and for individual limitations and capabilities. Not all deaf people will be able to communicate in Brazilian Sign Language or lip reading³⁴34. Torres EF, Mazzoni AA, Mello AG. Nem toda pessoa cega lê em braille nem toda pessoa surda se comunica em língua de sinais. Educ Pesqui 2007; 33(2): 369-86. http://dx.doi.org/10.1590/S1517-97022007000200013
https://doi.org/http://dx.doi.org/10.159... , just as not all blind or partially sighted people will use Braille. Some facilitators of communication, such as braille or embossed figures, may involve higher costs and logistics for the production of material, in addition to not reaching a large part of the visually disabled population, considering that people who lose their sight throughout their lives have less chances to use these methods³⁵35. Cawthra L. Older people’s health information needs. Health Libr Rev 1999; 16(2): 97-105. https://doi.org/10.1046/j.1365-2532.1999.00212.x
https://doi.org/https://doi.org/10.1046/... . Thus, although the health guidelines provided by means of audio description or braille increase the autonomy of individuals in relation to self-care in health, this conduct has not been made available in health services. In a study conducted in Fortaleza City (Brazil), only 1.5% of the 204 people with disabilities interviewed (n = 3) reported having received guidance in braille³⁶36. Leal Rocha L, Saintrain MVL, Vieira-Meyer APGF. Access to dental public services by disabled persons. BMC Oral Health 2015; 15. https://doi.org/10.1186/s12903-015-0022-x
https://doi.org/https://doi.org/10.1186/... .

The degree of information availability on the services offered also influences the use of these services and health equity³⁷37. Goddard M, Smith P. Equity of access to health care services: Theory and evidence from the UK. Soc Sci Med 2001; 53(9): 1149-62. https://doi.org/10.1016/S0277-9536(00)00415-9
https://doi.org/https://doi.org/10.1016/... . In the present study, we could notice that publishing service hours was associated to better results. Probably, teams that are concerned with information availability are also more aware of the need for facilitators of communication, especially professionals for welcoming users.

The decision of where to invest public resources to achieve better access to health must consider both the needs of users and the means that reach the greatest number of individuals³⁸38. Frieden TR. A Framework for Public Health Action: The Health Impact Pyramid. Am J Public Health 2010; 100(4): 590-95. https://doi.org/10.2105/AJPH.2009.185652
https://doi.org/https://doi.org/10.2105/... . Simple measures, such as the list of services published so that disabled persons have access, or signs or drawings indicating the services available at the unit should be encouraged. The cost of making these improvements is very low when compared to the benefit that these actions can bring to people with hearing disabilities.

The presence of professionals to welcome users with sensory disabilities, which should be present in all health units, is reported in only 21% of services. This presence, in the authors’ opinion, is the main facilitator of access and should be the focus of actions to improve health care for disabled persons. In a study on barriers to access, partially sighted people or blindness also pointed out individualized communication techniques and a welcoming attitude as effective measures for the quality of care¹⁴14. O’Day BL, Killen M, Iezzoni LI. Improving health care experiences of persons who are blind or have low vision: suggestions from focus group. Am J Med Qual 2004; 19(5): 193-200. https://doi.org/10.1177/106286060401900503
https://doi.org/https://doi.org/10.1177/... . Investing in professional training, enabling the human resources that already exist in the services, will bring great benefits for access and quality of care. This need for training and continuing education of the health team to reduce barriers to communication is also perceived by the professionals themselves¹⁷17. Morrison EH, George V, Mosqueda L. Primary care for adults with physical disabilities: perceptions from consumer and provider focus groups. Fam Med 2008; 40(9): 645-51..

The limitations of this study are the impossibility of causal inference, in addition to the lack of specific questions for disabled users about facilitators of communication. Moreover, in the first cycle of the PMAQ-AB, health teams that voluntarily adhered to the program participated in it, which may indicate that these teams had better performance in relation to the outcome studied here. The PMAQ-AB also has among its inherent limitations the fact that it is an instrument of mixed responses, in which some items were self-reported, and others were assessed with on-site verification. The presence of this bias can limit the interpretation of prevalence, and the result can be overestimated. Therefore, considering these limitations, accessibility to users who cannot read, with a visual disability and/or hearing or visual and/or hearing disability may be even less.

Due to the comprehensiveness of the study, which is national in its nature, several interviewers performed the external evaluation. Although they received training, this procedure may have caused information bias in the study. The presence of the field coordinator double verified it and, therefore, granted quality to the data collected by the PMAQ-AB. In addition to these limitations, some important explanatory variables for the assessment of barriers to and facilitators of communication for the care of people with sensory disabilities in primary health care were not addressed.

The absence of disabled persons in epidemiological studies is a problem that has already been reported by other authors³⁹39. Alwadi MA, Baker SR, Owens J. The inclusion of children with disabilities in oral health research: A systematic review. Community Dent Oral Epidemiol. 2018; 46(3): 238-44. https://doi.org/10.1111/cdoe.12374
https://doi.org/https://doi.org/10.1111/... and that must be overcome. The absence of indicators that assess the presence of specific facilitators, such as professionals qualified in Brazilian Sign Language is also a limitation of the study. On the other hand, this is a nationally based survey, which also considered contextual issues and brought barriers to communication to be discussed, which are usually neglected in favor of physical barriers. This discussion brings important contributions to improve health actions and guarantee access to health services for those who need it.

FINAL CONSIDERATIONS

The results found in research showed that most UBS in Brazil do not have the necessary communication facilitators to guarantee accessibility to people with sensory disabilities. The services that have the greatest physical accessibility are those with more facilitators of communication, possibly because they are better equipped units and are concerned with accessibility more widely.

Universal access with adequate services, removal of communication barriers and encouragement to properly welcome users must be promoted.

ACKNOWLEDGEMENT

Juliana Balbinot Hilgert and Fernando Neves Hugo are productivity fellows of the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq) and receive scholarships (source 001) by the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Capes) Post-Doc program. The PMAQ is funded by the Brazilian Ministry of Health.

References

Publication Dates

History