INTRODUCTION

Tuberculosis (TB) is a serious public health problem worldwide. In 2019, it is estimated that 10 million people fell ill with TB and 1.4 million died¹. Among the priority countries with high disease burden and TB/HIV co-infection, Brazil reported 73,864 new cases and 4,532 were deaths, which is equivalent to a mortality rate of 2.2 deaths/100,000 inhab.^1,2.

That same year, Rondônia had 582 new cases and 19 deaths (1.1 deaths/100,000 inhab.), in addition to a low percentage of cures among those with the clinical pulmonary form (70.3%). Of the cases reported in the state, 43.5% (253 cases) were in Porto Velho, with 14 deaths in the respective municipality (2.6 deaths/100 thousand inhab.), and in the country it is the second capital in percentage of abandonment (32.6%)².

These data represent the need to prioritize TB control measures, such as case tracking, diagnostic elucidation and care management with the provision and implementation of directly observed treatment (DOT) as well as the insertion and performance of community health workers (CHW), home visits for (ack)knowledge of the social determinants of health involving users, family and community, which can interfere with compliance and disease control actions^3,4. Furthermore, it is essential to establish and strengthen a bond with greater leading role and resoluteness of Primary Health Care (PHC) as the organizer of the Health Care Network (RAS – Rede de Atenção à Saúde) and care coordinator⁵.

Studies indicate that users, most of the time, are diagnosed in reference services⁶, either due to organizational and managerial weaknesses, which include lack of human and material resources, training, support network through the Expanded Center for Family Health and PHC units’ opening hours, which hinder the longitudinality of care and comprehensiveness of assistance⁷.

Complementarily, there are other barriers that imply delay in diagnosis, such as the distance from home to the health service, especially in populations residing in rural areas, additional costs with transportation for displacement, lack of knowledge that leads to a misperception of signs and symptoms due to similarity with other comorbidities, in addition to stigma, self-medication, seeking alternative treatment, such as healers or spiritual places, and singularities of some populations, such as indigenous or immigrants in terms of approach due to different languages and cultures⁸.

In addition to this, the lack of integration between information systems and the non-reporting of cases generate a deficit of data, interfering with disease control actions, which intensifies failures in the care provided, delay in diagnosis and initiation of treatment, culminating in the severity of signs and symptoms, high percentages of abandonment and, consequently, continuity in the disease transmission chain^6,7,9.

Considering the above, identifying the factors that weaken access to a TB diagnosis allows assessing PHC surveillance actions and strategies, in addition to ensuring follow-up and monitoring of cases. Thus, this study aimed to analyze the dimension of access to TB diagnosis in PHC, from health professionals’ perspective in Porto Velho-RO.

METHODS

This is a descriptive survey-type study, carried out in a cross-sectional way from a quantitative approach in Porto Velho, capital of Rondônia. Currently, the municipality’s PHC consists of 17 Basic Health Units (BHU) and 37 Family Health Units (FHU), totaling 54 PHC units, which are distributed in the urban (20) and rural (33) areas, subdivided into land (18) and riverside (15) units as well as a river mobile unit. In this study, only health establishments distributed in the urban area were considered.

TB care in the municipality is decentralized to PHC, which is responsible for carrying out actions to identify respiratory symptoms (RS), reporting cases in the Reporting Diseases Information System (SINAN - Sistema de Informação de Agravos de Notificação), follow-up TB cases undergoing treatment, identifying those who do not, offer DOT, investigate contacts, offer the HIV test, in addition to requesting diagnostic tests (sputum smear microscopy, Rapid Molecular Test for TB (TRM-TB) and chest X-ray) carried out in the municipal laboratory, in addition to sputum culture and sensitivity tests that are carried out in the state laboratory.

As a support network, at an outpatient level, the municipality has two specialized units, one for cases of extrapulmonary TB and childhood TB, and the other for those with TB/HIV co-infection. For cases of drug-resistant TB (DR-TB) and those that require hospitalization, the state has a hospital and an outpatient clinic located in this unit as a reference at the tertiary level.

The study population consisted of professionals working in PHC units in the urban area of Porto Velho-RO. Those who had been in their role for at least 12 months and who had dealt with at least one case of TB since their training were included. All those who were on vacation and/or leave during the data collection period were excluded. It is noteworthy that the delimitation of this study in the urban area occurred, to the extent that in these places there is a greater transmissibility of the disease, number of reported cases of TB and unfavorable outcomes when compared to the rural area. Thus, understanding access to diagnosis from professionals’ perspective becomes essential.

To calculate the sample of professionals interviewed, the sample calculation formula with a finite population was used:

In this regard, a 5% error (𝜀) was considered, a 95% confidence interval (Z), 50% sample proportion (P) of the population (N=737). At least 253 professionals would be interviewed, of which 136 CHWs, 65 nursing technicians/assistants, 26 nurses and 26 physicians.

For data collection, the Primary Care Assessment Tool (PCATool)¹⁰ questionnaire was used as an instrument, validated for Brazil¹¹ and later adapted for TB care¹². To meet the objective of this study, only the access to diagnosis dimension of the version for health professionals was considered, which has twelve variables (Chart 1).

The response categories vary according to the Likert scale, with values between one and five, referring to the degree of preference or agreement with the statements (Chart 2).

Data were collected between May 2018 and February 2019, then stored in Microsoft Excel. They were analyzed using descriptive statistics in the Statistica 13.4 software, from TIBCO. The mean score of the dimension listed for this study was determined, which corresponded to the sum of all the mean scores of the variables divided by the total of variables and, finally, a score for each variable that corresponds to the mean value obtained by the sum of the responses for each question and divided by the total number of participants¹².

Subsequently, according to the instrument’s Likert response scale, the mean scores were classified as unsatisfactory (0 to 1.6), regular (1.7 to 3.3) and satisfactory (3.4 to 5).

The matrix project entitled “Dimensõesorganizacionais e de desempenho dos serviços de saúde para o manejo do cuidado aos doentes de tuberculose em Porto Velho-RO” was approved by the Research Ethics Committee of the Fundação Universidade Federal de Rondônia, according to Opinion 2,585,934, meeting the recommendations of Resolution 466/12 of the Brazilian National Health Council.

The interviews took place after signing the Informed Consent Form (ICF) by health professionals at the health unit where they worked and a place that protected their privacy.

RESULTS

A total of 401 professionals were approached, of which 120 were excluded, 65 of which were CHW, 33, nursing technicians/assistants, 13, nurses and 9, physicians, considering that they had not dealt with at least one case of TB since their training (73). They were on vacation during the period of data collection (29), leave (14). They did not exercise their function for at least 12 months (4), in addition to 15 refusals, either due to unavailability of time, interruption of interview during questionnaire application, several attempts to approach without professional acceptance, desire to answer the questionnaire alone and affirmation that such research would not return to the service, totaling 266 health professionals interviewed.

The general mean score of the access to diagnosis dimension was classified as fair (3.3), which, regardless of the professional category, it also concerns that, with regard to users with signs and symptoms of TB, they almost always have difficulty obtaining information over the phone (1.71); sometimes they use motorized transport (3.02) and have public transport costs (2.96) to travel to the health unit; sometimes they miss a work shift or an appointment at the health services when they have signs/symptoms of TB (2.36) (Figure 1).

He presented a satisfactory score on the waiting time of one day to have an appointment (4.59), and they need to go to the health unit once to receive care (4.7) and twice for diagnosis (3.72), being that this occurs in two weeks (3.95). They always look for the closest unit to their home (4.32), almost never wait more than 60 minutes to be seen (3.54) and almost never have difficulty traveling to the unit (3.47). Moreover, they presented unsatisfactory appointment scheduling by telephone, considering that they almost always have difficulty (1.32) (Figure 1).

However, when it was observed according to the professional category, there was a regular score from doctors’ (3.0) and nurses’ (3.23) perspective on waiting times of more than 60 minutes when users have signs and symptoms of TB as well as for the nursing team regarding the difficulty users have to travel to the health unit when they have signs/symptoms of TB. Finally, unsatisfactory score was identified for physicians (1.48) and nursing technicians/assistants (1.64) on the difficulty of TB suspects in obtaining information by telephone at the health unit when they present signs/symptoms of TB (Figure 2).

DISCUSSION

Considering the findings found, it is important to reflect on the high number of professionals who stated that they had not dealt with any case of TB, considering that the municipality has a high incidence coefficient (66.7 cases/100 thousand inhab.) when compared to the country (54.7 cases/100 thousand inhab.) and abandonment², which contributes to transmission chain perpetuation, regardless of whether it is an area covered by the Family Health team. Complementarily, could there have been contact with TB during the consultations, but the Mycobacterium tuberculosis bacillus was not identified, referring to other levels of care for diagnostic elucidation and reflecting on the delay?

Furthermore, some professionals showed lack of motivation to participate in the research, which may be related to work overload and inability to perceive themselves as essential actors in the context of disease prevention and case control¹³ as well as contributing to the identification of challenges and obstacles that still exist, and participating in the formulation of health policies and reorganization of actions and services.

The regular mean score represents challenges in accessing the diagnosis that still persist in PHC’s resolvability and leading role, even though this level of care is the main entry point for RS and is responsible for the active search, early detection, diagnosis and treatment of cases of pulmonary TB, in addition to other actions involving health surveillance to control the disease in health territories.

In this regard, is it important to reflect on how PHC has been organized and structured to carry out home visits identifying early those who are characterized as RS for the diagnosis of active TB as well as those who have latent TB infection (LTBI)? How has health professionals’ training and awareness about TB been carried out? How has the team been empowered and included all its members in the discussion of TB cases, whether in their health territory and/or in the area covered by the unit, aiming at actions to prevent and control this condition?

With regard to the mean regular score from the variables, not obtaining information by telephone may make it difficult to clarify doubts about the signs and symptoms of either the index case, contacts or people in the community who, at different times, need to use motorized transport or pay for public transport to travel from their homes to the health unit, even looking for the one closest to their residence. Such aspects characterize geographically extensive territories and centralization of units that have more than one team in the same physical structure and, consequently, distance from their territory, which can interfere with access to health services, delay in diagnosis, creation and strengthening of the bond as well as the approximation and effectiveness of actions by teams.

At the same time, the loss of a work shift or appointment to attend the unit, which, in turn, works only during business hours for the most part, had repercussions on fear of unemployment, which, aiming at the social determinants of health, leads to serious vulnerabilities for the onset of diseases, including TB^8,14-16. At this point, it is also important to reflect on the “Saúde na Hora” Program, instituted by Ordinance 930 of May 15, 2019, with the expansion of PHC units’ opening hours, although it is not clear about other aspects, such as infrastructure improvements, hiring of human resources and salary increase concomitantly with working hours. It should also be noted that, in Porto Velho, the teams work 30 hours a week, i.e., in the morning or afternoon, which can be characterized as an obstacle and even greater challenge in the search for care and access to health services.

It should also be noted that using the telephone to schedule an appointment, which was assessed as unsatisfactory as well as obtaining information through it, is a tool that requires reflection on its insertion in the work process, especially when we consider the aforementioned aspects of distance between residences and the health unit, costs for displacement, people residing in rural areas with inadequate roads and difficult access.

At the same time, the pandemic period itself, for example, in which there is a reorganization of health services, social distancing and isolation, in addition to other health recommendations, reduced the demand for care by users with symptoms other than those of COVID-19, at the same time that it overloaded the already scarce scenario, with regard to human, material and structural resources, making it if even more worrying^8,17.

Studies point to a bureaucracy in the appointment scheduling system, disregarding risk stratification, care fragmentation and non-follow-up and monitoring of cases being treated by PHC, in addition to gaps in user guidance and health education actions, which only occur verbally and punctually^14,18-20.

With regard to the search for the health unit closest to home for a TB diagnosis appointment, studies point out the search outside its coverage area due to the stigma of the disease that implies the fear that other people in the community know about their condition as well as weaknesses in knowledge of users and even professionals in relation to the RAS functioning, with repercussions on the late search and/or for a more distant unit, in addition to other levels of attention even for diagnostic elucidation^16,19,14-21.

Although the variables on waiting time, demand for care and diagnosis were categorized with satisfactory scores, they raise reflections about the occurrence in practice, bearing in mind that early diagnosis is not enough, since the presence of trained professionals, inputs and a support network for carrying out the tests, implementing biosecurity measures and immediacy at the beginning of treatment is essential^20,22,23.

Differences between the scores correlate with singularities in the work process of the different professional categories with regard to the provision of actions and services to access diagnosis. As a limitation of this study, it is important that the complement of users’ point of view be inserted to understand how it is received and perceived by this user.

The results of this study point to difficulties in accessing diagnosis in PHC, which requires its leading role with its insertion and resolvability, aiming at controlling the disease, identifying the profile and vulnerabilities of the cases as well as adequate clinical conduct, considering the epidemiological data that still remain challenging in the municipality. The insertion of strategies that overcome the challenges can be characterized both in service performance and quality and in team motivation and integration when looking at the territory and acting according to the priorities, among them chronic conditions such as TB.

It is noteworthy that data collection took place in the period before the pandemic, whose changes in the health service a reorganization and focus on care make it even more worrying in the execution of strategies from access to diagnosis to follow-up of cases, in view of the system overload and prioritization of COVID-19 control. Therefore, there is an urgent need to resume and improve TB control strategies and strengthen PHC with regard to adequate structure, improvement in surveillance actions, training and incentives for professionals to provide quality care and improve access.

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