Therapeutic Itineraries Research Articles

Incapacidade prolongada para o trabalho: perda de direitos, sobrevivência e tangenciamento da atenção primária à saúde

Abstract This article aims to explore the experience of long-term work disability (LWD) of users-workers in primary health care (PHC), understanding the therapeutic itineraries and the search for social protection, the elements that contribute to the incapacitation process and the strategies constructed for living with this condition. LWD is a multidimensional phenomenon, with a negative impact on the lives of workers, families and society. PHC has an important role in caring for people on leave from work. This is a qualitative, descriptive-exploratory study of the daily lives of people in situations of LWD. The comprehensive perspective guides the analysis of data co-produced in interviews and field observation. Cross-cutting themes such as social lack of protection, lack of communication and co-operation between key actors that enhance or mitigate LWD were recognised. The social support network proved to be important to access health care and to avoid social decadence. The Family Health Strategy, with technical support in Occupational Health, emerges with potential in the production of care for worker-users, although the fragility of maintaining long-term care.

Therapeutic itinerary for people with Rheumatoid Arthritis and its impact on the production of care

RESUMO A falta de intervenção em momento oportuno para pessoas com Artrite Reumatoide pode acarretar dores, processos inflamatórios e incapacidades, fato que motivou a investigação, cujo objetivo foi analisar o itinerário terapêutico da pessoa com Artrite Reumatoide e sua repercussão para produção do cuidado. Abordagem qualitativa, com deslocamento in-mundo para construção de uma pesquisa-interferência, apoiada em alguns conceitos da análise institucional. A produção dos dados ocorreu por meio de entrevista com uma pessoa acometida pela Artrite Reumatoide para construção de seu itinerário terapêutico, posteriormente apresentado a grupos de trabalhadores da Atenção Primária à Saúde. Como resultado, o itinerário terapêutico concentrou-se no percurso assistencial, busca pelo diagnóstico e possíveis soluções para controle da dor. Nos grupos, os profissionais da Atenção Primária à Saúde manifestaram perda de autonomia e repasse da responsabilidade do acompanhamento e do cuidado longitudinal para a atenção especializada. Dessa forma, a não banalização da dor, a necessidade de debate acerca das garantias para o acesso aos serviços com acompanhamento adequado e a existência de novos investimentos para resgate das ações de matriciamento, além de elaboração de protocolos para melhoria do acesso são pistas para o combate à insuficiência dos serviços públicos na garantia do direito universal à saúde.

Therapeutic itinerary of individuals who use alcohol and other drugs: an integrative review

This study aimed to understand the trajectory of individuals who use alcohol and other drugs towards healthcare services. It is an integrative literature review that sought to answer the question: "What are the trajectories followed by drug users until they reach a healthcare service?". The descriptors "trajectory," "drug users," "qualitative research," and "health services" were used in the databases Pubmed, BVS, Web of Science, Scopus, and Science Direct, resulting in a total of seven articles. Drug use can be motivated by various factors, including peer influence, traumatic experiences, and the pursuit of well-being. Family can represent both a risk and a protective factor. Seeking help is often motivated by family concern and typically begins at the primary healthcare unit. Therefore, nurses play an important role, operating in different drug use contexts and encouraging the treatment and rehabilitation of users, as well as the support of their families.

Therapeutic Itinerary of Patients with Chronic Heart Failure at the Bafoussam Regional Hospital, West Region, Cameroon

Background: Cardiovascular diseases have emerged as a growing public health problem worldwide, with heart failure being the end point of a greater majority of poorly diagnosed and managed heart diseases. In Sub-Saharan Africa, traditional medicine still has a remarkable influence on health care systems, and in Cameroon, the referral/counter-referral system thought to be implemented is not efficiently applied. Heart failure patients fall amongst the group of victims affected by this problem. Many studies have been carried on heart failure in Cameroon, but data on this subject remains sparse.
 Objective: To identify the therapeutic itinerary adopted by symptomatic patients with chronic heart failure seen at the Bafoussam Regional Hospital (BRH) and determine the outcome following management by cardiologists, so as to provide results-driven interventions to increase the rate of early management of heart failure by appropriate health services and limit complications due to wrong therapeutic orientations.
 Methods: A hospital-based cross-sectional descriptive study was carried, from February 2019 to May 2019 at the Bafoussam Regional Hospital. A consecutive sampling technique using objective-related structured questionnaire was used to select patients aged above 18 years seen at the study site. Data was analyzed using SPSS (Statistical Package for Social Sciences) version 23. A p-value less than 0.05 was considered statistically significant.
 Results: The BRH Cardiologist consultation was the 1st station sought by 32 (23.7%) of patients. We found 14.8% of cases and 8.9% who had as first therapeutic stations home management and traditional healers respectively. Majority of participants went through a total of 2 stations, 60 (44.4%), and only 5 (3.7%) went through 5 therapeutic stations. Most participants (36.3%), delayed for 1-3 weeks after onset of symptoms before seeking a means of intervention. NYHA (New York Heart Association) stages were generally improved after cardiologists’ follow up (54.1% and 26.7% for stages I and II respectively), compared to that before entry (0.7% stage I, 41.5% stage II, 38.5% stage 3, and 19.3% stage IV), which was statistically significant with P < 0.0005.
 Conclusion: There is a high proportion of HF patients who do no adopt an ideal therapeutic itinerary following the health pyramid from the onset of symptoms, hence the need to educate the population on cardinal signs of heart failure, especially patients with known risk factors, and to encourage the referral of patients in order to limit complications between the onset of symptoms till cardiologist consultation.

Perceptions and use of Universal Health Coverage (Plan Sésame) among the elderly in Dakar (Senegal), impacts on health expenditure related to diabetes and hypertension

In 2006, the Senegalese government set up a health coverage programme for people aged 60 and over - the Plan Sésame - to provide free medical care in all the country's public health facilities. This scheme has been integrated into the Universal Health Coverage (CMU) promoted from 2013. The objective of the study was to describe and analyse the knowledge and representations of professionals and users about health coverage and the Plan Sésame, the use of the scheme by the elderly, to evaluate the amount of medical expenses incurred during a routine medical consultation for the monitoring of their illness (hypertension and diabetes), and to calculate the out-of-pocket expenses related to the consultation. Study conducted between July 2020 and October 2021 in two public health facilities in Dakar. Mixed approach: 1/ qualitative study by semi-directive interviews, informal interviews, observations and field diary with 35 people selected according to a reasoned choice procedure with the aim of diversifying gender, age, social status, therapeutic itineraries for 23 people (including 12 women, ages between 60 and 85 years), and professional activities for 12 health actors; 2/ quantitative cross-sectional study by questionnaire of 225 people (including 141 women) aged 60 and over; we calculated the total cost of the consultation and associated prescriptions (complementary examinations and medicines) as well as the remaining medical expenses (out-of-pocket) and the cost of transporting patients. This is a descriptive exploratory study of a non-representative sample of the elderly population in Senegal. The health professionals interviewed supported the principle of health coverage, but most of them had limited and sometimes imprecise knowledge of the existing schemes and the methods of access or the services covered. Their point of view about the consequences of the Plan Sésame on their practice reveals some contradictions: some complain about the increase in workload, the criticism is extended to all the free schemes which would have a negative impact on daily practice because of the increase in the number of consultations which would be linked to abuse by patients.The interviews highlight the heterogeneity of the knowledge of elderly people about the health coverage intended for them, even though the Plan Sésame has been in place for over ten years. The interviews clearly show that the use of the health coverage system by the elderly depends closely on the information they have and their ability to use it, both for women and men. There is a close link between the level of social integration of people and their use of health coverage: the most socially integrated people are those who know how to use CMU services best. The use of health coverage by the elderly appears to vary according to the individual.Although Plan Sésame is defined as part of a national strategy, its implementation varies according to the health structures and the periods; in the two study sites, the range of services covered by Plan Sésame is very limited, so the coverage provided by Plan Sésame is only partial: between 30 and 50% of the medical costs; the remaining cost of a consultation for elderly patients with hypertension and/or diabetes varies between 24,000 and 28,000 CFA francs.These amounts must be put into perspective with the resources available to people. Statistical studies published in 2021 report that in Senegal the average daily expenditure is 1,390 CFA francs/person/day; and that almost 38% of the population lives on 913 CFA francs/person/ day, which is the poverty line calculated in 2019. Thus, the average out-of-pocket expenses for a follow-up consultation for hypertension, diabetes or a combination of the two diseases represent 15 to 30 days of daily expenditure. While the vast majority of elderly people in Senegal do not have a retirement pension, health expenses are therefore borne by their relatives. Within households, medical expenditure for the elderly competes with basic needs, particularly food, which usually take up more than half of household resources. This indispensable family support places the elderly in a situation of total dependence. In 2021, Plan Sésame does not yet allow for completely free care for the elderly. However, its application, even partial, has resulted in a real reduction in health care costs for the elderly. Its use remains limited due to inconsistent application by most health structures. Its impact is insufficient in view of the amounts that users have to pay in a context of social and economic vulnerability. These observations reinforce the need to work on reducing the price of medical services and strengthening the UHC, in order to improve the equity and performance of the system, and to make it fully functional in all health structures.

The therapeutic itinerary of severe COVID-19 survivors in a small-town municipality

This study aimed to understand the trajectory undertaken by survivors of severe COVID-19 in a municipality in the interior of Brazil. It is a qualitative study with a descriptive and exploratory approach. Ten survivors of severe COVID-19 residing in a municipality with 17,000 inhabitants participated. Among the sought-after care were home, professional, and religious care. The categorization of narratives into "popular sphere and the praxis of self-care" and "professional sphere and the quest for resolution" highlights the influence of culture on the health-disease process and the care experience. The study demonstrated that the trajectory began with popular care, followed by professional and folk care, clearly indicating the interconnection of both practices in seeking health-related care. The importance of understanding the specificities in the care experience of severe COVID-19 reinforces the importance of including popular and religious practices in the healthcare system.

PSYCHOLOGISTS’ PERCEPTION OF PRE-EXPOSURE PROPHYLAXIS FOR HIV (PREP) IN MATO GROSSO

HIV Pre-Exposure Prophylaxis (PrEP) is a public health strategy to reduce the probability of HIV acquisition by people at high risk of exposure. This paper addresses the perception of psychologists in the primary health care public system about the PrEP policy in the state of Mato Grosso, Brazil. Through semi-structured interviews, we sought to understand the therapeutic itinerary in the unit where it takes, as well as the opinions and involvement of the psychologists in the implementation of PrEP. There is a lack of definition regarding the attributions and scope of action of the psychologist in relation to PrEP in health units. In some, reception is mandatory in the first service, in others only if there is a request from the user. The interviews revealed that there are distrust and prejudice in relation to the policy and users' social behaviour, as well as the recognition of the lack of training and dissemination as the primary motivations for the low adherence. Psychologists proved to be important professionals in implementing PrEP. Notwithstanding, more dialogue is needed with management at the local and state level so that doubts, beliefs, and social representations are discussed and do not compromise the effectiveness of the policy.

Therapeutic Itineraries of Breast Cancer Patients in Burkina Faso

Therapeutic Itineraries of Breast Cancer Patients in Burkina Faso

“Minha vida é me cuidar”: itinerários terapêuticos de cuidado para a pessoa idosa em processo de fragilização

Abstract The present study sought to understand how frail older adults perceive their therapeutic care itineraries. This qualitative research was based on Critical Medical Anthropology. Data were collected through interviews in the homes of 22 older adults, whose average age was 79. The emic analysis was guided by the model of Signs, Meanings, and Actions. All interviewees expressed access to professional care in their trajectories, which are understood as insufficient, unprepared, prejudiced, uncomfortable, contradictory, (un)accessible, realization, respectful, and excessive. Therapeutic itineraries were also revealed in the psychosocial and cultural spheres. Several day-to-day actions were evaluated and interpreted in the record of self-care and justified by this end: the time they wake up, sleep, what they eat, and how they behave. They face the lack of care policies in their trajectories, labeling their bodies as undesirable due to physical, symbolic, communicational, attitudinal, systematic, cultural, and political barriers. Thus, they bring to light therapeutic pluralism, challenges, confrontations, insistence, and resistance in maintaining care when experiencing old age with frailties.

"My life is about to take care of myself": therapeutic itineraries of care for frail older adults.

The present study sought to understand how frail older adults perceive their therapeutic care itineraries. This qualitative research was based on Critical Medical Anthropology. Data were collected through interviews in the homes of 22 older adults, whose average age was 79. The emic analysis was guided by the model of Signs, Meanings, and Actions. All interviewees expressed access to professional care in their trajectories, which are understood as insufficient, unprepared, prejudiced, uncomfortable, contradictory, (un)accessible, realization, respectful, and excessive. Therapeutic itineraries were also revealed in the psychosocial and cultural spheres. Several day-to-day actions were evaluated and interpreted in the record of self-care and justified by this end: the time they wake up, sleep, what they eat, and how they behave. They face the lack of care policies in their trajectories, labeling their bodies as undesirable due to physical, symbolic, communicational, attitudinal, systematic, cultural, and political barriers. Thus, they bring to light therapeutic pluralism, challenges, confrontations, insistence, and resistance in maintaining care when experiencing old age with frailties.

“It’s my life, not theirs!” Therapeutic itineraries and refugee reflections on referral health care in western Tanzania

Globally, refugees number over 25 million. Yet, little attention has been paid to how refugees access referral health care in host countries. By referral, I mean the process by which a patient deemed too sick to be managed at a lower-level health facility is transferred to a higher-level facility with more resources to provide care. In this article, I provide reflections on referral health care from the perspective of refugees living in exile in Tanzania. Through qualitative methods of interviews, participant observation, and clinical record review, I trace how global refugee policy on referral health care manifests itself in the lives of refugees locally in a country like Tanzania that has strict policies and limitations on freedom of movement. In this space, refugees experience complex medical problems, many of which began prior to or during their flight to Tanzania. Many refugees indeed are approved to be referred to a Tanzanian hospital for further treatment. Others are denied care or pursue other therapeutic itineraries outside the formal system. But, all are subject to policies of Tanzania that restrict freedom of movement and almost all experience delays on several levels (e.g., waiting for a referral, waiting at the referral hospital, waiting for follow-up appointments). In the end, refugees in this context emerge not simply as passive beings upon which biopower is enacted, but also as active agents, sometimes circumventing a system of power in their pursuit of their right to health, all in the context of strict policy that seeks to enforce state security over one's right to health. In the process, refugee experiences with referral health care become a window into the larger politics of refugee hosting in Tanzania in the present day.

Therapeutic improvisation in Cambodia: Moderated exposure, the Tuol Sleng Museum of Genocidal Crimes, and the quest to weave the “world’s longest krama”

This piece examines efforts by Cambodian mental health workers to incorporate two sites of cultural significance into narrative psychotherapy among Khmer Rouge survivors. As part of the “exposure” element of an imported form of Testimonial Therapy (TT)—in which patients retrieve traumatic memories from the past—a subset of patients was taken to the Tuol Sleng Museum of Genocidal Crimes. While embodied engagement with the memorial site served as an effective mnemonic device for participants, it also proved more emotionally overwhelming than counselors initially anticipated. As an antidote, counselors then decided to add another site to the patients’ therapeutic itinerary—an exposition where they could participate in efforts to weave the world’s longest krama. In examining this case of “therapeutic improvisation,” I explore the dynamic social life of memory sites and how they may assist people in renegotiating cultural memory (and identity) in the wake of traumatic social rupture.

Therapeutic Itineraries during the Ebola Epidemic in the Democratic Republic of Congo.

While treating a disease, patients or their relatives make decisions to pursue different therapeutic options, and various stages are involved in searching for a cure. This paper explored the pattern of health-seeking in the Democratic Republic of Congo (DRC) during the 10th Ebola virus disease (EVD) outbreak. Eight hundred randomly selected adults were surveyed using a questionnaire. Qualitative data were also collected through in-depth interviews with 17 community leaders and 20 focus group discussions with community members. The results showed that modern healthcare facilities are not usually considered the first option for treatment. The therapeutic journey generally begins with the patients, who treat themselves based on the what they know about the disease and the resources they have at their disposal. However, if the disease is not cured through self-medication, then patients or their relatives will visit a pharmacy. Patients request medication they know to be effective in treating the disease, and relatives can also assist in obtaining medication in the case of immobile patients. Pharmacies commonly sell the medication to patients or their relatives without a medical prescription.

Anthroposocial-Medical-Educational Approach and Educational Diagnosis of People Living with Type 2 Diabetes: Case of the National Obesity Centre in Cameroon

Therapeutic patient education is an approach that is increasingly used in the management of chronic diseases. It has a structure, the first essential component of which is the educational diagnosis. However, empirical findings show that this first link is often forgotten or poorly negotiated in the implementation of therapeutic patient education. This situation reveals a difficulty in contextualising the proposed models. Hence our objective, which was to describe the process of integrating the anthroposocial-medical approach into the construction of an educational diagnosis for people living with type 2 diabetes. We conducted a descriptive qualitative study in the National Obesity Centre of the Yaoundé Central Hospital. People living with type 2 diabetes and health professionals constituted our target population and our sample size reached saturation with 16 participants (10 patients and 6 professionals). Semi-structured interviews using interview guides were conducted with the participants. The results revealed that in order to integrate the anthropological dimension in the construction of the educational diagnosis, firstly, the health professional must become acquainted with the patient's culture, his or her eating habits, find out about his or her dietary difficulties and investigate his or her behaviour in the usual environment. Secondly, the health professional must get the patient to verbalise his or her representation of the disease, his or her practices and therapeutic remedies. Thirdly, the health professional must get the patient to narrate his or her therapeutic itinerary. In order to integrate the social dimension into the construction of the educational diagnosis, the professional must firstly find out about the patient's economic situation. Secondly, he/she must find out about the patient's profession, his/her plans, find out about his/her professional interactions and assess his/her physical activity. Thirdly, he/she has to find out about his/her interactions with his/her family. Finally, in order to integrate the medical dimension into the construction of the educational diagnosis, the health professional must collect the patient's biomedical data and assess the patient's knowledge of his or her illness. In conclusion, the anthroposocialmedical approach can be considered as a contextual guide in the process of constructing an educational diagnosis which constitutes the foundation for the development of a therapeutic education programme.

Non-Surgical Therapy and Oral Microbiota Features in Peri-Implant Complications: A Brief Narrative Review

The therapeutic discretion in cases of peri-implantitis should take into account the limits and advantages of specific therapeutic itineraries tailored according to each clinical case and each individual patient. This type of oral pathology emphasizes the complex classification and diagnostic issues coupled with the need for targeted treatments, in light of the oral peri-implant microbiota changes. This review highlights the current indications for the non-surgical treatment of peri-implantitis, describing the specific therapeutic efficacy of different approaches and discussing the more appropriate application of single non-invasive therapies The non-surgical treatment choice with antiseptics or antibiotics (single or combined, local, or systemic) for short courses should be considered on a case-by-case basis to minimize the incidence of side effects and concomitantly avoid disease progression.

Experience of ambulance drivers on transfer of suspected or confirmed patients for COVID-19.

To unveil the experience of ambulance drivers regarding the transfer of suspected or confirmed patients for COVID-19. Exploratory study with a qualitative approach conducted in October 2021 with 18 drivers from the Northwestern Mesoregion of the State of Ceará-Brazil. The individual interviews occurred virtually, via Google Meet®, and for data processing the IRAMUTEQ® software was used. Six classes were obtained: Feelings experienced during transfers; Concern about contamination of the work team and family members; Therapeutic itinerary, patients' clinical status and increase in the number of transfers; Disinfection of ambulances between transfers of patients with suspected and/or diagnosed COVID-19; Gowning for patient transfers and Psychospiritual aspects of drivers during the pandemic. The experience was marked by challenges in adapting to the new routine and procedures during transfers. It was evidenced feelings of fear, insecurity, tension and anguish in the worker's reports.

Trem das cores, estação Valença/RJ: itinerário pela saúde LGBTQIA+ no SUS e seus significados

ABSTRACT Even in the face of recent achievements, access to healthcare for the Lesbian, Gay, Bisexual, Transvestite, Transsexual and Transgender, Queer, Intersex, Asexual, and other (LGBTQIA+) population. Therefore, this article’s objective is to shed light on aspects related to the health of these individuals based on their therapeutic itineraries and thereby contribute to the reorientation of care practices with a focus on the potential of Primary Health Care (PHC) as a health system device. This exploratory and descriptive study seeks to understand aspects of health and its meanings for the LGBTQIA+ population based on analyzing answers to a questionnaire and narratives obtained through semi-structured interviews. The analysis is in line with the findings of other authors with whom the study dialogued and highlighted primary care as fundamental equipment in the public network to guarantee the right to health for this population, considering the guiding principles of the SUS and the attributes of the primary care network.

Socio-Cultural Representations and Therapeutic Itineraries of Parents of Autistic Children Followed in the INSP’s Children’s Mental Health Services

Pervasive developmental disorders (PDD) remain little known to populations in developing countries. In black Africa their social representations remain strongly influenced by local belief systems. The general objective of this study was to understand the perceptions and representations of Ivorian parents vis-à-vis PDD. This was a mixed (qualitative and quantitative) prospective cross-sectional study with a descriptive aim that involved a sample of 49 parents. The sampling was of the qualitative type by multiple cases with reasoned choice by saturation. Our results showed that male parents were mostly aged between 40 - 49 years (48.98%) with a higher level of education (67.34%) while mothers were mostly aged between 30 - 39 (61.22%) and a higher level (30.61%). Autistic children were negatively perceived by their parents: either as a source of psychological suffering (82.85%), or as mysterious children who sacrificed their parents (44.66%), or as “bobo” children (mute children in common Ivorian language) (16.66%) or like rude children (13.34%). The supposed origin of the disorder according to the parents was mystical-religious (60.94%); natural (25%); hereditary (6.25%). In 6.25% of cases, PDD were assumed to be of unknown or iatrogenic origin attributable to vaccination (1.56%). 75.51% of parents said that in addition to conventional medical therapies, they also used traditional therapies. The use of this therapeutic alternative would be linked to the perceptions and beliefs that feed the socio-cultural representations of our respondents.

Therapeutic Itinerary of Elderly Living with HIV/Aids: Oral History Perspectives

Resumo Objetivo: Analisar o itinerário terapêutico de idosos vivendo com HIV em assistência num município do Oeste Catarinense. Metodologia: Estudo qualitativo com método história oral temática. A população foi composta por idosos que vivem há mais de cinco anos com HIV/Aids, assistidos em um Serviço de Atendimento Especializado. Foram realizados dois encontros para aproximação e três momentos de entrevistas em profundidade abordando questões relacionadas as trajetórias assistenciais dos sujeitos e sua relação com a doença. A análise de dados foi realizada por meio da análise temática de conteúdo. Resultados e Discussão: Os idosos tiveram seu diagnóstico em fase tardia o que mostra a dificuldade dos serviços de saúde em identificar precocemente o HIV na pessoa idosa. O tratamento foi centralizado na medicação com antirretrovirais, de maneira setorializada em serviço especializado e com equipe constituída por profissional médico, enfermeiro e farmacêutico. Também foi evidenciado baixo acesso a recursos não farmacológicos, como assistência psicoterapêutica. Considerações finais: A trajetória assistencial precisa ser qualificada na direção de garantir maior acesso as redes de saúde e as equipes interprofissionais para uma atenção à saúde integral que realize o diagnóstico precoce com vistas a reduzir os riscos de complicações e ofereça um cuidado integral e humanizado, que extrapole o uso de medicamentos.

Itinéraires thérapeutiques des patients dans un contexte de défaillances du marché de soins au Togo

Introduction : Improving access to and the use of health services remains a challenge for the health system in Togo, given the confidence and quality of care perceived by Togolese citizens.Purpose of research : This study aims to analyze the determinants of the therapeutic itinerary of patients in Togo, with a particular focus on the institutions that regulate the health care market.Results : This is an empirical study, based on data from the Unified Survey of Basic Welfare Indicators (QUIBB, 2015) covering 2400 households. Issues of care market failures are addressed in terms of perceived quality of care and organizational quality. The patients’ care pathway includes self-medication, and the use of public or private health services. Within the framework of a multinomial probit model, the results show that improving the perceived quality of health services increases the probability of using public and private health services with a much higher marginal effect for the use of public services. Organizational quality of health services was also found to increase the probability of using private health services.Conclusions : In view of the results found, it is necessary to improve the regulatory institutions of the health care market in Togo. This improvement requires the implementation of health care policies aimed at improving the professionalism of health care personnel.