Primary care and healthcare utilization among older Brazilians (ELSI-Brazil)

Factors Related to Recurrent Falls Among Older Adults Attending Primary Health Care: A Biopsychosocial Perspective

The objective of this study was to investigate factors related to recurrent falls among older adults attending primary health care, considering the biopsychosocial perspective. A representative sample of 201 older adults were interviewed in three Primary Health Care units randomly selected in a city in southeastern Brazil. Outcome included self-report of two or more falls in the past 12 months. Exposures included personal and environmental aspects, according to domains of International Classification of Functioning of the World Health Organization (ICF-WHO). Recurrent falls were reported by 24.4% of the participants. Associations with depressive symptoms (p = .003), having osteoporosis (p = .031), chronic musculoskeletal pain (p = .020), frailty (p = .013), sleep satisfaction (p < .001), and functional status (p < .001) were found. In logistic regression models, cognitive status, musculoskeletal pain, and functional status were predictors of recurrent falls; however, only sleep satisfaction remained significant in the final model. Strategies aimed at preventing recurrent falls in primary health care should consider assessments and interventions targeting sleep aspects among older adults.

Access of older people to primary health care in low and middle-income countries: A systematic scoping review

INTRODUCTION

Ensuring access for older people to Primary Health Care (PHC) is vital to achieve universal health coverage, improve health outcomes, and health-system performance. However, older people living in Low-and Middle-Income Countries (LMICs) face barriers constraining their timely access to appropriate care. This review aims to summarize the nature and breadth of literature examining older people's experiences with access to PHC in LMICs, and access barriers and enablers.

METHODS

Guided by Arksey and O'Malley's framework, four databases [CINAHL, Cochrane, PubMed, and Embase] were systematically searched for all types of peer-reviewed articles published between 2002 and 2023, in any language but with English or French abstract. Gray literature presenting empirical data was also included by searching the United Nations, World Health Organization, and HelpAge websites. Data were independently screened and extracted.

RESULTS

Of 1165 identified records, 30 are included. Data were generated mostly in Brazil (50%) and through studies adopting quantitative designs (80%). Older people's experiences varied across countries and were shaped by several access barriers and enablers classified according to the Patient-Centered Access to Healthcare framework, featuring the characteristics of the care delivery system at the supply side and older people's attributes from the demand side. The review identifies that most access barriers and enablers pertain to the availability and accommodation dimension, followed by the appropriateness, affordability, acceptability, and approachability of services. Socio-economic level and need perception were the most reported characteristics that affected older people's access to PHC.

CONCLUSIONS

Older people's experiences with PHC access varied according to local contexts, socioeconomic variables, and the provision of public or private health services. Results inform policymakers and PHC practitioners to generate policies and services that are evidence-based and responsive to older people's needs. Identified knowledge gaps highlight the need for research to further understand older people's access to PHC in different LMICs.

Accessing Dementia Care in Brazil: An Analysis of Case Vignettes

BACKGROUND AND OBJECTIVES

Despite the rapid increase in the number of people living with dementia in Brazil, dementia care is limited. This study describes how people living with dementia and their carers access care, treatment, and support, and identifies what characteristics are likely to enable or prevent access.

RESEARCH DESIGN AND METHODS

We created 10 vignettes to illustrate fictitious but realistic scenarios involving people living with dementia in Brazil. The vignettes explore a combination of socioeconomic and demographic variables. They were completed using an in-depth desk review of the dementia care landscape in Brazil; a Strengths, Opportunities, Weaknesses, and Threats (SWOT) analysis of the desk review; and expert knowledge. The analysis focused on identifying common sources of service provision, barriers of access to care and support, and specific issues experienced by some population groups.

FINDINGS

Access to a dementia diagnosis, care, and support for people living with dementia in Brazil is limited. Demographic and socio-economic circumstances play a role in determining the type of services to which a person might have access. Poor knowledge about dementia, lack of capacity in the health system, and lack of formal long-term care support are among the identified barriers to accessing timely diagnosis, care, and support in the country.

DISCUSSION AND IMPLICATIONS

Understanding the barriers and facilitators of access to diagnosis, treatment, and support for people with dementia and families with different demographic and socioeconomic characteristics is crucial for designing dementia policies that are context-specific and responsive to the care needs of different socioeconomic groups in Brazil.

Utility of PHQ-2, PHQ-8 and PHQ-9 for detecting major depression in primary health care: a validation study in Spain

BACKGROUND

Primary health care (PHC) professionals may play a crucial role in improving early diagnosis of depressive disorders. However, only 50% of cases are detected in PHC. The most widely used screening instrument for major depression is the Patient Health Questionnaire (PHQ), including the two-, eight- and nine-item versions. Surprisingly, there is neither enough evidence about the validity of PHQ in PHC patients in Spain nor indications about how to interpret the total scores. This study aimed to gather validity evidence to support the use of the three PHQ versions to screen for major depression in PHC in Spain. Additionally, the present study provided information for helping professionals to choose the best PHQ version according to the context.

METHODS

The sample was composed of 2579 participants from 22 Spanish PHC centers participating in the EIRA-3 study. The reliability and validity of the three PHQ versions for Spanish PHC patients were assessed based on responses to the questionnaire.

RESULTS

The PHQ-8 and PHQ-9 showed high internal consistency. The results obtained confirm the theoretically expected relationship between PHQ results and anxiety, social support and health-related QoL. A single-factor solution was confirmed. Regarding to the level of agreement with the CIDI interview (used as the criterion), our results indicate that the PHQ has a good discrimination power. The optimal cut-off values were: ⩾2 for PHQ-2, ⩾7 for PHQ-8 and ⩾8 for PHQ-9.

CONCLUSIONS

PHQ is a good and valuable tool for detecting major depression in PHC patients in Spain.

A multiple health behaviour change intervention to prevent depression: A randomized controlled trial

OBJECTIVE

To examine the effectiveness of a 12-month MHBC intervention in the prevention of onset depression in primary health care (PHC).

METHODS

Twenty-two PHC centres took part in the cluster-randomized controlled trial. Patients were randomized to receive either usual care or an MHBC intervention. The endpoints were onset of major depression and reduction of depressive symptoms in participants without baseline depression at a 12-month follow-up.

RESULTS

2531 patients agreed and were eligible to participate. At baseline, around 43% were smokers, 82% were non-adherent to the Mediterranean diet and 55% did not perform enough physical activity. The intervention group exhibited a greater positive change in two or more behaviours (OR 1.75 [95%CI: 1.17 to 2.62]; p = 0.006); any behaviour (OR 1.58 [95%CI: 1.13 to 2.20]; p = 0.007); and adherence to the Mediterranean diet (OR 1.94 [95%CI: 1.29 to 2.94]; p = 0.002), while this increase was not statistically significant for smoking and physical activity. The intervention was not effective in preventing major depression (OR 1.17; [95% CI 0.53 to 2.59)]; p = 0.690) or reducing depressive symptoms (Mean difference: 0.30; [95% CI -0.77 to 1.36]; p = 0.726) during follow-up.

CONCLUSIONS

As compared to usual care, the MHBC intervention provided a non-significant reduction in the incidence of major depression.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03136211.

Content Validity of a Scale Designed to Measure the Access of Older Adults to Outpatient Health Services

The objective of this work was to validate the content of a scale formulated in Spanish for older adults in Mexico, with the aim of comprehensively measuring the access of this population group to outpatient primary-care services. To this end, we carried out a methodological content-validity study in four stages: (1) construction of the scale; (2) evaluation of item legibility; (3) quantitative content evaluation by two groups of judges selected by convenience: participant-judges including older adults with adequate reading comprehension, surveyed in person (n = 23), and expert-judges comprised of researchers specialized in the fields of health services, psychometrics and aging, surveyed online (n = 7); and (4) collection of qualitative feedback from several of the participant-judges (older adults, n = 4). The content was validated both by sequentially examining the level of consensus in the responses of both groups of judges, using the Tastle and Wierman method, and by calculating Aiken's Validity Coefficient with a 90% confidence interval. The scale contained 65 items pertaining to 10 dimensions of two major constructs: accessibility (n = 39) and personal abilities (n = 26). Five items were eliminated in accordance with the minimum-consensus criterion (0.5). This is the first psychometric scale to be developed in Mexico with the view of integrating the characteristics of health-care services and the abilities of the older adults in a single questionnaire designed to measure the access of this population group to outpatient primary-care services.

Factors related to the accumulation of healthy behavior among older adults attending primary Health Care

The adoption and maintenance of healthy behaviors contribute for its accumulation throughout life, which require more than information disclosure and recommendations. Biopsychosocial factors may work as barriers to adherence to healthier behaviors, and yet have been underexplored. The objective was to investigate the factors related to the accumulation of healthy behavior among older adults attending Primary Health Care. Cross-sectional analysis with 201 older adults from baseline of Longitudinal Investigation of Functioning Epidemiology (LIFE) was performed in a Southeastern Brazilian city. The Healthy Behavior Score (HBS), ranging from 0 to 8, was calculated by the sum of the following habits: Physical activity practice, healthy eating, water consumption, night sleep time, not smoking, not drinking alcohol, frequent social relations, and spirituality. A linear multivariate regression was performed to test the influence of biopsychosocial aspects on HBS, with 95% confidence interval. Higher number of healthy behaviors was related to high social support, better cognitive status, less depressive symptoms and lower functional performance. Additionally, age and resilience score were correlated to healthy behaviors, which were higher among women and those with sufficient income. Multivariate analysis revealed depressive symptoms, functional performance and education as independent predictors of HBS. Depressive symptoms, functional performance and education are predictors of accumulation of health behaviors, independently of health status, contextual and sociodemographic aspects. Higher social support partially contributed to the higher number of healthy behaviors, and should be considered in public health policies for healthy longevity.

Associated factors of doctor visits made by urban-dwelling older adults in Sri Lanka: an application of Anderson's model of health service utilization

Background

Although universal free healthcare is available for all Sri Lankan citizens, older adults face somewhat unique obstacles when utilizing available healthcare services. The aim of this study was to examine some vital predisposing, enabling, and need factors associated with doctor visits made by urban-dwelling older adults in Sri Lanka.

Methods

A representative sample of 880 urban-dwelling older adults (aged 60 years and above) was surveyed using an interviewer-administered questionnaire. Number of doctor visits, self-rated health, physical activity, and socio-demographic and self-report health conditions were collected. The data were analyzed using chi-squared tests and multinomial logistic regression.

Results

Participants’ mean age was 70.01 (± 6.02) years. The majority was women (75.0%). The mean number of doctor visits was 6.77 (± 5.92) per year. Nearly half of the participants (47.0%) had made, on average, at least one doctor visit per month. Older men and those of aged 80 years and above were the least likely to make frequent doctor visits. Participants who were physically active and who rated their health as poor were more likely to make frequent doctor visits after adjustment for age, gender, and educational level.

Conclusions

Doctor visits made by Sri Lankan older adults are satisfactory. The factors that best explain high frequency of doctor visits by older adults are female gender, younger age, higher physical activity and poor self-rated health. Attention should be paid to examine possible accessible and affordable issues related to doctor visits by bedridden or physically dependent older adults in advanced age categories.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03249-3.

What are the implications of problem-solving capacity at Primary Health Care in older adult health?

Objective

To evaluate Primary Health Care attributes and analyze the association between the fulfilment of these attributes and problem-solving capacity of services for elderly patients.

Methods

A cross-sectional, observational, quantitative study. The Primary Care Assessment Tool, designed to assess Primary Health Care attributes, was employed to evaluate elderly users of Primary Care Units located in the south region of the city of São Paulo (SP).

Results

Many attributes assessed at the reference services were considered as unsatisfactory by users. Overall scores were also below the cut-off point. “First contact access – use”, “longitudinality” and “coordination – information system” were the only attributes considered as satisfactory. Also, more than half (62.7%) of respondent patients reported having been referred to specialized services. A combined analysis of these three outcomes revealed users referred to other services had a significantly better perception of Primary Health Care attributes.

Conclusion

The study provides important insights on satisfaction of elderly individuals and the problem-solving capacity of health care services, especially for the study population. Findings reported emphasize the association between Primary Health Care attributes and the problem-solving capacity of health care services at this level.

Disparities in Stroke Patient-Reported Outcomes Measurement Between Healthcare Systems in Brazil

Introduction

Acute stroke interventions, such as stroke units and reperfusion therapy, have the potential to improve outcomes. However, there are many disparities in patient characteristics and access to the best stroke care. Thus, we aim to compare patient-reported outcome measures (PROMs) after stroke in two stroke centers representing the public and private healthcare systems in Brazil.

Methods

PROMs through the International Consortium for Health Outcomes Measures (ICHOM) were assessed at 90 days after the stroke to compare two Brazilian hospitals in southern Brazil: a public university and a private stroke center, both with stroke protocols and stroke units.

Results

When compared with the private setting (n = 165), patients from the public hospital (n = 175) were younger, had poorer control of risk factors, had more frequent previous strokes, and arrived with more severe strokes. Both hospitals had a similar percentage of IV thrombolysis treatment. Only 5 patients received mechanical thrombectomy (MT), all in the private hospital. Public hospital patients presented significantly worse outcomes at 3 months, including worse quality of life and functional dependence (60 vs. 48%, p = 0.03). Poor outcome, as measured by the mRS score, was significantly associated with older age, higher NIHSS score, and the presence of heart failure. However, the public practice was a strong predictor of any self-reported disability.

Conclusion

Patients assisted at a good quality public stroke center with the same protocol used in the private hospital presented worse disability as measured by mRS and patient-reported outcome measures, with greater inability to communicate, dress, toilet, feed, and walk.

The effects of an innovative integrated care intervention in Brazil on local health service use by dependent older people

BACKGROUND

Since 2011, the Brazilian city of Belo Horizonte has been operating an innovative scheme to support care-dependent older people in disadvantaged communities: Programa Maior Cuidado (PMC - Older Person's Care Program). This paper examines two potential associations between inclusion in PMC on types of outpatient health service utilization by dependent older people. The first is that being in PMC is associated with a higher frequency of outpatient visits for physical rehabilitation. The second is that being in PMC is associated with a higher frequency of planned versus unplanned outpatient visits.

METHODS

We apply a quasi-experimental design to a unique set of health administrative data recording visits to outpatient health services. We focus on comparisons of the universe of visits, transformed to ratios of planned/unplanned visits and rehabilitation/other reasons for visiting the outpatient service. First, we preprocess our sample through different matching techniques such as 'coarsened exact matching' (CEM), 'nearest neighbor' based on logit scores (NN), 'optimal pair' (OP) and 'optimal full' (OF) methods. Second, we estimate marginal effects of being in PMC on our outcomes of interest. We use Poisson regressions controlling for individual and community factors and use robust standard errors. Our results are presented as the comparative incidence ratio of PMC on rehabilitation and planned visits.

RESULTS

We find significant positive incidence rates for belonging to PMC for both outcomes of interest under all matching specifications. Poisson models using CEM shows a higher incidence rate for planned visits in comparison to unplanned visits, 1.3 (95% CI 1.1-1.4), by PMC patients compared to the non-PMC controls, and a higher proportion of visits for rehabilitation, 3.4 (95% CI 1.7-6.8). Similar positive results are found across other matching methods and models.

CONCLUSIONS

Our analysis reveals significant positive associations between older people included in PMC and a matched set of controls for a greater ratio of making outpatient visits that were planned, rather than unplanned. We find similar associations for the proportion of visits made for rehabilitation, as opposed to other reasons. These findings indicate that PMC influences some elements of outpatient health service utilization by dependent older people.

Inequalities in Older age and Primary Health Care Utilization in Low- and Middle-Income Countries: A Systematic Review

The objective of this research was to systematically review and synthesize quantitative studies that assessed the association between socioeconomic inequalities and primary health care (PHC) utilization among older people living in low- and middle- income countries (LMICs). Six databases were searched, including Embase, Medline, Psych Info, Global Health, Latin American and Caribbean Health Sciences Literature (LILACS), and China National Knowledge Infrastructure, CNKI, to identify eligible studies. A narrative synthesis approach was used for evidence synthesis. A total of 20 eligible cross-sectional studies were included in this systematic review. The indicators of socioeconomic status (SES) identified included income level, education, employment/occupation, and health insurance. Most studies reported that higher income, higher educational levels and enrollment in health insurance plans were associated with increased PHC utilization. Several studies suggested that people who were unemployed and economically inactive in older age or who had worked in formal sectors were more likely to use PHC. Our findings suggest a pro-rich phenomenon of PHC utilization in older people living in LMICs, with results varying by indicators of SES and study settings.

Inequalities in the use of health services by adults and elderly people with and without noncommunicable diseases in Brazil, 2019 National Health Survey

OBJECTIVE

The objective of this study was to investigate the use of health services and limitations in performing usual activities by adults and elderly people with and without noncommunicable chronic diseases (NCDs), according to sociodemographic strata.

METHODS

This is a cross-sectional study in which data from the 2019 National Health Survey were analyzed. The final sample corresponded to 88,531 households with interviews carried out, referring to individuals aged 18 years and above. The prevalence of use of services by the population with NCDs was compared with that of the population without NCDs and stratified by socioeconomic and demographic variables. Prevalence ratios (PRs) and 95% confidence intervals (95%CI) were calculated.

RESULTS

In 2019, 47.6% (95%CI 47.0-48.3) of the population reported having one or more NCDs. Population with NCDs had more medical consultations in the last 12 months (adjusted PR [APR]=1.21; 95%CI 1.20-1.23), used more health services in the last 2 weeks (APR=2.01; 95%CI 1.91-2.11), were referred to more hospitalization (APR=2.11; 95%CI 1.89-2.36), and had more limitations in performing usual activities (APR=2.52; 95%CI 2.30-2.76), compared with the population without NCDs. A positive dose-response gradient was observed between the number of comorbidities and the use of services. In all socioeconomic and demographic strata, the prevalence of indicators was higher in people with NCDs.

CONCLUSION

The presence of NCDs was associated with a higher frequency of use of health services (i.e., consultation, use of services, and hospitalization) and the restriction of usual activities in all socioeconomic and demographic strata.

[Frailty in elderly individuals and perception of problems in indicators of attributes of primary healthcare: results of the ELSI-Brasil]

This study aimed to examine the association between frailty syndrome and the perception of problems in indicators of attributes in primary healthcare (PHC) among elderly Brazilians. This was a cross-sectional study with 5,432 participants 60 years or older in the first wave of the Brazilian Longitudinal Study of Aging (ELSI-Brasil), conducted in 2015 and 2016. Frailty, the independent variable, was defined according to the theoretical framework of the frailty phenotype, and the indicators of problems in PHC attributes, the dependent variables, were obtained from questions related to health services use. Access, longitudinal care, coordination, comprehensiveness, family orientation, and cultural adequacy were the target attributes. For the data analysis, logistic regression models were used, adjusted for predisposing, enabling, and need factors for use of health services. Among the participants, 55.1% were females, 57.9% were 60 to 69 years of age, and 51.8% reported multimorbidity. Frail and pre-frail elders accounted for 13.4% and 54.5% of the sample, respectively. Multivariate analyses showed that frail elders (compared to robust elders) showed higher odds of reporting problems with access (OR = 1.45; 95%CI: 1.08-1.93), longitudinal care (OR = 1.54; 95%CI: 1.19-2.00), and comprehensive care (OR = 1.45; 95%CI: 1.14-1.85), in addition to more problems with attributes of PHC (OR = 1.38; 95%CI: 1.05-1.82, for 5 or more). The study suggests the occurrence of inequities in the care provided by Brazilian PHC for frail elders, particularly in the attributes of access, longitudinal care, and comprehensiveness.

Influence of Micronutrient Intake, Sociodemographic, and Behavioral Factors on Periodontal Status of Adults Assisted by a Public Health Care System in Brazil: A Cross-Sectional Multivariate Analysis

The lack of access to a balanced diet, rich in vitamins and minerals, can predispose people to inflammatory diseases such as obesity, diabetes mellitus, and periodontitis. We aimed to evaluate the relationship between micronutrient intake, sociodemographic behavioral characteristics, and periodontal health in adults assisted by a public health care system. Participants (n = 450) answered a food frequency questionnaire and were submitted to anthropometric and oral clinical examinations. Principal component analysis was used to summarize the number of components emerging from 17-micronutrient intake. Subsequently, cluster analysis was employed. The prevalence of at least one periodontal pocket ≥ 4 mm was 67.4%. Three clusters were identified according to periodontal status. Cluster 1 "poor periodontal status" was characterized by older individuals (n = 202; 85% females) with poor periodontal status, lower education level, mainly smokers with non-transmissible chronic diseases (NTCD), with lower energy, omega-3, fiber, Zn, K, Cu, and vitamin C intake. Cluster 3 "healthy periodontal status" included younger individuals (n = 54) with the healthiest periodontal status, a higher education level, without NTCD, and with higher energy, omega-3, fiber, Zn, calcium, retinol, and riboflavin intake. Cluster 2 was labeled as "intermediate periodontal status". Micronutrient ingestion was associated with periodontal status and may be considered in health promotion actions for low-income populations.

Catastrophic health expenditure and multimorbidity among older adults in Brazil

OBJECTIVE:

To estimate the relation between catastrophic health expenditure (CHE) and multimorbidity in a national representative sample of the Brazilian population aged 50 year or older.

METHODS:

This study used data from 8,347 participants of the Estudo Longitudinal de Saúde dos Idosos Brasileiros (ELSI – Brazilian Longitudinal Study of Aging) conducted in 2015–2016. The dependent variable was CHE, defined by the ratio between the health expenses of the adult aged 50 years or older and the household income. The variable of interest was multimorbidity (two or more chronic diseases) and the variable used for stratification was the wealth score. The main analyses were based on multivariate logistic regression.

RESULTS:

The prevalence of CHE was 17.9% and 7.5%, for expenditures corresponding to 10 and 25% of the household income, respectively. The prevalence of multimorbidity was 63.2%. Multimorbidity showed positive and independent associations with CHE (OR = 1.95, 95%CI 1.67–2.28, and OR = 1.40, 95%CI 1.11–1.76 for expenditures corresponding to 10% and 25%, respectively). Expenditures associated with multimorbidity were higher among those with lower wealth scores.

CONCLUSIONS:

The results draw attention to the need for an integrated approach of multimorbidity in health services, in order to avoid CHE, particularly among older adults with worse socioeconomic conditions.

Dietary guidelines for the elderly in Primary Health Care: development and validation of a protocol based on the Food Guide for the Brazilian Population

Abstract Objective Develop and validate a protocol for the use of the Food Guide for the Brazilian Population (FGBP) in the dietary guidelines for elderly people during individual clinic appointments in Primary Health Care (PHC). Methods The elaboration followed six methodological steps, namely: (1) protocol format definition; (2) definition of the instrument for assessing food consumption; (3) extracting applicable Food Guide recommendations for individual dietary guidelines; (4) evidence systematization on dietary and nutrition needs of the elderly; (5) development of nutritional guidelines messages for the elderly; (6) content and apparent validation and data analysis. Results As products of the steps, the protocol structure was defined and dietary guidelines were elaborated based on the nutritional and health needs of the elderly population, considering the functional capacity and physiological and social changes of this life cycle. The protocol was well assessed by experts and health professionals as to clarity, relevance (content validity index > 0.8) and applicability. In addition, the participants made some suggestions to improve the clarity of the messages and to expand the applicability of the instrument with elderly Brazilians. Conclusion The protocol can contribute to the qualification of dietary guidelines in PHC, dissemination of information from the Food Guide and promotion of comprehensive care and healthy aging of the population.

Orientação alimentar da pessoa idosa na Atenção Primária à Saúde: desenvolvimento e validação de um protocolo baseado no Guia Alimentar para a População Brasileira

Resumo Objetivo Desenvolver e validar um protocolo de uso do Guia Alimentar para a População Brasileira na orientação alimentar da pessoa idosa durante as consultas clínicas individuais na Atenção Primária à Saúde (APS). Métodos Esta construção seguiu seis etapas metodológicas, sendo elas: (1) definição do formato do protocolo; (2) definição do instrumento de avaliação do consumo alimentar dos indivíduos; (3) extração das recomendações do Guia Alimentar aplicáveis para orientação alimentar individual; (4) sistematização de evidências sobre necessidades de alimentação e nutrição da pessoa idosa; (5) desenvolvimento de mensagens de orientação alimentar para a pessoa idosa; (6) validação de conteúdo e aparente e análise dos dados. Resultados Como produtos das etapas, foi definida a estrutura do protocolo e construída as orientações alimentares baseadas nas necessidades nutricionais e de saúde da população idosa, considerando a capacidade funcional e alterações fisiológicas e sociais desse ciclo de vida. O protocolo foi bem avaliado por especialistas e profissionais de saúde nos critérios de clareza, pertinência (Índice de validade de conteúdo >0,8) e aplicabilidade. Além disso, os participantes deram sugestões para melhoria da clareza das mensagens e para ampliar a aplicabilidade do instrumento com pessoas idosas brasileiras. Conclusão O protocolo pode contribuir para qualificação da orientação alimentar na APS, disseminação das informações do Guia Alimentar e promoção do cuidado integral e envelhecimento saudável da população.

Access to Primary Health Care by older adults from rural areas in Southern Brazil

OBJECTIVE

To characterize the access and use of health services considered reference among the older rural population from a municipality in southern Brazil, whose rural area has full coverage of the Family Health Strategy (FHS), investigating factors associated with the choice of the Basic Family Health Unit (BFHU) as reference.

METHODS

This is a cross-sectional study conducted in 2017 with systematic sampling of rural households in the municipality of Rio Grande (RS) using a standardized in-house questionnaire. We performed descriptive analyses of sociodemographic profile, type of reference service chosen, and reasons for choosing/using the prime-choice service and the nearest BFHU. Poisson regression was used to investigate factors associated with the type of reference service chosen.

RESULTS

Among the 1,030 older adults who participated in the study, 61.4% considered the BFHU a prime choice/reference service mostly due to its proximity (82.6%); the others sought other places due to a greater ease (34.6%) and resoluteness (52.6%). Almost ⅔ of the respondents sought care at the BFHU during the last year, and the reasons differed among those who considered the unit as reference (chronic disease) and those who sought another place (procedures). We also found that the lower the age, income, education, and household-unit distance, the greater the likelihood of the older adult considering the nearest BFHU as reference service.

CONCLUSIONS

The FHS has reached the vulnerable older rural population, approaching an equitable public health system. However, further evaluations are necessary to verify the quality and adequacy of care, given that social structure, enabling factors (such as economic condition), and possible beliefs regarding health still establish the standards for choosing a service.

ELSI-COVID-19 initiative: methodology of the telephone survey on coronavirus in the Brazilian Longitudinal Study of Aging

The COVID-19 pandemic (caused by the SARS-CoV-2) is a public health emergency of international concern that particularly affects older people. Brazil is one of the countries most affected by the pandemic, ranking second with the highest number of confirmed cases and deaths worldwide as of mid-June 2020. The ELSI-COVID-19 initiative is based on telephone interviews with participants of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), conducted on a nationally representative sample of the population aged 50 or older. This initiative aims to provide information on adherence to preventive measures (social distancing, wearing masks, and handwashing/hygiene); reasons for leaving the house, when that was the case; difficulties obtaining medications, medical diagnosis of COVID-19, and receipt of confirmatory results; use of health-care services (recent care-seeking, care-seeking location, care receipt, among other aspects); and mental health (sleep, depression, and loneliness). The first round of telephone interviews was conducted between May 26 and June 8, 2020. The second and third rounds are expected to occur within the coming months. This article presents this initiative methodology and some sociodemographic characteristics of the 6,149 participants in the survey first round, relative the Brazilian population within the same age group.

Prevalence of Older Adult Disability and Primary Health Care Responsiveness in Low-Income Communities

In Brazil and in most low- and middle-income countries (LMICs), information about how prepared the health care system is for the rapid aging of the population is scarce. We investigated the prevalence of disability and areas of life affected by disability among elders of the public primary health care in São Paulo and Manaus, Brazil. We investigated whether people with disability visited a primary care professional more frequently, the individual characteristics associated with disability, and differences by city. We randomly selected participants aged ≥60 years (n = 1375). The main outcome was disability, evaluated with the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0). Exposure variables were consultation with a family physician, sociodemographic characteristics, health status, social support, and lifestyle. The prevalence of global disability was higher in Manaus (66.2% vs. 56.4% in São Paulo). In both cities, participation and mobility were the areas of life most affected by disability. The number of consultations with a family physician was not associated with disability. The high prevalence of disability and associated risk factors indicates that public primary health care is not meeting the needs of elders in both cities. It is warning because most elders in LMICs live in more underserved communities compared to Brazil.

AMPI-AB validity and reliability: a multidimensional tool in resource-limited primary care settings

Background

The early identification of individuals at high risk for adverse outcomes by a Comprehensive Geriatric Assessment (CGA) in resource-limited primary care settings enables tailored treatments, however, the evidence concerning its benefits are still controversial. The main objective of this study was to examine the validity and reliability of the “Multidimensional Assessment of Older People in Primary Care (AMPI-AB)”, a CGA for primary care in resource-limited settings.

Methods

Longitudinal study, with median follow-up time of 16 months. Older adults from a public primary care unit in São Paulo, Brazil, were consecutively admitted. Reliability was tested in a sample from a public geriatric outpatient clinic. Participants were classified by the AMPI-AB score as requiring a low, intermediate or high complexity of care. The Physical Frailty Phenotype was used to explore the AMPI-AB’s concurrent validity. Predictive validity was assessed with mortality, worsening of the functional status, hospitalizations, emergency room (ER) visits and falls. The area under the ROC curve and logistic regression were calculated for binary outcomes, and a Cox proportional hazards model was used for survival analysis.

Results

Older adults (n = 317) with a median age of 80 (74–86) years, 67% female, were consecutively admitted. At the follow-up, 7.1% of participants had died, and increased dependency on basic and instrumental activities of daily living was detected in 8.9 and 41.1% of the participants, respectively. The AMPI-AB score was accurate in detecting frailty (area under the ROC curve = 0.851), predicted mortality (HR = 1.25, 95%CI = 1.13–1.39) and increased dependency on basic (OR = 1.26, 95%CI = 1.10–1.46) and instrumental (OR = 1.22, 95%CI = 1.12–1.34) activities of daily living, hospitalizations (OR = 2.05, 95%CI = 1.04–1.26), ER visits (OR = 1.20, 95%CI = 1.10–1.31) and falls (OR = 1.10, 95%CI = 1.01–1.20), all models adjusted for sex and years of schooling. Reliability was tested in a sample of 52 older adults with a median age of 72 (85–64) years, 63.5% female. The AMPI-AB also had good interrater (ICC = 0.87, 95%CI = 0.78–0.92), test-retest (ICC = 0.86, 95%CI = 0.76–0.93) and proxy reliability (ICC = 0.84, 95%CI = 0.67–0.93). The Cronbach’s alpha was 0.69, and the mean AMPI-AB administration time was 05:44 ± 02:42 min.

Conclusion

The AMPI-AB is a valid and reliable tool for managing older adults in resource-limited primary care settings.