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Os circuitos diagnósticos da tuberculose na lógica do paciente: um estudo de caso num centro de tratamento para a tuberculose na área metropolitana de Lisboa
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Introdução: A tuberculose (TB) é uma doença intrinsecamente relacionada com determinantes sociais de saúde. Em países da União Europeia, tende a concentrar-se em zonas urbanas críticas tipicamente mais desfavorecidas, e por vezes, associada a pessoas estrangeiras. A área metropolitana de Lisboa obedece a essas características. A principal estratégia para o controle da doença preconizada pela Organização Mundial da Saúde, a EndTB, prevê um cuidado centrado no paciente. Este pode ser analisado através dos circuitos de cuidados de saúde.
Objetivos: A pesquisa teve dois objetivos principais: analisar os comportamentos de procura de cuidados de saúde e os itinerários, nacionais e transnacionais, percorridos pelos doentes de tuberculose nos circuitos pré-diagnósticos da doença. Quantificar os casos notificados de TB em doentes nascidos no estrangeiro e explorar as dinâmicas que motivam a sua migração recente enquadrando-as no contexto do adoecimento.
Métodos: Um estudo de caso único e crítico utilizando metodologia mista foi realizado entre novembro 2018 e janeiro 2019 num Centro de Diagnóstico Pneumológico (CDP) situado numa zona metropolitana de Lisboa que acumula fatores de risco para a doença. Realizaram-se entrevistas semi-estruturadas a doentes de tuberculose, e análise temática da informação obtida. Quantitativamente realizou-se uma análise exploratória dos casos notificados de TB para o CDP objeto de estudo (2008-2018), utilizando dados do sistema de vigilância da tuberculose.
Resultados: Os circuitos pré-diagnósticos dos doentes foram descritos e analisados. Os comportamentos de procura de cuidados de saúde foram categorizados em quatro tipos: inibido, atempado, prolongado e ausente, de acordo com os atrasos associados. Na área de estudo, entre 2008 e 2018, 46.7% dos casos notificados de TB deveram-se a doentes nascidos no estrangeiro, entre migrantes recentes e migrantes longo-termo. Alguns doentes TB com entrada recente no país empreenderam circuitos transnacionais em busca de cuidados de saúde essencialmente devido a uma perceção de baixa qualidade dos cuidados de saúde nos seus países de origem. O serviço de urgência foi a principal porta de entrada para o diagnóstico da tuberculose na área de estudo e os cuidados de saúde primários foram infrautilizados.
Conclusão: A prestação de um cuidado de saúde centrado no doente pode ser analisada através dos itinerários dos doentes e os seus atrasos associados; assume-se que quanto maiores os atrasos diagnósticos, menos a prestação de cuidados é centrada no doente. O comportamento de procura de cuidados de saúde reflete uma relação entre os serviços de saúde e a população servida; a sua categorização ajuda na identificação de padrões de comportamento que pode ser útil no desenho de intervenções na saúde. A sobreutilização dos serviços de urgência pode significar uma falha na prestação de serviços de saúde na área de estudo e deve ser analisada nas suas causas e consequências. A tuberculose no contexto estudado apresenta uma componente considerada de origem endógena e outra exógena. Os circuitos transnacionais de procura de cuidados de saúde por parte de pacientes migrantes recentes refletem as perceções e experiências negativas de adoecimento nos seus países de origem.
Introduction: Tuberculosis (TB) is a disease intrinsically related to social determinants of heath. In the European Union countries, tuberculosis tends to cluster in typically unequal critical urban areas, sometimes associated with foreign-born people (migrants). The Lisbon Metropolitan Area follows this pattern. The main strategy for disease control endorsed by the World Health Organisation, the EndTB, supports a patient centred care. This type of care can be analysed through patients´ healthcare pathways. Objectives: This research presented two main goals: analyse TB patients´ healthcare seeking behaviour and healthcare pathways in their national and transnational (migrants) pre- diagnostic itineraries. Quantify the number of notified TB cases in foreign-born patients and explore the dynamics motivating their recent migration in the context of illness. Methods: A critical single mixed-method case study was performed, and field work carried out between November 2018 and January 2019, in a Centre for Pneumological Diseases (CDP) localised in an urban setting of the Lisbon Metropolitan Area accumulating TB risk factors. Semi-structures interviews were conducted with TB patients and thematic analysis of the information was performed. Quantitatively, an exploratory analysis of the notified tuberculosis cases (2008-2018) for the studied CDP was conducted using data from the tuberculosis surveillance system. Results: Patients´ pre-diagnostic pathways were described and analysed. Healthcare seeking behaviour was categorised in four groups according to delays, which were: inhibited, timely, prolonged, and absent. For the period of 2008-2018, 46.7% of notified cases in the studied area were due to foreign-born patients; some were recently arrived migrants and others long-term migrants. Perception of low-quality healthcare in origin countries led recently arrived migrants to travel over transnational pathways of healthcare. The emergency room was the main entry point for TB diagnosis in the studied area and primary healthcare was underused. Conclusion: A patient-centred care can be analysed through patients´ healthcare circuits of care and its associated delays; we assumed the longer the delays presented by healthcare delivery services, the less patient-centred it is. Healthcare seeking behaviour reflects a relationship between health delivery service and the population served; its categorization helps to identify patterns of behaviours that can shape healthcare interventions. The overuse of emergency room services may suggest a failure of health delivery services in the studied area and should be analysed in its causes and consequences. Tuberculosis in the studied context presents an exogenous and an endogenous component regarding its origin. Recent migrant patients´ transnational circuits of healthcare reflect negative illness experiences and perceptions in their origin countries.
Introduction: Tuberculosis (TB) is a disease intrinsically related to social determinants of heath. In the European Union countries, tuberculosis tends to cluster in typically unequal critical urban areas, sometimes associated with foreign-born people (migrants). The Lisbon Metropolitan Area follows this pattern. The main strategy for disease control endorsed by the World Health Organisation, the EndTB, supports a patient centred care. This type of care can be analysed through patients´ healthcare pathways. Objectives: This research presented two main goals: analyse TB patients´ healthcare seeking behaviour and healthcare pathways in their national and transnational (migrants) pre- diagnostic itineraries. Quantify the number of notified TB cases in foreign-born patients and explore the dynamics motivating their recent migration in the context of illness. Methods: A critical single mixed-method case study was performed, and field work carried out between November 2018 and January 2019, in a Centre for Pneumological Diseases (CDP) localised in an urban setting of the Lisbon Metropolitan Area accumulating TB risk factors. Semi-structures interviews were conducted with TB patients and thematic analysis of the information was performed. Quantitatively, an exploratory analysis of the notified tuberculosis cases (2008-2018) for the studied CDP was conducted using data from the tuberculosis surveillance system. Results: Patients´ pre-diagnostic pathways were described and analysed. Healthcare seeking behaviour was categorised in four groups according to delays, which were: inhibited, timely, prolonged, and absent. For the period of 2008-2018, 46.7% of notified cases in the studied area were due to foreign-born patients; some were recently arrived migrants and others long-term migrants. Perception of low-quality healthcare in origin countries led recently arrived migrants to travel over transnational pathways of healthcare. The emergency room was the main entry point for TB diagnosis in the studied area and primary healthcare was underused. Conclusion: A patient-centred care can be analysed through patients´ healthcare circuits of care and its associated delays; we assumed the longer the delays presented by healthcare delivery services, the less patient-centred it is. Healthcare seeking behaviour reflects a relationship between health delivery service and the population served; its categorization helps to identify patterns of behaviours that can shape healthcare interventions. The overuse of emergency room services may suggest a failure of health delivery services in the studied area and should be analysed in its causes and consequences. Tuberculosis in the studied context presents an exogenous and an endogenous component regarding its origin. Recent migrant patients´ transnational circuits of healthcare reflect negative illness experiences and perceptions in their origin countries.
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Saúde pública Tuberculose