Avaliação da acessibilidade na atenção primária à saúde na perspectiva dos gerentes / Evolution of accessibility in primary health care from the perspective of managers

Introdução: O sistema público brasileiro está alicerçado pela atenção primária à saúde, que se caracteriza como o primeiro contato preferencial dos usuários com o serviço de saúde. Nesse contexto, destaca-se a avaliação do serviço como uma ferramenta de gestão que busca detectar possíveis fragilidades e potencialidades do serviço. Objetivo: Avaliar a presença e extensão do atributo acessibilidade na perspectiva dos gerentes da atenção primária à saúde. Material e Métodos: Estudo transversal de caráter avaliativo. Os dados foram coletados entre 42 gerentes das unidades de atenção primária à saúde, por meio do questionário auto aplicável Primary Care Asssessment Tool ­ Brasil, versão para profissionais. A análise estatística foi realizada através do software Statiscal Package for the Social Sciences (versão 22). O teste U de Mann Whitney foi utilizado para comparação dos escores entre os modelos de atenção (eSF e eAB), áreas (rural e urbana), formação e qualificação profissional, com nível de significância de 5%. Resultados: A acessibilidade mostrou-se insatisfatória em todas as análises, com melhor avaliação das equipes de Saúde da Família (p=0,375), na área rural (p=0,528), entre os profissionais que possuem especialização em saúde da família (p=0,685) e residência em saúde da família (p=0,196). Conclusão: O estudo apontou fragilidades estruturais do serviço no que diz respeito à acessibilidade e identificou a importância de investimentos na qualificação dos profissionais como fator que promove melhor acesso ao serviço.

Introdution: The Brazilian public system is enabled by Primary Health Care, wich presents as the first preferential contact of users with the health service. Given this importance, select a service evaluation as a search management tool that can detect potential service weaknesses and potentials. Objective: To assess the presence and extension of the accessibility attribute from the perspective of primary health care managers. Material and Methods: Evaluative cross-sectional study. Data were collected from 42 managers of primary health care units, through the self-administered questionnaire Primary Care Assessment Tool-Brazil, version for professionals. Statistical analysis was performed using the Statiscal Package for Social Sciences software (version 22). The Mann Whitney U test was used to compare the scores the attention models (eSF na eAB), areas (rural and urban), training and professional qualification, with a significance level of 5%. Results: Accessibility was unsatisfactory in all analyzes, with better evaluation of Family Health teams (p=0,375) in the rural areas (p=0,528) among professionals who havespecialization in Family health (p=0,685) and Family health residency (p=0,196). Conclusion: The study pointed out structural weaknesses of the service regarding accessibility, and identified the importance of investments in the qualification of professionals as a factor that promotes better access to the service.

Structural Violence in Health Care: Lived Experience of Street-Based Female Commercial Sex Workers in Kathmandu.

Thirty-five in-depth, semi-structured interviews were conducted with female, street-based, commercial sex workers in Kathmandu, Nepal. The framework of structural violence guided this study in identifying the structural context that impacts the female sex workers' lives and may cause harm to their health. Structural violence in health care was revealed through thematic analysis as (a) discrimination, (b) forced choice, and (c) limitations to health information sources. Lived experiences highlight how the sex workers engaged with structural limitations in health care access, services, and utilization. Structural violence conveys a message about who is entitled to health care and what a society emphasizes and expects regarding acceptable health behavior. Examining the structural violence highlighted how the sex workers negotiated, understood, and engaged with structural limitations in health care access, services, and utilization.

Conditional Disclosure on Pathways to Care: Coping Preferences of Young People at Risk of Psychosis.

The interrelationship between stigma and help-seeking is under-researched among children and adolescents. This study explored stigma in relation to pathways to care among young people putatively in an early stage of increased risk of developing psychotic disorders. "Pathways to care" was defined as help-seeking and support from informal and formal resources, and increased risk was determined through the presence of persistent psychotic-like experiences and internalizing/externalizing psychopathology. Twenty-nine qualitative interviews were analyzed using thematic analysis. We defined the superordinate theme in these data as "conditional disclosure," a concept reflecting the rules and prerequisites that influenced how/whether participants sought help. Through parallels between these findings and established stigma theory, we examined how these conditions could be interpreted as influenced by stigma. Our findings demonstrate the influence of stigma on young people's perceptions of a range of pre-clinical symptoms, and on how they seek support for these symptoms.

The Experiences and Perceptions of Street-Involved Youth Regarding Emergency Department Services.

Street-involved (SI) youth comprise a substantial component of the urban homeless population. Despite being significant users of hospital emergency department (ED) services for acute and ongoing health needs, little is known about their experiences of ED care and the factors affecting their ED use. This study used a grounded theory and community-based approach to examine these issues. Focus groups and individual interviews were facilitated with 48 SI youth between ages 15 and 26 years, recruited in hospital or through community agencies serving SI youth in a major Western Canadian city. Results demonstrate that SI youth often perceived suboptimal care and experienced long waiting periods that led to many avoiding or prematurely exiting the ED. Service gaps appeared to have a negative bearing on their care and health outcomes. Findings invite a critical review of ED care processes, structures, and staff interactions in the aim of enhancing ED services to SI youth.

Chronic Obstructive Pulmonary Disease Patients' Experiences of an Enhanced Self-Management Model of Care.

Chronic obstructive pulmonary disease (COPD) is debilitating and costly. Self-management is championed to empower individuals to better manage their condition and also to efficiently utilize health resources. As a multi-disciplinary team, we conducted focus group research with individuals living with COPD who were participating in a longitudinal study to use an electronic "diary" to monitor, record, and transmit their own health status, plus receiving regular nurse visits. The main aims of the focus groups were to investigate how far individuals embraced the electronic diary and experienced it as an aid to the self-management of their condition. We also looked at the importance of the nurse visits to the process. Thematic analysis revealed that patients responded positively to the use of technology (the electronic diary), including psychological benefits of perceived support offered by the remote symptom surveillance. Findings also showed patients' increased awareness and monitoring of personal symptoms together with an improved understanding of disease self-management. Nurse support emerged as an important "human" factor in the process. In addition, a reduction in hospital admission was observed, thus reducing costs to the health service.

Exploring Professional Help-Seeking for Mental Disorders.

Only a third of people with mental disorders seek professional help. In this study, we aimed to investigate attitudes toward help-seeking among non-help-seekers drawn from a community survey in South London. We conducted qualitative interviews with 24 participants with symptoms of mental disorders. We analyzed data using thematic analysis. Participants' reasons for not seeking professional help included perceiving their problems as normal or unsuitable for professional help, negative expectations of professional help, believing informal strategies were sufficient, fearing being stigmatized for having a mental disorder and help-seeking, and self-perceptions of being strong and/or self-reliant. A small number (n = 4) had resolved their problems. Participants with unresolved mental disorders (n = 20) had more chronic stressors, particularly about finances and family relationships, and greater concerns about professional help and stigma than other participants. Potential targets for interventions to encourage help-seeking could be focused around stigma about help-seeking as well as the self-perception of being strong.

Acceptable care? Illness constructions, healthworlds, and accessible chronic treatment in South Africa.

Achieving equitable access to health care is an important policy goal, with access influenced by affordability, availability, and acceptability of specific services. We explore patient narratives from a 5-year program of research on health care access to examine relationships between social constructions of illness and the acceptability of health services in the context of tuberculosis treatment and antiretroviral therapy in South Africa. Acceptability of services seems particularly important to the meanings patients attach to illness and care, whereas-conversely-these constructions appear to influence what constitutes acceptability and hence affect access to care. We highlight the underestimated role of individually, socially, and politically constructed healthworlds; traditional and biomedical beliefs; and social support networks. Suggested policy implications for improving acceptability and hence overall health care access include abandoning patronizing approaches to care and refocusing from treating "disease" to responding to "illness" by acknowledging and incorporating patients' healthworlds in patient-provider interactions.

Visibility and Voice: Aboriginal People Experience Culturally Safe and Unsafe Health Care.

In Canada, cultural safety (CS) is emerging as a theoretical and practice lens to orient health care services to meet the needs of Aboriginal people. Evidence suggests Aboriginal peoples' encounters with health care are commonly negative, and there is concern that these experiences can contribute to further adverse health outcomes. In this article, we report findings based on participatory action research drawing on Indigenous methods. Our project goal was to interrogate practices within one hospital to see whether and how CS for Aboriginal patients could be improved. Interviews with Aboriginal patients who had accessed hospital services were conducted, and responses were collated into narrative summaries. Using interlocking analysis, findings revealed a number of processes operating to produce adverse health outcomes. One significant outcome is the production of structural violence that reproduces experiences of institutional trauma. Positive culturally safe experiences, although less frequently reported, were described as interpersonal interactions with feelings visibility and therefore, treatment as a "human being."

Trauma systems in Kenya: a qualitative analysis at the district level.

Injury is a leading cause of death and disability in low- and middle-income countries. Kenya has a particularly high burden of injuries, accounting for 88.4 deaths per 100,000 population. Despite recent attempts to prioritize injury prevention in Kenya, trauma care systems have not been assessed. We assessed perceptions of formal and informal district-level trauma systems through 25 qualitative semi-structured interviews and 16 focus group discussions with Ministry of Health officials, district hospital administrators, health care providers, police, and community members. We used the principles of theoretical analysis to identify common themes of prehospital and hospital trauma care. We found prehospital care relied primarily on "good Samaritans" and police. We described hospital care in terms of human resources, infrastructure, and definitive care. The interviewers repeatedly emphasized the lack of hospital infrastructure. We showed the need to develop prehospital care systems and strengthen hospital trauma care services.

The healing journey: help seeking for self-injury among a community population.

Help seeking is known to be a complex and difficult journey for people who self-injure. In this article, we explore the process of help seeking from the perspective of a group of people living in Northern Ireland with a history of self-injury. We conducted 10 semistructured interviews and employed a grounded theory approach to data analysis. We created two major categories from the interview transcript data: (a) "involution of feeling," which depicts participants' perspectives on barriers to help seeking; and (b) "to be treated like a person," in which participants communicate their experiences of help seeking. The findings pose important implications for policy, practice, theory, and future research, including the need to increase the uptake of follow-up care among people who arrive at hospitals as a result of self-injury, self-harm, or suicidal behaviors.

Understanding Barriers to Mental Health Care for Recent War Veterans Through Photovoice.

Despite an urgent need for mental health care among U.S. service members returning from deployments to Iraq and Afghanistan, many veterans do not receive timely or adequate treatment. We used photovoice methods to engage veterans in identifying barriers to utilizing mental health services. Veterans described how key aspects of military culture and identity, highly adaptive during deployment, can deter help-seeking behavior and hinder recovery. Veterans' photographs highlighted how mental health symptoms and self-coping strategies operated as barriers to care. Many veterans' photos and stories revealed how negative health care encounters contributed to avoidance and abandonment of treatment; some veterans described these experiences as re-traumatizing. Visual methods can be a powerful tool for engaging recent war veterans in research. In particular, community-based participatory research approaches, which have rarely been used with veterans, hold great promise for informing effective interventions to improve access and enhance provision of patient-centered care for veterans.

Assistive technology provision within the Navajo Nation: user and provider perceptions.

In this study we explored the factors that affect assistive technology (AT) provision within the Navajo Nation using a qualitative approach to inquiry. Focus groups were held in which AT users discussed their awareness of AT and their need for, use of, and satisfaction with AT devices and services. Twenty-eight individuals who used wheelchairs, orthotics or prosthetics, hearing aids, communication aids, vision aids, and other AT participated in one of seven focus groups. Seven AT providers discussed the facilitators and barriers that affect AT provision. The findings revealed six themes common to both stakeholder groups and two additional themes for AT users. The central theme for AT users centered on (not) feeling understood; the central theme for AT providers revolved around the processes, activities, and roles the providers engaged in at times for different clients. Activities to increase awareness and to promote successful AT provision and satisfaction with AT devices were proposed.

Health services for linguistic minorities in a bilingual setting: challenges for bilingual professionals.

We explore in this qualitative research the challenges faced by bilingual health and social services professionals in a Canadian bilingual setting, as well as the strategies used to overcome them. Eight focus groups were conducted with a total of 43 bilingual Francophone professionals who offered services in French in 21 health and social service organizations in eastern Ontario, Canada. We highlight linguistic issues affecting a minority Francophone clientele, the shortage of services in French, and organizational issues within these agencies. The solutions that the professionals adopt for better serving the clients and overcoming these challenges focus on adapting services from linguistic angles. In the long term, such an enhanced approach can affect staff well-being. Ensuring access to services for linguistic minority populations and the active offer of same should not rest solely on the shoulders of such professionals, but rather on organizational strategies.

How people with serious mental illness seek help after leaving jail.

In this study, I examined how people with serious mental illness defined and prioritized their service needs when released from jail and how these service priorities shaped the sequencing of help-seeking activities after their release. Data included ethnographic observations and interviews with the staff and clients of a mental health reentry program and responses to an open-ended questionnaire that was given to the program's clients (N = 115). Sixty-three percent of the clients identified housing and 35% identified financial assistance as one of their two most important service needs, whereas only 12% selected treatment services. These service priorities reflect a hierarchy in help-seeking activities postrelease in which clients' access to treatment services was predicated on their ability to first find sustainable economic and material support. I conclude that reentry programs need to have the resources required to meet both the basic and treatment needs of people with serious mental illness leaving jail.

Understanding health constraints among rural-to-urban migrants in China.

The main purpose of this article is to examine the understanding and experience of health and health care among rural-to-urban migrants in China, and to explain the impact of the internal factors of migrants themselves and the external factors of their social environment. Understanding the perceptions and consciousness of health issues among migrants is crucial to prevention, intervention, and other health-related measures for the migrant population in China, but this has rarely been explored in studies. On the basis of a case study of a migrant community in Beijing, I explore the migrants' understandings of health and health care and analyze factors in the social environment, including exclusion from the social system and the possibility of health participation, exclusion from social relation networks, obstructed channels of health maintenance, and exclusion of crowd psychology, which impact heavily on their health understanding and health behavior. I argue that the internal and the external factors are linked together closely and interact as reciprocal causation. However, the migrants should not be seen as primarily responsible, because their poor understanding of health mainly results from the socioeconomic environment in which they live and work.

Health care among street-involved women: the perpetuation of health inequity.

I present the findings from a study that explored the experiences and decision making of street-involved women navigating the health care system. Data were drawn from a larger qualitative study situated in a western Canadian inner-city neighborhood that examined the health-management strategies of street-involved women with a history of crack cocaine use. Data were collected over a 17-month period and included ethnographic methods of participant observation, group interviews (n = 57), and in-depth interviews (n = 10). Inductive thematic analysis derived two major themes: power and punishment, and organization and delivery of care. The themes illustrate how women's experiences and decision making were located within a nexus of power relations that operated across women's shared social location as downtown eastsiders. Implications of the findings are discussed in relation to supporting women's efforts and improving health outcomes.

Structural barriers to receiving health care services for female sex workers in Russia.

Female sex workers in Russia have been particularly vulnerable to recent social, political, and economic changes. In this article, we describe the facilitators and barriers for sex workers receiving health care services in St. Petersburg, Russia. We conducted observations at medical institutions and nongovernmental organizations and in-depth interviews with 29 female sex workers. We identified the following barriers: poverty, not having documents, lack of anonymity in testing, and the official registration system. We identified the following facilitators: intervention by family members, social connections within the health care system, and referral services from a nongovernmental organization. Our findings indicate a need for reassessing policies and designing programs that better facilitate the use of health care services for the most vulnerable populations. This should include the expansion of support systems and outreach services designed to help female sex workers navigate the health care system.