(De)constructing ‘therapeutic itineraries’ of hypertension care: A qualitative study in the Philippines

Jhaki A Mendoza,Gideon Lasco,Alicia Renedo,Lia Palileo-Villanueva,Maureen Seguin,Benjamin Palafox,Arianna Maever L Amit,Veincent Pepito,Martin Mckee,Dina Balabanova

doi:10.1016/j.socscimed.2021.114570

Abstract

Hypertension, a major risk factor for non-communicable diseases, remains poorly controlled in many countries. In the Philippines, it is still one of the leading causes of preventable deaths despite the accessibility and availability of essential technologies and medicine to detect and treat hypertension. This paper characterizes the ‘therapeutic itineraries’ of people with hypertension from poor communities in rural and urban settings in the Philippines. We employ longitudinal qualitative methodology comprised of repeat interviews and digital diaries using mobile phones from 40 recruited participants in 12 months. Our findings demonstrate that therapeutic itineraries, rather than being organized according to categories that stem from the structure of the health system (i.e., diagnosis, treatment, follow-up, adherence), diverge from clinical pathways. Therapeutic itineraries begin at a stage we label as ‘pre-diagnosis’ (PD). Following this, itineraries diverge according to two possible entry points into the healthcare system: via incidental diagnosis (ID) whereby participants were diagnosed with hypertension without deliberately seeking care for hypertension-related symptoms and symptom-driven diagnosis (SD) whereby their diagnosis was obtained during a clinical encounter specifically prompted by hypertension-related symptoms. Participants whose itineraries follow the SD route typically oscillated between periods of regular and intermittent medical treatment, while participants who were diagnosed incidentally (ID) typically opted for self-care As we follow our participants' therapeutic itineraries, we explore the confluence of factors informing their care journey, namely, their conceptions of hypertension, their social relationships, as well the choices and trade-offs they make. We conclude with policy implications from our findings, chief of which is our proposition that models of care based on mere access and availability of clinical interventions fail to reflect the complexity of people's lay understanding and their lived experiences of hypertension and are thus ultimately unhelpful in improving its control.

Highlights

Non-communicable diseases (NCDs) are a growing global health issue, in low- and middle-income countries (LMICs) (WHO, 2014)
Itineraries diverge according to two possible entry points into the healthcare system: via incidental diagnosis (ID) whereby participants were diagnosed with hypertension without deliberately seeking care for hypertension-related symptoms and symptom-driven diagnosis (SD) whereby their diagnosis was obtained during a clinical encounter prompted by hypertensionrelated symptoms
Our findings demonstrate that therapeutic itineraries — shaped by people’s own lived experiences, understanding of care, and beliefs about what constitutes hypertension, rather than being organized according to categories that stem from the structure of the health system — diverge from clinical pathways

Summary

Introduction

Non-communicable diseases (NCDs) are a growing global health issue, in low- and middle-income countries (LMICs) (WHO, 2014). Concerns about the poor control of hypertension have been sup ported by a growing number of qualitative studies on the knowledge and attitudes of people with hypertension about their condition. These studies problematize lay understandings of hypertension as cultural barriers that, alongside health care system barriers, have led to poor health outcomes (Najimi et al, 2018; Risso-Gill et al, 2015; Sison et al, 2020)

Methods

Results

Discussion

Conclusion