DETERMINANTS AND USE OF HEALTH SERVICES AMONG THE ELDERLY DETERMINANTES DO ACESSO E UTILIZAÇÃO DOS SERVIÇOS DE SAÚDE ENTRE IDOSOS

this study aimed to describe the characteristics related to access to and use of health services, and verify factors associated with the use of services among the elderly. This is a cross-sectional analytical study conducted with 705 urban elderly in Uberaba/Minas Gerais. Were used: structured instrument related to socioeconomic data, Katz, Lawton and Brody scales and Fried Fragility Phenotype; and questionnaire from the National Survey by Domicile Sample for access and use of health services. The procedure was the descriptive and logistic regression analysis (p<0.05). It was found that 86.2% accessed the same place or the same doctor when they needed care; 86.5% consulted a doctor in the last 12 months; 85.2% were using continuous medication, from this 40.4% received part of their medicines; and those who did not receive all medications, 86.1% effected the purchase. Most went to the dentist last three years or more (54.2%) while 21.7% for less than one year, and 16.9% used health services in the two weeks preceding the interview. Polypharmacy (OR: 2.88; p=0.026) and the perception of negative health (OR: 1.89; p=0.009) were consolidated as factors associated with the use of health services. The knowledge of standard consumption and related factors enables the service organization as the presented characteristics.


INTRODUCTION
The increased longevity of the population is changing the epidemiological profile in Brazil with increased mortality from non-communicable diseases (NCDs) to the detriment of infectious and parasitic diseases (GEOGRAPHY AND STATISTICS BRAZILIAN INSTITUTE, 2012).In this perspective, aging confers changes in demands for health services with greater demand for elderly (DELLAROZA et al., 2013;VERAS, 2009).Hospital admissions are more frequent and the bed occupancy time is longer when compared to other age groups (VERAS, 2009).
The use of health services for the elderly is multifactorial and is related to the individual and structural factors and aspects of the social environment where the elderly is inserted (DELLAROZA et al., 2013).The access is understood as an element of the health system that covers the entry and treatment follow-up (TEIXEIRA; OLIVEIRA; SILVA, 2011).It is an issue that involves political, economic, social, organizational, technical and symbolic aspects, in determining directions for the universalization of its attention (ASSIS;JESUS, 2012).
According to the National Health Survey (NHS) performed in 2013, 83.5% of elderly sought medical service, exceeding the national average compared to other age groups.The same group reported the lowest percentage of dentist appointments (28.9%) (GEOGRAPHY AND STATISTICS BRAZILIAN INSTITUTE, 2015).A domicile survey conducted with elderly enrolled in public services in Guarapuava/Paraná found that the health services most used in the last three months were the medical consultation (49.6%) and clinical examinations (38.4%); while 55.6% reported not seeking dental services (PILGUER; MENON;MATHIAS, 2013).
In contrast, other studies mentioned this issue in specific conditions and/or different contexts and/or cutout, namely: elderly people with or without health insurance (HERNANDES et al., 2012.), physical activity participants (VIRTUOSO et al., 2012), elderly with chronic pain (DELLAROZA et al., 2013) and disability (FIALHO et al., 2014).
In this perspective, the literature points to factors associated with the use of health services the worst self-perceived health (OR=1.92),disease presence (OR=2.73),private health insurance (OR=1.57)and female (OR=1.55)(LOUVISON et al., 2008).More recent studies showed the female (PILGUER; MENON; MATHIAS, 2013), increasing age (BASTOS; HARZHEIM; SOUSA, 2014), the presence of more intense chronic pain, the most recent and with work impact (DELLAROZA et al., 2013) and functional disability among elderly (FIALHO et al., 2014).
Studies that address the access and use of health services contribute to the perception of the consumption pattern, which allows health planning actions of the elderly population, decreasing spending with the high complexity services and specialties.It also favors the proposal of appropriate public policies and the development of care models (PILGUER; MENON: MATHIAS, 2013), from the observed population context.Thus, since the limitation of current investigations that relate the access determinants to the use of health services among the elderly and to deepen discussions about the subject, this study aimed to describe the characteristics related to access and use of health services; and verify the factors associated with the use of services among the elderly.

MATERIAL AND METHODS
Domicile, observational, analytical and cross-sectional survey conducted in 2014 with 705 elderly residents in the urban area of the city of Uberaba/Minas Gerais.
The sample size calculation considered an accuracy of 3.5% and a 95% confidence interval, for a finite population of 36,703 elderly, reaching a sample of 684 subjects.Considering a sampling loss of 20%, the maximum number of interviews attempts was 855.
The conglomerate sample in multiple stages was used for the definition of the urban population.The first stage proceeded with the arbitrary selection of 50% of the census tracts in each municipality through systematic sampling organizing a single list of sectors but identifying the neighborhood to which it belongs.Some urban census tracts in the city of Uberaba/Minas Gerais is 409, and 204 selected.The sample interval (SI) was calculated using the following formula: SI=Nct/nsct; where Nct is the total number of census tracts and nsct the number of selected census tracts (SI≈2).The first census tract was randomly selected and the other according to SI.The list of sectors was ordered in ascending numerical order, for the selection purpose.
In the second stage, the number of elderly people to be interviewed according to sample calculation (724) was divided by the number of census tracts randomly selected in the first stage (204), obtaining the value of 3,55 elderly, rounded to four elderly by census tract.In this context, considering the sample size calculation, 204 census tracts and four people per sector, originate from a sample of 816 elderly.Inclusion criteria were: aged equal or over 60 years old, being a resident in urban areas, do not having cognitive decline, being able to walk around, and allowed the use of assistive devices for gait (cane, crutch or walker) and agree participating in the research by signing the Informed Consent Form (ICF).The following were considered as exclusion and losses criteria: not located after three attempts by the interviewer; hospitalization condition; neurological disorders that impaired the evaluations performance; those who have not completed all the tests for fragility; and sectors without elderly, homes and that have not completed the number of elderly.Thus, 705 elderly were interviewed.
Ten interviewers were selected, with previous experience in data collection, and were trained in the completion of the data collection instruments and how to approach the interviewee.Interviewers noted the complications (absences, refusals and other) on the field sheet.Field supervisors conferred each interview and verified completion and consistency of items, ensuring quality control.Systematics meetings were performed between researchers, supervisors and interviewers for training, monitoring and guidelines for data collection.
The procedure was initially cognitive assessment by the Mini Examination of Mental State (MEMS), translated and validated in Brazil (BERTOLUCCI et al., 1994).The cutoff point for cognitive decline considered the respondent's educational level, corresponding 13 points for illiterates, 18 points or less for those 1 to 11 years of study and 26 points for higher education superior than 11 years (BERTOLUCCI et al., 1994).
The socio-demographic and economic data, anthropometric and clinical variables (self-perceived morbidities, medication use, and self-perceived health), were measured from structured form designed by the Research Group on Collective Health of UFTM.
Functional capacity was assessed by performing basic activities of daily living (BADL), using the Katz Index, adapted to Brazilian reality (LINO et al., 2008), which consists of six items that measure the performance of person in self-care activities (LINO et al., 2008).They also measured the instrumental activities of daily living (IADL) through Lawton and Brody Scale, adapted in Brazil (SANTOS, VIRTUOSO JUNIOR, 2008).This scale consists of seven items with scores ranging from 7 to 21 points (SANTOS; VIRTUOSO JUNIOR, 2008).
The presence of frailty syndrome was verified using the five items described as components of frailty phenotype proposed by Fried et al. (2001), namely: unintended weight loss; decreased muscle strength, self-perceived exhaustion and/or fatigue, slowness and low level of physical activity.The information detailed for the parameters adopted for each component were previously published (PEGORARI; TAVARES, 2014).Elderly with three or more of these items were classified as frail and those with one or two items, such as pre-fragile and those with absence score in the criteria, non-fragile (FRIED et al., 2001).
The access and the use of health services were assessed through two sections of the questionnaire of the National Survey by Domicile Sample (NSDS) (GEOGRAPHY AND STATISTICS BRAZILIAN INSTITUTE, 2010).
The study variables were gender (male and female); age group in years (60|-70, 70|-80, 80 years old and over); marital status (single, married, widowed or separated); education in years (without education, 1-|4, and 5 and over); individual income in minimum wages (no income, up to 1 minimum wage, 1|-3 and 3 and over); self-perceived morbidities (none, 1-|4 and 5 and over); drug use (none, 1-|4 and 5 and over); functional capacity in BADL: bathing, dressing, toileting, transference, sphincter control, food; functional disability in BADL (dependent and independent); functional capacity in IADL: using the phone, to travel, shopping, preparing meals, performing housework, medication use and handle money; functional disability in IADL (dependent and independent); self-perceived health (positive and negative); frailty: unintentional weight loss in the last year; muscle strength; self-perceived exhaustion; gait performance and level of physical activity; use and access to health services: access looking the same place of health care, local demand for health care, medical consultation in the last 12 months, use of continuous medications, dentist appointments; use services related to their health in the last two weeks, attendance reason, number of times and local; nonattendance reason; demand for health care for the same reason in the last two weeks, local, non-attendance reason, primary health care which received nature of the service, health insurance coverage, payment for the service, services provided by SUS, received care assessment and medication use.
The collected data were entered by two people, with double entry and checked for inconsistencies between the two bases.After the necessary corrections in the original interview, the database was transported to the Statistical Package for Social Sciences (SPSS), version 17.0, to undertake the analysis.
To characterize the population and describe the characteristics related to access to and to the use of health services; proceeded to statistical analysis through a distribution of absolute and percentage frequencies.The multivariable analysis was performed through logistic regression, preceded by bivariate analysis (chi-square test) to determine the factors associated with the use of services among the elderly.The variables that had p<0.10 value in the bivariate analysis were included in the regression model (enter method).The nominal variables were re-categorized to become dichotomous.The tests were considered significant at p<0.05.
The project was submitted to the Research Ethics Committee with Human Beings of UFTM and approved with the opinion 493211.The subjects were contacted in their domiciles, introducing the objectives, the Informed Consent Form (ICF) and provided the relevant information.The interview was conducted only after the consent of the interviewee and signing the Form.
It was found that 86.2% accessed the same place or the same doctor when they needed care; 86.5% made a medical consultation in the last 12 months; 85.2% were using continuous medication, of this 40.4% received part of their medicines; and those who did not receive all medications, 86.1% effected the purchase.Predominated those who went to the dentist for the last three years or more (54.2%),while 21.7% for less than one year; and 16.9% used health services in the last two weeks before the interview, Table 1.Regarding the associated factors, the variables of the preliminary bivariate analysis, submitted to multi-variable analysis, according to the established inclusion criteria (p<0.10)were: individual monthly income of up to 1 minimum wage (p=0.016)self-perceived negative health (p<0.001),five and more self-perceived morbidities (p=0.001),use of five and more drugs (p<0.001),fragile condition (p=0.011),functional incapacity to basic activities (p=0.051) and instrumental daily living (p=0.011),Tables 2 and 3.They were consolidated as factors associated with the use of Polypharmacy health services (p=0.026) and self-perceived negative health (p=0.009),Table 4.
As for education, research also showed that most elderly reported having one to four years of study (FERREIRA;ANTUNES;ANDRADE, 2013;FILAHO et al., 2014.).The highest percentage of individual monthly income of one minimum wage obtained in this investigation does not suit with a study of elderly in the city of Montes Claros/Minas Gerais, in which the majority (70.5%) received up to one minimum wage (OLIVEIRA et al., 2013).
Regarding access to health services, a similar data to this study was identified in the National Health Survey, in which 79.3% of elderly people accessed the same place or the same doctor when they needed care (GEOGRAPHY AND STATISTICS BRAZILIAN INSTITUTE, 2015).The use of health services involves factors associated with the services availability, the access conditions, quality of care and the relationship of the population with services (DELLAROZA et al., 2013.); are aspects that could justify the result.
Concerning the medical consultation, a similar percentage was found in a national survey (85.3%) (GEOGRAPHY AND STATISTICS BRAZILIAN INSTITUTE, 2015); and higher in the study among the elderly of Belo Horizonte/MG community, in which it was found that in the last 12 months 92.4% consulted the doctor at least once (FIALHO et al., 2014).The increase in the elderly population leads to higher prevalence of NCDs and consequently to increased demand for health services and medicine (DELLAROZA et al., 2013;CABRELLI et al., 2014.).
The data obtained in this study are consistent with research in the city of Carlos Barbosa/RS (72.3%) (DAL OIZZOL et al., 2012) and Quixadá/Ceará region (70.6%)(SILVA et al., 2012) regarding the use of continuous medication among the elderly.The age group between 65 to 69 years annually consumes an average of 13.6 drugs, while aged 80 to 84 years come to consume 18.2 per year (SILVA; MACEDO, 2013).It is worth mentioning that many drugs may increase the risk of adverse reactions, incorrectly use by the elderly, as well as increasing the risk of morbidity and mortality (SILVA et al., 2012).Being a complex parameter that involves the responsibility of health professionals, patients, and families, the rational use of drugs by the elderly has become a major challenge for public health in Brazil (KHALIL; RODRIGUES, 2015).Thus, the knowledge about drug use by this population is essential to perform redefinitions in public policies aimed at improving the living conditions and health of the elderly (KHALIL; RODRIGUES, 2015;MACEDO;SILVA, 2013).
The percentage of drug acquisition had shown less than that of the population attended by the Unified Health System (45.0%) (VIACAVA, 2010); and to the research among the elderly of Ribeirão Preto/São Paulo community (46.8%),where a higher percentage acquired all remedies for free (BALDONI et al., 2014.).A survey among elderly of Bagé/Rio Grande do Sul community found that 45.0% bought their medicines (TAVARES et al., 2013), a lower value than the obtained in the present study.The low availability of generic and similar to the public health system interfere with the access to medicines and in this situation, the elderly tend to buy them in private pharmacies (VIANA et al., 2015.); a fact that can reduce funds for food and other basic necessities, and it also reflects negatively on the health status and quality of life of this population (GAUTEIRO et al., 2013).
Most seniors reported having been to the dentist for the last three years or over, a result similar to the National Oral Health Survey (53.5%) (FERREIRA; ANTUNES; ANDRADE, 2013); but inferior than a research in Montes Claros/Minas Gerais (61.9%) (OLIVEIRA et al., 2013).In Brazil, especially in the public service, there are still few of dental care services to the elderly.The need to develop a health promotion policy aimed at this segment of the population is observed in several studies that prove the lack of such services (SOUZA et al., 2012;MOURA et al., 2014.).Thus, the precariousness of the public service, as well as the lack of access to health insurance or private offices, contribute to the elderly neglect their oral health (MOURA et al., 2014).
It is noteworthy that 16.9% of respondent elderly used health services in the two weeks preceding the interview.National Health Survey data indicate, overall, a higher percentage (25%) among people aged 60 years and over (GEOGRAPHY AND STATISTICS BRAZILIAN INSTITUTE, 2015); while among elderly practitioners of physical activity, (71.5%) were observed higher values (VIRTUOSO et al., 2012).The expansion of supply and reorganization of health services that occurred in recent years contributed to better access of elderly to these services (VIRTUOSO et al., 2012;OLIVEIRA et al., 2012.).
It should be mentioned that despite the income, illness, disability, and fragility variables did not remain associated in the final regression model; literature (ALMEIDA, 2015;ROCHAT et al, 2010;LOUVISION et al., 2008;FIALHO et al., 2014) shows the relationship between these aspects and the use of health services in the last two weeks.
The Polypharmacy present in this study was associated with greater use of health services among the elderly.Research conducted in the municipalities of Rio de Janeiro/RJ and Belo Horizonte/Minas Gerais identified that the increased use of drugs was associated with the elderly who underwent more medical consultations and had hospitalization history in the last 12 months (SILVA et al., 2012).Research among elderly living in urban and rural areas in Rio Grande do Sul/RS found a positive association between polypharmacy and the use of health services (DAL PIZZOL et al., 2012).Increased access to health services contributes to a greater identification of NCDs, and consequently to an increase in the number of prescript drugs (DAL PIZZOL et al., 2012).Thus, the discussion and adoption of clinical protocols by the health services and the promotion of continuing education of the professionals in the elder care demands are relevant.The prescription of drugs for the elderly should be conducted in accordance by the overall health conditions of the elderly, and not only according to the treatment of a particular disease, reflecting a posture that minimizes Polypharmacy and prescribing unsafe drugs to the elderly (NEVES et al., 2013).
The association between the use of health services in the last two weeks and self-perceived negative health is according to research conducted in São Paulo/SP (LOUVISON et al., 2008); and a systematic review that found that variables such as hospitalizations and physician visits were associated with self-assessment negative health (PAGOTTO; BACHION; SILVEIRA, 2013).Also, data from the National Sample by Domicile Survey (NSDS) between 1998 and 2008 showed that the better the state of health of the elderly, the demand for health services for the treatment of disease is reduced approximately from 11 to 12% (ALMEIDA, 2015).

CONCLUSIONS
The most elderly went to the same service and professional; searched for medical appointments in the last year and a dentist for more than three years; and made use of continuous medication.The use of health services in the last two weeks represented 16.9% and was associated with polypharmacy and the perception of negative health.
The study presents as limitation the crosssectional design, which does not allow establishing causal relationships; and the use of questionnaires that may underestimate or overestimate some information, although widely reported in studies in the scientific literature.
This study contributes to knowledge about the access and use of health care of the elderly services in the investigated scenario; presenting the factors that influence the use of health services, and promote understanding from the perception of the consumption standard, which enables the planning of health actions as the presented characteristics.

Table 1 .
Characteristics related to access and use of health services.Uberaba/Minas Gerais, 2014.

Table 2 .
Distribution of socio-economic characteristics according to the use of health services in the last two weeks.Uberaba/Minas Gerais, 2014.

Table 3 .
Distribution of clinical and health characteristics according to the use of health services in the last two weeks.Uberaba/Minas Gerais, 2014.

Table 4 .
The final logistic regression model for the variables associated with the use of health services in the last two weeks.Uberaba/Minas Gerais, 2014.