Primary health care (PHC) is structured around a set of essential attributes that guide the organization of health services and support the provision of comprehensive and continuous care.^(1,2) Among these attributes, first-contact access has a central role because it reflects whether PHC is recognized and used as the preferred entry point whenever a new health need arises or a new episode of an existing problem occurs.⁽²⁾ According to Starfield, this attribute comprises two complementary components: utilization, which refers to the use of the service as the usual source of care, and accessibility, which refers to the organizational conditions that enable users to obtain care when needed.⁽²⁾ If access is not adequately ensured, individuals may be prevented from benefiting from the other essential attributes of PHC.⁽³⁾

The relevance of strengthening PHC was reaffirmed in 2018 at the Global Conference on Primary Health Care held in Astana, Kazakhstan. At this conference, PHC was recognized as the most inclusive, effective, and efficient approach to improving population health and advancing universal health coverage.⁽⁴⁾ In this context, evaluating first-contact access is important for identifying barriers that limit timely entry into the health system and for supporting improvements in service organization.^(2,4)

Among the instruments available for evaluating PHC, the Primary Care Assessment Tool (PCATool) is noteworthy because its use enables the core PHC attributes to be assessed from the users’ perspective and because it can be used in different evaluation contexts.^(5,6) In Brazil, the Ministry of Health published the manual for the PCATool-Brazil in 2020, consolidating the instrument as an important methodological reference for evaluating PHC in the Brazilian Public Health System (SUS - Sistema Único de Saúde).⁽⁷⁾ Although health outcomes cannot be directly assessed using the PCATool, it provides relevant information on the structure and process dimensions of care, supporting decision-making and the continuous improvement of services.^(6,7)

In oral health, evaluating the attributes of PHC is particularly relevant because the incorporation of oral health teams (OHTs) into PHC has not always been accompanied by equivalent advances in the organization ofaccess and care.⁽³⁾ Evaluating first-contact access from the perspective of users of family health teams (FHTs) and OHTs may contribute to identifying gaps in how this PHC attribute is expressed across these two components of care.

To evaluate the primary health care attribute of first-contact access from the perspective of users of family and oral health teams in São Paulo, Brazil.

A total of 537 individuals participated in the study, including 129 users of OHT and 408 users of FHT. Among OHT users, female participants (71.32%) and individuals younger than 45 years (66.96%) predominated. Most participants self-identified as brown (44.53%), had completed education up to the level of high school (50.39%), were unemployed (40.31%), did not receive government social benefits (78.91%), and did not have private health insurance (82.81%). Most also reported no difficulties in seeing, hearing, or walking (50.78%), had no reported diseases (60.47%), and did not report hypertension or diabetes (73.64%; Table 2).

Among FHT users, female participants also predominated (82.11%), as did individuals younger than 45 years (56.05%). Most participants self-identified as brown (46.44%), had completed education up to the level of high school (45.32%), were unemployed (36.30%), did not receive government social benefits (62.56%), and did not have private health insurance (91.23%). In this group, most participants reported difficulties in seeing, hearing, or walking (59.95%), had one or two reported diseases (42.89%), and did not report hypertension or diabetes (62.25%; Table 2).

The mean scores and performance of the first-contact access components according to service type are presented in table 3. In both groups, higher mean scores were achieved for utilization than for accessibility. Among OHT users, the mean scores were 8.08 and 4.37 for utilization and accessibility, respectively. Among FHT users, the mean scores were 8.43 and 3.80, respectively. A high performance in utilization was observed in 85.37% of OHT users and in 87.53% of FHT users, whereas a low performance in accessibility was observed in 95.08% and 97.70% of users, respectively.

The mean utilization and accessibility scores among OHT users according to the independent variables are shown in table 4. Among OHT users, individuals without private health insurance had significantly higher utilization scores than those with private health insurance (8.33 versus 6.83; p=0.019). No statistically significant differences were observed for accessibility.

The corresponding analyses for FHT users are shown in table 5. In this group, higher utilization scores were observed among individuals aged 45 years or older (8.70; p=0.003), retirees or pensioners (9.09; p=0.001), beneficiaries of government social programs (8.62; p=0.047), those without private health insurance (8.53; p=0.036), and those with hypertension and or diabetes (8.86; p=0.001). Significantly higher mean scores were observed for accessibility among male participants (4.15; p=0.047), individuals aged 45 years or older (3.93; p=0.048), and retirees or pensioners (4.39; p<0.001).

The findings of this study showed that, in both family and oral health teams, the utilization component of first-contact access was more positively evaluated than the accessibility component. Overall, this suggests that PHC services were recognized by users as a usual source of care, but important organizational barriers still limited timely access. The results also indicated that a more consistent pattern of differences in sociodemographic and clinical characteristics was present among FHT users than among OHT users. Together, these findings highlight that, although PHC services appear to be an established point of entry into care, accessibility is a persistent challenge, particularly in oral health care.

Similar results have been reported in previous studies conducted in Brazilian PHC settings, especially with regard to difficulties related to service hours, appointment scheduling, and time spent waiting for care.^(3,10,11) Recent Brazilian studies have also shown that, from the user's perspective, first-contact access—particularly for the accessibility component—tends to be among the most fragile of the PHC attributes, even in services otherwise oriented toward primary care.^(12,13) This convergence reinforces the interpretation that the main challenges lie in recognizing PHC as a usual source of care, as well as in ensuring timely and feasible access under everyday service conditions.

First-contact access is a core PHC attribute because it conditions the user's entry into the health system and influences the possibility of benefiting from the other essential attributes of care.^(2,3) In this sense, the more favorable performance observed for utilization may reflect the role of PHC services as a regular point of care, particularly for follow-up and routine health needs. By contrast, the low scores observed for accessibility in both groups indicate persistent barriers in the organization of care, reinforcing the need to improve service availability and responsiveness to users’ needs.^(7,14)

Among OHT users, few statistically significant differences were observed in participants’ sociodemographic and clinical characteristics. The only significant association was found for private health insurance coverage, with higher utilization scores among users without private health insurance. This finding may reflect a greater dependence on public oral health services among individuals who rely exclusively on the SUS. It also suggests that this population is using oral health care as a reference source of care, although this did not translate into better accessibility scores. The limited variation observed across OHT subgroups should not be interpreted as evidence of more equitable access; rather, it may reflect a broadly low level of accessibility across different user profiles.

Among FHT users, more positive evaluations of utilization were observed among older adults, retirees or pensioners, beneficiaries of social programs, those without private health insurance, and those with hypertension and or diabetes. This finding suggests that PHC has been functioning more consistently for patients with greater health needs and for those who depend more directly on public services. The result is compatible with the programmatic role of PHC in the longitudinal management of chronic conditions, which requires more regular contact with the health service and may strengthen its recognition as the usual source of care.^(15,16) However, better evaluation of utilization among these groups should not be interpreted as the absence of barriers, but rather as evidence of stronger insertion into established care flows and follow-up routines.

Regarding accessibility among FHT users, more positive evaluations were observed among men, older adults, and retirees or pensioners. These findings may be related, at least in part, to greater compatibility between the opening hours of basic health units and the daily routines of these groups. However, the low scores observed overall for accessibility indicate that this component remains fragile, even among subgroups with relatively more favorable evaluations. Expanding service hours and adopting strategies that facilitate adults of working age gaining access may help reduce these barriers.⁽¹⁷⁾ Similar concerns have been raised in recent Brazilian studies, in which persistent weaknesses in first-contact access despite broader PHC orientation have been noted.^(12,13)

The findings in oral health deserve particular attention. Although OHT users reported satisfactory utilization scores, accessibility remained low, and few subgroup differences were identified. This may indicate that, in oral health care, difficulties continue to be faced in organizing access in accordance with a broader PHC approach and in the context of the growing emphasis on oral health within universal health coverage.^(18,19) In practice, oral health services may still be more strongly oriented toward responding to immediate or procedure-centered demands than toward the comprehensive and timely organization of care within PHC.^(20,21) Furthermore, the weaker differentiation observed among user subgroups may suggest that barriers to accessibility are distributed more uniformly, rather than concentrated in specific profiles.

This study had some limitations that should be considered when interpreting the results. First, its cross-sectional design does not allow causal inferences. Second, the PCATool assesses the structure and process dimensions of care, but does not directly evaluate health outcomes.⁽¹⁴⁾ The study may also have been subject to selection bias, because the sample included only individuals who were able to access the basic health unit and complete care. Consequently, the experiences of users who may have faced more severe barriers—such as being unable to schedule an appointment, failing to obtain care, or dropping out before receiving care—were not captured. This may have led to an overestimation of first-contact access, particularly for the utilization component.

Despite these limitations, the study provides relevant evidence on first-contact access from the perspective of PHC users in family and oral health teams. These findings may support service planning and management, especially in efforts aimed at reducing organizational barriers and strengthening access as a core PHC attribute.

The evaluation conducted using the Primary Care Assessment Tool showed that, in both family and oral health teams, the utilization component of first-contact access was more positively assessed by users than the accessibility component. These findings suggest that primary health care services are recognized by users as a usual source of care, but that they still face important organizational barriers to timely access.

Among family health teams users, the findings indicated more positive evaluations of utilization among groups with greater health needs and greater dependence on public services. Conversely, among oral health teams users, fewer differences in user characteristics were observed, and accessibility remained low. Overall, the findings suggest persistent challenges in organizing access in oral health care in accordance with a broader primary health care approach. These findings reinforce the importance of strengthening accessibility in primary health care, particularly through organizational strategies that facilitate timely access and reduce barriers related to service availability and functioning.