Assessment of primary care attributes from the perspective of elderly peopleRESUMO
Objetivo: Verificar a avaliação de idosos sobre os atributos de acesso, longitudinalidade e coordenação da Atenção Primária à Saúde e fatores associados.
Método: Realizou-se um inquérito domiciliar de delineamento transversal com 310 idosos vinculados a uma Unidade Básica de Saúde em Maringá, PR, Brasil. A coleta de dados ocorreu entre junho e agosto de 2024. Os atributos da Atenção Primária foram avaliados por meio de entrevistas domiciliares, utilizando instrumento validado que abrange dimensões de acesso, longitudinalidade e coordenação. Foram realizadas análises descritivas e regressão multivariada para identificar fatores sociodemográficos associados à qualidade dos serviços.
Resultados: A percepção dos atributos avaliados foi predominantemente positiva. Na análise multivariada, o sexo masculino e a ausência de ocupação associaram-se a menor percepção positiva do acesso, enquanto a raça amarela apresentou associação positiva. Idosos de raça parda (p=0,043), aposentados (p=0,022) e aqueles com consultas mensais (p<0,001) apresentaram maior avaliação positiva da longitudinalidade. Já a coordenação foi positivamente associada a consultas mensais (p<0,001), à raça parda (p=0,044) e à boa adesão ao tratamento medicamentoso (p<0,001).
Conclusão: Os achados apontam uma avaliação favorável dos idosos quanto aos atributos da Atenção Primária à Saúde. Observou-se a influência de fatores socioeconômicos e da frequência de uso dos serviços na percepção da qualidade. Destaca-se a necessidade de aprimorar recursos e processos de trabalho para reduzir desigualdades, fortalecer a coordenação e promover um cuidado mais integrado e contínuo.
Descritores:
Atenção primária à saúde; Idoso; Qualidade da assistência à saúde
ABSTRACT
Objective: Check the evaluation of older adults regarding the attributes of access, continuity of care, and coordination in Primary Health Care and associated factors.
Method: A household survey with a cross-sectional design was conducted with 310 older adults registered at a Primary Health Care Unit in Maringá, Paraná, Brazil. Data collection took place between June and August 2024. The attributes of Primary Health Care were assessed through home interviews, using a validated instrument that covers the dimensions of access, longitudinality, and coordination. Descriptive analyzes and multivariate regression were performed to identify sociodemographic factors associated with the quality of services.
Results: The perception of the evaluated attributes was predominantly positive. In the multivariate analysis, male sex and lack of occupation were associated with a lower positive perception of access, while the yellow race showed a positive association. Older adults of brown race (p=0.043), retirees (p=0.022), and those with monthly consultations (p<0.001) showed a higher positive evaluation of longitudinality. Coordination was positively associated with monthly consultations (p<0.001), brown race (p=0.044), and good adherence to medication treatment (p<0.001).
Conclusion: The findings indicate a favorable evaluation by older adults regarding the attributes of Primary Health Care. Socioeconomic factors and frequency of service use were found to influence the perception of quality. It is emphasized the need to improve resources and work processes to reduce inequalities, strengthen coordination, and promote more integrated and continuous care.
Descriptors:
Primary health care; Older adults; Quality of health care
RESUMEN
Objetivo: Verificar la evaluación de los adultos mayores sobre los atributos de acceso, longitudinalidad y coordinación de la Atención Primaria de Salud y los factores asociados.
Método: Se realizó una encuesta domiciliaria de delineamiento transversal con 310 personas mayores vinculadas a una Unidad Básica de Salud en Maringá, PR, Brasil. La recolección de datos se llevó a cabo entre junio y agosto de 2024. Los atributos de la Atención Primaria fueron evaluados por medio de entrevistas domiciliarias, utilizando un instrumento validado que abarca las dimensiones de acceso, longitudinalidad y coordinación. Se realizaron análisis descriptivos y regresión multivariada para identificar factores sociodemográficos asociados a la calidad de los servicios.
Resultados: La percepción de los atributos evaluados fue predominantemente positiva. En el análisis multivariado, el sexo masculino y la falta de ocupación se asociaron con una menor percepción positiva del acceso, mientras que la raza amarilla mostró una asociación positiva. Los adultos mayores de raza parda (p=0,043), los jubilados (p=0,022) y aquellos con consultas mensuales (p<0,001) presentaron una evaluación más positiva de la longitudinalidad. La coordinación se asoció positivamente con las consultas mensuales (p<0,001), la raza parda (p=0,044) y la buena adherencia al tratamiento medicamentoso (p<0,001).
Conclusión: Los hallazgos indican una evaluación favorable de las personas mayores con respecto a los atributos de la Atención Primaria de Salud. Se observó la influencia de factores socioeconómicos y de la frecuencia de uso de los servicios en la percepción de la calidad. Se destaca la necesidad de mejorar los recursos y los procesos de trabajo para reducir las desigualdades, fortalecer la coordinación y promover una atención más integrada y continua.
Descriptores:
Atención primaria de salud; Persona mayor; Calidad de la atención de salud
INTRODUCTION
The demographic transition, marked by population aging, has become one of the biggest challenges to the Brazilian health system. Currently, Brazil has an aging index of 80.03, which means that there are 80 people aged 60 or over for every 100 individuals aged 14 or under1.
This increase in the elderly population is associated with a growth in the prevalence of chronic non-communicable diseases (NCDs), such as hypertension, diabetes, and cardiovascular diseases, which require continuous care and adequate monitoring2. In this context, Primary Health Care (PHC) is paramount, as it overcomes the strictly biomedical logic and offers comprehensive care, centered on the needs of users, including the monitoring of chronic conditions and the promotion of healthy aging. To achieve this goal, the care offered at this level of care must be effective and of high quality3.
Therefore, the quality of healthcare depends on the adequacy of the physical structure, human and material resources, as well as the organization of care processes and the results obtained, in order to meet the needs of patients safely and effectively3. These principles are in line with the guidelines of Primary Health Care (PHC), which encompasses actions of promotion, prevention, treatment, and rehabilitation. In this regard, PHC assumes global relevance due to its strategic position in reducing inequities and preventing harm4-5.
The quality of care provided in primary health care can be measured by attributes that guide actions in primary health care, increasing its power of interaction with individuals and the community. Among these attributes, access, longitudinality, and coordination of services stand out as fundamental to ensuring the effectiveness of care6. Access in primary health care refers to the ability of users to obtain the necessary care without facing barriers such as location, cost, or availability of services6-7. For older people, these barriers can be even more pronounced due to limited mobility, transportation difficulties, or lack of family support, compromising the use of services and resulting in discontinuity of care8.
In this context, many elderly people report difficulties in accessing consultations, examinations and medications, which directly impacts the offer of continuous care and negatively influences their perception of the quality of primary health care. In addition, the low availability of reference physicians and the fragmentation of the care network aggravate this scenario, reducing the confidence of elderly people in the services offered and compromising the quality and effectiveness of the care provided6,8) .
Longitudinality, in turn, refers to the continuous monitoring of individuals over time, allowing the building of bonds between health teams and the community, which favors a more personalized and effective monitoring9. Finally, the coordination of services in primary health care aims to ensure the integration of care between different levels of care7. For older people, who frequently need specialized services, adequate coordination and articulation between primary health care and secondary and tertiary levels is essential to avoid fragmentation of care. In this way, it can be ensured that recommended treatments are carried out in a timely manner3,9.
It is evident that older people's perception of the quality of primary health care is directly related to practical experience with the essential attributes of this level of care, especially access, longitudinality and coordination. The ease or difficulty in accessing services influences trust and continuity of care, since barriers such as reduced mobility, limited transport and a shortage of professionals can generate frustration and demotivation in health monitoring8.
Similarly, longitudinality, by providing a continuous link with health professionals, favors more personalized and effective care, contributing to greater adherence to treatment and better perception of the care received9. However, the fragmentation of services and the lack of coordination between the different levels of care undermine the comprehensiveness of care, compromising the resolution of the health demands of older people and negatively impacting their evaluation of PHC6-9.
Therefore, the importance of integrating the attributes of Primary Health Care is highlighted, as it contributes to improving the experience of older adults in the health services, promoting more efficient and appropriate care for their needs.
Although the quality attributes of PHC, such as access, longitudinality and coordination, are widely discussed, gaps remain in the literature regarding how these factors are perceived by the elderly population and influence their evaluation of services. Some studies on the issue prioritize technical and administrative indicators, while fewer address the subjective experience of users and its relationship with adherence to care9.
Access barriers - such as mobility limitations, transportation difficulties, and lack of family support - are recognized in some research as challenges for this population. However, scientific production that systematically explores the relationship between such barriers, the perception of service quality, and the continuity of their use is still incipient8.
The link between elderly users and health professionals also appears in certain studies as an essential aspect for longitudinality. Low continuity of care can affect trust in the service and the evaluation of quality3,4. Furthermore, the fragmentation of the network and insufficient coordination between levels of care are pointed out in specific research as factors that compromise the flow of care, especially among elderly people who need specialized follow-up, impacting the effectiveness of PHC8,9.
Finally, although research already exists linking the quality of Primary Health Care with treatment adherence and health outcomes, the available evidence is still limited and inconclusive, especially in studies that address these dimensions in an integrated way. Thus, the present study seeks to contribute to the advancement of knowledge by analyzing the perception of older adults regarding the attributes of access, longitudinality, and coordination of Primary Health Care and their associated factors.
METHOD
This is a population-based household survey, quantitative in nature, with a cross-sectional design, conducted with elderly individuals assisted at a Basic Health Unit (UBS) in the municipality of Maringá (PR). The population survey is a methodology applied with the purpose of producing health information, which is inferred from the responses obtained in an interview applied to a significant probabilistic sample of the population analyzed10. The excerpt presented is part of a larger study entitled “Analysis of living conditions and health of elderly people assisted in primary care in Maringá: a look at the integrality of care for health promotion”.
The selection of the primary health care unit (UBS) was based on the researchers' convenience, considering its proximity and ease of access to data on the local elderly population. Furthermore, the area in question presents significant socioeconomic vulnerability and a high concentration of elderly people, indicating intensive use of the services provided by the UBS. At the time of data collection, the municipality had 33 UBSs and 71 Family Health Strategy (ESF) teams. The UBS in question had 1,660 registered elderly individuals, with 562 in team 1, 664 in team 2, and 434 in team 3.
Elderly people registered with the three teams located at the UBS, who had been assisted by the said team for at least six months, were included in the study. Those who, according to the application of the Mini-Mental State Examination, showed limitations in understanding and responding to the research instrument autonomously were excluded, in order to preserve the reliability of the information and respect for conscious participation 11 Elderly individuals who were absent from their homes during at least three attempted visits, conducted on different days and at different times, were also excluded.
After the number of individuals eligible for inclusion in the study was determined, lists with the names and addresses of elderly people were requested; subsequently, a proportional random selection of participants was carried out. For the sample size calculation, a prevalence of 50% was adopted, aiming for greater variability in the event investigated, associated with an estimation error of 5% and a sample reliability and precision of 95%, with an additional 10% (32 individuals) to account for potential losses, resulting in a sample of 344 individuals. After refusals (18) and changes/absence of addresses (18), 310 elderly people were effectively interviewed (Table 1).
Thus, 310 elderly people were interviewed, according to a proportional subsample based on those registered in each of the teams. Data was collected in the homes of the elderly people, from June to August 2024, after signing the Informed Consent Form, during weekdays and Saturdays, in the morning and afternoon. When the individual was not at home, two more visits were made at different times. If it was not possible to conduct the interview, the next person on the list was chosen, with only one substitution allowed.
The dependent variables were defined as the evaluation of indicators related to the studied attributes, namely: access, longitudinality, and coordination; with responses based on adequacy levels: Poor, Good, and Very Good. The independent variables included sociodemographic data (sex, age group, marital status, income, and education), as well as clinical profile and use of health services (adherence to medication treatment, frequency of visits to the Family Health Strategy, and risk of comorbidities).
Treatment adherence was assessed using the Morisky-Green test (MGT), which consists of four questions that check for non-adherence behaviors (such as forgetfulness, carelessness, or interruption of medication use). It classifies patients according to the number of affirmative responses: 0 indicates high adherence, 1 to 2 moderate adherence, and 3 to 4 low adherence12.
The frequency of visits to the primary health care unit was classified as weekly, monthly, or quarterly. For the assessment of risk for comorbidities, the Van Walraven score was used to classify patients according to their risk of morbidity and mortality. The scale used is an adaptation of the Elixhauser classification, which includes five risk possibilities: low (0 points), moderately low (1-2 points), moderate (3-5 points), high (6-10 points), and very high (>10 points)13. For statistical analysis purposes, the score was condensed, resulting in three classifications: low risk (0-2 points), medium risk (3-5 points), and high risk (≥ 6 points).
For data collection, a semi-structured instrument was used, containing two parts: 1. Socioeconomic characterization, lifestyle habits, and clinical profile; and 2. Evaluation of the adequacy of primary health care attributes. The interviews lasted approximately 60 minutes, and the data were recorded on a printed form.
To assess the adequacy of the attributes (variable of interest), an instrument was developed based on previous studies on satisfaction and quality of primary health care, using as a reference the Pcatool - Brazil for Adult Patients Reduced Version14. An instrument was also developed and applied in a study aimed to analyze the quality of care for people with DM (diabetes mellitus) in the same municipality15) and also served as the basis for the questionnaire.
The final questionnaire was developed with 17 items across the attributes (9 for access, 5 for longitudinality, and 3 for coordination) following a logic similar to that of modern instruments such as the reduced version of the PCATool, recently validated in Brazil16,17. The evaluation was carried out with a Likert scale, widely used in research on health service assessment18. After calculating the scores and averages, the result was subdivided into tertiles, as stratifying the scores in this way facilitates comparative analysis between the different levels of evaluation18,19.
The maximum score for the access attribute was 27 points, with scores up to 9 points considered poor, 10-18 points good, and 19 or higher very good. For the longitudinality attribute, the maximum score was 15 points, with scores up to 5 points considered poor, 6 to 10 points good, and 11 or higher very good. The coordination attribute had 9 points, with scores up to 3 points considered poor, 4 to 6 points good, and 7 or higher very good.
The data were recorded in an Excel® spreadsheet and subsequently organized and categorized to facilitate data interpretation. With the variables organized, a descriptive analysis of the data was performed, and the different levels of access, coordination, and longitudinality were compared according to the sociodemographic characteristics of the participants. To further the investigation, logistic regression models were fitted to explore the associations between the independent variables and the outcomes of the three domains studied. Binary and multinomial regression models were used according to the nature of the outcome, allowing for the evaluation of the magnitude and direction of the associations between sociodemographic variables and indicators of satisfaction with health services.
The diagnosis of the models included a fit assessment through simulations, verifying the adequacy of the models and identifying possible outliers. The regression results were presented as odds ratios, which facilitated the interpretation of the effects of the explanatory variables on each domain, highlighting the statistical significance of the findings and offering a deeper understanding of the factors associated with service quality.
In accordance with the recommendations20, artificial intelligence tools were used, namely ChatGPT 4.0®, to support text revision, and Elicit®, to assist in the search and organization of bibliographic references related to the study topic. The use of these technologies observed ethical and transparent parameters, as advocated by the authors, ensuring the integrity and academic adequacy of the use of such tools in the context of this study.
The research development complied with national and international ethical recommendations and standards for studies involving human subjects, and the project was approved by the Research Ethics Committee of Unicesumar (Protocol no 6.841.861/2024). After being informed about the objectives and criteria for participation, all participants signed the Informed Consent Form (ICF), in duplicate.
RESULTS
Among the 310 elderly participants in the study, there was a prevalence of women (61.9%), retirees (72.6%), and those who had a partner (61.3%). Regarding education and income, 55.2% had incomplete education; 71.3% of participants earned between 1 and 2 minimum wages.
All detailed educational options were provided in the interview, including different levels of education. However, for analysis purposes, the responses were grouped into two categories: incomplete education (illiterate, incomplete primary education, incomplete secondary education, and incomplete higher education) and complete education (complete primary education, complete secondary education, and complete higher education).
Regarding adherence to medication use, 55.8% showed low adherence, 41.6% medium adherence, and 2.58% high adherence. Analysis of the frequency of primary care use revealed that 53.2% of the participants used the service quarterly, followed by 45.8% who used it monthly. Regarding the risk of comorbidities, 48.7% had a high risk, 36.7% a low risk, and 14.5% a medium risk.
Table 2 shows the analysis of factors associated with the perceived adequacy of the access attribute, divided into three groups: Good/satisfactory (n=182), Poor/Unsatisfactory (n=3), and very good/Very satisfactory (n=125). Although no variable examined showed statistical significance regarding the adequacy of the access attribute, from the perspective of older people, a high level of satisfaction with this attribute was observed, regardless of the variable analyzed.
The median age was similar among the three groups, as was the gender, with a predominance of women. The largest percentage of individuals were white, and they reported being satisfied (66%) or very satisfied (61%) with their access to primary health care.
Most individuals were retirees, and of these, the largest proportion (72%) reported satisfaction with access to health services, as did those who had a partner (62%) and those with incomplete primary education (32%). Regarding the risk of comorbidities, it is noteworthy that the largest share of individuals who rated access as good (47%) or very good (51%) had a high risk, a result similar to that observed among those who attended the health care service quarterly (54% and 49%, respectively) and who had low adherence to drug treatment (58% and 53%, respectively).
Table 3 presents statistical data on the quality of longitudinal care, divided into three groups: satisfactory/good (n=221), unsatisfactory/poor (n=6), and very satisfactory/very good (n=83). Analyzing the determining factors for the perception of the adequacy of longitudinal care, it is observed that some tested variables showed a significant association. Regarding occupation, the group with unsatisfactory access had a significantly higher proportion of individuals who were working (83%) compared to the other groups (p=0.004). Marital status also showed significant differences (p=0.034), with a higher percentage of individuals who lived with a companion in the very satisfactory group (67%) compared to the unsatisfactory group (17%).
The frequency of use of primary health care differed significantly between the groups (p < 0.001), with higher monthly use in the very satisfactory group (64%) compared to the others. Although not statistically significant, the analysis of comorbidity risk showed that 34% of the individuals had satisfactory access, 50% had unsatisfactory access, and 43% had very satisfactory access and presented a low risk, without statistical significance (p = 0.5). Treatment adherence was similar between the groups, with low adherence predominating in all of them (p = 0.7), as shown in Table 3.
Analysis of the adequacy of the coordination attribute, according to elderly individuals, shows that 147 rate it as very good, 82 as good, and 81 as poor. Statistical results indicate some significant differences between the coordination quality groups in the variables of frequency of use of primary health care and adherence to treatment, as shown in Table 4.
Regarding the frequency of use of PHC, the group with unsatisfactory coordination showed the highest proportion of quarterly use (81%), while the very satisfactory group used the health services monthly more often (59%). This difference was statistically significant (p<0.001). Regarding adherence to treatment, 70% of participants in the unsatisfactory group demonstrated low adherence, contrasting with 48% in the satisfactory group and 52% in the very satisfactory group. The difference between the groups was also statistically significant (p=0.006), according to Table 4.
Other variables, such as age, sex, race/color, occupation, marital status, and smoking, did not show significant differences between the groups regarding the adequacy of coordination, showing that these characteristics are relatively homogeneous among the groups.
In the analysis of odds ratios (OR), among the aspects that influence the positive perception of access to health services, it was found that sex, race/color, and occupation had significant associations with the perception of quality. Men were less likely to be very satisfied with access compared to women (OR = 0.53), as were people identified as Asian compared to white (OR = 9.88). Individuals who were not currently employed showed a lower probability of being very satisfied with access compared to those who were employed (OR = 0.30).
Regarding the variables that remained associated with longitudinality, it was found that brown individuals had a lower chance of rating longitudinality as very satisfactory compared to white individuals (OR = 0.47), as did retired individuals compared to those who are employed (OR = 0.42). The frequency of use of primary care also showed a relevant association, with individuals who use the services monthly having a much higher chance of rating longitudinality as very satisfactory compared to those who use them quarterly (OR = 3.48).
When analyzing factors associated with satisfaction with coordination, comparisons were considered between those who rated coordination as satisfactory versus unsatisfactory; and satisfactory versus very satisfactory. In the comparison between satisfactory and unsatisfactory, individuals who use the services monthly showed a lower probability of rating coordination as unsatisfactory compared to those who use it quarterly (OR = 0.28), as well as those with high adherence to treatment (OR = 0.00).
When comparing satisfied and very satisfied long-term users with the service coordination, it was found that brown users were less likely to rate it as very satisfactory compared to white users (OR = 0.49). The frequency of primary care use also had an impact, as users who attend services monthly were more likely to rate the coordination as very satisfactory compared to those who use it quarterly (OR = 2.04) (Table 5).
DISCUSSION
The sociodemographic characteristics of the 310 elderly people participating in the study confirm the profile described in national research, which points to a predominance of women, black and brown people, low education and low income among older SUS users21,22.
Regarding the clinical profile and use of services, low adherence to drug treatment and a high risk of comorbidities were observed, a result that aligns with studies that show an inverse relationship between adherence and risk of complications22,23. In addition, quarterly attendance was the most prevalent frequency, which may be related to the care flowchart for chronic conditions established in the state24.
Regarding access, the study identified a lower chance of positive evaluation among men. This finding may be associated with the greater use of health services by women, either for their own benefit or as companions, which allows them to more accurately assess the quality of care25. In line with this, research carried out in Minas Gerais showed that men tend to value specific aspects, such as friendliness and waiting time, which helps to explain differences in perception between the sexes26. Furthermore, cultural and structural factors, such as the restricted search for preventive care and operating hours that are not very compatible with working hours, contribute to lower male satisfaction26.
Access, however, remains one of the most valued attributes by primary health care users. Ease of scheduling, reduced waiting time and availability of supplies are frequently cited as determinants of satisfaction15. Among older people in greater socioeconomic vulnerability, such barriers may have an even more pronounced impact, limiting the continuous use of services8,9,27) .
The analysis also revealed that race/color was a significant variable. Brown and yellow elderly people showed a lower chance of satisfaction with access, longitudinality and coordination compared to white people. This inequality, already described in studies on access of black women to health services21, reflects persistent structural conditions.
Data from the 2019 National Health Survey show that racial and gender inequalities amplify vulnerabilities, with black, brown, and indigenous people presenting worse socioeconomic and access indicators21,28. These structural barriers reduce engagement, hinder coordination, and help explain the lower satisfaction found9,15.
Another important finding was the lower chance of positive evaluation among retirees and unemployed people, especially in the longitudinality attribute. Despite having more time to seek care, these individuals face limitations resulting from the disorganization of care flows and the fragmentation of care, which hinders continuity and reduces the perception of quality 27. Furthermore, 53.23% of the elderly reported dissatisfaction with the waiting time, revealing a need to reorganize the scheduling processes. Long intervals for care compromise preventive actions and can lead to the postponement of essential care29.
In an integrated way, the results indicate that both the physical structure and resources of the units and the organization of flows directly interfere with the perception of quality. Units with stable and well-structured teams favor continuous access, adherence to treatment and overall satisfaction29. The monthly frequency of service also deserves mention, being associated with greater satisfaction with longitudinality and coordination. This pattern suggests that greater regularity of contact contributes to stronger bonds and more effective follow-up30.
Studies reinforce that longitudinality is key for the management of chronic conditions and the prevention of fragmentation of care7,9. However, the precariousness of work in health after the 2017 PNAB Reform, marked by flexible contracts and high turnover, weakens the bond between professionals and users, impacting coordination and continuity of care31,32. When preserved, continuity of care favors therapeutic adherence and personalization of care, an aspect confirmed in this study33.
Treatment adherence showed a direct relationship with the perceived quality of coordination. Elderly people with high adherence showed a lower chance of dissatisfaction, highlighting engagement as a determining factor for positive perception29,34. However, barriers such as reduced mobility, cognitive limitations, and the absence of caregivers exacerbate difficulties in fragmented systems, resulting in delays, duplication of examinations, and worsening health outcomes30,35. To minimize such problems, strategies involving team stability, continuous training, and the use of integrated electronic health records are necessary. These measures were found to be effective in national and international experiences29.
Systematically, the findings show that socioeconomic variables (sex, race/color, occupation) and frequency of service use simultaneously influence different attributes of primary health care. The integration of these factors points to the need for reorganization of work processes, strengthening of bonds, and greater coordination between levels of care. For nursing practice, such evidence suggests specific interventions, such as strategies for monitoring adherence, home visits to reinforce the bond, and training focused on interprofessional management. Furthermore, it opens avenues for new nursing-led research focused on innovative models of elderly-centered care.
It should be noted, however, that the use of tertiles as cut-off points for score stratification constitutes a limitation of the study, as it is an arbitrary methodological definition. This decision was intended to facilitate comparative analysis between different levels of assessment, although it may influence the sensitivity of the results. It is recommended that future studies consider other forms of categorization and perform comparisons with more objective and standardized indicators of Primary Health Care quality.
CONCLUSION
The results show that the attributes of access, longitudinality, and coordination were, in general, favorably evaluated by older adults. Yet coordination proved to be the attribute with the greatest relative vulnerability, especially among those with low adherence to medication treatment and lower frequency of use of health services, indicating the need for greater integration between points of care to ensure continuity of care.
Moreover, sociodemographic characteristics, such as male sex and lack of occupation, were associated with a lower positive perception of access, while the yellow race showed a favorable association. The brown race showed different perceptions among the attributes, revealing inequalities that influence how older adults evaluate the quality of care.
The findings reinforce the need for investments directed towards improving care coordination and reducing socioeconomic barriers that limit access to and continuity of care. Measures such as expanding resources, strengthening multidisciplinary teams, adopting health information technologies, and strategies focused on bonding and therapeutic adherence can contribute to enhancing the quality of services provided. The study offers important insights to guide interventions that promote more efficient, integrated, and person-centered care for the elderly, favoring healthy aging and improving quality of life.
Acknowledgements
The authors thank the Coordination for the Improvement of Higher Education Personnel (CAPES) for the support and funding that contributed to the completion of this research.
REFERENCES
-
1. Instituto Brasileiro de Geografia e Estatística (IBGE). Panorama 2022 [Internet]. 2023[cited 2024 Dec 10]. Available from: https://censo2022.ibge.gov.br/panorama/indicadores.html?localidade=BR
» https://censo2022.ibge.gov.br/panorama/indicadores.html?localidade=BR -
2. Silva DSM, Assumpção D, Francisco PMSB, Yassuda MS, Neri AL, Borim FSA. Doenças crônicas não transmissíveis considerando determinantes sociodemográficos em coorte de idosos. Rev Bras Geriatr Gerontol. 2022;25(5):e210204. https://doi.org/10.1590/1981-22562022025.210204.pt
» https://doi.org/10.1590/1981-22562022025.210204.pt -
3. Soares DA, Kochergin CN, Mistro S, Macedo JCL, Carvalho VCHD, Oliveira MG. Atenção Primária à Saúde abrangente: análise a partir do trabalho das equipes de Saúde da Família frente às doenças crônicas. Physis: Rev Saúde Coletiva [Internet]. 2024[cited 2024 Dec 10];34:e34015. Available from: https://www.scielo.br/j/physis/a/yq3gg8hGHKJ6NvwNWVZtGgd/?format=html⟨=pt
» https://www.scielo.br/j/physis/a/yq3gg8hGHKJ6NvwNWVZtGgd/?format=html⟨=pt -
4. Ren M, Zhang T, Xu J, Qiao J, Qiao J, Zhan S, et al. Building quality primary health care development in the new era towards universal health coverage: a Beijing initiative. Global Health Res Pol. 2023;8(53). https://doi.org/10.1186/s41256-023-00341-y
» https://doi.org/10.1186/s41256-023-00341-y -
5. Masochini RG, Farias SNP, Sousa AI. Avaliação dos atributos da Atenção Primária à Saúde na perspectiva dos idosos. Esc Anna Nery. 2022;26:e20200433. https://doi.org/10.1590/2177-9465-EAN-2020-0433
» https://doi.org/10.1590/2177-9465-EAN-2020-0433 -
6. Machado GA, Dias BM, Silva JJ, Bernardes A, Gabriel CS, et al. Avaliação de atributos da Atenção Primária à Saúde: a perspectiva dos profissionais. Acta Paul Enferm. 2021;34:eAPE00973. https://doi.org/10.37689/acta-ape/2021AO00973
» https://doi.org/10.37689/acta-ape/2021AO00973 - 7. Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002.
-
8. Nascimento FA, Quental OB, Souza AC, Nóbrega RO. A assistência de enfermagem no cuidado de idosos e seus desafios na atenção primária. Rev Ibero-Am Hum Cienc Educ. 2025;11(6):1663-73. https://doi.org/10.51891/rease.v11i6.19806
» https://doi.org/10.51891/rease.v11i6.19806 -
9. Oliveira LGF, Fracolli LA, Castro DMCL, Gryschek ALFPL, Oliveira AAP, Silva LA, et al. Longitudinalidade na atenção primária à saúde: explorando a continuidade do cuidado ao longo do tempo. Arq Cienc Saude UNIPAR [Internet]. 2023[cited 2024 Dec 10];27(7):3385-95. Available from: https://revistas.unipar.br/index.php/saude/article/view/10048/4917
» https://revistas.unipar.br/index.php/saude/article/view/10048/4917 -
10. Silva VSTM, Pinto LF. Inquéritos domiciliares nacionais de base populacional em saúde: uma revisão narrativa. Ciênc Saúde Colet. 2021;26:4045-58. https://doi.org/10.1590/1413-81232021269.28792020
» https://doi.org/10.1590/1413-81232021269.28792020 -
11. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res[Internet]. 1975[cited 2024 Dec 10];12(3):189-98. Available from: https://nesdo.onderzoek.io/wp-content/uploads/2016/08/MMSE_Folstein-1975.pdf
» https://nesdo.onderzoek.io/wp-content/uploads/2016/08/MMSE_Folstein-1975.pdf -
12. Ben AJ, Neumann CR, Mengue SS. Teste de Morisky-Green e Brief Medication Questionnaire para avaliar adesão a medicamentos. Rev Saúde Pública. 2012;46:279-89. https://doi.org/10.1590/S0034-89102012005000013
» https://doi.org/10.1590/S0034-89102012005000013 -
13. Sharma N, Schwendimann R, Endrich O, Ausserhofer D, Simon M. Comparing Charlson and Elixhauser comorbidity indices with different weightings to predict in-hospital mortality: an analysis of national inpatient data. BMC Health Serv Res. 2021;21(13). https://doi.org/10.1186/s12913-020-05999-5
» https://doi.org/10.1186/s12913-020-05999-5 -
14. Ministério da Saúde(BR). PCATool: instrumento de avaliação da atenção primária à saúde: primary care assessment tool [Internet]. Brasília, DF: Ministério da Saúde; 2020. Available from: https://www.conasems.org.br/wp-content/uploads/2020/05/Pcatool_2020.pdf
» https://www.conasems.org.br/wp-content/uploads/2020/05/Pcatool_2020.pdf -
15. Berardinelli D, Conti A, Hasnaoui A, Casabona E, Martin B, Campagna S, Dimonte V. Nurse-led interventions for improving medication adherence in chronic diseases: a systematic review. Healthcare (Basel). 2024;12(23):2337. https://doi.org/10.3390/healthcare12232337
» https://doi.org/10.3390/healthcare12232337 -
16. Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics [Internet]. 2004[cited 2024 Dec 10];113(5):1493-8. Available from: https://pubmed.ncbi.nlm.nih.gov/15121917/
» https://pubmed.ncbi.nlm.nih.gov/15121917/ -
17. Menegazzo GR, Harzheim E, Oliveira MMC, Hauser L. Psychometric properties of the reduced version of the Primary Care Assessment Tool (PCATool). Rev Bras Epidemiol. 2024;27:e240057. https://doi.org/10.1590/1980-549720240057
» https://doi.org/10.1590/1980-549720240057 -
18. Morera OF, Nyugen T, Stern M, Filion AJ, Chen T. Discretizing continuous variables in nutrition and obesity research: a practice that needs to be cut short. Nutr Diabetes. 2023;13:20. https://doi.org/10.1038/s41387-023-00248-0
» https://doi.org/10.1038/s41387-023-00248-0 -
19. Bennette C, Vickers A. Against quantiles: categorization of continuous variables in epidemiologic research, and its discontents. BMC Med Res Methodol. 2012;12:21. https://doi.org/10.1186/1471-2288-12-21
» https://doi.org/10.1186/1471-2288-12-21 -
20. Hosseini M, Resnik DB, Holmes K. The ethics of disclosing the use of artificial intelligence tools in writing scholarly manuscripts. Res Ethics. 2023;19(4):449-65. https://doi.org/10.1177/17470161231180449
» https://doi.org/10.1177/17470161231180449 -
21. Silva LGC, Martins IS, Martins FES, Oliveira FS, Garcia TFM, Sousa ACPA. Perfil sociodemográfico, de saúde e hábitos de vida de idosos na Atenção Primária à Saúde. Rev Baiana Saúde Pública. 2023;45(4):138-52. https://doi.org/10.22278/2318-2660.2021.v45.n4.a3384
» https://doi.org/10.22278/2318-2660.2021.v45.n4.a3384 -
22. Vieiro MM, Perseguino MG, Rastelli VMF, Vismari L. Análise do perfil sociodemográfico e de utilização de medicamentos de idosos atendidos em ambulatório universitário. Rev Gest Sist Saúde. 2020;9(3):479-98. https://doi.org/10.5585/rgss.v9i3.14523
» https://doi.org/10.5585/rgss.v9i3.14523 -
23. Khatri R, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A et al. Continuity and care coordination of primary health care: a scoping review. BMC Health Serv. Res. 2023;23(750). https://doi.org/10.1186/s12913-023-09718-8
» https://doi.org/10.1186/s12913-023-09718-8 -
24. Ministério da Saúde(BR). Nota Técnica Nº 10/2023-CAIN/CGESCO/DESCO/SAPS/MS. Diretrizes para reorganização das equipes multiprofissionais na Atenção Primária à Saúde [Internet]. 2023[cited 2024 Dec 10]. Available from: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/notas-tecnicas/2023/nota-tecnica-no-10-2023.pdf/@@download/file
» https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/notas-tecnicas/2023/nota-tecnica-no-10-2023.pdf/@@download/file -
25. Soares MM, Caldeira TCM, Sousa TM, Rezende LFM, Claro RM. Leisure time physical activity among older adults in Brazil: a time series analysis of a population-based survey (2009-2020). Cad Saude Publica. 2023;39(8):e00212622. https://doi.org/10.1590/0102-311XEN212622
» https://doi.org/10.1590/0102-311XEN212622 -
26. Pavan IP, Baptista ASL, Rosa CP, Cabral DS, Bittencourt F, Silva SA. Satisfação do usuário com os serviços de saúde de atenção básica: percepção masculina. Cienc Cuid Saúde. 2020;19:e46760. https://doi.org/10.4025/cienccuidsaude.v19i0.46760
» https://doi.org/10.4025/cienccuidsaude.v19i0.46760 -
27. Gonçalves JL, Silva RM, Sousa GS, Bezerra IC, Praça Brasil CC, Vieira LJES, et al. Barriers to care for dependent older adults: Brazilian Primary Health Care managers’ perspective. PLoS One. 2024;19(12):e0316657. https://doi.org/10.1371/journal.pone.0316657
» https://doi.org/10.1371/journal.pone.0316657 -
28. Cesário VAC, Santos MMD, Mendes TCD, Souza PRBD Júnior, Lima KCD. Tendências de acesso e utilização dos serviços de saúde na APS entre idosos no Brasil nos anos 2008, 2013 e 2019. Ciên Saúde Coletiva. 2021;26:4033-44. https://doi.org/10.1590/1413-81232021269.08962021
» https://doi.org/10.1590/1413-81232021269.08962021 -
29. Ferreira J, Geremia DS, Geremia F, Celuppi IC, Tombini LHT, Souza JBD. Avaliação da Estratégia Saúde da Família à luz da tríade de Donabedian. Av Enferm [Internet]. 2021[cited 2024 Dec 10];39(1):63-73. Available from: http://www.scielo.org.co/pdf/aven/v39n1/0121-4500-aven-39-01-63.pdf
» http://www.scielo.org.co/pdf/aven/v39n1/0121-4500-aven-39-01-63.pdf -
30. Costa BC, Santos- LA Filho, Teles LMR. Implantação de um serviço de atenção à pessoa idosa no interior do Ceará. Cad Saúde Pública. 2022;16(2):148-53. https://doi.org/10.54620/cadesp.v16i3.979
» https://doi.org/10.54620/cadesp.v16i3.979 -
31. Pereira AAC, Lemos M, Cunha CLF, Souza HS, Alvarenga EC, Ferreira GRON et al. Os impactos da Reforma Trabalhista sobre o trabalho da Enfermagem. REME Rev Min Enferm. 2022;26:e-1439. https://doi.org/10.35699/2316-9389.2022.39242
» https://doi.org/10.35699/2316-9389.2022.39242 -
32. Esteves TV, Almeida IM. Saúde, trabalho e a Reforma Trabalhista de 2017: revisão integrativa das repercussões da nova legislação nas formas de viver e adoecer da classe trabalhadora. Rev Jur Trab Desenvolv Hum. 2023;6:1-43. https://doi.org/10.33239/rjtdh.v6.169
» https://doi.org/10.33239/rjtdh.v6.169 -
33. Veras RP. Doenças crônicas e longevidade: desafios futuros. Rev Bras Geriatr Gerontol . 2023;26:e230233. https://doi.org/10.1590/1981-22562023026.230233.pt
» https://doi.org/10.1590/1981-22562023026.230233.pt -
34. Almeida R, Rosa M, Nauman LG, Silva VE, Moreira A, Silva ML, et al. A utilização do teste Morisky-Green na adesão ao tratamento anti-hipertensivo: detecção precoce na atenção primária à saúde. Rev Arq Cient IMMES. 2020;3(1):132-41. https://doi.org/10.5935/2595-4407/rac.immes.v3n1p132-141
» https://doi.org/10.5935/2595-4407/rac.immes.v3n1p132-141 -
35. Silva RM, Brasil CCP, Bezerra IC, Figueiredo MLF, Santos MCL, Gonçalves JL et al. Desafios e possibilidades dos profissionais de saúde no cuidado ao idoso dependente. Ciên. Saúde Coletiva. 2021;26(1):89-98. https://doi.org/10.1590/1413-81232020261.31972020
» https://doi.org/10.1590/1413-81232020261.31972020
Access to the dataset may be obtained by requesting it from the corresponding author.
