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Background. Young women often have diverse options for addressing their reproductive health and other health needs in urban settings. In Brazil, they may access care through the government-run Family Health Program (FHP). Understanding factors associated with service utilization can enhance access to and delivery of appropriate services.
Objectives. To describe demographic, behavioural and clinical characteristics of young women accessing services through FHP in Vitória, Brazil.
Methods. From March to December 2006, women aged 18–29 years were recruited into a population-based, household survey. Responses were analysed to assess previous 6 months utilization of FHP services in this population and characteristics associated with accessing care through this public family practice model.
Results. Of 1200 eligible women identified, 1029 enrolled (85.7%). Median age was 23 (interquartile range 20–26) years, 42.7% were married or cohabitating with a male partner. A majority (72%) accessed FHP services in the preceding 6 months, principally for routine and gynaecological visits. Factors independently associated with seeking FHP included: ever tested for human immunodeficiency virus, using anal sex as contraceptive method and reporting a current vaginal discharge. Prior commercial sex work, previous diagnosis with an sexually transmitted infection or using oral sex as a contraceptive method were associated with less use of FHP services.
Conclusions. A public option for delivery of FHP has attracted wide utilization across a cross-section of young women in Vitoria, Brazil. Greater sensitization to specific practices and needs of this population, especially around reproductive health, could further enhance the services provided by family practitioners.
The integration of sexual health into existing primary health care services, including reproductive health programmes, has been a priority since the International Conference on Population and Development in 1994.1 The goals of integrated services are to improve service accessibility; increase quality, efficiency and client satisfaction; meet unmet needs and ultimately improve health status.2,3 In the Brazilian health system, since 1996, the Family Health Program (FHP) has been the principal strategy to improve primary health care.4 FHP provides a comprehensive range of preventive and curative health care services in a family practice model delivered by a team composed of one physician, one nurse, a nurse assistant and several community health workers (CHWs). In some places, the team also includes dental and social work professionals.5 Each team is assigned to a geographical area and is then responsible for enrolling and monitoring the health status of the population living in this area, providing primary care services and making referrals to other levels of care as required. Each team is responsible for an average of 3500 clients or ~1000 households. Physicians and nurses typically deliver services at health facilities centrally located in communities or neighbourhoods, whereas CHWs provide health promotion and education services during household visits.6 As of December 2007, the programme covered ~88 million people, 46.6% of the entire Brazilian population.
In 1998, Vitoria Municipality implemented the FHP as its primary strategy for delivering primary care, including reproductive health care for women. This study describes demographic, risk behaviour and clinical factors associated with accessing family practice-based health care in a population-based sample of young women attending by FHP in Vitória, Brazil. The information will be used for planning and implementing primary care interventions for this population.
This is an analysis of data collected in a 2006 project that had the primary objective of measuring the prevalence of human immunodeficiency virus (HIV), syphilis, markers of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and related risk behaviour in young women (18–29 years old) in Vitória, Brazil. Details of the methods for that analysis, including sampling, self-reported and laboratory measures and results of the primary outcomes, have been previously published.7 The study utilized a recently completed, comprehensive census of the population done for implementation of the FHP; this provided a representative sampling frame, maps and contact information for the Vitoria metropolitan area. We conducted a single-stage, population-based, door-to-door, cross-sectional survey of young women aged 18–29 years residing in Vitória. The study recruited 1200 women in order to provide 80% power to estimate a point prevalence of HIV at 0.5% with a 95% confidence interval (CI) of 0.2–1.1.
Three of the six administrative regions (Health Region I, II and VI) of the Municipal Health Department were targeted for this study, having higher, median and lower average household income, respectively, based on the FHP census data. The administrative health region is classified to assist in determining how resources are allocated within the public health municipality. The total population of the target areas was 117056, of whom 10660 (9.1%) were females aged 18–29 years. Women were proportionately sampled in each region relative to their population size: 30.7% for Region I, 51.0% for Region II and 18.3% for Region VI. Enrolment goals were 368 women from Region I, 612 from Region II and 220 from Region VI to self-weight the sample and to meet the sample size goal of 1200 women. The number of households targeted for contact took into account an anticipated 80% participation rate. Households with eligible women were selected by simple random sample from the FHP census available for each target area.
Selected households were visited by CHWs and eligible women were invited to participate in the study. Eligibility criteria included female sex, age 18–29 years old and residency in the targeted health regions in Vitória, Brazil. ‘Residency’ was defined as staying at a dwelling during the previous 6 months and having no other home. CHWs used an enumeration form for each participant to record and monitor household contact attempts, successes, resident eligibility, enrolment and refusals; a minimum of six contact attempts were made at residences. Study eligibility was established through a face-to-face interview. Eligible women were invited to participate and be enrolled immediately and interviewed at home or, at later, at an alternatively arranged date and/or location including clinic office or an alternative neutral location, such as a park or cafe. All interviews were anonymous, no names were recorded and only a study ID number was used on paperwork and in the database. Participants used the study ID number to obtain results of testing. Recruitment occurred from March to December 2006.
Informed consent procedures were conducted at recruitment time and before participation in any activity of the study. After the consent form was read and discussed with the participant, and after any questions posed by the participant had been answered, she was asked to sign the consent form. All women with diagnosed infections were offered counselling and treatment according to the Brazilian National Guidelines for Sexually Transmitted Infections (STIs) and referrals to care as necessary or requested. The Ethics Committees from the Federal University of Espírito Santo and from University of California San Francisco approved the protocol for the study.
A 30-minute face-to-face interview was conducted with the use of a standardized questionnaire by trained field staff from the local health department. The questionnaire used in this project was adapted from a population-based study of young (ages 18–29 years) low-income women conducted in five Northern California counties, the ‘Young Women's Survey’.8 The adaptation involved translation, adaption and then pretesting and pilot testing in the target population in Brazil. The lexicon and measures were adapted for the Brazilian setting, especially for questions capturing socio-demographic data. Items assessing sexual and reproductive health, clinical symptoms and previous STI were not changed measurably. Health care utilization measures were adapted to reflect the services provided in the Brazilian family services context. The risk assessment questionnaire questioned participants regarding socio-demographic characteristics (age, schooling, profession, marital status and monthly income), clinical history (vaccine history, clinical symptoms, previous STI, contraception, pregnancy, abortion or miscarriage), sexual and drug-related exposures (condom use, number of sexual partners, commercial sex workers, rape, alcohol and drug abuse and blood transfusion) associated with risk of sexually transmitted or acquired and blood borne infections, family planning methods and clinical factors, including current STI symptoms. Blood and urine samples were obtained for HIV, viral hepatitis (HBV and HCV) and syphilis testing. The main outcome of interest ‘health care seeking’ was derived from the survey question which queried participants ‘In the last six months, did you seek Family Health services to see a doctor, a nurse or other health professional in the health facility unit?’
Standard descriptive statistical analyses were performed, including frequency distributions, medians and interquartile ranges (IQRs) or means and SDs for continuous variables with non-normal and normal distributions, respectively. Prevalence and 95% CIs were estimated based on a binomial distribution. Odds ratios and 95% CI were calculated in bivariate analyses and multivariate logistic regression analyses to assess variables associated with health care-seeking outcomes. Variables which were significant at P<0.15 in the bivariate analyses and known confounders (for instance, age and number of sexual partners) were considered in the multivariate analysis using a stepwise multiple logistic regression model, with P<0.15 as the critical value for variable entry and P<0.10 as the criterion for variable elimination. Parsimonious models were finalized based on variables found to be significantly associated with the outcome at P≤0.05.
A total of 1200 eligible women were identified and 1029 enrolled (85.7%). No specific information was gathered about non-respondents. Some of them had moved after sampling (9.0%), and some declined because they worked full time and said they were too tired to answer the interview in the evening (5.3%).
The median age of the participants was 23 (IQR, 20–26) years, 42.7% were married or cohabitating with a male partner, and 68.4% had >8 years of education. A majority of women, 743 [72.2% (95% CI, 69.5–74.9%)], reported having received personal health care in the last 6 months (Table 1). Principal reasons for seeing a family physician in the last 6 months were: 285 (38.4%) for clinical routine check-up (when the patient initiated visit with no ‘symptoms or signs’ of concern), 251 (33.8%) for gynaecologic care, 70 (9.4%) cardio-respiratory symptoms, 44 (5.9%) digestive symptoms, 44 (5.9%) dental symptoms and 40 (5.4%) other symptoms, such as dermatological, orthopaedic and ophthalmologic ones. More than half (58.2%) reported that assistance was good or very good, 26.6% responded that care was bad and 26.7% reported that they did not have an opinion about it. The median number of visits in the last 6 months were 1.5 (IQR=1, 2).
Compared to women who did not seek FHP services for gynaecological care, women who sought it were significantly more likely to be married than unmarried (41.3% versus 27.5%, P = 0.001), had higher education (40.6% versus 30.3%, P = 0.005) and were more sexually active (36.9% versus 12.5%, P = 0.005).
Table 1 shows socio-demographic data. Women with a household income higher than the median were less likely to have sought health care in FHP facilities compared to women with a lower income. Women who reported <20 years of residence in the same neighbourhood were more likely to have sought health care compared to those who had been there most or all of their lives (>20 years). Table 2 describes risk exposure and clinical assessments and associations with health care seeking. The odds of having sought health care in the past 6 months were significantly lower among women who reported any previous non-injecting illicit drug, any previous domestic violence and having used condoms use at last sexual intercourse. However, women who reported having had a previous HIV test, previous abnormal cervical cytology (Pap smear), a previous STI diagnosis and a previous pregnancy and/or abortion had significantly higher odds of reporting having sought health care in the past 6 months.
Results of multivariate analyses are shown in Table 3. Factors independently associated with higher odds of seeking health care services in the last 6 months included previously testing for HIV, using anal sex as contraceptive method and reporting vaginal discharge. Women who reported a previously diagnosed STI, any history of commercial sex work and using oral sex as a contraceptive method were less likely to have sought health care compared to their counterparts.
This population-based study showed a high rate among young women in Vitoria of receiving clinical services at the Brazilian FHP: 72% of all women aged 18–29 years residing in households in Vitoria reported having sought and received personal health care through FHP in the preceding 6 months, the majority for routine check-ups and gynaecologic exams. No real norms exist in Brazil for health care seeking among young women in the core reproductive health years, so it is not easy to contrast this figure to an expected level of receipt of primary care services. Nonetheless, it seems a very high-effective access to and acceptability of services of a government-run family practice model of care for a subpopulation (young women with sexual and reproductive health needs) that often has received care through specialized gynaecologic and family planning facilities.
It is significant that gynaecological symptoms are associated with health care seeking among these young women. Those who sought health care, compared to those who did not, were significantly more likely to be married, have more years of education and report more sexual activity in univariate analyses. The literature shows that being married or living in a common law relationship has a mixed effect on health practices.9,10 In comparison, women who had other indicators of higher sexual risk, including previous STI and those with a history of commercial sex work, were less likely to seek care. They may avoid seeking care at Family Health facilities because they do not want to be identified by health agents and they are afraid of prejudice or stigma.11 They seek care in reference centres for STI/AIDS or pharmacies. These findings reinforce the importance of a connection of confidence with the family medicine team, the need for education and intervention programmes to pay special attention to issues related to the sexual and reproductive health of a wide range of young women in developing countries12,13 and including a wide range of sexual and risk exposures.
The effect of income on health care seeking, although not independently significant, is nevertheless important to consider. In this study, women with lower income were more likely to seek public health care through the FHP compared to women in the highest income strata. In recent years, differences in health outcomes by socio-economic factors have been recognized as a persisting concern in public health,14,15 as it has been observed in this study and others in Brazil.6,16 A large body of research and theory demonstrates that a complex interplay of factors, including not only income but also education, gender, age, social support, cultural background and physical environment, create a range of life contexts within which an individual's capacity to adopt healthy practices is either enhanced or constrained.17 These data on the broad range of factors associated with the sexual and reproductive health of young women demonstrate how those influences and concerns mediate care-seeking at FHP facilities by this important target population for family practice providers. Greater awareness can help sensitize providers to those needs.
Although not the principal focus of this analysis, sexual and domestic violence was an important contextual variable identified in the lives of women who participated in this study. While neither positively nor negatively associated with health-seeking behaviour, participants nonetheless frequently reported it. A previous study performed in Vitoria reported that 33.8% of young women experienced domestic violence and 27.2% had experienced sexual violence.18 Effects of domestic, sexual and racial violence on physical and mental health of women have been reported in several articles.19–22 Even if it was not the main outcome evaluated in this study, it remains important to document this problem and investigate its association with other health problems in young women. Primary care physicians may provide an opportunity for further investigation and, potentially, early intervention.
This study has several limitations. First, since it focused on sexually acquired and blood borne infections and associated risks, the health-seeking behaviours of young women were principally assessed in the context of these risks and infections. As HIV, other STI, and pregnancy are principal health concerns among young women and the focus of significant public health attention in Brazil, we believe that the findings are nonetheless highly relevant to the health and preventive care needs of young Brazilian women. The relatively modest sample size is also a limitation. As the Brazilian population is highly heterogeneous, inferences from this study may be limited with respect to urban women attending private health care and/or from other parts of the country.
The possibility of response bias, owing to the tendency to provide socially acceptable responses, cannot be excluded. Inaccuracies of recall about anal sex, oral sex, condom use, age of first intercourse and number of sexual partners also may have occurred. As in Brazil, women do not need a prescription to obtain birth control pills, women who were effectively preventing pregnancy could feel less need to visit family health. However, the combination of systematic sampling methods and the high response rate are strengths that contribute to the understanding of health-seeking behaviour in reproductive-aged women in contemporary Brazil. The possibility of response bias, owing to the tendency to provide socially acceptable responses, cannot be excluded. However, such biases would likely result in underestimation of the associations between the behaviour and the outcome, for instance among women who reported illicit drug use. Significantly, the participation rate demonstrates that FHP can successfully implement confidential and acceptable services for women in primary care and that it remains feasible to elicit high response rates on even sensitive health information in household surveys in Brazil.
It is important to emphasize that young women might have health concerns never explicitly stated during a consultation. Some of these may result in substantial stress because they are related to unwanted pregnancy, contraception, condom use and STI. Many persons have difficulty discussing sexual practices, needs and concerns. Difficulties to access family practice setting may be a challenging context in which to provide the sense of privacy and relaxed listening style that can elicit the true range of concerns. This report points to some of the ways in which women's health, risk factors and health-seeking behaviour can be investigated and documented with the aim of improving the coverage of and access to primary care and family practice programmes. It suggests that FHP is an important and effective strategy to delivery prevention and health care services for women in Vitoria and other cities in Brazil or Latin America where family medicine is a strategy of primary care, including providing early and relatively destigmatized access to reproductive health services to this population.
This study is the first to demonstrate how women access and use the government's FHP for female reproductive and gynaecological care in Brazil. Owing to the challenge and complexity of women's health care, reproductive-aged women constitute perhaps the population subgroup most likely to seek care through a specialized service such as gynaecologic clinics or family planning services. As a result, most studies assessing women's health are conducted in gynaecological and obstetric services and family planning clinics. This study is distinctive in conducting the study in a representative sample of women residing in households and examining moreover their pattern of use of a family practice model of care. Further assessments of factors associated with seeking care for women's reproductive and other health concerns in primary and family health care settings can offer practical and valuable additional information on how to provide comprehensive preventive and treatment services for a range of women from diverse backgrounds and life exposures. Family physicians not only can contribute towards good quality care but also can play an important role in timely reproductive health assessments and health advice for women in Brazil and in other countries of Latin America that likewise are moving towards increased participation in primary care and in family practice models of care.
Funding: University of California, San Francisco, Center for AIDS Prevention Studies (P30 MH062246); Fogarty International Center's International, Operational and Health Services Research Training Award, Brazilian Scientists Program (D43 TW005799).
Ethical approval: The Ethics Committees from the Federal University of Espírito Santo State and from University of California San Francisco approved the protocol for the study.
Conflicts of interest: None.
We wish to thank the University of California, San Francisco, Center for AIDS Prevention Studies for technical support of this research, as well as the Fogarty International Center's International, Operational and Health Services Research Training Award, Brazilian Scientists Program. We also wish to thank to Vitoria Municipality for allowing us to do the research and Health Family Program team that helped us during data collection.