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Objetivo: traduzir e adaptar o PCATool versão usuários adultos ao contexto brasileiro e avaliar sua validade e fidedignidade. Métodos: Foi realizado um estudo transversal no qual foram entrevistados 2.404 usuários adultos residentes nas áreas adscritas da rede pública dos serviços de Atenção Primária à Saúde (APS) em Porto Alegre e usuários vinculados a um plano de autogestão. O processo de validação constituiu-se de tradução e tradução reversa, adaptação, validade de conteúdo, validade fatorial e fidedignidade. Resultados: Na análise fatorial, foram considerados 12 fatores que explicaram 50,83% da variação total. Assim, foram reconhecidos os seguintes atributos da APS: acesso - acessibilidade e utilização, longitudinalidade, coordenação - coordenação do cuidado e sistemas de informação, integralidade - serviços disponíveis e serviços prestados, enfoque familiar e orientação comunitária. Para a consistência interna, foi obtido alfa de Cronbach variando de 0,15 a 0,90. A estabilidade temporal não foi verificada para coordenação do cuidado (p<0,05), coordenação de sistema de informação (p<0,05) e integralidade de serviços prestados (p<0,05). Na razão êxito da escala, todos os componentes/atributos apresentaram valores próximos de 100%, à exceção do componente sistema de informação. Conclusões: os resultados indicaram que o PCATool-Brasil possui adequada validade e fidedignidade, podendo constituir-se em instrumento nacional de avaliação da APS para usuários adultos.

Objective: to translate and adapt the PCATool version for adult users to the Brazilian context and assess its validity and reliability. Methods: We conducted a cross-sectional study of 2404 adult users living in areas covered from public services Primary Care in Porto Alegre, and users of a self- management plan. We performed translation, reverse translation and adaptation of the instrument as well as its assessment in respect of content validity, factorial validity and reliability. Results: In the factor analysis were considered 12 factors that explained 50.83% of the total variation. In this way were recognized the attributes of Primary Care: access - accessibility and utilization; longitudinality; coordination - coordination of care and systems of information; comprehensiveness - services available and services provided; family orientation; and community orientation. In terms of internal consistency the values of Cronbach's alpha ranged from 0.15 to 0.90. The stability over time was not observed for coordination of care (p<0.05), coordination information of system (p<0.05) and comprehensiveness of services provided (p<0.05). The scaling success rate was close to 100% for all attributes, except to coordination of information system. Conclusions: the results indicated that the PCATool-Brazil has adequate validity and reliability, and it can act as a national instrument for the assessment of Primary Care from the perspective of adult users.

Objetivo: traducir y adaptar el PCATool versión usuarios adultos al contexto brasileño y evaluar su validez y fiabilidad. Métodos: Se realizó un estudio transversal en el cual se encuestaron a 2404 usuarios adultos residentes en áreas adscritas a la red pública de servicios de Atención Primaria de Salud (APS) en Porto Alegre y a otros usuarios vinculados a un seguro de salud de auto-gestión. El proceso de validación consistió en traducción y traducción reversa, adaptación, validez de contenido, validez factorial y fiabilidad. Resultados: En el análisis factorial se consideraron 12 factores que explicaron 50,83% de la variación total. Así, se reconocieron los siguientes atributos de la APS: acceso - accesibilidad y utilización, longitudinalidad, coordinación - coordinación del cuidado y sistemas de información, integralidad - servicios disponibles y servicios prestados, enfoque familiar y orientación comunitaria. Para la consistencia interna se obtuvo un alfa de Cronbach oscilando entre 0,15 y 0,90. La estabilidad temporal no se verificó para la coordinación del cuidado (p<0,05), la coordinación del sistema de información (p<0,05) y la integralidad de servicios prestados (p<0,05). En la razón de éxito de la escala todos los componentes/atributos presentaron valores próximos al 100%, con excepción del componente sistema de información. Conclusiones: los resultados indicaron que el PCATool-Brasil tiene una adecuada validez y fiabilidad, pudiendo constituirse en herramienta nacional para la evaluación de la APS en usuarios adultos.

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OBJECTIVE: To determine the validity and reliability of the version of the Primary Care Assessment Tool for adult users, adapted for Argentina (known as AR-PCAT-AE). METHODS: Two cross-sectional pilot studies were conducted among people over age 17, largely through self-administered questionnaires. Items that were equivalent to the original version of the PCAT and 13 others proposed for the instruments were analyzed. The factorial validity and reliability of the scores for each dimension were studied. The validity indicators were: factors that had three or more items with a factorial load of > 0.35, item-total correlation > 0.30, and interpretation of the solution according to the theoretical model. RESULTS: The factorial analysis yielded nine factors that explained 57.4% of the variability. Considering the pre-established criteria for validity, two items were excluded from the dimensions of continuity and comprehensiveness and six were added to comprehensiveness and cultural competency. In the dimensions, the percentage of questions with an item-total correlation of greater than 0.30 ranged from 67% to 100% and the Chronbach's (alpha) coefficient of internal consistency ranged from 0.44 to 0.90. CONCLUSIONS: The validity and reliability of the AR-PCAT-AE questionnaire are adequate, maintaining high equivalence with the original version. The process presented could be adopted in other contexts to advance the evaluation of primary health care functions with quality tools.

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OBJETIVO: Determinar la validez y la fiabilidad de los "instrumentos para evaluar la atención primaria de salud" (Primary Care Assessment Tool [PCAT, por su siglas en inglés]), versión dirigida a usuarios adultos, adaptada para Argentina (AR-PCAT-AE). MÉTODOS: Se realizaron dos estudios piloto transversales con personas mayores de 17 años, mediante cuestionarios mayoritariamente autoadministrados. Se analizaron los ítems equivalentes a la versión original de los PCAT y otros 13 propuestos para ser adicionados. Se examinó la validez factorial y la fiabilidad de las puntuaciones de cada dimensión. Los indicadores de validez fueron: factores que tuvieran tres o más ítems con una carga factorial >0,35, correlación ítem-total >0,30 e interpretación de la solución en consecuencia con el modelo teórico. RESULTADOS: El análisis factorial resultó en nueve factores que explicaron 57,4% de la variabilidad. Considerando los criterios de validez preestablecidos, se excluyeron dos ítems de las dimensiones de continuidad e integralidad y se adicionaron seis en integralidad y competencia cultural. En las dimensiones, el porcentaje de preguntas con correlación ítem-total mayor de 0,30 osciló entre 67% y 100% y el coeficiente de consistencia interna alfa de Cronbach entre 0,44 y 0,90. CONCLUSIONES: El cuestionario AR-PCAT-AE tiene validez y fiabilidad adecuadas, manteniendo una alta equivalencia con la versión original. El proceso presentado podría ser adoptado en otros contextos para avanzar en la necesidad de evaluar las funciones de la atención primaria con herramientas de calidad.

OBJECTIVE: To determine the validity and reliability of the version of the Primary Care Assessment Tool for adult users, adapted for Argentina (known as AR-PCAT-AE). METHODS: Two cross-sectional pilot studies were conducted among people over age 17, largely through self-administered questionnaires. Items that were equivalent to the original version of the PCAT and 13 others proposed for the instruments were analyzed. The factorial validity and reliability of the scores for each dimension were studied. The validity indicators were: factors that had three or more items with a factorial load of > 0.35, item-total correlation > 0.30, and interpretation of the solution according to the theoretical model. RESULTS: The factorial analysis yielded nine factors that explained 57.4% of the variability. Considering the pre-established criteria for validity, two items were excluded from the dimensions of continuity and comprehensiveness and six were added to comprehensiveness and cultural competency. In the dimensions, the percentage of questions with an item-total correlation of greater than 0.30 ranged from 67% to 100% and the Chronbach's (alpha) coefficient of internal consistency ranged from 0.44 to 0.90. CONCLUSIONS: The validity and reliability of the AR-PCAT-AE questionnaire are adequate, maintaining high equivalence with the original version. The process presented could be adopted in other contexts to advance the evaluation of primary health care functions with quality tools.

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INTRODUCCION: El conjunto PCAT [Primary Care Assessment Tools: instrumentos para la valoración de la atención primaria de la salud (APS)] permite medir desde varias perspectivas el grado en que se cumplen las funciones de la APS. OBJETIVO: Obtener versiones de los cuestionarios PCAT para usuarios (infantiles y adultos), proveedores y centros, con equivalencia semántica y conceptual a las versiones originales y con adecuación a la población y al sistema sanitario en Argentina. METODOS: Se realizó una adaptación cultural de medidas en las siguientes fases: 1) traducción directa y adaptación ling³ística; 2) revisión del contenido y adaptación al sistema sanitario por expertos locales y la autora del modelo teórico; 3) traducción inversa y comparación con la versión original; 4) pruebas preliminares con usuarios y profesionales. En el procedimiento se controló la equivalencia semántica, práctica y cultural, así como la comprensión y la viabilidad de los cuestionarios. RESULTADOS: Casi la mitad de los ítems recibieron alguna modificación después de la primera traducción al español. Los elementos pertenecientes a las funciones de la APS fueron, en general, levemente modificados, salvo un ítem que fue eliminado. Las preguntas de caracterización de centros, proveedores y cobertura sanitaria sufrieron cambios mayores. CONCLUSIONES: Se obtuvieron versiones del PCAT adaptadas para Argentina, equivalentes a las originales. Se estudiará su validez en próximos estudios.

INTRODUCTION: The Primary Care Assessment Tools (PCAT) measure the degree of achievement of the functions of primary care (PC) from different perspectives. OBJECTIVE: To obtain versions of the PCAT for users (children and adults), care providers and care centers, which are both semantically and conceptually equivalent to the original versions, and appropriate to the population and health system in Argentina. METHODS: Cross-cultural adaptation by the following steps: (1) direct translation and linguistic adaptation; (2) content review and adaptation to the health system by local experts and the theoretical modelÆs author; (3) back-translation and comparison with the original version; and (4) pre-test with users and health professionals. Semantic, cultural, practical equivalence, understanding and feasibility of the questionnaires were assessed. RESULTS: Almost half of the items were modified after forward translation. Items belonging to the PC domains were low or moderately modified, and one of them was removed. Questions to characterize centers, providers and health care coverage suffered major changes. CONCLUSIONS: It was possible to obtain PCAT versions adapted to Argentina and equivalent to the original. Their validity must be tested in future studies.

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INTRODUCCION: El conjunto PCAT [Primary Care Assessment Tools: instrumentos para la valoración de la atención primaria de la salud (APS)] permite medir desde varias perspectivas el grado en que se cumplen las funciones de la APS. OBJETIVO: Obtener versiones de los cuestionarios PCAT para usuarios (infantiles y adultos), proveedores y centros, con equivalencia semántica y conceptual a las versiones originales y con adecuación a la población y al sistema sanitario en Argentina. METODOS: Se realizó una adaptación cultural de medidas en las siguientes fases: 1) traducción directa y adaptación ling³ística; 2) revisión del contenido y adaptación al sistema sanitario por expertos locales y la autora del modelo teórico; 3) traducción inversa y comparación con la versión original; 4) pruebas preliminares con usuarios y profesionales. En el procedimiento se controló la equivalencia semántica, práctica y cultural, así como la comprensión y la viabilidad de los cuestionarios. RESULTADOS: Casi la mitad de los ítems recibieron alguna modificación después de la primera traducción al español. Los elementos pertenecientes a las funciones de la APS fueron, en general, levemente modificados, salvo un ítem que fue eliminado. Las preguntas de caracterización de centros, proveedores y cobertura sanitaria sufrieron cambios mayores. CONCLUSIONES: Se obtuvieron versiones del PCAT adaptadas para Argentina, equivalentes a las originales. Se estudiará su validez en próximos estudios.

INTRODUCTION: The Primary Care Assessment Tools (PCAT) measure the degree of achievement of the functions of primary care (PC) from different perspectives. OBJECTIVE: To obtain versions of the PCAT for users (children and adults), care providers and care centers, which are both semantically and conceptually equivalent to the original versions, and appropriate to the population and health system in Argentina. METHODS: Cross-cultural adaptation by the following steps: (1) direct translation and linguistic adaptation; (2) content review and adaptation to the health system by local experts and the theoretical modelÆs author; (3) back-translation and comparison with the original version; and (4) pre-test with users and health professionals. Semantic, cultural, practical equivalence, understanding and feasibility of the questionnaires were assessed. RESULTS: Almost half of the items were modified after forward translation. Items belonging to the PC domains were low or moderately modified, and one of them was removed. Questions to characterize centers, providers and health care coverage suffered major changes. CONCLUSIONS: It was possible to obtain PCAT versions adapted to Argentina and equivalent to the original. Their validity must be tested in future studies.

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INTRODUCCIÓN: el conjunto PCAT [Primary CareAssessment Tools: instrumentos para la valoración de la atención primaria de la salud (APS)] permite medir desde varias perspectivas el grado en que se cumplen las funciones de la APS. OBJETIVO:obtener versiones de los cuestionarios PCAT para usuarios (infantilesy adultos), proveedores y centros, con equivalencia semántica y conceptual a las versiones originales y con adecuación a la población y al sistema sanitario en Argentina. MÉTODOS: se realizó una adaptación cultural de medidas en las siguientes fases: 1) traducción directa y adaptación lingüística; 2) revisión del contenido y adaptación al sistema sanitario por expertos locales y la autora del modelo teórico; 3) traducción inversa y comparación con la versión original; 4) pruebas preliminares con usuarios y profesionales. En el procedimiento se controló la equivalencia semántica, práctica y cultural, así como la comprensión y la viabilidad de los cuestionarios. RESULTADOS: casi la mitad de los ítems recibieron alguna modificación después de la primera traducción al español. Los elementos pertenecientes a las funciones de la APS fueron, en general, levemente modificados, salvo un ítem que fue eliminado. Las preguntas de caracterización de centros, proveedores y cobertura sanitaria sufrieron cambios mayores. CONCLUSIONES: se obtuvieron versiones del PCAT adaptadas para Argentina, equivalentes a las originales. Se estudiará su validez en próximos estudios.

INTRODUCTION: The Primary Care Assessment Tools(PCAT) measure the degree of achievement of the functions of primary care (PC) from different perspectives. OBJECTIVE:To obtain versions of the PCAT for users (children and adults),care providers and care centers, which are both semantically and conceptually equivalent to the original versions, and appropriate to the population and health system in Argentina. METHODS: Cross-cultural adaptation by the following steps:(1) direct translation and linguistic adaptation; (2) content review and adaptation to the health system by local experts and the theoretical model’s author; (3) back-translation and comparison with the original version; and( 4) pre-test with users and health professionals. Semantic, cultural, practical equivalence, understanding and feasibility of the questionnaires were assessed. RESULTS: Almost half of the items were modified after forward translation. Items belonging to the PC domains were low or moderately modified, and one of them was removed. Questions to characterize centers, providers and health care coverage suffered major changes. CONCLUSIONS: It was possible to obtain PCAT versions adapted to Argentina and equivalent to the original. Their validity must be tested in future studies.

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Estratégias em saúde baseadas na atenção primária à saúde vêm aumentando no Brasil. Existe um instrumento aplicado a usuários, o Primary Care Assessment Tool (PCATool), que mede a extensão dos atributos da atenção primária à saúde, já validado nos Estados Unidos. Objetivamos adaptar o PCATool ao Brasil e analisar sua validade e confiabilidade, por meio de estudo seccional de validação da sua versão infantil. A validação constou de: tradução e tradução reversa, adaptação, pré-teste, validade de construto, consistência interna e análise de confiabilidade. O questionário foi aplicado a 468 cuidadores de crianças cadastradas em 18 serviços de atenção básica de Porto Alegre, Rio Grande do Sul, Brasil, representativos deste universo de usuários. Na análise fatorial foram identificadas oito dimensões, com o ade Cronbach variando de 0,74 a 0,88. O instrumento final ficou com 45 itens, divididos em oito atributos (acesso de primeiro contato, continuidade, coordenação, três atributos de integralidade, orientação familiar e comunitária). Estes resultados indicaram que o PCATool-Brasil possui adequada validade e confiabilidade, podendo constituir-se em instrumento nacional de avaliação da atenção primária à saúde após sua aplicação em outros contextos populacionais.

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Health strategies based on primary health care have been expanding in Brazil. An instrument applied to users, the Primary Care Assessment Tool (the PCATool), which measures the extent of primary care, has been validated in the United States. We sought to adapt the PCATool to Brazil and analyze its validation and reliability through a cross-sectional validation study of the Child PCATool. Validation included: translation, back-translation, adaptation, debriefing, content and construct validate, internal consistency, and reliability analysis. The questionnaire was applied to 468 parents or guardians of children registered with 18 primary health services in Porto Alegre, representing the services' normal pediatric population. Using factor analysis, 8 domains were identified, with Cronbach's aranging from 0.74 to 0.88. Validation resulted in a 45-item scale, divided into 8 attributes (Access to First Contact, Continuity, Coordination, 3 attributes of Comprehensiveness, Community Orientation, and Family Orientation). These results showed that the PCATool-Brasil has adequate validity and reliability and could be used as a national instrument to evaluate primary health care after its application to other population settings in the country.

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This pooled, cross-sectional, time-series study assesses the impact of health system variables on the relationship between wage inequality and infant mortality in 19 OECD countries over the period 1970-1996. Data are derived from the OECD, World Value Surveys, Luxembourg Income Study, and political economy databases. Analyses include Pearson correlation and fixed-effects multivariate regression. In year-specific and time-series analyses, the Theil measure of wage inequality (based on industrial sector wages) is positively and statistically significantly associated with infant mortality rates--even while controlling for GDP per capita. Health system variables--in particular the method of healthcare financing and the supply of physicians--significantly attenuated the effect of wage inequality on infant mortality. In fixed effects multivariate regression models controlling for GDP per capita and wage inequality, variables generally associated with better health include income per capita, the method of healthcare financing, and physicians per 1000 population. Alcohol consumption, the proportion of the population in unions, and government expenditures on health were associated with poorer health outcomes. Ambiguous effects were seen for the consumer price index, unemployment rates, the openness of the economy, and voting rates. This study provides international evidence for the impact of wage inequalities on infant mortality. Results suggest that improving aspects of the healthcare system may be one way to partially compensate for the negative effects of social inequalities on population health.

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OBJECTIVE: To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades. DATA SOURCES/STUDY SETTING: Data were primarily derived from OECD Health Data 2001 and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (total n = 504). STUDY DESIGN: Pooled, cross-sectional, time-series analysis of secondary data using fixed effects regression. DATA COLLECTION/EXTRACTION METHODS: Secondary analysis of public-use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in-country experts. PRINCIPAL FINDINGS: The strength of a country's primary care system was negatively associated with (a) all-cause mortality, (b) all-cause premature mortality, and (c) cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p<0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro-level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health. CONCLUSIONS: (1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.

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The nonrandom distribution of ill health across and within populations is cause for ethical concern. Systematic differences in health across populations and subpopulations are a result of interactions among many types of influences operating on broad ecological, community, and individual levels. The operation of this web of influences potentiates health disadvantage for some populations and subpopulations and, conversely, enhances resilience to health threats in more advantaged populations. Understanding the genesis of inequity requires an appreciation of the dynamics of these interactions. Thus, research directed at elucidating the causes of inequity in order to facilitate policy changes requires the adoption of conceptual frameworks to guide more efficient and effective future scientific inquiry concerning this worldwide imperative.

La distribución no aleatoria de los problemas de salud en una población y entre diferentes poblaciones es un problema ético. Las diferencias sistemáticas en la salud de diferentes poblaciones y subpoblaciones son el resultado de interacciones entre muchos tipos de influencias que actúan en los ámbitos ecológico, comunitario e individual. La actuación de esta red de influencias potencia las desventajas de salud de algunas poblaciones y subpoblaciones, al mismo tiempo que incrementa la resistencia a las amenazas para la salud en las poblaciones mejor situadas. Para comprender la génesis de la inequidad es necesario tener en cuenta la dinámica de estas interacciones. Así pues, las investigaciones destinadas a elucidar las causas de la inequidad con el fin de facilitar la modificación de las políticas requieren la adopción de marcos conceptuales que dirijan de forma más eficaz y eficiente las investigaciones científicas futuras relacionadas con este imperativo mundial.

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