Satisfaction of Users of the Family Health Strategy in a Capital City of Northeast Brazil

Results: The results indicated that in the Reliability dimension, participants agreed that the healthcare professionals record the attendance, perform on the promised date and have an interest in solving the problems. In the Security dimension, the majority of the participants were indifferent as to the behavior of the professionals generating confidence. They demonstrated security in requesting the services because they were politely attended by the professionals. Moreover, in the two dimensions analyzed, it was noticed that there is a tendency to increase satisfaction as the participants' income decreases with significant statistical relations, with satisfaction on Reliability and Security inversely proportional to income.


Introduction
Brazil underwent remarkable changes in the organizational structure of healthcare from the creation of the Unified Health System (SUS), formulated with a view to changing attention to the health in the country with emphasis on Primary Care.In this context, programs and strategies aimed at improving care are included, among them the Family Health Strategy (ESF), which emerges from a proposal for reorganization of Primary Care services, prioritizes preventive care with activities aimed at the promotion and prevention, in order to break with the biomedical model rooted in the Brazilian healthcare culture.However, there are organizational and cultural obstacles so that the reorganization of Primary Care can reach full effectiveness [1,2].
One of the challenges of Primary Care in the country is the provision of quality care that is characterized as an important tool for the effectiveness of the system.One of the ways of assessing quality is to measure user satisfaction, as it is possible to identify points that can be improved.However, evaluating health services is a complex activity that deserves special attention [3,4].
The approach on the satisfaction of users of healthcare services has been shown to be relevant in international discussions.In the context of family health, high user dissatisfaction rates can be built from the relationships between health teams and community, as the proximity of professionals awakens trust in users.In this sense, when the relations of proximity are established, the capacity of evaluation of the services by the users increases and their perceptions are more reliable [5,6].
In view of the above, the study aims to analyze the satisfaction of users of the Family Health Strategy regarding Reliability and Safety aspects.

Method
This is a field research with a quantitative approach, carried out with a sample of 353 participants enrolled in an Integrated Health Center of the eastern region of a capital of Northeast Brazil, through the SERVQUAL instrument.The data collection took place from January to May 2015.
The instrument used for data collection was validated, disseminated and used in health research.It was tested and applied to measure the satisfaction of users of family health team services located in the Southeast Region of Brazil [3].
It was decided to evaluate the satisfaction with the application of an already validated instrument and which includes aspects related to tangibility, empathy, reliability, promptness and safety, being an evaluation methodology that contemplates dimensions ranging from professionals' attention to ver, there is a need for more studies with different methodological approaches to better elucidate the intersubjective issues that shape the process of interaction between users, healthcare professionals and services.the physical structure of healthcare facilities, so that it is possible to guide the perception of services more reliably [7].
The SERVQUAL model has five dimensions: tangibility, reliability, responsibility, security and empathy.However, only two are discussed in this paper: Reliability, which is related to the ability of the teams to provide services with trust and accuracy, and Security, which concerns the knowledge to answer questions, the transmission of trust and the ability to keep secrecy about certain subjects [7].
For the first part of the data, a structured questionnaire containing variables was used: gender, age, marital status, number of children, educational level, job market situation and monthly family income.
For the second part, the SERVQUAL scale was applied.The questionnaire consists of 22 statements on users' perception regarding Reliability and Safety.To answer the assertions, a Lickert-type scale containing five points numbered from 1 to 5 was used, in which the extremes of the scale correspond to "Totally Disagree" and "Totally Agree".
Data collection was performed in the users' own homes.The sample was determined from demographic data and data from the Basic Health Unit.For the sample calculation, the following formula was used: Being: Z = level of confidence (95%).P = amount of expected accuracy (50%).Q = amount of expected error (50%).

N = population (3,384 people). e = level of precision (5%). n = 345
The data were processed in the StatisticalPackage for the Social Sciences (SPSS) version 20.0.The data were organized into charts and graphs.To relate variables, we used the Chi-square Test with significance of p> = 0.05.
This research was approved by the Research Ethics Committee of the UNINOVAFA-PI University Center through the CAAE opinion: 38532614.0.0000.5210.The ethical precepts set forth in resolution n. 466/2012 of the National Health Council were respected, and the Term of Free and Informed Consent was signed.The questionnaires were coded with numbers ensuring the participants' anonymity [8].
Research on the insertion in the labor market showed that 208 (58.9%) were unemployed.Regarding family income, it was observed that 134 (38.0%) had income of a minimum wage and 7 (1.1%) had income of five minimum wages.(Table 1 The data in Table 2 show the level of satisfaction of the users participating in the research regarding Reliability of the services provided by the Family Health Teams characterized by: promises/compliant, compliant, records. The data show that 56.6% (200) agreed partially or totally that EFS employees insist on registering the service performed, 51.1% (184) agreed that the ESF performs services on the promised date, 46.2% (163) agreed that it is in the interest of teams to solve users' problems.
Table 3 shows users' satisfaction with the Security dimension.52.1% (184) agreed partially or totally that ESF staff are knowledgeable about responding to users' doubts about health services, 48.4% (171) agreed that they feel secure in applying for ESF services, 46.7% (165) agreed that employees are educated during service, 41.9% (148) agreed that employee behavior generates confidence in the provision of services.
After using crosstab tool cross-referencing income with the variables that form the reliability dimension, the only one that did not present statistical significance (p = 0.356) was "When the health strategy of the local family promises to make a service at a certain time, it does it", which corresponds to variable C1.The other relations, statistically significant, are presented in Figure 1 below with the graphs of this crossing.According to what was shown in Figure 01, it was observed that individuals with income from a minimum wage -55.97% (75) -agree with the statement (C2) "When you have any health problem, the Family Health Strategy shows interest in solving it", but 25.37% (34) disagree.Analyzing this variable with the six income categories, it was observed that the agreement is higher in individuals with a minimum wage income, the level of users' dissatisfaction in this affirmation decreases with the income increase.According to the Chisquare test (X 2 ) there is a statistically significant relationship between these variables (p=0,000).
Regarding the statement (C3), "The health strategy of the local family does the right service the first time", it was observed that the highest level of satisfaction was among individuals with a minimum wage, 49.25% (66) of the individuals agreeing with the statement, however 23,13% (31) disagreed with the statement and 27.61% (37) felt indifferent.It is also observed that among individuals with income of five minimum wages, there is no satisfaction with the variable C3.According to the Chi-square test (X 2 ) there is a statistically significant relationship between these variables (p=0.000).
In the statement "The local family health strategy provides services on the promised date" that corresponds to variable C4, 76 individuals agreed with it, but 38 disagreed with this statement.According to the Chi-square test (X 2 ) there is a statistically significant relationship between these variables (p=0,015).It is emphasized that as the income variable increases, users' satisfaction with the variable P4 decreases.It was possible to observe that 100% of individuals with income of five minimum wages were dissatisfied with the variable C4.
In variable C5, "The family health strategy of the locality insists on recording the care taken", it was observed that 78 individuals agreed with the statement to the detriment of 34 who disagreed.The income relation with the variable C5 obtained by means of the Qui-square test (p = 0.005) with statistical significance.

Discussion
The predominant profile of ESF users investigated are mostly female, adults, with low schooling, unemployed and with incomes up to one minimum wage.The two satisfaction dimensions -Reliability and Security -were well evaluated by most users.The Reliability dimension had greater satisfaction for users with incomes up to one minimum wage.
Regarding user satisfaction regarding the Reliability and Security Dimensions evaluated through SERVQUAL, it was possible to observe in the Reliability Dimension that the trust that the professionals transmit to the users was evaluated in a positive way.The trust generated by health professionals is an implicit form of reception that generates confidence in users and increases the possibility of searching for services.In this way, it is corroborated by the consolidation of the Family Health Strategy as the entrance of the SUS [9].
However, a reality currently experienced by Brazilian public health services is the long waits to mark appointments for medical specialties.Long waits are grounds for user dissatisfaction.A study that evaluated the satisfaction of the users regarding the reception, identified that many subjects felt satisfied with the care, however, they reported negative aspects such as the long waits and the difficulty in marking consultations [10].
In Nigeria, the overall quality of services was positively evaluated, but a gap was identified related to the waiting time and the resolution of the health service, the study used SERVQUAL for quality evaluation.In a district of Pakistan, the health service investigated with the use of SEVQUAL was poorly evaluated by the users.In Saudi Arabia, users were dissatisfied with all dimensions of sa-tisfaction of SERVQUAL over nursing services [11,12,13].
Regarding the Security Dimension, it was possible to observe that the users feel safe when requesting the services of the teams.The best evaluated variable in this dimension was that related to the questions and doubts of the users and the responsiveness of the employees of the teams.Authors have reported that low income is related to high levels of satisfaction of users of public health services, because they are more condescending with the services received [14].
The difficulty of evaluating the satisfaction of users of the Family Health Strategy is related to the culture present in our society, in which the focus is the illness and the figure of the doctor as protagonist of the process, seeming that other professionals are not relevant in the system.In this perspective, a user can report full satisfaction when receiving care from a medical professional, having his "illness" treated.
The use of multifactorial instruments, such as the one used in the present research, increases the reliability of the users' responses.Much has been discussed in the literature about the excess of positive responses, with a general and directed approach to obtaining answers.When using such an instrument, one can get closer to what users want to convey in their answers [15].

Conclusion
It is concluded that the predominant profile of the users of the Family Health Strategy investigated were: the majority were female, adults, with low schooling, unemployed and with income up to a minimum wage.In the associations made with the variables of the SERVQUAL instrument and the variable income, it was evidenced that the satisfaction of the users tends to decrease as the purchasing power of the users increases.The users of the Family Health Strategy have demonstrated satisfaction with the services received, however, there is a need for more studies with different methodological approaches to better elucidate the intersubjective issues that shape the process of interaction between users, healthcare professionals and services.

Figure 1 :
Figure 1: Graph of cross references between the income variable and the reliability dimension.

Table 1 .
) Sociodemographic characterization of users participating in the research of the Family Health Strategy teams.Teresina-PI, 2017.

Table 2 .
Satisfaction of Family Health Strategy users with regard to Dimension Reliability.Teresina-PI, 2017.

Table 3 .
Satisfaction of the users participating in the research of health teams of the Family Health Strategy regarding the Safety Dimension.Teresina-PI, 2017.The employees of the family health strategy of the locality have the knowledge to answer their doubts regarding the health services.