RESUMO Iniquidades de acesso ao Sistema Único de Saúde comprometem a garantia de cuidados primários de saúde para populações rurais e para outros grupos em situação de vulnerabilidade. Estudo transversal que avaliou acesso de usuários e cobertura assistencial de Equipes de Saúde da Família (EqSF) dos sete estados da região norte do Brasil e que aderiram à avaliação externa do segundo ciclo Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). Os dados do PMAQ-AB foram relacionados a indicadores demográficos, socioeconômicos e de saúde, por meio do coeficiente de correlação de Spearman. Para o conjunto da região, a cobertura assistencial de equipes sediadas em área rural, urbana e urbana que declararam atender a populações rurais foi de 83,3%. Coberturas entre 90-100% foram encontradas para o Acre, o Amapá, Roraima e o Tocantins. Menores percentuais foram encontrados no Pará (50,5%) e no Amazonas (60,5%). A extensão de cobertura encobre barreiras de acesso geográfico ligadas à concentração de equipes da Estratégia Saúde da Família nos espaços urbanos, situação que se estende a 451 (25,3%) unidades e a 494 (22,9%) equipes encarregadas do atendimento de populações rurais, mas que atuam em espaço urbano, adicionando barreiras à chegada dos usuários às unidades. Dificuldades no acolhimento à demanda espontânea, agendamento de consulta e disponibilidade de transporte para o atendimento também foram reportadas.

Background: The ways of life in the Amazon are diverse and not widely known. In addition, social inequities, large geographic distances and inadequate health care network noticeably limit access to health services in rural areas. Over the last decades, Brazilian health authorities have implemented fluvial mobile units (FMU) as an alternative to increase access and healthcare coverage. The aim of the study was to identify the strategies of access and utilization of primary health care (PHC) services by assessing the strengths and limitations of the healthcare model offered by the FMU to reduce barriers to services and ensure the right to healthcare.Methods: Qualitative and ethnographic research involving participant observation and semi-structured interviews. Data collection consisted of interviews with users and health professionals and the observation of service organization and healthcare delivered by the FMU, in addition to the therapeutic itineraries that determine demand, access and interaction of users with healthcare services.Results: Primary care is offered by the monthly locomotion of the FMU that serves approximately 20 rural riverside communities. The effectiveness of the actions of the FMU proved to be adequate for conditions such as antenatal care for low-risk pregnancy, which require periodic consultations. However, conditions that require continued attention are not adequately met through the organization of care established in the FMU. The underutilization of the workforce of community health workers and disarrangement between their tasks and those of the rest of the multi-professional team are some of the reasons pointed out, making the healthcare continuity unfeasible within the intervals between the trips of the FMU. From the users’ perspective, although the presence of the FMU provides healthcare coverage, the financial burden generated by the pursuit for services persists, since the dispersed housing pattern requires the locomotion of users to reach the mobile unit services as well as for specialized care in the urban centers.Conclusions: The implementation of the FMU represents an advance in terms of accessibility to PHC. However, the organization of their activity uncritically replicates the routines adopted in the daily routine of health services located in urban spaces, proving to be inadequate for providing healthcare strategies capable of mitigating social and health inequalities faced by the users.

Inequalities in the utilisation of dental services in Brazil are remarkable. The aim of this study was to evaluate the association of contextual and individual factors with the utilisation of dental services by Brazilian adults using the Andersen’s behavioural model. Individual-level data from 27,017 adults residents in the State capitals who were interviewed in the 2013 Brazilian National Health Survey were pooled with contextual city-level data. The outcomes were non-utilisation of dental services and last dental visit over 12 months ago. Individual predisposing variables were age, sex, race/skin colour, schooling and social network. Individual enabling variables included income, health insurance and registration in primary health care. Individual need variables were self-perceived dental health and self-reported missing teeth. Multilevel logistic regression models were performed to estimate odds ratio (OR) and 95% confidence intervals (95% CIs) of the association of contextual and individual predisposing, enabling and need-related variables with dental services outcomes. Predisposing (OR = 0.89; 95% CI 0.81–0.97) and enabling (OR = 0.90; 95% CI 0.85–0.96) contextual factors were associated with non-utilisation of dental services. Individual predisposing (sex, race/skin colour, schooling), enabling (income, health insurance) and need (self-perceived oral health, missing teeth) were associated with non-utilisation of dental services and last dental visit over 12 months ago. The latter was also associated with other individual predisposing (age, social network) and need (eating difficulties due to oral problems) characteristics. Individual and contextual determinants influenced dental services utilisation in Brazilian adults. These factors should be on the policy agenda and considered in the organisation of health services aiming to reduce oral health inequalities related to access and utilisation of dental services.

Background: The utilisation of health services is determined by complex interactions. In this context, rural populations face greater barriers in accessing dental services than do urban populations, and they generally have poorer oral health status. The evaluation of the determinants of health services utilisation is important to support planning and management of dental services. The aim of this study was to evaluate the predictors of dental services utilisation of Brazilian adults living in rural and urban areas. Methods: Data from 60,202 adults aged 18 years or older who took part in the Brazilian National Health Survey carried out in 2013 were analysed. Predisposing (age, sex, education, social networks), enabling financing (income, durable goods and household’s crowding), enabling organisation (health insurance, registration in primary health care [PHC]) and need variables (eating difficulties, self-perceived tooth loss and self-perceived oral health) were selected based upon the Andersen behavioural model. Multi-group structural equation modeling assessed the direct and indirect associations of independent variables with non-utilisation of dental services and the interval since the last dental visit for individuals living in rural and urban areas. Results: Adults living in urban areas were more likely to use dental services than those living in rural areas. Lower enabling financing, lower perceived dental needs and lack of PHC registration were directly associated with lower utilisation of dental services (non-utilisation, β = − 0.36, β = − 0.16, β = − 0.03, respectively; and interval since last dental visit, β = 1.25, β = 0.82, β = − 0.12, respectively). The enabling financing (non-utilisation, β_rural = − 0.02 [95%CI: − 0.03 to − 0.02], β_urban = 0.00 [95%CI: − 0.01 to 0.00]) and PHC registration (non-utilisation, β_rural = − 0.03 [95%CI: − 0.04 to − 0.02], β_urban = − 0.01 [95%CI, − 0.01 to − 0.01]) non-standardised total effects were stronger in rural areas. Enabling organisation (β = 0.16) and social network (β = − 2.59) latent variables showed a direct effect on the interval since last dental visit in urban areas. Education and social networks influenced utilisation of dental services through different pathways. Males showed less use of dental services in both urban and rural areas (non-utilisation, β_rural = − 0.07, β_urban = − 0.04; interval since last dental visit, β_rural = − 0.07, β_urban = − 0.07) and older adults have used dental services longer than younger ones, mainly in rural areas (β_rural = 0.26, β_urban = 0.17). Conclusion: Dental services utilisation was lower in rural areas in Brazil. The theoretical model was supported by empirical data and showed different relationships between the predictors in the two geographical contexts. In rural areas, financial aspects, education, primary care availability, sex and age were relevant factors for the utilisation of services.

Background: Tooth loss is an oral health condition with high prevalence and negative impact on quality of life. It is the result of the history of oral diseases and their treatment as well as provision of dental care and access to dental services. Socioeconomic characteristics are determinants of tooth loss and living in rural areas is also a risk factor for its incidence. Objective: To identify contextual and individual factors associated with self-reported tooth loss among adults and elderly people living in rural riverside areas. Methods: A cross-sectional household-based survey was conducted in 2019 with rural riverside communities on the left bank of the Rio Negro River, Manaus, Amazonas. These communities are covered by a fluvial health team and two riverside health teams. Interviews were conducted in a representative random sample of dwellers aged ≥ 18 years, using electronic forms to obtain information on oral health conditions, demographic and socioeconomic characteristics, and use of and access to health services. The outcome was self-reported tooth loss. After the descriptive analysis of the data, a multilevel Poisson regression analysis was performed to estimate the prevalence ratio for the outcome. Variables with p-value ≤0.20 in the bivariate analyses were included in the multiple analysis considering the hierarchy between individual and contextual variables in the multilevel model. Variables with p-value ≤0.10 were kept in the final model and the significance level adopted was 0.05. Results: 603 individuals from 357 households were assessed (mean age 44.1 years). The average number of missing teeth was 11.2 (±11.6); 27.4% of individuals had lost more than 20 teeth (non-functional dentition) and 12.1% were completely edentulous. Contextual characteristic of primary healthcare offered was associated with the outcome. The tooth loss was lower in territories covered by riverside health teams. At individual level, tooth loss was greater in older individuals who had experienced dental pain over the past six months and whose sugar consumption was high. Black or brown individuals, individuals whose household income was higher, those who were on the Bolsa Família cash transfer program, those who consulted a dentist over the past year, and those who reported satisfaction with their teeth/oral health reported less tooth loss. Conclusion: Tooth loss was associated with contextual territorial factors related to the healthcare service and individual demographic, behavioral, socioeconomic, and service-related characteristics as well as self-perceived oral health conditions. The findings suggest that actions focused on the oral health of these populations involve not only changes in the healthcare service organization, but also intersectoral policies that contribute to reducing social inequalities.

Cervical cancer is a major public health problem, especially in the north region of Brazil. The aim of the study was to identify the factors associated with not undergoing the cervical cancer screening test in rural riverside populations in the Amazon. A cross-sectional home-based survey was carried out in 38 locations covered by a fluvial primary healthcare team, and the administrative records of the screening tests from January 2016 to May 2019 were analyzed. After the descriptive analysis, logistic regression was performed considering the outcome of having undergone cervical cancer screening within the past three years. Of the 221 women assessed, 8.1% had never undergone the test, and 7.7% had undergone it more than three years ago. Multiparity (OR = 0.76 (95%CI = 0.64–0.90)), occupation in domestic activities (OR = 0.31 (95%CI = 0.11–0.89)), and lack of knowledge of the healthcare unit responsible for the service (OR = 0.18 (95%CI = 0.04–0.97)) were associated with not undergoing the cervical cancer screening test. The administrative records revealed that the screening test was performed outside the recommended age range (24%), performed needlessly (9.6%) with undue repetitions (3.2%), and a high percentage of the samples collected were unsatisfactory (23.5%). The findings revealed the existence of barriers for riverside women to access cervical cancer screening tests.