ABSTRACT

OBJECTIVE

To characterize the access and use of health services considered reference among the older rural population from a municipality in southern Brazil, whose rural area has full coverage of the Family Health Strategy (FHS), investigating factors associated with the choice of the Basic Family Health Unit (BFHU) as reference.

METHODS

This is a cross-sectional study conducted in 2017 with systematic sampling of rural households in the municipality of Rio Grande (RS) using a standardized in-house questionnaire. We performed descriptive analyses of sociodemographic profile, type of reference service chosen, and reasons for choosing/using the prime-choice service and the nearest BFHU. Poisson regression was used to investigate factors associated with the type of reference service chosen.

RESULTS

Among the 1,030 older adults who participated in the study, 61.4% considered the BFHU a prime choice/reference service mostly due to its proximity (82.6%); the others sought other places due to a greater ease (34.6%) and resoluteness (52.6%). Almost ⅔ of the respondents sought care at the BFHU during the last year, and the reasons differed among those who considered the unit as reference (chronic disease) and those who sought another place (procedures). We also found that the lower the age, income, education, and household-unit distance, the greater the likelihood of the older adult considering the nearest BFHU as reference service.

CONCLUSIONS

The FHS has reached the vulnerable older rural population, approaching an equitable public health system. However, further evaluations are necessary to verify the quality and adequacy of care, given that social structure, enabling factors (such as economic condition), and possible beliefs regarding health still establish the standards for choosing a service.

Aged; Health Services Accessibility; Primary Health Care; Family Health Strategy; Rural Health

INTRODUCTION

Broader concepts and practices have been rebuilding the notion of health care over time. The Alma-Ata¹1. International Conference on Primary Health Care; 1978 Sept 6-12; Alma- Ata, URSS. Declaration of Alma-Ata. Geneva: WHO; 1978 [cited 2019 Dec 17]. Available from: https://www.who.int/publications/almaata_declaration_en.pdf
https://www.who.int/publications/almaata... declaration internationally broaden the focus on primary health care (PHC). In Brazil, PHC is being developed by the Family Health Strategy (FHS) – a multidisciplinary work that functions as the gateway to the health care system by the action of teams that assume health responsibility for populations of specific territories²2. Ministério da Saúde (BR). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 ago 2017; Seção 1:68.. Nowadays, the FHS assists 64.34% of the Brazilian population⁶6. Ministério da Saúde (BR). Histórico de Cobertura da Estratégia Saúde da Família. Brasília, DF; 2017 [cited 2019 Dec 17]. Available from: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaAB.xhtml
https://egestorab.saude.gov.br/paginas/a... . Despite the challenges in relocating traditional basic units to the FHS, the access to primary care increased about 450% between 1981 and 2008⁷7. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. O sistema de saúde brasileiro: história, avanços e desafios. Lancet. 6736(11):11-31 (Série Saúde no Brasil). 2011;1:11-31. https://doi.org/10.1016/S0140-6736(11)60054-8
https://doi.org/10.1016/S0140-6736(11)60... .

Evaluation is an essential component in the constant expansion and restructuring of health systems, especially regarding the way users access services⁵5. Silva KF, Pucci VR, Weiller TH, Mayer BLD, Concatto MEP. O acesso do idoso na Atenção Primária à Saúde: uma revisão integrativa. Rev APS. 2018;21(1):122-33. https://doi.org/10.34019/1809-8363.2018.v21.15911
https://doi.org/10.34019/1809-8363.2018.... ,⁸8. Arruda NM, Maia AG, Alves LC. Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008. Cad Saude Publica. 2018;34(6):e00213816. https://doi.org/10.1590/0102-311X00213816
https://doi.org/10.1590/0102-311X0021381...

9. Almeida APSC, Nunes BP, Duro SMS, Facchini LA. Determinantes socioeconômicos do acesso a serviços de saúde em idosos: revisão sistemática. Rev Saude Publica. 2017;51:50. https://doi.org/10.1590/S1518-8787.2017051006661
https://doi.org/10.1590/S1518-8787.20170... -¹⁰10. Szwarcwald CL, Damacena GN, Souza Júnior PRB, Almeida WS, Malta DC. Percepção da população brasileira sobre a assistência prestada pelo médico. Brasil, 2013. Cienc Saude Colettiva. 2016;21(2):339-49. https://doi.org/10.1590/1413-81232015212.19332015
https://doi.org/10.1590/1413-81232015212... . Defining the concept of “access” is a complex task, and no unanimity has been reached among scholars in the field. Its meaning varies according to time and context, but the prevailing one is associated with health services supply capacity¹¹11. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica. 2004;20 Supl 2:S190-8. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... .

Evaluating access is even more important when it comes to populations that historically have faced greater barriers to accessing adequate care, such as older rural residents¹²12. Shimizu HE, Trindade JS, Mesquita MS, Ramos MC. Avaliação do Índice de Responsividade da Estratégia Saúde da Família da zona rural. Rev Esc Enferm USP. 2018;52:e03316. https://doi.org/10.1590/s1980-220x2017020203316
https://doi.org/10.1590/s1980-220x201702... . For presenting greater needs, this group tends to use health services more often⁸8. Arruda NM, Maia AG, Alves LC. Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008. Cad Saude Publica. 2018;34(6):e00213816. https://doi.org/10.1590/0102-311X00213816
https://doi.org/10.1590/0102-311X0021381... ,¹⁵15. Pedraza DF, Nobre AMD, Albuquerque FJB, Menezes TN. Acessibilidade às Unidades Básicas de Saúde da Família na perspectiva de idosos. Cienc Saude Coletiva. 2018;23(3):923-33. https://doi.org/10.1590/1413-81232018233.11702016
https://doi.org/10.1590/1413-81232018233... , so that difficulties in accessing adequate care may entail consequences. Studies comparing the use of primary health care services regarding location found less use and/or worse quality in rural areas than urban areas⁴4. Garbaccio JL, Tonaco LAB, Estêvão WG, Barcelos BJ. Envelhecimento e qualidade de vida de idosos residentes da zona rural. Rev Bras Enferm. 2018;71Supl 2:776-84. https://doi.org/10.1590/0034-7167-2017-0149
https://doi.org/10.1590/0034-7167-2017-0... ,⁸8. Arruda NM, Maia AG, Alves LC. Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008. Cad Saude Publica. 2018;34(6):e00213816. https://doi.org/10.1590/0102-311X00213816
https://doi.org/10.1590/0102-311X0021381... ,¹²12. Shimizu HE, Trindade JS, Mesquita MS, Ramos MC. Avaliação do Índice de Responsividade da Estratégia Saúde da Família da zona rural. Rev Esc Enferm USP. 2018;52:e03316. https://doi.org/10.1590/s1980-220x2017020203316
https://doi.org/10.1590/s1980-220x201702...

13. Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Acesso e cobertura da Atenção Primária à Saúde para populações rurais e urbanas na região norte do Brasil. Saude Debate. 2018;42 Nº Espec 1:81-99. https://doi.org/10.1590/0103-11042018s106
https://doi.org/10.1590/0103-11042018s10...

14. Travassos C, Viacava F. Acesso e uso de serviços de saúde em idosos residentes em áreas rurais, Brasil, 1998 e 2003. Cad Saude Publica. 2007;23(10):2490-502. https://doi.org/10.1590/S0102-311X2007001000023
https://doi.org/10.1590/S0102-311X200700...

15. Pedraza DF, Nobre AMD, Albuquerque FJB, Menezes TN. Acessibilidade às Unidades Básicas de Saúde da Família na perspectiva de idosos. Cienc Saude Coletiva. 2018;23(3):923-33. https://doi.org/10.1590/1413-81232018233.11702016
https://doi.org/10.1590/1413-81232018233... -¹⁶16. Bortolotto CC, Loret de Mola C, Tovo-Rodrigues L. Qualidade de vida em adultos de zona rural no Sul do Brasil: estudo de base populacional. Rev Saude Publica. 2018;52 Supl 1:4s. https://doi.org/10.11606/s1518-8787.2018052000261
https://doi.org/10.11606/s1518-8787.2018... . In turn, the low variety or quality of locally available services may cause treatment seeking delays or in farther services, resulting in greater physical, emotional, and financial attrition¹⁷17. Gustafsdottir SS, Fenger K, Halldorsdottir S, Bjarnason T. Social justice, access and quality of healthcare in an age of austerity: users’ perspective from rural Iceland. Int J Circumpolar Health. 2017;76(1):1347476. https://doi.org/10.1080/22423982.2017.1347476
https://doi.org/10.1080/22423982.2017.13... .

Despite the vulnerability of older rural populations and the complexity of developing a care plan, few studies have directed efforts to this portion of the population⁴4. Garbaccio JL, Tonaco LAB, Estêvão WG, Barcelos BJ. Envelhecimento e qualidade de vida de idosos residentes da zona rural. Rev Bras Enferm. 2018;71Supl 2:776-84. https://doi.org/10.1590/0034-7167-2017-0149
https://doi.org/10.1590/0034-7167-2017-0... ,¹⁸18. Macinko J, Andrade FB, Souza-Júnior PRB, Lima-Costa MF. Primary care and healthcare utilization among older Brazilians (ELSI-Brazil). Rev Saude Publica. 2018;52 Supl 2:6s. https://doi.org/10.11606/s1518-8787.2018052000595
https://doi.org/10.11606/s1518-8787.2018... . Given the specific needs and limitations of this group, it is pertinent to investigate how they seek for health services and possible difficulties they encounter. Considering that, this study aims to characterize the access and use of health services considered reference among older adults living in a rural area with full FHS coverage from a municipality in southern Brazil, investigating factors associated with the choice of the Basic Family Health Unit (BFHU) as reference.

METHODS

This research collected data on the profile of access and use of health services by older residents (individuals aged 60 years or older) of the rural area of Rio Grande (RS). The data represent a cut-off of the cross-sectional study Saúde da População Rural Rio-Grandina (Health of the Rio-Grandina Rural Population), conducted by the Graduate Program in Public Health of the Universidade Federal do Rio Grande (FURG). The study investigated health indicators and the pattern of morbidity, access, and use of health services by children up to 5 years old, women of childbearing age, and older residents of the rural area of Rio Grande.

The municipality of Rio Grande is located within the state of Rio Grande do Sul, 350 km from the capital Porto Alegre, and has approximately 200 thousand inhabitants. Of these, 5.5% (about 8,225 individuals) lived in rural areas at the time of the cross-sectional study, and 13.1% among those were older adults¹⁹19. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico, 2010. Rio de Janeiro: IBGE; 2011.. Regarding Public Health Network, 53% of the municipality total area was attended by the FHS, reaching 100% in the rural area. The rural population disposed of 10 family health teams in eight BFHU (one of them functioning as an emergency service, open 24 hours) supported by two Expanded Family Healthcare Centers (EFHC).

Minimum sample size was calculated to estimate the prevalence of the dependent variable (considering 95% confidence level, 70% frequency for estimating results, 3-percentage point margin of error, and 1.5 design effect) and its associated factors (considering 80% power, 10% addition for losses and refusals, and 15% for controlling confounding factors), reaching the number of 857 individuals.

Households within the 23 rural census sectors of the municipality were interviewed between April and November 2017, with a systematic interval of one household for every four sampled, covering approximately 80% of the populations of interest. Households without individuals in the age groups of interest were not considered eligible, but when residents of sampled households fit into the age groups of interest, all eligible individuals were interviewed. Older adults who were institutionalized by the interview period were excluded from the study. Caregivers were interviewed whenever individuals within the age group of interest were physically or mentally incapable of answering the questionnaire.

Data was collected using a standardized questionnaire. Usage profile was analyzed according to the service considered reference by the interviewee through the question: “When you need health care, which is the first service that you go to?”. Response options were posteriorly categorized into “reference BFHU” (the closest unit to participants’ household) or “other service”, including hospitals, private practice or medical offices affiliated to health insurance plans, and services located in other municipalities.

Independent variables were: gender (male and female); age (60 to 69 years; 70 to 79 years; 80 years or older), skin color (white or black/brown/Asian/native American), education level (0 to 4 years; 5 to 8 years; 9 years and over), family income (in tertiles), living alone (no or yes), have a health insurance plan (no or yes), and distance from the nearest BFHU (< 1 km; 1 to 2.9 km; 3 to 5.9 km; 6 to 9.9 km; 10 km or more). The following health status-related variables were also investigated: presenting chronic disease (no or yes) and self-reported health status (good/very good; fair; poor/very poor).

Descriptive statistical analyses of the sample sociodemographic profile, the type of reference service chosen, and the reasons for choosing and using it were performed in the Stata 14.1 statistical software. Poisson regression with robust adjustment for variance was used to investigate factors associated with the type of reference service chosen.

For the adjusted analysis, we developed a conceptual model with hierarchical levels²⁰20. Victora CG, Hutlly SR, Fuchs SC, Olinto MT. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol. 1997;26(1):224-7. https://doi.org/10.1093/ije/26.1.224
https://doi.org/10.1093/ije/26.1.224... considering the three categories of factors influencing access to health services⁹9. Almeida APSC, Nunes BP, Duro SMS, Facchini LA. Determinantes socioeconômicos do acesso a serviços de saúde em idosos: revisão sistemática. Rev Saude Publica. 2017;51:50. https://doi.org/10.1590/S1518-8787.2017051006661
https://doi.org/10.1590/S1518-8787.20170... identified by Aday and Andersen²¹21. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974 [cited 2019 Dec 18];9(3):208-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/4436074
https://www.ncbi.nlm.nih.gov/pubmed/4436... : predisposing factors (individual characteristics, prior to the health problem, influencing subject’s propensity to use health services), enabling factors (means that allow care provision), and health needs (related to disease level). Thus, the model employed in the analyses was: 1) distal level: predisposing factors (gender, age, and skin color); 2) intermediate level: enabling factors (education, family income, living alone, having health insurance, and distance from the nearest BFHU); and 3) proximal level: health needs (chronic disease and self-reported health status). The model suffered adjustments for potential confounding factors of the same or higher level, considering p value < 0.20 as the limit to maintain variables in the final model, for controlling positive confusions.

The research project was approved by the Research Ethics Committee of the Universidade Federal do Rio Grande under Opinion No. 51/2017, process 23116.009484/2016-26. All older adults surveyed or their respective caregivers (in case of limitation of the participant) signed the informed consent form.

RESULTS

Of the 1,351 older adults living in the rural area of Rio Grande, 83.7% (n = 1,131) were sampled for the study, reaching a final number of 1,030 respondents (8.9% of losses and refusals). The sample comprised mostly men, between 60 and 69 years old, white, with 0 to 4 years of education, and living with at least one more person. Only ⅓ of the participants had private health insurance and only 14.9% lived less than one kilometer away from the nearest Basic Family Health Unit (BFHU – Table 1). Median monthly household income was R$1,874. 00 (IQQ = R$1,000.00–R$2,000.00).

Regarding seek for health services, almost ⅔ of the respondents (61.4%) considered the BHFU closest to their residence its prime choice/reference service. By stratifying the analyses between the reference BHFU and other care sites, we found different reasons for choosing the service (Table 2). While those who preferred to be attended at their reference BHFU did so mainly due to its proximity from their households, the others underwent follow-up in other services due to habituation, knowing the greater ease and resoluteness of these services in providing the necessary care.

As for reasons that led users to seek care, treating already-established diseases (chronic and acute) was the main reason in both groups. Just over half of participants with chronic disease sought care at their reference service (although 79.2% reported presenting with some chronic disease, only 44% sought care).

Tables 3 and 4 outline data on the demand for care at the BHFU closest to older participants’ residences in the 12 months prior to the survey; that is, the BHFU considered as reference unit by the municipal healthcare management. In total, 60.1% of the interviewees sought care at the site, with higher demand among those who considered it as their reference service (75% versus 36%); 87.7% of those evaluated the service positively, with no significant difference among groups.

The reasons that led users to seek care at the respective BHFU differed between participants considering it their prime option and those considering another site as reference: while the former had more general reasons (disease treatment, assessment, examinations), the others sought the BHFU more frequently to undergo clinical procedures.

As for those who did not seek BHFU in the last 12 months (n = 405), the reasons likewise differed between the two groups. Those who considered the BHFU as prime option reported feeling no need to seek some type of care (84.2% versus 35.2%) whereas the others reported preferring another place, which they considered more resolute for obtaining the appropriate care (42.1% versus 8.2%).

Table 5 shows factors associated with choosing the BHFU as reference service, indicating that the lower the age, income, education, and household-unit distance, the greater the likelihood of the older adult considering the nearest BFHU as reference service. Having a private health insurance plan decreased the probability of choosing the BHFU by 25%, and characteristics associated with participants’ health needs were not statistically associated with the choice (Table 5).

DISCUSSION

We found that almost ⅔ (61.4%) of the older residents of the rural area of the municipality of Rio Grande considered the Basic Family Health Unit (BHFU) closest to their residences as a reference health service. The lower the age, education, income, and household-unit distance, the greater the likelihood of the Primary Health Care (PHC) service being chosen as prime option by users. We found a higher percentage of older adults who considered the PHC as a customary service than that reported by another study conducted in Brazil – especially regarding older (36.2%) and rural population (49.2%)²²22. Dourado I, Medina MG, Aquino R. The effect of the Family Health Strategy on usual source of care in Brazil: data from the 2013 National Health Survey (PNS 2013). Int J Equity Health. 2016;15(1):151. https://doi.org/10.1186/s12939-016-0440-7
https://doi.org/10.1186/s12939-016-0440-... .

Reference services have been positively associated with improvements in users’ health condition and system efficiency, since longitudinal monitoring prevents diseases onset and progression, avoiding the overload of emergency services and consultations with specialists for preventable causes¹⁵15. Pedraza DF, Nobre AMD, Albuquerque FJB, Menezes TN. Acessibilidade às Unidades Básicas de Saúde da Família na perspectiva de idosos. Cienc Saude Coletiva. 2018;23(3):923-33. https://doi.org/10.1590/1413-81232018233.11702016
https://doi.org/10.1590/1413-81232018233... ,²²22. Dourado I, Medina MG, Aquino R. The effect of the Family Health Strategy on usual source of care in Brazil: data from the 2013 National Health Survey (PNS 2013). Int J Equity Health. 2016;15(1):151. https://doi.org/10.1186/s12939-016-0440-7
https://doi.org/10.1186/s12939-016-0440-... ,²³23. Veras RP, Oliveira M. Envelhecer no Brasil: a construção de um modelo de cuidado. Cienc Saude Coletiva. 2018;23(6):1929-36. https://doi.org/10.1590/1413-81232018236.04722018
https://doi.org/10.1590/1413-81232018236... . Moreover, reference services enable the development of a trust relationship between health team and user, strengthening adherence to treatment²2. Ministério da Saúde (BR). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 ago 2017; Seção 1:68.,³3. Fontenelle LF, Camargo MBJ, Bertoldi AD, Gonçalves H, Maciel ELN, Barros AJD. Utilização das unidades básicas de saúde da ESF conforme a cobertura por plano de saúde. Rev Saude Publica. 2018;52:55. https://doi.org/10.11606/S1518-8787.2018052000383
https://doi.org/10.11606/S1518-8787.2018... , ²⁴24. Gontijo TL, Duarte AGS, Guimarães EAA, Silva J. Avaliação da atenção primária: o ponto de vista de usuários. Saude Debate. 2017;41(114):741-52. https://doi.org/10.1590/0103-1104201711406
https://doi.org/10.1590/0103-11042017114... .

Following Aday and Andersen’s categorization²¹21. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974 [cited 2019 Dec 18];9(3):208-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/4436074
https://www.ncbi.nlm.nih.gov/pubmed/4436... , the main health needs that lead older adults to seek the BFHU and other reference services were already-established diseases (chronic and acute), underlining a similar needs profile between both groups. The higher demand for public PHC services may reflect government annual efforts to immunize older adults against influenza through campaigns that, in 2018, exceeded 97% vaccinated individuals and reached 99.39% in 2019²⁵25. Ministério da Saúde (BR), DATASUS. Sistema de Informações do Programa Nacional de Imunizações. Brasília, DF; 2018 [cited 2019 Dec 18]. Available from: http://sipni.datasus.gov.br/si-pni-web/faces/relatorio/consolidado/vacinometroInfluenza.jsf
http://sipni.datasus.gov.br/si-pni-web/f... .

The literature shows that individuals presenting with chronic diseases have a greater demand for healthcare⁵5. Silva KF, Pucci VR, Weiller TH, Mayer BLD, Concatto MEP. O acesso do idoso na Atenção Primária à Saúde: uma revisão integrativa. Rev APS. 2018;21(1):122-33. https://doi.org/10.34019/1809-8363.2018.v21.15911
https://doi.org/10.34019/1809-8363.2018.... , ⁹9. Almeida APSC, Nunes BP, Duro SMS, Facchini LA. Determinantes socioeconômicos do acesso a serviços de saúde em idosos: revisão sistemática. Rev Saude Publica. 2017;51:50. https://doi.org/10.1590/S1518-8787.2017051006661
https://doi.org/10.1590/S1518-8787.20170... , ²³23. Veras RP, Oliveira M. Envelhecer no Brasil: a construção de um modelo de cuidado. Cienc Saude Coletiva. 2018;23(6):1929-36. https://doi.org/10.1590/1413-81232018236.04722018
https://doi.org/10.1590/1413-81232018236... . However, as already indicated by another study conducted in Brazil¹⁴14. Travassos C, Viacava F. Acesso e uso de serviços de saúde em idosos residentes em áreas rurais, Brasil, 1998 e 2003. Cad Saude Publica. 2007;23(10):2490-502. https://doi.org/10.1590/S0102-311X2007001000023
https://doi.org/10.1590/S0102-311X200700... , the percentage of service use is still inadequate to users’ needs, given that 40% of participants who reported having some chronic condition did not seek care in the past year.

The groups were quite similar regarding enabling factors, although service supply differed between them. Emergency services and private/affiliated medical offices have a more responsive nature, usually meeting only demands of already sick users; in turn, PHC services aim to develop, besides treatment and rehabilitation, practices of disease prevention, health promotion, and popular participation²2. Ministério da Saúde (BR). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 ago 2017; Seção 1:68..

However, these latter purposes did not excel among reasons for seeking for BFHU, which may be explained by the health beliefs and behaviors of the studied population – for example, users and staff unfamiliarity or disengagement regarding PHC broader goals, not deemed as priority¹²12. Shimizu HE, Trindade JS, Mesquita MS, Ramos MC. Avaliação do Índice de Responsividade da Estratégia Saúde da Família da zona rural. Rev Esc Enferm USP. 2018;52:e03316. https://doi.org/10.1590/s1980-220x2017020203316
https://doi.org/10.1590/s1980-220x201702... ,²³23. Veras RP, Oliveira M. Envelhecer no Brasil: a construção de um modelo de cuidado. Cienc Saude Coletiva. 2018;23(6):1929-36. https://doi.org/10.1590/1413-81232018236.04722018
https://doi.org/10.1590/1413-81232018236... ,²⁶26. Araújo LUA, Gama ZAS, Nascimento FLA, Oliveira HFV, Azevedo WM, Almeida Júnior HJB. Avaliação da qualidade da atenção primária à saúde sob a perspectiva do idoso. Cienc Saude Coletiva. 2014;19(8):3521-32. https://doi.org/10.1590/1413-81232014198.21862013
https://doi.org/10.1590/1413-81232014198... . The high percentage of older adults who reported not having sought chronic illness care, the way they dealt with it, and its possible stigmas may also be implied within such beliefs and behaviors¹⁵15. Pedraza DF, Nobre AMD, Albuquerque FJB, Menezes TN. Acessibilidade às Unidades Básicas de Saúde da Família na perspectiva de idosos. Cienc Saude Coletiva. 2018;23(3):923-33. https://doi.org/10.1590/1413-81232018233.11702016
https://doi.org/10.1590/1413-81232018233... ,²¹21. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974 [cited 2019 Dec 18];9(3):208-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/4436074
https://www.ncbi.nlm.nih.gov/pubmed/4436... ,²⁴24. Gontijo TL, Duarte AGS, Guimarães EAA, Silva J. Avaliação da atenção primária: o ponto de vista de usuários. Saude Debate. 2017;41(114):741-52. https://doi.org/10.1590/0103-1104201711406
https://doi.org/10.1590/0103-11042017114... .

Although the Brazilian Public Health System provides free service for everyone, enabling an easier access to care, respondents with private health insurance or better economic conditions tended to choose other health services as prime option, possibly meaning (as previously identified in the literature) that older adults seek other care sites when they have the means to access more expensive services¹⁷17. Gustafsdottir SS, Fenger K, Halldorsdottir S, Bjarnason T. Social justice, access and quality of healthcare in an age of austerity: users’ perspective from rural Iceland. Int J Circumpolar Health. 2017;76(1):1347476. https://doi.org/10.1080/22423982.2017.1347476
https://doi.org/10.1080/22423982.2017.13... ,¹⁸18. Macinko J, Andrade FB, Souza-Júnior PRB, Lima-Costa MF. Primary care and healthcare utilization among older Brazilians (ELSI-Brazil). Rev Saude Publica. 2018;52 Supl 2:6s. https://doi.org/10.11606/s1518-8787.2018052000595
https://doi.org/10.11606/s1518-8787.2018... , ²⁶26. Araújo LUA, Gama ZAS, Nascimento FLA, Oliveira HFV, Azevedo WM, Almeida Júnior HJB. Avaliação da qualidade da atenção primária à saúde sob a perspectiva do idoso. Cienc Saude Coletiva. 2014;19(8):3521-32. https://doi.org/10.1590/1413-81232014198.21862013
https://doi.org/10.1590/1413-81232014198... .

Regarding education, the association between lower education and choosing the BHFU as prime option may be related to a greater general self- and health-knowledge, as well as to higher self-medication rates, allowing users to better identify an appropriate service for their health status or decreasing their understanding of the need for follow-up¹⁴14. Travassos C, Viacava F. Acesso e uso de serviços de saúde em idosos residentes em áreas rurais, Brasil, 1998 e 2003. Cad Saude Publica. 2007;23(10):2490-502. https://doi.org/10.1590/S0102-311X2007001000023
https://doi.org/10.1590/S0102-311X200700... ,²⁶26. Araújo LUA, Gama ZAS, Nascimento FLA, Oliveira HFV, Azevedo WM, Almeida Júnior HJB. Avaliação da qualidade da atenção primária à saúde sob a perspectiva do idoso. Cienc Saude Coletiva. 2014;19(8):3521-32. https://doi.org/10.1590/1413-81232014198.21862013
https://doi.org/10.1590/1413-81232014198... ,²⁷27. Arrais PSD, Fernandes MEP, Dal Pizzol TS, Ramos RL, Mengue SS, Tavares NUL, et al. Prevalência da automedicação no Brasil e fatores associados. Rev Saude Publica. 2016;50 Supl 2:13s. https://doi.org/10.1590/s1518-8787.2016050006117
https://doi.org/10.1590/s1518-8787.20160... .

Another enabling factor is health services structure and organization: while distance was decisive for choosing the BFHU as a reference service, those who sought other care sites indicated other elements – such as resoluteness (“offers the treatment I need”), ease and speed in care provision, and confidence in the treatment/professional. Several studies approached the influence of distance to the desired care site, showing that greater distances entail lower service use³3. Fontenelle LF, Camargo MBJ, Bertoldi AD, Gonçalves H, Maciel ELN, Barros AJD. Utilização das unidades básicas de saúde da ESF conforme a cobertura por plano de saúde. Rev Saude Publica. 2018;52:55. https://doi.org/10.11606/S1518-8787.2018052000383
https://doi.org/10.11606/S1518-8787.2018... ,¹³13. Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Acesso e cobertura da Atenção Primária à Saúde para populações rurais e urbanas na região norte do Brasil. Saude Debate. 2018;42 Nº Espec 1:81-99. https://doi.org/10.1590/0103-11042018s106
https://doi.org/10.1590/0103-11042018s10... ,¹⁷17. Gustafsdottir SS, Fenger K, Halldorsdottir S, Bjarnason T. Social justice, access and quality of healthcare in an age of austerity: users’ perspective from rural Iceland. Int J Circumpolar Health. 2017;76(1):1347476. https://doi.org/10.1080/22423982.2017.1347476
https://doi.org/10.1080/22423982.2017.13... , especially among individuals with low mobility, few available service options, and little or no access to means of transportation⁴4. Garbaccio JL, Tonaco LAB, Estêvão WG, Barcelos BJ. Envelhecimento e qualidade de vida de idosos residentes da zona rural. Rev Bras Enferm. 2018;71Supl 2:776-84. https://doi.org/10.1590/0034-7167-2017-0149
https://doi.org/10.1590/0034-7167-2017-0... ,¹⁵15. Pedraza DF, Nobre AMD, Albuquerque FJB, Menezes TN. Acessibilidade às Unidades Básicas de Saúde da Família na perspectiva de idosos. Cienc Saude Coletiva. 2018;23(3):923-33. https://doi.org/10.1590/1413-81232018233.11702016
https://doi.org/10.1590/1413-81232018233... ,²⁸28. Stentzel U, Piegsa J, Fredrich D, Hoffmann W, Berg N. Accessibility of general practitioners and selected specialist physicians by car and by public transport in a rural region of Germany. BMC Health Serv Res. 2016;16(1):587. https://doi.org/10.1186%2Fs12913-016-1839-y
https://doi.org/10.1186%2Fs12913-016-183... . Yet, proximity is not the only factor to guarantee access, as rural residents may be willing to travel longer distances (despite the higher costs and greater physical and emotional attrition) when they assume they would not receive the most suitable care near their residences¹⁰10. Szwarcwald CL, Damacena GN, Souza Júnior PRB, Almeida WS, Malta DC. Percepção da população brasileira sobre a assistência prestada pelo médico. Brasil, 2013. Cienc Saude Colettiva. 2016;21(2):339-49. https://doi.org/10.1590/1413-81232015212.19332015
https://doi.org/10.1590/1413-81232015212... ,¹⁷17. Gustafsdottir SS, Fenger K, Halldorsdottir S, Bjarnason T. Social justice, access and quality of healthcare in an age of austerity: users’ perspective from rural Iceland. Int J Circumpolar Health. 2017;76(1):1347476. https://doi.org/10.1080/22423982.2017.1347476
https://doi.org/10.1080/22423982.2017.13... ,²⁸28. Stentzel U, Piegsa J, Fredrich D, Hoffmann W, Berg N. Accessibility of general practitioners and selected specialist physicians by car and by public transport in a rural region of Germany. BMC Health Serv Res. 2016;16(1):587. https://doi.org/10.1186%2Fs12913-016-1839-y
https://doi.org/10.1186%2Fs12913-016-183... .

We found predisposing factors to be only associated with age. Older adults of a younger age may have better mobility and functional capacity, enabling them to actively seek care beyond home visits; but older individuals may require more specific and specialized care, unavailable at primary healthcare level⁵5. Silva KF, Pucci VR, Weiller TH, Mayer BLD, Concatto MEP. O acesso do idoso na Atenção Primária à Saúde: uma revisão integrativa. Rev APS. 2018;21(1):122-33. https://doi.org/10.34019/1809-8363.2018.v21.15911
https://doi.org/10.34019/1809-8363.2018.... ,¹⁴14. Travassos C, Viacava F. Acesso e uso de serviços de saúde em idosos residentes em áreas rurais, Brasil, 1998 e 2003. Cad Saude Publica. 2007;23(10):2490-502. https://doi.org/10.1590/S0102-311X2007001000023
https://doi.org/10.1590/S0102-311X200700... ,²⁹29. Antunes JLF, Chiavegatto Filho ADP, Duarte YAO, Lebrão ML. Desigualdades sociais na autoavaliação de saúde dos idosos da cidade de São Paulo. Rev Bras Epidemiol. 2018;21 Supl 2:e180010. https://doi.org/10.1590/1980-549720180010.supl.2
https://doi.org/10.1590/1980-54972018001... .

Reasons that lead individuals not to seek service are also important, complementing their perceived organization of the site. Among those who consider the BFHU as the prime care option, the main reason not to seek for it was feeling no need for any type of care, similar to that identified by other studies⁵5. Silva KF, Pucci VR, Weiller TH, Mayer BLD, Concatto MEP. O acesso do idoso na Atenção Primária à Saúde: uma revisão integrativa. Rev APS. 2018;21(1):122-33. https://doi.org/10.34019/1809-8363.2018.v21.15911
https://doi.org/10.34019/1809-8363.2018.... . However, perceived non-need is a questionable aspect given that our study population demands greater care and, consequently, more frequent qualified assessment of their actual health status. FHS principles are particularly relevant in this context, for it strives for an active search and longitudinal follow-up through family monitoring and home visits conducted by community health agents and technical teams²2. Ministério da Saúde (BR). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 ago 2017; Seção 1:68.,¹⁸18. Macinko J, Andrade FB, Souza-Júnior PRB, Lima-Costa MF. Primary care and healthcare utilization among older Brazilians (ELSI-Brazil). Rev Saude Publica. 2018;52 Supl 2:6s. https://doi.org/10.11606/s1518-8787.2018052000595
https://doi.org/10.11606/s1518-8787.2018... .

Being a cross-sectional research and thus susceptible to reversing causality, this research is not intended at investigating cause-effect relationships between the presented variables. This study has some limitations: (1) data related to the service organization was provided only by users, without directly contacting the care services; (2) household-unit distance was also provided by respondents, generating data not as accurate as it would be if collected by georeferencing, as well as a high loss of answers, as some respondents were unable to provide such information.

Given that access is strongly associated with individual perceptions¹⁵15. Pedraza DF, Nobre AMD, Albuquerque FJB, Menezes TN. Acessibilidade às Unidades Básicas de Saúde da Família na perspectiva de idosos. Cienc Saude Coletiva. 2018;23(3):923-33. https://doi.org/10.1590/1413-81232018233.11702016
https://doi.org/10.1590/1413-81232018233... (i.e., perceived ease of access), the use of other sources to complement data would enrich results. Yet, the exclusive focus on the user is highly relevant and does not invalidate our findings, given that their perceived health needs allow anticipating demands and function as an underlying basis for developing public policies²⁹29. Antunes JLF, Chiavegatto Filho ADP, Duarte YAO, Lebrão ML. Desigualdades sociais na autoavaliação de saúde dos idosos da cidade de São Paulo. Rev Bras Epidemiol. 2018;21 Supl 2:e180010. https://doi.org/10.1590/1980-549720180010.supl.2
https://doi.org/10.1590/1980-54972018001... .

As aforementioned, the FHS reached a great amount of the older rural population, especially those in vulnerable situations, approaching an equitable public health system. However, ⅓ of the study group sought other services for follow-up despite having access to BFHU; that is, even with FHS full coverage, social structure, enabling factors (such as economic condition), and beliefs about health still establish the standards for choosing a service.

This finding elucidates the urge for continuous strengthening of the care network for those with greater health needs, as well as spotlighting the profiles of users who did not seek the service. For that, we may develop preventive and health promotion activities targeting individuals who do not perceive the need for follow-up, as well as adapt BFHU structure and organization to attract those who seek another care site. These strategies require new evaluations by managers, researchers, and professionals for expanding knowledge on this matter in different contexts and assessing the adequacy and quality of the service provided.

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