Fonte usual de cuidados em saúde: abordagens conceituais e metodológicas e fatores determinantes entre adolescentes escolarizados.

Abstract

Introduction: Having a usual source of care (FUC) from Primary Health Care (PHC) can improve health care for Brazilian adolescents, and access to health promotion and disease prevention actions. Among the recommended actions to be developed by PHC professionals, the School Health Program (PSE) stands out, developed through intersectoral actions between Primary Health Care services (PHC) and school units in the public sphere. These actions can favor a relationship of bond and reliability between adolescents and PHC services, based on the integration between the health and education sectors, contributing to the recognition of PHC as their FUC. A longitudinal relationship of accountability and trust can favor access to PHC health services. In this sense, adolescence is a period of life considered vulnerable due to the experience that can compromise the integrity of health. It is necessary to develop studies that make it possible to understand the determining factors in access to health and health care practices that consider the specificities and singularities of these individuals, in order to favor inclusion, autonomy and social participation in their care processes for adolescents. the health. General objective: To analyze the conceptual and methodological approaches and the determining factors for the recognition of a usual source of care and its association with access to PHC services among Brazilian adolescents. Specific Objectives: Systematize in national and international scientific literature, the concepts of usual source of care, the methodological approaches used and the determining factors evidenced by the studies; To analyze the demographic, socioeconomic, health factors and risk behaviors associated with the recognition of a usual source of care, according to sex, among Brazilian adolescents; To analyze the association between the development of intersectoral actions between school/health services and the recognition of a usual source of PHC care; To analyze the association between the recognition of a usual source of PHC care and access to PHC services, according to sex, among Brazilian adolescents. Methodology: The thesis was presented in four articles according to each specific objective. To carry out the first objective, a scope review study was carried out, with an article from the international literature, being developed with 41 original articles as a final sample. In the second objective, a cross-sectional study was conducted with 100,464 Brazilian adolescents, using complex sampling by cluster, based on data from the National School Health Survey (2015), with the dependent variable - Usual Source of Care. For data analysis, multilevel logistic regression models were used, based on the analysis of the Prevalence Ratio (PR), adjusted for demographic, socioeconomic, risk behavior and health variables, and stratified by sex. In the third objective, a cross-sectional study was conducted with 97,903 Brazilian adolescents, based on the PeSNE survey (2015) which considered adolescents from schools who reported developing intersectoral actions between the school and PHC services. For the statistical analysis, defined as the main independent variable – intersectoral actions and the dependent variable – Usual Source of Care of PHC, multilevel logistic regression models were used, estimating the PR. In the fourth objective, a cross-sectional study was conducted, based on the PeNSE survey (2015) with 68,968 Brazilian adolescents who sought PHC services in the last 12 months after the interview. It considered as the main independent variable – FUC APS and the dependent variable – Access to PHC health services. PRs were estimated from multilevel logistic regression models and adjusted for demographic, socioeconomic, risk behavior and health variables, and stratified by sex. For the analyses, corrections were made for complex, multilevel sampling using the stata 14 software and the use of the adjrr command for PR estimates. Results regarding the first objective: 632 articles were identified, of which 291 were excluded because they were repeated in the databases, with a final sample of 41 articles that were selected for review after the process of reading and evaluating the inclusion criteria. Being female, white race/color, higher income and education, and having health insurance were associated with the recognition of a FUC. The same association was observed for FUC APS, in addition to studies highlighting the relationship with mixed race/color, lower level of education and living in rural areas. Results regarding the second objective: The recognition of a FUC was mentioned by 55.5% of Brazilian adolescents, being 58.6% for females and 51.4% for males. In the multivariate analysis, the variables that present social, economic and risk behavior inequalities showed positive associations for FUC APS, for both sexes (race/black/childbirth/yellow and indigenous, low level of maternal education, being a high school student, public schools, unprotected sexual intercourse and having suffered violence). The other types of FUC (private practice, hospital and emergency), the demographic and socioeconomic characteristics when associated, showed negative associations, with positive associations for the variables of risk behavior and health conditions. Results regarding the third objective: Of the adolescents analyzed, 72.8% studied in schools that developed intersectoral actions with PHC services. Among the adolescent students from schools that developed intersectoral actions, an association was observed between the recognition of FUC APS and intersectoral actions (PR: 1.11; 95%CI: 1.08 – 1.15). When analyzing the multivariate model for the variations of the main independent variable, positive associations were observed for actions of the Health at School Program (PSE) (PR: 1.34; 95%CI: 1.30 – 1.38), and the development of actions between the school and PHC services (PR: 1.10; 95%CI: 1.06 – 1.14). Results regarding the fourth objective: Of the adolescents who sought PHC services, 74.6% reported access, with the highest proportion being female (79.3%). In the multivariate analysis, between the recognition of a FUC APS and access to PHC services, a positive association was observed (PR: 1.25; 95%CI: 1.24 – 1.26), and in the stratified by sex, it was observed that positive associations were found for both sexes, (PR: 1.30; 95%CI: 1.28 – 1.31) for males and (PR: 1.21; 95%CI: 1.20 – 1.23) for the female sex. Final considerations: The results of this study showed that social, economic and risk behavior determinants, such as being female, white race/color, higher level of education and income, and the availability of health insurance, are associated with the recognition of a FUC. The findings between the social determinants and the recognition of PHC as a FUC showed that adolescents in conditions of greater social and economic vulnerability are more likely to recognize PHC as a FUC. FUC APS also showed an association with intersectoral actions, between health and education. Regarding access to PHC services, the present study showed a positive association between the recognition of FUC APS and access to PHC services, with individuals experiencing less social inequalities, despite recognizing PHC as their FUC, they are less likely to access when compared to adolescents who do not recognize PHC as their FUC. In addition, social policies must be improved to expand the quality and access to PHC services and strengthen bonds and trust.