Deconstructing the patient pathway to (in)effective care for hypertension: an application to the Philippines

Abstract

Abstract Patient pathways for hypertension care are clinically-determined and depicted as a linear process: from diagnosis and initiation of treatment, to subsequent follow-up. However, increasing evidence suggests that patient journeys are more complex, involving different points of diagnosis; starting, stopping and changing treatment-in the formal and informal sectors-and multiple re-entries into the system. This longitudinal qualitative study sought to obtain in depth knowledge of these pathways over time. We thematically analysed data from 40 interviews with hypertensive Filipino patients of low socio-economic status, repeated after 12 months to capture health events and actions taken. Data was also collected using mobile phone-based digital diaries in the interim. Low-income hypertensive patients in the Philippines navigate a complex terrain to manage their condition. Barriers facing patients and their coping strategies differ at each stage. The pluralistic health system affects pathway through conflicting and alternative information from outside the formal health sector, social networks and commercial bodies. Patients proactively make decisions on how to manage their condition in relation to these formal and informal systems. Barriers to adherence include factors beyond the health system, notably precarious work contexts which require patients to compromise their livelihoods to follow provider-proscribed treatment. Families act as enables of care, motivating patients to follow or modify their pathway. The concept of an optimal ‘patient pathway' is normative and often ignores the complex reality of patients' lives as they manage multiple priorities. In reality, pathways are cyclical and iterative. Advocating rigid pathways that patients must follow for life is unrealistic, especially for the poor. Instead, health systems need to adapt to reflect patients' fluid life trajectories and expectations to enable them to effectively manage their condition alongside other demands.