Primary Health Units Research Articles

Barriers faced by patients in the diagnosis of multidrug-resistant tuberculosis in Brazil.

ABSTRACTOBJECTIVE To understand patients’ narratives about the barriers they faced in the diagnosis and treatment of multidrug-resistant tuberculosis, and their consequences in Rio de Janeiro State, Brazil.METHODS This is a qualitative cross-sectional study with non-probabilistic sampling. A theoretical saturation criterion was considered for composing the number of interviewees. Semi-structured interviews were conducted from August to December 2019 with 31 patients undergoing treatment for multidrug-resistant tuberculosis at an outpatient referral center in Rio de Janeiro. Data were transcribed and processed with the aid of the NVIVO software. Interviews were evaluated by content analysis, and their themes, cross-referenced with participants’ characterization data.RESULTS Our main findings were: a) participants show a high proportion of primary drug resistance, b) patients experience delays in the diagnosis and effective treatment of multidrug-resistant tuberculosis ; c) healthcare providers fail to value or seek the diagnosis of drug-resistant tuberculosis, thus beginning the inadequate treatment for drug-susceptible tuberculosis, d) primary health units show low report rates of active case-finding and contact monitoring, and e) patients show poor knowledge about the disease.CONCLUSIONS We need to improve referral systems, and access to the diagnosis and effective treatment of multidrug-resistant tuberculosis; conduct an active investigation of contacts; intensify the training of healthcare providers, in collaboration with medical and nursing schools, in both public and private systems; and promote campaigns to educate the population on tuberculosis signs and symptoms.

Awareness and attitude of primary healthcare patients towards telehealth in Cairo, Egypt

Background Telehealth is delivering health care services remotely from healthcare facilities using telecommunications and virtual technology. Egypt is aiming to reach Universal Health Coverage; this increases the demand for telehealth in routine health services. Telehealth helps in increasing access to areas with no available medical services as patients can be monitored remotely. Objective To measure the awareness of telehealth among attendees of primary health care units and their acceptance of applying telehealth. Methodology This was a cross-sectional study among attendees of primary health units. Ethical issues were considered. Results A sample size was calculated to be 162 and 170 valid Arabic interview questionnaires were filled by attendees. The awareness percentage of telehealth among attendees was 64.7% while the willingness to implement telehealth was 78%. Both awareness and willingness were significantly associated with age groups, residence, socioeconomic status, and presence of computer with internet access. Age, residence, and possession of a PC were the only adjusted predictive factors for knowledge about telehealth among patients in the multivariable analysis. Conclusion Large percentages of attendees to primary health care centers are aware of telehealth and are willing to implement it. The major cause of refusal to implement telehealth was ignorance of using telecommunication devices and the desire to be in close contact with the physicians.

Implementation of the Strategy for Breastfeeding and Complementary Feeding in the Federal District in Brazil.

Background: The Brazilian Breastfeeding and Complementary Feeding Strategy—Estratégia Amamenta e Alimenta Brasil (EAAB) aims to promote optimal breastfeeding (BF) and complementary feeding (CF) practices through the training of primary health professionals. Competition among health priorities and programs is one of the organizational contextual barriers to consolidating the implementation of the EAAB. Methods: This case study included six Primary Health Units (PHU) certified in the EAAB. Documentary analysis, interviews, and surveys were conducted, which informed a conceptual logical model. Organizational context indicators (positive and negative) were identified across the logical model based on the Matus Triangle, and they were used to analyze the degree of implementation of the EAAB in the PHUs. Results: The logic model elucidated six stages of EAAB implementation, but none on post-certification monitoring. Ten indicators positively influenced the implementation, including having legislation that prioritizes BF and CF. Seven indicators exerted negative influence, especially the lack of specific funding resources for the EAAB. Only one PHU had a consolidated degree of implementation. Conclusions: Lack of specific funding, monitoring of BF and CF practices, and compliance with certification criteria are the main challenges for the EAAB’s sustainability.

Primary care provider notions on instituting community-based geriatric support in Uganda

BackgroundUnderstanding of the most economical and sustainable models of providing geriatric care to Africa’s rising ageing population is critical. In Uganda, the number of old adults (60 years and above) continues to rise against absence of policies and guidelines, and models for providing care to this critical population. Our study explored public primary health care provider views on how best community-based geriatric support (CBGS) could be instituted as an adaptable model for delivering geriatric care in Uganda’s resource-limited primary public health care settings.MethodsWe interviewed 20 key informants from four districts of Bukomansimbi, Kalungu, Rakai, and Lwengo in Southern Central Uganda. Respondents were leads (in-charges) of public primary health units that had spent at least 6 months at the fore said facilities. All interviews were audio-recorded, transcribed verbatim, and analysed based on Hsieh and Shannon’s approach to conventional manifest content analysis.ResultsDuring analysis, four themes emerged: 1) Structures to leverage for CBGS, 2) How to promote CBGS, 3) Who should be involved in CBGS, and 4) What activities need to be leveraged to advance CBGS? The majority of the respondents viewed using the existing village health team and local leadership structures as key to the successful institutionalization of CBGS; leveraging community education and sensitization using radio, television, and engaging health workers, family relatives, and neighbors. Health outreach activities were mentioned as one of the avenues that could be leveraged to provide CBGS.ConclusionProvider notions pointed to CBGS as a viable model for instituting geriatric care in Uganda’s public primary healthcare system. However, this requires policymakers to leverage existing village health team and local governance structures, conduct community education and sensitization about CBGS, and bring onboard health workers, family relatives, and neighbors.

Exploratory Study on Municipalization of Health in Angola – Characterization of Human Resources for Health staffing and Health Units’ managers’ profile in Healthcare services and Training institutions of Cabinda Province

In Angola, the scarcity of human resources for health (HRH) is well known. Lately, there has been a focus on education and professional training structures, as well as the necessary profile of health units’ managers. The general objective of this study was to describe the perceptions of HRH Managers of Primary Health units of Cabinda Province about HRH training and retention. A cross-sectional observational study was performed, with semi-structured interviews supported by a survey, followed by a focus group, addressed at a convenience sample of HRH and Health Units managers in the province of Cabinda. 10 health units participated, where 13 managers were interviewed. As for the HRH profile, there is a majority of nurses, with a ratio of nurses to physicians of 8.6:1. As for the profile of managers, only three are postgraduate technicians in management. Training schools’ output in the previous year was 746 senior and middle technicians. Managers cited two main areas of improvement as essential to address the HRH imbalances in Cabinda: "Leadership empowerment" and "Improving information system efficiency". Opportunities were identified to improve the training of Health students, retention of HRH and managers of Health and training units in Cabinda. The definition of policies for HRH in Cabinda should focus on improving health teaching and management conditions with a special focus on empowerment of leaderships, and reinforcing the use of management tools and information systems. Desirably, implementing Management, Control and Quality Assurance Systems. Keywords: Health Workforce; Quality of Health Care; Health Management; Angola

Evaluation of the National Electronic Disease Surveillance System Amid the COVID-19 Pandemic in Elsahel District, Cairo Governorate, Egypt, 2020

Background The Egypt National Disease Surveillance is a routine system established in 2002. The system electronically reports on 41 infectious diseases including COVID-19. Reporting sites include all Egyptian governorates, districts, governmental infectious disease hospitals, and primary health units. Surveillance is essential during the pandemic to detect cases early, describe the epidemiology of health problems, guide priority setting, and plan and evaluate public health policy and strategies. Objective This study aims to evaluate the surveillance system during the pandemic to assess its effectiveness in achieving its objectives and to find and fill the gaps. Methods The evaluation was performed using the Centers for Disease Control and Prevention guidelines. A structured questionnaire was used to evaluate the qualitative attributes including simplicity, flexibility, and acceptability through interviewing surveillance teams at the central level, health directorate, and Sahel district. Quantitative attributes, including completeness, timeliness, and predictive positive value, were performed using COVID-19 surveillance data of Sahel district in March-December 2020. Data were assessed for completeness and accuracy. The usefulness of surveillance was assessed in terms of achieving its objectives and use of data. Results Of 33 respondents, 90% thought that the system was simple, and 77% thought it was acceptable; work overload reduced the acceptability rate. The system is funded by the Ministry of Health and Population and was operational 53% of the time due to connectivity problems. The system was flexible when adapting to include COVID-19 in a short time with minimal cost. It is quite representative, as it covers 60% of the population. Completeness was 82%, positive value predictive was 58%, and data validity was 86%. The median duration between patient admissions and reporting was 2.7 days. Conclusions The evaluation of the Egypt COVID-19 surveillance system indicated that the system partly achieved its objectives in the area of simplicity and flexibility with adequate data quality. There is a need to improve acceptability and timeliness through increasing manpower and to enhance stability through effective connectivity. Expansion of the system to cover all of the Egyptian population is recommended to improve representativeness.

Panorama do acesso à fonoaudiologia com base no perfil de crianças e adolescentes encaminhados na atenção básica

ABSTRACT Purpose: to analyze the profile and access of patients who need speech-language pathology care in a Primary Health Unit (UBS). Methods: a descriptive analytical study, including data obtained from a spreadsheet with information provided by patients from May 2013 to February 2020. The following variables were analyzed: gender, age at referral, speech-language pathology complaint, year of referral, year of the first visit and service, and professional responsible for the health referral, speech therapy conduct after first visit, and outcome after therapy. Categorical variables were analyzed by means of frequency and numeric variables by measures of central tendency and dispersion. For inferential statistical analysis, the Mann-Whitney test was used, considering 5% as the significance level. Results: in total, 171 individuals were referred, most were males, aged 4 to 6 years, with language complaints; 73.66% were referred by professionals from the UBS, mainly by pediatricians. After the speech-language pathology assessment, 27.49% were referred to the specialty. Among the 78 individuals who started speech-language therapy at the UBS, 24.36% were discharged and 32.05% were dismissed, due to absences. A statistically significant correlation was observed when analyzing data of waiting time and non-attendance at the first speech therapy visit. Conclusion: as it addresses a large part of the demands in Primary Care, speech-language pathology helps to increase solubility at this level of the health system. Lack of compliance is considered a barrier in service organization and in promoting access to other patients.

Acupuncture for perceived stress in pregnant women: an intervention study.

To analyze the effects of acupuncture in the treatment of perceived stress in pregnant women. A before-after intervention study, carried out in a primary health unit in Fortaleza-Ceará, with 56 pregnant women. The pregnant women underwent six acupuncture sessions, with two 30-minute sessions per week. Before the first session, an instrument to collect sociodemographic, clinical, and obstetric data was applied. The Global Perceived Stress Scale (PSS10) was applied weekly to monitor the progression of stress during treatment. After the intervention, there was a significant decrease in the scores of the following scale items: being upset, inability to control, nervousness, tiredness, anger, and inability to overcome stress. (p < 0.05). There was a significant increase in the score of the item control of situations (p = 0.003). There was a significant difference in the mean perceived stress of the initial session compared to the 1st, 2nd and 3rd week sessions (p < 0.001). The use of acupuncture to treat stress during pregnancy reduced the stress perceived by pregnant women.

Assessment of the appropriate management of syphilis patients in primary health care in different regions of Brazil from 2012 to 2018.

This study aimed to analyze the presence of adequate infrastructure and work process in primary health care for the diagnosis, management, and treatment of syphilis in Brazil in 2012, 2014, and 2018. This is a cross-sectional, nationwide study with data from the three cycles of the Program for Improvement of Access and Quality of Basic Healthcare (PMAQ-AB): 2012 (Cycle I), 2014 (Cycle II), and 2018 (Cycle III). Two outcomes were assessed: adequate infrastructure and work process. The independent variables were macroregion, municipality size, Municipal Human Development Index (HDI-M), and coverage of the Family Health Strategy (FHS). Variance-weighted least squares regression was used to estimate annual changes in percentage. In total, 13,842 primary basic health units (UBS) and 17,202 professional health care teams were assessed in Cycle I; 24,055 UBS and 29,778 teams in Cycle II, and 28,939 UBS and 37,350 teams in Cycle III. About 1.4% of UBS had adequate infrastructure in Cycle I; 17.5% had in Cycle II; and 42.7% had in Cycle III. Adequate work process also increased in the three cycles, ranging from 47.3% in Cycle I to 45.5% in Cycle II and 75.4% in Cycle III. However, inequities are observed, considering that richer regions and larger municipalities, with higher HDI-M and lower FHS coverage improved the most. The low prevalence of adequate infrastructure and work process for the care of patients with syphilis in Brazil reflects a significant weakness in the Brazilian health system.

Design issues of a pan European Smart Cross Border "dream like" e-Gov Primary Health Care Medical Service

The European Commission of the European Union has provided Member States with the appropriate regulation and systems for the development of services facilitating cross border transactions. So far there has been little progress in putting such services to full practice. This may be justified where such systems involve the processing of confidential and personal data. Nevertheless, the proposed by the European Commission systems guarantee (as far as recent developments in network and cloud securities can do it) efficient validation of data, through authentication procedures. Cross border systems are essential in supporting one of the key principles of the EU that of free movement. Recent research and the relevant literature has witnessed the proposal and development of a few cross border systems focusing on health, social services, the environment, and life sciences. In this paper, design issues of such a cross border authentication service, linking public or/and private primary health units, are presented. The system in support of this service will offer a standard conceptual design model to interested European Member States. To evaluate the potential of such a system and its practical appeal, Greece's and the UK's primary health care services are examined. They are used as a case study of a conceptual design model applied in building up a pan European smart cross border primary health service to the benefit of citizens of any European countries being on mobility.

Cardiovascular risk in primary care: comparison between Framingham Score and waist circumference

Objectives: To estimate and compare the cardiovascular risk using the Framingham risk score (FRS) and waist circumference (WC) in primary care individuals and, secondarily, determine the main factors associated with these scores. Methods: Cross-sectional study involving individuals of both sexes attended in a primary health unit and aging between 30 and 74 years. The cardiovascular risks (FRS and WC) were stratified as low, intermediate, and high. The weighted Kappa coefficient was used to assess agreements between scores. Results: Fifty-five individuals (52.8 ± 9.4 years, 70.9% women) were evaluated. Using the FRS, 40.0% of the sample presented a low risk, 45.5% intermediate risk, and 14.5% high risk of cardiovascular disease. Conversely, when analyzed using the WC score, the highest frequency (71%) was observed in the high-risk category. Also, no agreement (K= 0.36; p= 0.55) was found between scores. FRS was associated with hypertension (p&lt;0.01), diabetes (p=0.01), and stress in women (p=0.01), while the WC score was associated with hypertension (p=0.02), obesity (p&lt;0.01), and high-density lipoprotein cholesterol HDL-c (p=0.03). Conclusions: Primary care individuals presented intermediate cardiovascular risk in the FRS and high risk in the WC, with no agreement between scores. Hypertension, diabetes, stress, obesity, and HDL-c represented the factors that were most associated with these scores.

Association between ambulance prehospital time and maternal and perinatal outcomes in Sierra Leone: a countrywide study

IntroductionSierra Leone, one of the countries with the highest maternal and perinatal mortality in the world, launched its first National Emergency Medical Service (NEMS) in 2018. We carried out a...

Prevalence of cardiovascular risk factors in adults registered in a primary health unit of Porto

PurposeThe study aims to describe the adult’s overall cardiovascular disease risk factors prevalence, including arterial stiffness and physical inactivity.MethodsThe cross-sectional study involved 197 adults (males: 42%; mean age: 47 ± 13 years) from a Portuguese health centre. Traditional cardiovascular disease risk factors were measured during clinical assessment. Arterial stiffness was evaluated with carotid-femoral pulse wave velocity (≥ 10 m/s). Physical inactivity (&lt; 30 min/day of moderate to vigorous physical activity) was objectively assessed with accelerometry. The statistical procedures included descriptive analysis (means, medians, and frequencies) and between-gender comparisons (chi-square test and t-test) for cardiovascular disease risk factors.ResultsCardiovascular disease risk factors prevalence was as follows: dyslipidaemia: 71%, physical inactivity: 51%, hypertension: 43%, metabolic syndrome: 36%, arterial stiffness: 31%, smoking: 29%, and obesity: 20%. The prevalence of cardiovascular disease risk factors increases with age and is higher in males than in females. The prevalence of hypertension and metabolic syndrome was higher in participants with a lower educational level. The majority of hypertensive patients were more physically inactive (56.5%) than active (43.5%; &lt;i&gt;p&lt;/i&gt; = 0.044).ConclusionsThe overall prevalence of cardiovascular disease risk factors was high, with 1/3 having augmented arterial stiffening and half being physically inactive.

EVALUATION OF THE IMPACT OF PAIN FROM DENTAL URGENCIES ON THE PATIENTS’ ORAL HEALTH-RELATED QUALITY OF LIFE: A CROSS-SECTIONAL STUDY

Background. This cross-sectional study aimed to evaluate the impact of pain from dental urgencies on the oral health-related quality of life (OHRQoL).Methods. A sample of sixty-eight patients seeking urgent attention to a primary health unit were included. Clinical diagnosis and sociodemographic data were assessed, dental pain measured by visual analog scale (VAS) and numerical pain rating scale (NPRS). The Oral Health Impact Profile-14 (OHIP-14) instrument was used to measure the OHRQoL. Associations were analyzed using the Student t-test, except for types of urgencies, that were evaluated with one-way analysis of variance (ANOVA) test.Results. The most prevalent urgency type was of endodontic origin (81%). There was no difference between pain and other variables. The type of tooth showed significant differences in OHIP-14 scores.Conclusion. Dental urgencies were associated with a high level of pain and impacted negatively on the patients’ OHRQoL. The type of tooth had a positive association the OHRQoL measures.

Distal Symmetric Polyneuropathy Pain in Diabetes Mellitus

Objective: To evaluate neuropathic pain (NP), its intensity, and complications in people with type 2 diabetes mellitus (T2DM) in a city of eastern São Paulo. Method: Cross-sectional study conducted with 96 individuals with T2DM served by primary health units in São João da Boa Vista-SP. The following instruments were used to screen NP: Michigan Neuropathy Screening Instrument, Leeds Assessment of Neuropathic Symptoms and Signs, Douleur Neuropathique 4, and Brief Pain Inventory. The data were analyzed using descriptive and inferential statistics, with a 5 % significance level. Results: Of the 96 people with T2DM for longer than five years, 22.9 % had pain. NP was related to high levels of fasting blood glucose (mean = 214 ± 65.58 mg/dl; p = 0.0002), glycated hemoglobin (mean = 8.8 ± 0.11 %; p &lt; 0.001), absence of a balanced diet (p = 0.0066), obesity (p = 0.023), and high blood pressure (p &lt; 0.001). Conclusion: Higher values ​​of glycated hemoglobin rates increased three times the chance of NP. The screening and management of painful diabetic neuropathy is a challenge but adopting a screening protocol supports the secondary prevention of this manifestation.

Low back pain prevalence and associated factors in nurses from Brazilian primary health units.

Primary health unit (PHU) nursing work is different when compared to hospital environment. Although low back pain (LBP) literature presents studies conducted in hospital nursing personnel, there is a lack of studies in PHU nurses. This study aimed to measure the prevalence of LBP in PHU nursing personnel in the city of Pelotas, Brazil. Sociodemographic (age, gender, number of children, skin color, income and marital status), occupational (PHU type, formal education, professional experience, weekly workload, extra work activity, workload perception), nutritional (BMI), health (self-perceived health, smoking, sleep quality and minor psychiatric disorders, PHU physical structure perception) and behavioral (leisure-time physical activity) characteristics were assessed. LBP was defined as pain or discomfort between the last rib and gluteal fold. Poisson regression was used to evaluate the relationship among LBP and covariates. LBP prevalence was 65.2%. Chronic (12 weeks) and acute (7 days) LBP prevalence were 22.4%and 53.4%, respectively. LBP was associated with obesity (PR 1.39 95%CI 1.01-1.92) and poor self-perceived health (PR 2.77 95%CI 1.32-5.80). Prevalence of LBP in PHU nursing personnel is high and similar to hospital nurses. Individual characteristics such as body mass and health perception were associated with LBP.

Patient safety culture in Primary Health Care

Objective: to evaluate the patient safety culture in a primary care health unit. Methods: cross-sectional study conducted with 51 professionals linked to Primary Health Care. Data were collected using the self-administered instrument Medical Office Survey on Patient Safety Culture, translated, adapted and validated for use in Brazil. Descriptive statistical analysis was performed. Nurses, physicians, Community Health Agents, among other professionals participated. Results: the dimensions of the patient safety culture in Primary Health Care indicated opportunities for improvement or weaknesses in the service. The general assessment of patient safety and the global assessment of the quality of care provided in Primary Health Care were appointed as good or fair. Conclusion: the safety culture in Primary Care did not identify strong dimensions; there were problems with equipment, performance and availability of test results and exchange of information with imaging centers/laboratories in the care network.

Peripheral oxygen measurements in suspected elderly COVID-19 patients can be an effective tool for alerting physicians

Background: Since December 2019 the world has been facing a newly identified corona virus named SarsCov-2 which is the causative agent of COVID-19 that produces different symptoms. One of these symptoms is asymptomatic hypoxia, particularly in elderly patients. Despite the absence of signs of respiratory distress, many patients evolve to respiratory failure. The cause of this asymptomatic hypoxia remains unclear. Objective: Our goal was to evaluate the utility of peripheral oxygen measurements using oximetry in elderly patients with suspected COVID-19 and with no apparent signs of shortness of breath, during 10 consecutive days. Method: Every elderly patient with suspected COVID-19 who sought medical care at one of the 12 Primary Health Unit (PHU) in the South-West area of Campinas, Sao Paulo State was enrolled in the 10-days monitoring report. Each patient had the levels of oxygen saturation (SpO2) monitored by pulse ox meter from the fifth to the tenth days after the onset of symptoms and, when possible twice a day. Results: 1297 patients (pts) were followed during the period from August 2020 to February 2021. A total of 9023 measurements were carried out using a SpO2 pulse ox meter. 163 (12.5%) cases were referred to the Emergency Room and 37 (3%) had to be hospitalized. The highest frequencies of symptoms occurred during the 6th and 8th day and included cough (16.8%), fatigue (12.8%), headache (9.7%), loss of taste and/or smell (6.8%). Among the patients who were hospitalized, 13 died (1%). Conclusion: The asymptomatic hypoxia remains unclear; however, the measurement of SpO2 levels appears to be a cheap and effective tool to be used as an alert system or further evaluation.

856-P: Long-Term Benefits of Multicomponent Integrated Care Program Participation on Diabetes Care Goals: The DIABEMPIC Program

Diabetes burden is greater in low- middle-income countries, where large gaps exist in achieving diabetes care goals. We examined a quality initiative multicomponent integrated care (MIC) program (DIABEMPIC, DIABetes EMPowerment and Improvement of Care) on diabetes care goals in adults with type 2 diabetes (T2D) implemented in a public primary care specialized diabetes clinic in Mexico City/Iztapalapa. DIABEMPIC is a 5-month empowerment-based program that includes an interdisciplinary case management team, diabetes self-management education, shared medical appointments, a patient-centered approach, and audit and feedback. At the end of the program patients continue routine care in public primary care units. We report the effect of the intervention on diabetes care goals at the end of the program and 18 months after the initial recruitment (long-term evaluation). Results: 704 patients with T2D completed the program, and 182 already have a long-term evaluation. The mean (SD) age of this subgroup was 57 (10.9) years, 67% female, 61% had elementary or less education, 68% had medium-low or lower socioeconomic status, mean diabetes duration was 13 (8) years, and mean A1c was 9.5% (2.2). After the program (n=182) systolic and diastolic blood pressure (-11, -4 mmHg respectively), A1c (-2.6%), and non-HDL cholesterol (-29 mg/dl) decreased significantly (p&amp;lt;0.0001). Clinical benefits persisted in long-term evaluation in systolic and diastolic blood pressure (-9, -3 mmHg respectively, p&amp;lt;0.0001), A1c (-1.4%, p&amp;lt;0.0001), and non-HDL cholesterol (-11 mg/dl, p=0.018). Conclusions: This quality-of-care initiative had valuable short and long-term effects on diabetes care goals in a real-world setting. The long-term impact is smaller than the impact observed at the end of the intervention. This work suggests further replication of the intervention and enhances the need to improve routine follow-up in primary health units after the participation in MIC programs. Disclosure R. Silva-tinoco: None. A. Gallardo-hernández: None. J. Ochoa-moreno: None. V. Delatorre-saldaña: None. T. Cuatecontzi-xochitiotzi: None. A. Gonzalez-cantu: None. C. Castillo-galindo: None. B. Pimentel-hernández: None. M. Romero-ibarguengoitia: None. A. Núñez-rodríguez: None. F. Orozco-gutiérrez: None.

Older adult health and primary care: autonomy, vulnerabilities and challenges of care.

ABSTRACTOBJECTIVE:To understand the relations between autonomy and health-disease-care processes of older adults in the daily life of primary health care.METHODS:Qualitative research developed in 2019, in a primary health unit in the central region of the city of São Paulo, using participant observation and in-depth interviews with 16 health professionals and 8 older adults. The construction and interpretation of the narratives produced in the study were guided by the perspective of Gadamer’s philosophical hermeneutics and Ricoeur’s theory of interpretation. The theoretical framework of vulnerability/Careᵃ, as proposed by Ayres, guided the definition of the study and interpretative categories.RESULTS:Closely related to the difficulties, facilities and strategies to cope with the daily challenges in the health care of older adults, autonomy was an important marker of vulnerability (interpersonal, social and programmatic), indicating areas that require special attention, such as drug dispensing, urban mobility, social isolation, financial frailties and adequacy of service routines.CONCLUSION:Distinctly from an individual attribute, autonomy has proved to be the expression of relational characteristics, requiring plural and flexible practical-moral strategies, techniques and horizons, although always guided by the same ethical commitment to respect the singular needs of individuals.