Healthcare trajectories and obstacles faced by women in a health region in Northeast Brazil

Abstract: The article aims to assess organization and access to the Healthcare Network in a health region, from the perspective of female users. Healthcare trajectories were constructed for women with high-grade cervical squamous intraepithelial lesions, covered by different modalities of primary health care (PHC) in urban and rural areas, in municipalities in the interior, and in the capital city of the Northeast health region, Brazil. Women used PHC as their regular service for prevention and care, but reported barriers to access to medical appointments, especially in rural areas. Positive assessments were associated with positive reception by the health service and representation of the basic health unit or family health unit as the available locus for care. A perception of low case-resolution capacity in PHC was associated with delays in scheduling referrals, irregular/insufficient supply of medicines, and physician turnover. Women reported difficulty in access to specialized care, especially in municipalities in the interior, with the use of public and private services. All the users in the capital city of the health region underwent confirmatory diagnostic tests and surgeries in the Brazilian Unified National Health System (SUS). Support from family members, friends, and local politicians were part of the healthcare trajectories. Interprofessional communication was nearly non-existent and health professional-patient communication was precarious. The regionalized network appeared disconnected and with confusing flows in terms of guaranteeing timely access for users in municipalities in the interior and with additional difficulties for those in rural areas, even in the capital city, revealing incompleteness in regional arrangements and persistence of inter- and intra-municipal inequalities in access.

摘要：本研究旨在从女性使用者视角，评估巴西东北部卫生区域内医疗保健网络的组织架构与可及性。研究针对该区域内陆各市及首府城市的城乡地区中，接受不同模式初级卫生保健（Primary Health Care, PHC）服务的高级别宫颈鳞状上皮内病变（cervical squamous intraepithelial lesions）女性患者，构建了其医疗照护轨迹。女性患者将初级卫生保健作为预防与诊疗的常规服务渠道，但反馈存在就医预约障碍，该问题在农村地区尤为突出。患者给出的正面服务评价，与医疗服务机构的友好接待，以及将基层卫生单位或家庭卫生单位作为可及照护场所的认知呈正相关。对初级卫生保健病例处置能力不足的认知，与转诊预约延误、药品供应不规律或不足以及医师流动性高等因素相关。女性患者反馈获取专科诊疗服务存在困难，在内陆各市尤为明显，为此她们会同时使用公立与私立医疗服务。该卫生区域首府城市的所有患者，均在巴西统一国家卫生系统（Sistema Único de Saúde, SUS）内完成了确诊性诊断检测与手术治疗。医疗照护轨迹中还包含来自家人、朋友与当地政客的支持。跨专业沟通几乎不存在，医护人员与患者间的沟通也极为薄弱。该区域化医疗网络呈现割裂状态，在内陆各市保障患者及时就医的流程混乱，即便在首府城市，农村地区患者也面临额外困难，这暴露出区域卫生安排的不完善，以及市内和跨市就医可及性不平等问题依然存在。