The elderly in family health units : morbidity and use of health care services

This cross-sectional study aimed to identify the profile of morbidity and use of health services by the elderly in the Family Health Program Antonio Estevão de Carvalho, from São Paulo, Brazil. The information of 92 seniors from the database of the project “Family Health – assessment of the new assistance strategy in the setting of public policies” were used. A descriptive data analysis showed the elderly with an average age of 70.6 years old; 64.1%, females; 93.5% reported any kind of health problems, especially hypertension (67.4%) and diabetes mellitus (19.6%), 77.3% looked for health care; public hospitals (42.4%) were the most sought after services. The reasons for the choice of services were ease of access (18.5%) and need of care (7.6%). The main reason of satisfaction was the interpersonal care and of dissatisfaction the lack of medicines and the long wait to set appointments. Descriptors: Health of the Elderly; Family Health Program; Health Services; Consumer Satisfaction.


Introduction
The aging of the population's age structure and consequently a bigger relative and absolute quantitative of the population who is 60 years old and older contributed to a notable demographic change in Brazil and in the world at the end of the twentieth century (1) .In the 2010 census the elderly population reached 20.5 million people (2) in Brazil, with almost 4.8 million in the state of São Paulo.Demographic changes modify the epidemiological profile of this population that begins to show a higher prevalence of chronic noncommunicable diseases (NCDs), which represents a problem for the health sector, which is not prepared to care appropriately for their chronic health problems (3) .
Studies have shown that the prevalence of NCDs in the elderly is high, especially hypertension, diabetes mellitus, cardiovascular and osteoarticular diseases (1,4) .Due to the higher prevalence of NCDs and medications, the elderly tend to use more health services than other age groups.The health and social services contribute to an active aging of the population, the elderly look for health services, but the best adherence to health promotion and prevention measures come from specific actions, such as the influenza vaccine campaign (5) .
The economic resources of the elderly, especially from poor areas, are restricted to meeting their health needs.A study (6)

Carvalho.
Data were collected through interviews with a structured form (7) with the elderly in their homes or in the FHU.The 92 senior citizens included in the study were selected randomly through their registration forms from the FHU. and has half of household heads with completed elementary education (8) .

Founded in
The form used in the interviews from the original project was divided into four parts: (A) Socioeconomic Data; (B) Living Conditions; (C) Data about health and (D) a Form for the senior's caregiver.
Most questions were structured and closed, but there were also some open questions to qualify the closed answers.
In the present study, to analyze morbidity and use of health services by the elderly registered at the FHU demographic variables (gender, education and age) were considered, reported health problems were coded according to the Tenth Revision of the International Classification of Diseases -ICD 10 (9) , the services used (type and maintaining source), the coverage area, the reason for choosing the service, the name of the service used and possible removal to the FHU, regular use of medications, medical appointments and satisfaction with the assistance at the FHU.To better understand the results, there was the need of telephone conversations with the FHU's manager.
For the analysis one used absolute and relative

Results
The age of the elderly ranged from 60 to 89 years old (average 70.6 years old, standard deviation of 6.5 years and mode of 69 years).The age in the positions of the first quartile and the third quartile was 66.5 and 76.5 years old, respectively.Most of them were females (64.1%), with no statistically significant difference between sex and age (Table 1).
Regarding education, 80.2% of the elderly had not finished elementary school and 22% did not attend school, including the illiterate elderly and those who could read.It was observed that among males, there were some seniors who had finished high school or higher education (12.1%).
Health problems were reported by 93.5% of the elderly and 52.3% of them reported from two to five NCDs.Among women there was a higher number of them with two to five health problems (p = 0.0181).
The main problems reported were hypertension (67.4%), diabetes mellitus (19.6%).The proportion of seniors who had hypertension and diabetes was 15.2%.Hypertension was more mentioned by women (p = 0.0279).
Most seniors (88.0%) made use of medications.
No association was found between the use of medications and gender.When asked about how often they saw a doctor or went to a health service, 57.6% of respondents reported seeing a doctor on a regular basis and 42.4% only when they really needed it and there was no difference between genders (p = 0.9808) (Table 2).
The main services sought according to the sustaining source were the philanthropic hospitals (43.6%), private/health insurance (24.6%).Although the sample was drawn from the register of the elderly, the demand for HBU/FHU was small (12.8%), regardless of the gender (p = 0.8379).Regarding the type of service, 12.0% used the FHU Qualis A.E. Carvalho, 31.0% the Hospital Santa Marcelina, 14.1% other hospitals and 18.3% health insurance services.

Figure 1 -Percentage distribution of morbidities according to the chapters of ICD-10
The reasons why older people chose the service were related to ease of access (32.7%), the need for care (28.8%), socio-economic conditions of the respondents (15.4%), the service organization (15.24%).The difference between genders was shown more present due to socioeconomic reasons in women and the need for care among men, although without statistical significance (p = 0.2581).was observed.The same occurred when one verified the association of satisfaction with variables of morbidity and service use (Table 3).The main reason for satisfaction was the interpersonal care and for dissatisfaction, lack of medicines and long wait to set appointments.
The proportion of the elderly with no education in this study was lower than those observed in other places that presented frequencies of 41.0 and 63.0% among old patients attended in health services of the FHP from the south and northeast regions, respectively (2) .The proportion of the elderly with elementary education in this study is similar to those reported by other studies (11,(16)(17) , and it is higher than studies in Alto Vale do Itajaí-SC (9.18%) (5) , Caracol-PI (10.6%) and Garrafão do Norde-PA (13.6%) (12) .
The predominance of females reflected a bigger longevity of women compared to men (10,12,14) .
One should also consider the fact that more women attend the BHU/FHU and the source for selection of research subjects was the FHU.Other epidemiological studies (5,(10)(11)(13)(14)(15)16) showed similar results to those found in this investigation. The tendeny of women live more than men, showing a lower mortality, occurs worldwide, but that does not mean they enjoy better health conditions (2) .It can be observed in the present study that more than half of the women had two or more health problems, while men had predominantly only one.
The number of seniors who reported presence of any chronic diseases revealed a high demand for permanent care of health services.However, this finding could be attributed to the fact that respondents were selected from among those registered at the FHU.
In a study conducted with an old population who lived in São Carlos-SP, one observed a prevalence of obesity in older women associated with the presence of diabetes mellitus when compared to the male population (4) .In Fortaleza, about 80.0% had morbidities, predominating circulatory diseases, followed by musculoskeletal and connective tissue diseases (15) .The most common morbidities were hypertension (61.0%), back problems (60.0%),poor circulation and diabetes mellitus (approximately 20.0% each).Similar findings to other studies (11)(12)(13)(14) .
A study to analyze inequalities in mortality from chronic diseases among the elderly conducted in the states of Brazil pointed out that cardiovascular diseases in the elderly are the most prevalent causes among the diseases analyzed.And they follow the trend of the population's aging, being higher at the states with more advanced stages of aging and better socioeconomic indicators (South and Southeast) (3) , an index that shows the importance of controlling hypertension in the region of this study.In another study hypertension accounted for 68.6% and diabetes mellitus for 18.3% of the elderly population attended at the BHU in Fortaleza-CE (17) ; in the populations over 60 years old in Botucatu-SP (11) hypertension occurred (continuation) in 44.2% of the population and in Alto Vale Itajaí-SC (5) 86.20% had cardiovascular diseases.
Generally similar to this study, hypertension, diabetes mellitus and osteoarticular disorders appear as the most frequent in the old population.Public health policies have not incorporated musculoskeletal disorders in their actions of prevention and control.
However, as observed in the SABE (1) project, 83.2% of individuals with rheumatism/arthrosis/arthritis had pain and 63.1% had limitation due to the disease.
This situation contributes to the reduction of physical activities among older people, harming the measures to control hypertension and diabetes related to changes in lifestyle habits.
The prevalence of medication use among the elderly in this study was high, especially among women.In a research conducted with elderly people in the southern region, 91.0% reported the use of medication (5) , 78.16% of the elderly from Alto Vale Itajaí-SC said it is part of their routine, out of these 44.83% self-medicated without supervision and said they made no mistakes.In Fortaleza 66.7% of the elderly used medications regularly (15) .In southern Santa Catarina one observed the use of 3.5 drugs per individual, with the number of daily doses of 5.4 considered polypharmacy (18) .
In general, most elderly people sought health services or the doctor, through routine visits, but many of them did that only when they needed it, that is, in acute situations or in serious morbidities, increasing the possibility of sequels and negative effects on the functional capacity of the elderly.The variables: education, age, medication use and presence of morbidity were not statistically significant on the use of health services by the elderly.
In a multicenter study conducted in Campinas, Botucatu, São Paulo municipalities (Itapecerica da Serra, Embu and Taboão da Serra) and the district of Butantan (São Paulo) 75.2% of the elderly reported visiting the health center regularly, without significant difference between values of lower or higher per capita income (10) .In another SABE investigation, 69.0% of seniors used healthcare facilities and not using it was related to low disease severity, quality and distance of services and costs (19) .In Santa Catarina 65.4% of seniors reported having sought health services two or more times in the last year (18) .
In the present study with data collected in 2003 were not investigated the use of health services by the elderly, but the percentage of those who visited the doctor regularly or only when they needed it reached 90.0%.It is worth remembering that at that time the FHU studied was taken as a model.
Regarding the type of service used, another study with the elderly from São Paulo revealed that about half of the attendances with old people occurred in public services (19) , being the hospital the most present institution (19) .Regarding the use of private services, the frequency of use was higher (48.3%) (15) than in the present study, which was expected because in this study the elderly population lives in a poor region of São Paulo with high poverty levels.
The study data are consistent with the records of the PNAD (National Household Survey) 2008 (20) from São Paulo, which showed that only 3.4% of the elderly aged over 65 had a health insurance.Data obtained in 2010 in Guarapuava, Parana, identified that 12.1% of the elderly registered in the basic health unit studied had a private health insurance (21) .
Referral services obtained in 2003 were modified under the current management of the Health Department.For admissions, hospitals from that period remain as references.Moreover, these services are indicated for specialized care.Other procedures are set through a regulated and computerized schedule for the city of São Paulo.This new system seeks to supply the demand of the population from the regions of São Paulo, but for the elderly public it can create difficulties in access due to the bigger distance of the services from their homes, since they are located in other regions of São Paulo.
Regarding the percentage of the elderly sent from the services chosen by them to the FHU Qualis (counter-reference) it can be inferred that these subjects had problems or complaints that could be resolved in FHU Qualis' primary care.
Regarding satisfaction with the care offered at FHU Qualis, most seniors were pleased characterizing the service as "good".A similar finding was observed in a study with the elderly in the region of Qassim in Saudi Arabia, where 76.9% of seniors were satisfied with the care received (22) .Although a restructuring of the service is desired for the elderly's care, in a systematic review 19.7% of the references found observed inequality in the use and access to health services and inadequate care model (23) .
Although the data collection of this study was conducted ten years ago, it is observed that the time for scheduling appointments is still an obstacle for meeting the health needs of the population.
Study with elderly individuals who practice physical activities showed that 48.4% attributed the wait to set appointments as one of the difficulties in the use of health services (24) .
As a limitation of this study there is the fact that the information are about senior citizens registered in the FHU from the region A. E. Carvalho, and even being a random sample, its results do not allow generalizations to the elderly population of São Paulo, Brazil.

Conclusion
The study achieved the objective of knowing how the elderly registered at the FHU Qualis A. E.
Carvalho use health services.The elderly population was characterized as young as it was in the age group between 60 and 70 years old and predominantly females.Most seniors had at least one health problem (93.5%), the most mentioned disease was hypertension (67.4%) and 88.0% of the elderly use medications.Despite the large quantity of seniors who used medications, one observed that 57.6% visited the doctor regularly.The elderly who participated in the study were registered at the FHU, however, only 12.8% of them looked for care in this unit when it was necessary.On the other hand, 50.3% of the patients who were sent to the FHU QUALIS needed to go to the unit twice or more to set an appointment.
It was observed that the elderly often look for assistance to solve their health problems and most of them used services from their area.Although the service has a system to send patients for examinations and specialized care, these are far from the elderly's homes, which is a problem given the advanced age of the patients, health problems and low income of the population of this region.
In general, older people were satisfied with the health services offered, valuing interpersonal relationships.Reasons for dissatisfaction are often observed in public services of health care.The results of the services use show difficulties similar to those found at the BHU, such as the lack of medicines and the difficulty in access.
The study contributes to measure the elderly's accessibility to health services and to show that both in the past and currently, the wait to set an appointment and the lack of medicines in primary health care units are still a problem to be overcome by public health policies.The Unified Health System and the reference and counter-reference system still have as a challenge to meet their demands and offer services with hierarchical levels of easy access to the population.analysis, data interpretation and writing of the article.
Turrini RNT contributed to data interpretation, drafting of the article and final approval of the version to be published.Cianciarullo TI contributed to the drafting of the article and final approval of the version to be published.
frequencies, measures of central tendency for continuous quantitative variables and association test by chi-square to verify the association between the study variables and gender and satisfaction at the FHU.This study was approved by the Ethics Committee from the Nursing College of the Universidade de São Paulo (Case No. 202/2001).

Figure 1
Figure 1 shows the distribution of all health problems reported by the elderly (160).It was observed that the diseases from Chapter IX -Diseases of the Circulatory System -were the most frequent (51.0%), followed by Chapter IV -Endocrine, Nutritional and Metabolic Diseases -(18.1%) and Chapter XIII -Diseases of the Musculoskeletal System and Connective Tissue (12.0%).The remaining chapters contributed with 18.8% of referred complaints.In Chapter XIII, the back problems (9.8%) were the most common.

Table 1 -
Distribution of the elderly by gender and demographic and morbidity variables F = Fisher's exact test

Table 2 -
Distribution of the elderly according to the services use When one studied the relationship between demand for service and age, education, medication use and presence of pathological conditions there was no significant association to explain the variations in the use of health services, being it on a regular basis or due to health problems among the elderly.Considering the elderly with hypertension, it was found that 54.8% of them visited the doctor regularly, while this proportion among diabetic patients was 66.7%.Through telephone conversations with the manager of the FHU Qualis, one obtained information about referral services in 2003 for patients routing.(MECS, or SAMU in Portuguese) or Rescue (Regaste in Portuguese -a state project of pre-hospital care developed by the Fire Department), or the patients

Table 3 -
Distribution of the elderly according to the satisfaction and variables of morbidity and use of health services F = Fisher's exact test