Itinerário Terapêutico de pessoas acometidas por amputação em decorrência de pé diabético: enredos de (des)cuidado.

Abstract

Introduction: Chronic illness requires continuous care from individuals and requires that health care modes include interprofessional and intercultural actions. Thus, the subjects compose their therapeutic itineraries, both via the institutionalized sphere of health services, and through the “informal” field, such as religious practices and homemade medications. In this plot, the biomedical model is predominant in the ways services are organized, in the professionals' work processes and in the way users build their paths in the health care network – formal or informal. In this context, diabetes brings with it implications that often require changes in daily activities, social, family and work relationships. In addition, when not properly controlled, it is responsible for several complications, among which the diabetic foot. Diabetic foot is a very serious problem, since it is responsible for greater chances of lower limb amputation. This study analyzes the therapeutic itineraries of individuals with lower limb amputation due to diabetic foot. Methodology: This is a qualitative research, developed with 20 people who had amputation of lower limbs due to diabetic foot, living in rural and urban areas of Vitória da Conquista, Bahia. Data production involved in-depth semi-structured interviews and data were analyzed using Thematic Content Analysis, with the Holistic Analysis of Therapeutic Itineraries as theoretical-methodological support. Results: Four dimensions were evidenced: 1) Facing the illness - senses and meanings lead behaviors. The understanding of the health-disease-care process, influenced by the sociocultural context, defined the starting moment of the search for care. The absence of symptoms delayed the search for assistance and limited knowledge about the disease conditioned the reluctant behavior. In addition, the illness brought suffering to the subjects who felt powerless when facing the complications of the disease. 2) Dealing with vulnerabilities – economic and social aspects mark IT decisions. The subjects lived in socioeconomic vulnerability and this condition worsened with the amputation. The long waiting periods in the public network led the subjects to search for private services, negatively affecting the financial capacity of the families, once aggravating the health situation due to the economic impossibility of continuing the care in this way. In addition, geographic and economic barriers made it difficult to access health care in a timely manner, since there was a lack of health transport; 3) Mishaps along the way – the search for assistance in the care arenas. The search for care in the formal network was undertaken mostly by the user himself. However, the lack of guidance and referrals by primary health care (PHC) professionals to other points of care may have delayed timely care. This scenario led users to look for other gateways. Furthermore, the lack of counter-referral to the family health unit (USF) led users to seek PHC only in the face of occasional needs after the amputation. Along with care in the formal arena, the subjects concomitantly used informal care, which ranged from religious practices to domestic care; 4) Experiencing illness – assessments of care experiences. Long queues for appointments and exams delayed timely care, generating user dissatisfaction. The absence and turnover of physicians compromised longitudinality in the PHC, leading users to look for these professionals in the private sector. The pandemic was also an important limiting factor in access. These obstacles generated judicialization processes, evidencing access difficulties present in therapeutic itineraries, pointing to dysfunctions in the health system. Final Considerations: The therapeutic itinerary of different people signaled the multiplicity of experiences and the (lack of) care that permeates the different arenas. The symbolic aspects constructed from the sociocultural experiences of the subjects, composed understandings about health-disease-care, defining choices and behaviors along the way. Living conditions surrounded by vulnerabilities widened the gaps in access to health, placing subjects in even more unfavorable social situations. The pathways also exposed important obstacles related to fragile arrangements in the health care network, with incipient coordination of care by the PHC, leaving users at the mercy of building their own care map.