Demands in the therapeutic itinerary of the elderly: a descriptive study

ABSTRACT

Objective

To analyze the demands in the therapeutic itinerary of the elderly within the health care network.

Method

Descriptive, time cut, qualitative approach study. Sample consisted of 23 elderly, aged 70 to 79 years attending an outpatient care unit, from June 2014 to July 2015. The semi-structured interviews were conducted individually, in the unit that makes up the secondary level of the Health Care Network. The transcripts of the recorded interviews and data analysis were based on the principles of Grounded Theory.

Results

Experiences of comings and goings within the health care network were evidenced; long and complex paths and trajectories; lack of humanity and delay in service.

Conclusion and implications for practice

For the elderly, the health network structure generates itineraries that are permeated by streams of uncertainty regarding their health condition and illness, also pervaded by delayed exams and treatment. The study points out the existing need for nursing assessment and interventions sensitive to the elderly’s experiences at different levels of the healthcare system.

Keywords:
Elderly; Health care; Treatment; Nursing

RESUMO

Objetivo

Analisar as demandas no itinerário terapêutico de idosos na rede de saúde.

Método

Estudo descritivo, corte temporal, de abordagem qualitativa. Amostra constituída por 23 idosos, entre 70 e 79 anos em tratamento ambulatorial, entre junho de 2014 a julho de 2015. As entrevistas semiestruturadas foram realizadas individualmente, dentro da unidade que compõe o nível secundário da Rede de Atenção à Saúde. Transcrição das entrevistas e análise dos dados orientadas pelos princípios da Teoria Fundamentada nos Dados.

Resultados

Foram evidenciadas experiências de idas e vindas pela rede; longos e complexos caminhos e percursos; falta de humanidade e demora no atendimento.

Conclusão e implicações para a prática

Para os idosos, a estrutura da rede de saúde gera itinerários permeados por fluxos de incertezas com relação à sua condição de saúde e doença, atravessada também pela demora nos exames e no tratamento. O estudo indica que existe a necessidade de avaliações e intervenções de enfermagem sensíveis às vivências do idoso nos diferentes níveis de atenção.

Palavras-chave:
Idoso; Assistência à Saúde; Tratamento; Enfermagem

RESUMEN

Objetivo

Analizar las demandas en el itinerario terapéutico de personas mayores en la red de salud.

Método

Estudio descriptivo, corte temporal, de abordaje cualitativa. Muestra constituida por 23 pacientes, entre 70 y 79 años en tratamiento ambulatorio, de junio de 2014 a julio de 2015. Las entrevistas semiestructuradas fueron realizadas individualmente, dentro de la unidad que conforma el nivel secundario de la Red de Atención a la Salud. Las transcripciones y el análisis de las entrevistas grabadas se realizaron siguiendo los principios de la Teoría Fundamentada en los Datos.

Resultados

Se evidenciaron experiencias de idas y venidas en la red; largos y complejos caminos y trayectos; falta de humanidad y retraso en el atendimiento.

Conclusión e implicaciones para la práctica: Para los mayores, la estructura de la red de salud genera itinerarios impregnados por flujos de incertidumbres con respecto a su estado de salud y enfermedad, también por la demora en los exámenes y tratamiento. El estudio señala la necesidad existente de evaluación e intervenciones de enfermería sensibles a las experiencias de las personas mayores en diferentes niveles de atención del sistema de salud.

Palabras clave:
Personas mayores; Atención a la Salud; Tratamiento; Enfermería

INTRODUCTION

Population aging is a phenomenon of global coverage, presents challenges and opportunities for nursing worldwide, especially in Brazil. The fast and continuous increase in the proportion of people aged 60 years or older, characterizes this age group as having differentiated growth, when compared to other age groups. The change in the demographic profile of the Brazilian population is in line with the change in the epidemiological profile, with an increase in the number of chronic noncommunicable diseases (NCDs), which, in the middle of the second decade of the 21^st century, are responsible for 74% of deaths in Brazil,¹ when 71% is the world average.² People with NCDs need health and nursing care at different levels of attention. In Brazil, national indicators show that the elderly are the portion of the population that most makes use of health services.^1,3

Configuring, therefore, a challenge for the public health system, this epidemiological reality generates an increase in the demand for health services, especially for people aged 60 or over, being them the ones most affected by the main causes of hospitalization.⁴

In the public health system, the demand of elderly people with NCDs is quantified based on the record of their care. In this study, the voice of the participants advances and brings to science what has not been achieved by the registration systems and attendance statistics. In addition to the itinerary, followed by the elderly person during the treatment process, they bring their experiences with the disease, the professionals and the procedures performed.

Namely, in this context, the term itinerary means path to be taken⁵ in the field of health, in addition, the expression therapeutic itinerary is understood as the path taken by the individual throughout the entire treatment process, including access to health services, consultations, and exams, among other elements.

In order to meet the specificities of the elderly and in accordance with the recommendations of public policies aimed at this age group, it is essential and necessary to understand the treatment process for the elderly, including those who have NCDs. In a local context with the potential to inform global impact actions, aligned to support the improvement of health care, with regard to the system, its structure, physical and of personnel, the present study aimed to analyze the demands in the therapeutic itinerary of elderly people in the health network.

METHOD

Descriptive study, time cut, with a qualitative approach. The sample consisted of 23 elderly people, with preserved cognitive ability, undergoing treatment/monitoring of their physical health, with active medical records at the School Clinic of the Faculdade de Medicina de Petrópolis and Faculdade Arthur Sá Earp Neto. Data collection was carried out from June 2014 to July 2015, a period in which the elderly were captured in the waiting room of the school clinic and invited to participate in the study. The interviews were conducted individually, in a reserved environment, within the outpatient care unit with a maximum duration of 20 minutes and guided by a semi-structured interview script. The participants’ preserved cognitive ability was assessed prior to the interviews using a Mental Assessment tool⁶ in order to ensure the reliability of the interviews. This instrument is widely used cross-culturally, and it verifies the presence or absence of brain syndrome / cognitive preservation in the elderly, regardless of their level of education and culture. Those who had a diagnosis of mental disorder and had a score lower than five (˂5) on that scale were excluded. After recording in digital audio, each testimony was transcribed, checked, coded, compared and contrasted between themselves and the others using analysis tools and in the light of Grounded Theory.⁷ Performed continuously, since the beginning of the collection, the analysis determined the sample size by the criteria of saturation and reaching of data density. In compliance with Resolution 466/2012 of the National Health Council,⁸ all ethical and legal aspects were respected. The study approved by the Research Ethics Committee of the Escola de Enfermagem Anna Nery / São Francisco de Assis Hospital of the Universidade Federal do Rio de Janeiro, under protocol No. 664,853, on May 28, 2014. The elderly were clarified about the objectives and study procedures, then signed the Free and Informed Consent Form. To ensure anonymity, participants were identified by the vowel E, followed by the number of the order in which the interviews were conducted.

RESULTS

The study included 23 elderly people aged between 70 and 79 years old, most of them female, widows, retired and with incomplete high school education. The participants’ therapeutic itinerary consisted of permeated flows of uncertainties regarding their health and illness condition, due to the delay in exams and treatment, as revealed in their testimonies and experiences.

Paths taken

The course of predictable or traditional paths, present in the interviewees’ testimonies, reveals a therapeutic itinerary accompanied by several comings and goings in different health services, aligned with strategies to achieve their treatment.

I was undergoing treatment at that clinic that was on the side of Lojas Americanas [Downtown], later transferred to [neighborhood] Morin, from there to Rua Dom Pedro [Downtown] and now it is by UPA Centro (emergency care unit), where I remain treating (E1).

I started treatment at the UPA [Downtown], but I had a leg problem for a long time. They gave me a paper to take an exam, I went to book at the clinic that is in Ponte Fones [in the Quitandinha district], but as I was very ill I went straight to the Emergency Room [in the Bingen neighborhood]. I was lucky there, because the doctor who saw me in the emergency made the prescription and I did the exam right there. If I was going to do it at the previous clinic, it would take a long time, I would have to make an appointment, I wouldn’t be able to wait (E1).

To perform the surgery, I took the papers to the Health Department [Downtown], because I was sent there, but first, I went to a popular health consultation (affordable healthcare) at the clinic of the doctor who operated on me, to get the surgery order, but as the request could not be from the private clinic, I had to make an appointment at the UHS post in the [neighborhood] Cascatinha, there the doctor gave me the UHS referral to the eye clinic with the public service. After that, I waited two months and managed to have the surgery (E22).

Difficulties pointed out

The difficulties faced by the elderly before and during the treatment process brought positive and negative aspects related to health services, professionals and the treatment location. In the analysis of the testimonies, it was possible to apprehend that the therapeutic itinerary was complex, described as a long path, where the majority of the elderly found it difficult to schedule routine and/or return visits, perform exams, get hospitalized, receive information and/or clarifications about treatment. Sometimes it has a lack of humanity, of specialists and, delays in attending and performing exams. In the emotional sense, the trajectory is difficult, time-consuming and uncomfortable, permeated by uncertainties regarding their health, illness and treatment.

I did all the exams in January before operating on March 12. Here at the hospital, right here, but before I stayed in the Emergency Room waiting for a place to stay, I waited eight days because the hospital couldn’t admit me, it was crowded. It was only after eight days of waiting that I was able to enter the surgical clinic (E8).

I think there needs to be more specialists, orthopedists, if there were more specialists, things like that, it would be better not only for me, but for everyone. It would be easier to make an appointment, because it takes too long. Check this out, I’ve been in line for an eye exam for four months now, waiting to make an appointment. I once waited two years, and ended up paying for a popular health consultation (affordable healthcare) (E21).

I was treating myself at the hospital with doctor L.H., I had a bladder problem, I spoke to the doctor: doctor, don’t you think I could have an exam to see what it is? He said he didn’t need to, because this is a woman’s disease. Day after day, I was feeling worse, when it came a day that I left home, when I came back, I came back feeling really bad, wanting to urinate and I couldn’t, so I went to the emergency room. There, I did some tests with Doctor R. and he said: it will need operating. So, I went to the hospital and I had an operation, thank God I’m not feeling anything anymore (E2).

Treatment assessment

The assessment of the treatment/care received during the treatment process revealed, in most statements, appreciation and opinion about the treatment instituted. It showed that the experience by the elderly person was satisfactory or adequate. However, despite the fact that the elderly affirm in most of the testimonies, that the health services somehow met their needs, they also reiterate the delay in scheduling, and an insufficient number of professionals.

Oh, no doubt, very good! I live practically normal with the treatment I have here, I have the drugs that they give me for free. I found a way, here I stayed and stopped and I don’t intend to leave. I ask God not to send me away. I am being very well attended by doctors, nurses, I have been very well attended (E3).

It was not difficult to make an appointment, it is now difficult because it takes many days to get the next appointment. It was like that, I left the house I brought the paper to the reception and they scheduled this nursing consultation. This appointment has been in effect since June 23, two months apart. In the meantime, we could even die (E6).

Revealed suggestions

In contrast, we addressed the question about what changes could be made in health services to make better and/or improve the care of the elderly person undergoing treatment in the outpatient or hospital environment. Most responded that there was nothing to suggest, since their needs were met during the treatment process.

A suggestion is even difficult to say, because they treat you very well, what else, what more would I demand? I will want something that is not in reach, it’s great! (E2).

The service here is something out of this world, it is a precious thing. I have no suggestions, I think there is no way to improve the treatment, the sympathy, taking things seriously, there is no such thing, this is very important. The service is rated 1000, I am satisfied, it is too good, there is nothing like it (E24).

Ah, I went to the A.C. hospital, I don’t remember when, but I know it was when I had a very strong crisis. Oh! I remember now, I had a thrombosis in that right leg. I almost passed out from so much pain, so I had to be hospitalized and had my thrombosis treated at this hospital. I was hospitalized for about 20 days, I was well attended, at the time I was very well attended. Everything just right. Everything I needed, including at night, when I woke up 2 am screaming in pain, the nurse at the same time ran there with the medicine (E3).

The elderly also pointed out that there is a need to improve care, hire more health professionals, anticipate appointments and promote educational actions to make the population aware of the need for self-care or taking care of your own self and the importance of prevention.

It can get better, having more doctors, making an appointment faster, that sometimes it takes us two months to get the appointment. There is an exam that takes three months to do. I go after it, I can’t afford a health plan, I have to go after it, there are other people who wait and even forget. I don’t forget, I really go after it (E25).

Empowering people, referring to the population. Guiding on how to take more care, you know? Not letting go and always seeing a doctor, if it takes long it happens what happened to me. I did the exams, one year I stopped doing it, I had the request, but I didn’t do it, when I went to do it again, lung cancer appeared. Only in a year how do you say ... I don’t know how, but it appeared (E4).

DISCUSSION

The testimonies and the meanings of the elderly with CNDs in relation to the therapeutic itinerary demonstrate that the experience of the treatment process was not harmonious, calm or easy. In most of the testimonies, two to three services were listed that the individual went through before being able to establish themselves in the place where they actually received the assistance they needed. Reality for the elderly population that causes disorders, dependence on companions and, often to give up on continuing treatment.

The reports indicate that the services do not offer support to meet the needs of exams, consultations with specialists and specific medications, considering that they are constantly referred to other health units, with delay in resolving the problem.

In a study carried out in Northwest Paraná with people who had cancer similar data was found, which showed that stream and communication were weakened during the therapeutic itinerary, where the waiting time between diagnosis and the decision to treat generated anguish, expectation and uncertainties as to the next steps to be followed.⁹

Although with people in a more advanced stage of life, similar situations in search of care also occur with other age groups in different contexts, as found in the study carried out with women with high-grade scaly intraepithelial lesion of the cervix, and attended in different modalities of primary health care in the interior of Northeastern Brazil, which revealed that the treatment path is permeated with challenges and obstacles, with low resolution regarding the delay in scheduling medical appointments and access to cervical cytopathological examination, in addition to revealing disjointed and incomplete actions among health services.¹⁰ Such results corroborate and reveal a path taken with comings and goings through several consultations before obtaining the diagnosis, treatment, or reaching the solution of the health problem.

The investigation and the results found in this study confirm that the reported therapeutic itineraries are not exclusive to the elderly population, but rather a reflection of the difficult reality found in the local and regional health services network, which are similar and inefficient to meet the needs of health of the general population, regardless of age or diagnosis. However, when considering the propensity for the elderly to be more fragile, the challenges can be even more striking.

The slowness of services and professionals in the different paths taken by the elderly made them look for strategies to get care. However, even with important challenges until getting the treatment they were looking for, the interaction with the service and the professionals was rated as satisfactory.

Therefore, it is necessary to elaborate measures for the inclusion of specialized care in strengthening care for the elderly, with a view to the effective integration with primary care and other levels of care, guaranteeing comprehensive care, by establishing streams of reference and counter-reference care, also including backup streams to the hospital network and other specialties.¹¹

The main difficulties punctuated by the elderly during the therapeutic itinerary throughout treatment in the present study are supported by literature. Regarding the delay in attendance, a study¹² developed in Fortaleza/Ceará, with users of primary care in the public network found that there is a delay between the day of the consultation or examination and the day of the appointment, few specialists and discontinuity of treatment, a fact that does not occur in isolation, as it is in this contradiction that the public health system articulates.

The delay in assisting the elderly in Brazil is due to the fact that public policy aimed at this age group is in disarray with the guidelines for the care of the elderly in the Unified Health System, which provides that health services must guarantee health care for the elderly, at different levels of care,¹³ and point to the need to reformulate the care service for the elderly.

Factors related to difficulties and dissatisfaction with care were also found in other studies, such as, delay in making an appointment, delivery of exams and difficulties in accessing specialized services, factors that can lead to discontinuity of treatment/follow-up. Other aspects of interpersonal relationships are also highlighted in this process, since communication and reception when not appropriate can generate discomfort and be decisive for the user’s withdrawal or permanence in the health care network, as well as information, facilities, coverage, authorizations procedures and costs,^14,15 corroborating the data pointed out in this study.

The study on users of the UHS¹² also pointed out that, despite the difficulties revealed, the participants were satisfied with the services provided. They positively evaluated service and complementary assistance, such as access to medications, exams and outpatient consultations for follow-up, defining them as being fast and efficient, corroborated by the data in this study.

Satisfaction with the use of public and private health services was also investigated in three capitals in southern Brazil, the results showed that 64.1% of the participants are satisfied with the care received in the countless trajectories and in the different services analyzed.¹⁴ However, the consulted literature does not describe possible conflicts of interest, cultural issues of the elderly generations interviewed or even fear by the elderly to criticize the health system in the context where data collection took place.

CONCLUSION

The elderly undergoing treatment considered the therapeutic itinerary “easy” in the context of public health, had favorable social relationships and received help to arrange appointments, schedule exams and/or hospitalization. However, it is clear the need for public services to present solutions in services provided to the population in order to serve them with quality and efficiency.

The contradictions in the perception of the elderly regarding the challenging treatment process and the contentment with the service provided and with the professionals involved in the care, also point to a stream which is bureaucratized and subject to substantial improvements. For them, the structure of the health network generates an itinerary permeated by streams of uncertainties regarding their health condition and illness, due to the delay in exams and treatment.

It is noteworthy that this study has limitations due to the small sample of participants and because it is a reality in an outpatient clinic, so the results do not allow to state that the situations found are conclusive. It is necessary to expand the data with longitudinal studies in different scenarios, processes, paths and, cultures in favor of checking for possible variations in care demands and generalization of the findings in the present study.

An additional limitation is that the participants in the studies did not have the necessary comfort to verbalize the potential for improvement of services, when by comparison and contrast, they were shown to describe episodes of insufficient respect for citizenship rights as a principle and direct/indirect mistreatment by people that operationalize the health system.

Therefore, as an outstanding recommendation for nursing, the results indicate the need for production - in care and research - of nursing assessments and interventions sensitive to the experiences of the elderly with CNDs in their trajectory at different levels of care.

• FINANCIAL SUPPORT: This work was carried out with the support of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil – CAPES (Coordination for the Improvement of Higher Education Personnel, in free translation) - Financing Code 001, granted to Cristina Gonçalves Hansel with a Full Doctorate scholarship.

REFERÊNCIAS

• ¹
  Instituto Brasileiro de Geografia e Estatística. Síntese de indicadores sociais: uma análise das condições de vida da população brasileira 2018 [Internet]. Rio de Janeiro: IBGE; 2018 [citado 2019 Jun 22]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101629.pdf
  » https://biblioteca.ibge.gov.br/visualizacao/livros/liv101629.pdf
• ²
  Word Health Organization. Noncommunicable diseases: country profiles [Internet]. Geneva: WHO; 2018 [citado 2019 Mar 15]. Disponível em: https://www.who.int/nmh/publications/ncd-profiles-2018/en/
  » https://www.who.int/nmh/publications/ncd-profiles-2018/en/
• ³
  Instituto Brasileiro de Geografia e Estatística. Síntese de indicadores sociais: uma análise das condições de vida da população brasileira 2019 [Internet]. Rio de Janeiro: IBGE; 2019 [citado 2020 Mar 9]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101678.pdf
  » https://biblioteca.ibge.gov.br/visualizacao/livros/liv101678.pdf
• ⁴
  Carvalho IA, Epping-Jordan J, Pot AM, Kelley E, Toro N, Thiyagarajan JA et al. Organizing integrated health-care services to meet older. Bull World Health Organ. 2017;95(11):756-63. http://dx.doi.org/10.2471/BLT.16.187617 PMid:29147056.
  » http://dx.doi.org/10.2471/BLT.16.187617
• ⁵
  Amaral CE, Onocko-Campos R, Oliveira PRS, Pereira MB, Ricci ÉC, Pequeno ML et al. Systematic review of pathways to mental health care in Brazil: narrative synthesis of quantitative and qualitative studies. Int J Ment Health Syst. 2018;12(1):65. http://dx.doi.org/10.1186/s13033-018-0237-8 PMid:30450125.
  » http://dx.doi.org/10.1186/s13033-018-0237-8
• ⁶
  Kahn R, Goldfarb A, Pollack M, Peck A. Brief objective measures for the determination of mental status in the aged. Am J Psychiatry. 1960;117(3):326-8. http://dx.doi.org/10.1176/ajp.117.4.326 PMid:13750753.
  » http://dx.doi.org/10.1176/ajp.117.4.326
• ⁷
  Charmaz K, Belgrave LL. Thinking about data with grounded theory. Qual Inq. 2019;25(8):743-53. http://dx.doi.org/10.1177/1077800418809455
  » http://dx.doi.org/10.1177/1077800418809455
• ⁸
  Resolução n. 466, de 12 de dezembro de 2012 (BR). Dispõe sobre normas e diretrizes regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União [periódico na internet], Brasília (DF), 13 jun 2012 [citado 2019 maio 20]. Disponível em: http://bvsms. saude.gov.br/bvs/saudelegis/cns/2013/res0466_12_12_2012.html
  » http://bvsms.
• ⁹
  Teston EF, Fukumori EFC, Benedetti GMS, Spigolon DN, Costa MAR, Marcon SS. Feelings and difficulties experienced by cancer patients along the diagnostic and therapeutic itineraries. Esc Anna Nery. 2018;22(4):e20180017. http://dx.doi.org/10.1590/2177-9465-ean-2018-0017
  » http://dx.doi.org/10.1590/2177-9465-ean-2018-0017
• ¹⁰
  Galvão JR, Almeida PF, Santos AM, Bousquat A. Percursos e obstáculos na Rede de Atenção à Saúde: trajetórias assistenciais de mulheres em região de saúde do Nordeste brasileiro. Cad Saude Publica. 2019;35(12):e00004119. http://dx.doi.org/10.1590/0102-31100004119 PMid:31800777.
  » http://dx.doi.org/10.1590/0102-31100004119
• ¹¹
  Portaria n. 2528/GM, de 19 de outubro de 2006 (BR). Aprova a Política Nacional de Saúde da Pessoa Idosa. Diário Oficial da União [periódico na internet], Brasília (DF), 19 out 2006 [citado 2020 fev 19]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html
  » http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html
• ¹²
  Arruda CAM, Bosi MLM. Satisfação de usuários da atenção primária à saúde: um estudo qualitativo no Nordeste do Brasil. Interface. 2017;21(61):321-32. http://dx.doi.org/10.1590/1807-57622015.0479
  » http://dx.doi.org/10.1590/1807-57622015.0479
• ¹³
  Ministério da Saúde (BR). Diretrizes para o cuidado das pessoas idosas no SUS: proposta de modelo de atenção integral [Internet]. Brasília; 2014 [citado 2019 Ago 18]. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/diretrizes_cuidado_pessoa_idosa_sus.pdf
• ¹⁴
  Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Cien Saude Colet. 2018;23(6):1751-62. http://dx.doi.org/10.1590/1413-81232018236.06022018 PMid:29972484.
  » http://dx.doi.org/10.1590/1413-81232018236.06022018
• ¹⁵
  Silva LAV, Santos M, Dourado I. Entre idas e vindas: histórias de homens sobre seus itinerários ao serviço de saúde para diagnóstico e tratamento de HIV/Aids. Physis. 2015;25(3):951-73. http://dx.doi.org/10.1590/S0103-73312015000300014
  » http://dx.doi.org/10.1590/S0103-73312015000300014

Edited by

ASSOCIATE EDITOR: Antonio José de Almeida Filho

Publication Dates

• Publication in this collection
  19 June 2020
• Date of issue
  2020

History

• Received
  08 Jan 2020
• Accepted
  14 Apr 2020