Abstract: This study aimed to learn about the conditions of access to health services that seniors living in rural areas have, as well as their satisfaction. This is a qualitative, descriptive and exploratory research conducted in a municipality located in the southern region of Rio Grande do Sul, Brazil. It included 19 elderly individuals registered in three Basic Health Units organized in the form of Family Health Strategy. Data were collected between July and August 2018 through semi-structured interviews, which were analyzed based on Minayo's operational proposal. Afterwards, two categories were defined: "Access to health services used by elderly residents of rural areas" and "Satisfaction with health services used by elderly residents of rural areas". Concerning access, many are the difficulties faced, such as long distances to be traveled until arriving at a health service, poor road conditions, limitations related to public transport days, timetables and itineraries, lack of human and material resources, and long waiting time to make appointments with specialists and schedule exams through the Brazilian Unified Health System. As for satisfaction, the main complaint of the elderly participants refers to issues involving, above all, health management and work process, such as delay in making health care appointments, although most participants reported being satisfied with the care provided by health professionals. It is worth noting that learning about the conditions of access to health services used by elderly people living in rural areas and their satisfaction contributes to the planning, implementation, development and evaluation of public health actions, programs and policies.
Keywords:the elderlythe elderly,rural arearural area,health serviceshealth services,access to health servicesaccess to health services,patient satisfactionpatient satisfaction.
Enfermagem
Accessibility and satisfaction of the elderly living in rural areas in relation to the health services.
Universidade Estadual de Maringá
This work is licensed under Creative Commons Attribution 4.0 International.
Received: 25 July 2019
Accepted: 11 May 2020
The aging process of the population is a multifactor and progressive phenomenon with impacts on different sectors of society, including health services, therefore representing a challenge for the planning, implementation, development and evaluation of health care actions, programs and policies. Based on that, it is interesting to look at the aging process of the population by taking into account the social and cultural contexts of which people are part. Although the aging process of people living in rural areas is similar to that of those residing in urban areas, there are unique conditions in these environments that influence one's health and quality of life (Garbaccio, Tonaco, Estêvão, & Barcelos, 2018).
In Brazil, the aging process is heterogeneous and commonly related to social inequalities that persist over the years and need to be faced. And this, added to the fact that the inversion of the population pyramid has been occurring rapidly, requires an immediate response from health services (Miranda, Mendes, & Silva, 2016). It is worth stressing that older people differ from each other and from people at other stages of human development, and that aging must be accompanied by social and health conditions that allow them to live and experience old age with quality, that is, actively and free from physical, mental and emotional disabilities. This results in a need to rethink and reframe Health Care for the Elderly, with a focus, mainly, on the characteristics of each age group (Maia, Colares, Moraes, Costa, & Caldeira, 2020).
In this sense, the Brazilian Ministry of Health [Ministério da Saúde] (MS) created the Policy on Comprehensive Health Care for Countryside and Forest Populations [Política de Saúde Integral das Populações do Campo e da Floresta] (PNSIPCF), which seeks to meet the health needs and expectations of said populations, according to their characteristics, and, thus, improve their access to health services. To do so, ongoing-education activities are recommended for health professionals, including nurses, working in rural areas, so that they understand the specificities of the work process with the population that resides in these locations (Brazil, 2013).
In addition, the Brazilian National Health Policy for the Elderly [Política Nacional de Saúde da Pessoa Idosa] (PNPI) aims at a comprehensive health care for people over 60 years of age, in order to promote the maintenance of their independence and autonomy, by means of an assessment based on knowledge of the aging process and its singularities, according to the socio-cultural context of which they are part, thus contributing to an active and healthy aging (Brazil, 2006).
It is worth pointing out that the Policy on Comprehensive Health for Rural and Forest Populations (PNSIPCF) and the Brazilian National Health Policy for the Elderly (PNPI) have emerged to reaffirm the principles of universality, comprehensiveness and equity of the Brazilian Unified Health System [Sistema Único de Saúde] (SUS). The latter was created from the 1988 Constitution of the Federative Republic of Brazil, which recognizes health as a right of all and a duty of the State (Brazil, 1988). Thus, it is of utmost importance to be aware of the health needs and expectations of elderly individuals living in rural areas, with a view to providing nursing and health care in a comprehensive, equitable and humanized way. This also comprehends access to health services and the satisfaction with them, since access is one of the main factors that influence the possibility of the population using health services, and bearing in mind that, even with them being now offered at a larger scale, especially in Primary Health Care (PHC), guaranteeing the constitutional right of SUS's universality remains as a challenge (Viegas, Carmo, & Luz, 2015).
Therefore, it is relevant to learn about the conditions of access to health services for people aged 60 or over residing in rural areas, in a broader sense, which encompasses, above all, the problem-solving capacity of services when it comes to the health needs and expectations of people, considering the social and cultural factors of their context, and goes beyond the concept of accessibility that strictly concerns the possibility of people reaching health services (Starfield, 2002; Souza, Vilar, Rocha, Uchoa, & Rocha, 2008). In other words, access to health services comprehends, especially in PHC, the entry of people in health services through Basic Health Units (BHUs) or not, though the latter is considered the gateway to SUS, as well as the availability of material and human resources, the care practices offered to users, in addition to their efficacy and effectiveness and the commitment of health professionals to the social and health problems of the population for which they are caring (Starfield, 2002).
Learning about how satisfied elderly people living in rural areas are with health services, in terms of health care quality, is also important for improving care practices developed by nurses and other health professionals, since the health care quality perspective considers the characteristics of health services that directly determines a user's dissatisfaction or satisfaction with the care provided, such as the humanization and longitudinality of this care, as well as the technical and scientific capacity of the health professionals who make up teams, availability of material resources, such as equipment for laboratory and image exams, costs and infrastructure, and the security of the place where they are installed (Starfield, 2002).
In short, learning about the conditions of access to health services used by elderly people living in rural areas and their satisfaction with them allows enhancing health management and work processes at all different levels of complexity in health services, as it facilitates decision making and allows reframing proposals for health actions, programs and policies (Arruda & Bosi, 2017). Moreover, a knowledge gap as to access and satisfaction among seniors living in rural areas when it comes to health services was reported in a free literature review carried out to bring researchers closer to the subject.
Based on that, the present research aimed to learn about the conditions of access to health services used by elderly people living in rural areas and their satisfaction with them.
This is a qualitative, descriptive and exploratory research conducted in a municipality located in the southern region of Rio Grande do Sul, Brazil. It included 19 elderly people living in rural areas, all registered in three Basic Health Units (BHUs) organized in the form of Family Health Strategies (FHSs) installed in locations of French, Italian and German colonization. The inclusion criteria were: age equal to or greater than 60 years old; communicating verbally in Portuguese, or having a family member who could translate; living in rural areas since childhood, and being registered in the Family Health Strategy. The exclusion criteria were: being absent after three visits made at different times and days; presenting cognitive incapacity to answer the research questions, and being deprived of freedom by legal decision, institutionalized or hospitalized.
Data were collected in July and August 2018 through semi-structured interviews, which included previously prepared questions addressing the access and satisfaction of elderly people living in rural areas concerning health services. Data were analyzed based on Minayo's operational proposal (2010), following the stages of pre-analysis, exploration of the material, and interpretation of the results, then two categories were defined: “Access to health services used by elderly people living in rural area” and “Satisfaction with health services used by elderly residents of rural areas”.
The study complied with all ethical principles set forth in Resolution No 466/2012 of the Brazilian National Health Council, which provides guidelines and regulatory norms for research involving human beings (Brazil, 2012). The development of the research was approved by the Research Ethics Committee of the Federal University of Pelotas's Medical School, under opinion number 2.677.558 and CAAE: 89943718.1.0000.5317.
The elderly research participants reported that they use public health services, mainly the BHUs organized in the form of FHSs in charge of the coverage areas where they reside, for routine medical appointments, to request preventive and laboratory tests, renew prescriptions, and for procedures of low complexity. They also use private health services, both uninsured and insured, in an attempt to have their health needs and expectations fully met, as they are still poorly covered by health actions, programs and policies, especially in situations that demand an assistance of greater complexity. The access and satisfaction of elderly people living in rural areas as to health services are addressed on this basis.
With regard to access to health services used by elderly people living in rural areas, the participants’ statements show that their main access difficulties consist of long distances to be traveled until reaching health services, poor road conditions, and limitations concerning public transport, such as timetables and itineraries.
For us, if we always had service (referring to the Family Health Strategy in the coverage area of their residence), it'd be much better because it's much closer to my house. Half the way. (Senior 15- 64 years old)
These roads are just potholes and mud. (Senior 10- 77 years old)
I get on the bus and go. But, sometimes, it's hard because of the timetables, so we ask someone for a lift. (Senior 7- 79 years old)
However, it is worth recognizing the improvements, though slight, with respect to the difficulties reported, as shown in the following statement:
The access is good, it's a lane. The bus passes just in front of the door of the center (referring to the Family Health Strategy in the coverage area of their residence) and, here, it passes right over there (referring to a stop on the road near their residence). There is no distance to walk. (Senior 8- 71 years old)
The use of FHSs by the elderly living in rural areas is mainly due to their geographical proximity and because PHC is characterized as the gateway to SUS, whereas the demand for private and public emergency services, and those of greater complexity, located in the urban area, commonly derives from a lack of human and material resources in the FHSs, and because of delays in making appointments with specialists and scheduling exams referred through PHC.
Private, because there's no dentist there (referring to the Family Health Strategy in the coverage area of their residence). (Senior 4- 63 years old)
Now in September, it's going to be a year that I'm waiting for the endoscopy referred here by the center (referring to the Family Health Strategy in the coverage area of their residence), to do it through SUS. I paid because, otherwise, I don't even know what would happen. (Senior 15- 64 years old)
It should also be noted that part of the research participants reported that they use public and private health services located in the urban area of neighboring municipalities, since the distance to be traveled from their homes to these places is shorter than the distance to reach the health services located in the urban area of the municipality where they live.
The rural union is in the urban area of our municipality, but I hardly go there. I go straight to the neighboring municipality, which is close, eighteen, nineteen kilometers away. For me it's close, it's where I go. (Senior 14- 67 years old)
I think it's easier to go to the neighboring municipality than to the city (urban area of the municipality where they live) because it's closer. It's half the way. Along the lane, to the city, I don't know how many kilometers there are, but to the neighboring municipality I think it's twenty kilometers. (Senior 15- 64 years old)
Finally, based on the results found about access to health services for the elderly living in rural areas, it was possible to notice that, even with the expansion of PHC in rural areas through the implementation of FHSs, rural populations face difficulties accessing health services, both public and private, especially the elderly, when taking into account limitations resulting from the aging and health-disease process and sociodemographic characteristics such as low income. These difficulties are reported in the following statements:
Sometimes I go by bus, but it's complicated for me. Before, I'd just get on a bus, but now I can't (referring to the limitations resulting from the aging and health-disease process). (Senior 12- 80 years old)
We have family health care plans (health insurance), but we don't use it because we're always short on money. (Senior 6- 65 years old)
I'd always go to the rural union. But now I don't go there anymore. No, no, no... I gave up. Where am I supposed to get the money to pay for all the exams? (Senior 12- 80 years old)
The statements above make it clear that the access to health services used by the elderly living in rural areas is still precarious. This is because, usually, they are not offered at all levels of complexity and, even with the implementation of FHSs, the health actions, programs and policies are rarely really thought through to take into account the people who are living and experiencing old age. Many are the difficulties faced by elderly residents of rural areas concerning access to health services, which, directly or indirectly, affect their satisfaction with said services
When it comes to satisfaction with health services used by elderly people living in rural areas, most of the research participants positively rated the care provided by health professionals in public health services, mainly in PHC and Emergency Care.
But I have no complaints about it (referring to the Family Health Strategy in the coverage area of their residence). The doctor's really good. (Senior 1- 73 years old)
We went to the emergency room, which I was really afraid of. I was afraid, but I liked it and praised it because, when there was no doctor I could see at the center (referring to the Family Health Strategy in the coverage area of their residence), I went to the emergency room and was treated very, very well. (Senior 15- 64 years old)
The participants are, however, dissatisfied with issues related to health management and work process, such as difficulty in scheduling appointments at BHUs organized in the form of FHS due to low availability of medical consultations and long waiting time in lines, in addition to delays in making appointments with specialists and scheduling exams referred by health professionals working in PHC. Such dissatisfactions are recorded in the following statements:
It's a little slow actually (referring to scheduling appointments with specialists and exams), but it's what they say: that's what you get from SUS. Service is slow. (Senior 10- 77 years old)
Here (referring to the Family Health Strategy in their area), availability is low and you still have to schedule. That is the main problem and I think it can't be that way. All of a sudden, we need it and don't have it, we have to schedule. (Senior 19- 69 years old)
Elderly residents of rural areas were also dissatisfied with private health services, both insured and uninsured, due to their coverage failures, as well as expensive monthly fees, consultations and exams, all combined with the non-continuity of the care provided, which can be seen in the following reports:
You have to pay for consultations, you have to pay for exams. And you have to pay every month. But how? Our salary is just so small, and then we need to buy medicine. Everything's expensive. (Senior 12- 80 years old).
Thus, it is possible to understand that the main complaint of the elderly refers to issues involving, above all, health management and work process, since health care services, especially at the highest levels of complexity, through PHC referral, take long to be scheduled, leading those seniors with better financial conditions to seek private health services, while those with low income are held hostage by lines at health centers, which often result in diseases and injuries that could be prevented.
The results of this research showed that elderly people living in rural areas still face many difficulties in accessing health services, even with the implementation of FHSs in rural areas in order to expand, qualify and consolidate PHC towards improving the quality of life of people, families and communities, taking into account the socio-cultural context of which they are part.
Main difficulties include long distances to be traveled to health services, within the scope of PHC and other levels of complexity, poor road conditions, and limitations concerning public transport, such as days, timetables and itineraries. Similarly, a research addressing the vulnerability of rural old age in the municipalities of Camaquã and Canguçu, RS, Brazil, found that, with regard to the access of elderly people living in rural areas to health services, compared to access to health services among seniors residing in urban areas, there is a lower availability of FHSs. It is important to stress their displacement difficulties resulting from the long distances to be traveled to the health services, and that the majority of the seniors participating in the study did not have their own means of transportation and, consequently, depended on public transport, which was limited to certain days and times, with expensive fares, not to mention the poor conditions of rural roads (Tonezer, Trzcinski, & Dal Magro, 2017).
Furthermore, a research on PHC access, from the perspective of professionals and users of a health service network in Recife, Pernambuco, Brazil, revealed that difficulties in accessing health services consist, especially, of the distance of people's residences from BHUs, due to the inadequate distribution of the latter, which are organized in the form of FHS within the territory, in addition to physical barriers along the way to be traveled through (Lima et al., 2015). Considering the social, cultural and environmental characteristics of rural areas, these and other difficulties related to income and the elderly's own attitude in seeking health services with a curative and non-preventive purpose for diseases and injuries can be lived and experienced more intensely in rural seniors (Garbaccio et al, 2018).
Lack of human and material resources, including in FHSs, and delay in making appointments with specialists and scheduling exams through SUS were also reported as access hindrances by the research participants. It is worth noting that this lack of human and material resources further delays health care services for the population and, oftentimes, negatively affects their quality, commonly failing to meet the health needs and expectations of people comprehensively. This results in a demand for other health services, including private insured and uninsured ones, which stands as another access issue for elderly people living in rural areas, as a result of their low income (Lima et al., 2015).
When it comes to satisfaction with private health services and insurances, dissatisfaction is common among senior citizens living in rural areas due to coverage failures, high monthly fees, consultations and exams, and the non-continuity of care. On this note, an article about preventive punishment in cases of coverage denial revealed that the Brazilian population's dissatisfaction with health insurance is growing. Coverage-related denial or postponements and different monthly fees on the basis of aging are a significant part of demands in all instances of the Judiciary (Bahia, 2015).
Just as in this research, concerning the delay in making appointments with specialists referred by PHC, an investigation on user satisfaction at this level of complexity carried out in Fortaleza, Ceará, CE, Brazil, showed that difficulties in accessing specialties and continuing care at other levels of complexity are the main causes of people's discontent (Arruda & Bosi, 2017). These results are similar to others found in the literature, with highlight to difficulties in accessing health services of medium complexity due to problems in the flow of the Health Care Network (HCN), which leads to a repressed demand, to a long waiting time for consultations with specialists and exams consequently, and even to the break of the longitudinality of care. All this is reflected in the problem-solving capacity of PHC, that is, in its capacity to meet the health needs and expectations of the population for which it cares (Silva, Carvalho, Cordoni Junior, & Nunes, 2017; Protasio, Gomes, Machado, & Valença, 2017).
Additionally, as mentioned in the results, difficulties in making appointments at the BHUs themselves, organized in the form of FHS, due to low availability of medical consultations and the long waiting time in line to which they are exposed are considered another reason for the dissatisfaction of the elderly people living in rural areas with the health services they use. Therefore, health care for the elderly should be fast and accurate, since the aging process contributes to the onset of diseases and conditions and, therefore, disabilities that compromise their quality of life (Santos, Tonhom, & Komatsu, 2016).
Some suggestions from the seniors living in urban and rural areas of five municipalities located in the Triângulo Mineiro to improve health services involve matters related to health management and work process, such as organization and qualification of health care services with the hiring of professionals specialized in geriatrics and gerontology, with a larger number of consultations, and with the prioritization of people considered elderly when scheduling appointments, thus reducing the waiting time (Lima, Vilella, & Bittar, 2016).
Moreover, the option of pre-scheduling FHS appointments is another suggestion for improving health services, as it reduces waiting time in lines, meeting the health needs and expectations of the elderly population (Rigon et al., 2016). Besides, the short distance and the short time from home to FHSs, as well as the possibility of dispensing with one's own or collective means of transportation can be considered by people as reasons for their satisfaction with health services (Protasio et al., 2017).
Finally, it should be noted that the majority of the elderly people living in rural areas are satisfied with the care provided by health professionals in public health services. Corroborating the above, a survey conducted by the Brazilian Ministry of Health (MS) found that 62.96% of SUS users rated the nursing team's service as "good" or "very good", and 71.9% rated the doctor's service as “good” and “very good” (Brazil, 2011). In light of the foregoing, it is essential to take into account that the way in which people's health needs and expectations are seen by health professionals stands as one of the main issues in assessing satisfaction with health services, even surpassing technical knowledge, for it determines the bonding between users and health professionals and, therefore, contributes to the comprehensiveness and continuity of care (Arruda & Bosi, 2017).
Many are the difficulties that elderly residents of rural areas face when accessing health services, which affect their satisfaction. This opposes to the principles of universality, comprehensiveness and equity of SUS, especially taking into account that BHUs, organized in the form of FHS, are the gateway to this system. Thus, given Brazil's social and cultural diversity, it is worth stressing the importance of further research being conducted on this subject in order to reduce inequalities in nursing and health care aimed at this population.
