INTRODUCTION

Arterial hypertension (AH) is a morbid condition, defined as the persistent elevation of the force or pressure with which blood flows through the arteries, making it one of the main public health problems due to the global burden of morbidity and mortality it generates, responsible for about 10 million deaths and 200 million disability-adjusted life years lost ⁽¹⁾. It is considered the leading cause of premature death, affecting 1.13 billion people, two-thirds of whom belong to low- and middle-income countries ⁽²⁾.

In Colombia, the prevalence of prehypertension and hypertension has been estimated at 62% in adults ⁽³⁾. The CARMELA study showed that at early ages, it is more prevalent in men; however, as age increases, this rate is inverted, becoming more prevalent in women ⁽⁴⁾. A study that followed 33,000 people for 40 years showed that women had a more pronounced elevation of blood pressure ⁽⁵⁾, experiencing a 25% increase in the risk of cardiovascular disease, and men a 15% increase.

One risk for AH is the process of internal migration due to forced displacement, defined as 'persons or groups of persons forced to flee or abandon their homes or habitual places of residence, particularly as a result of armed conflict, situations of generalized violence, or violation of human rights' ⁽⁶⁾. This event fractures the dimensions of material well-being and fundamental rights. This factor is associated with an increased stress and risk of cardiovascular disease ⁽⁷⁾ due to cultural change, even having a greater effect than adjustments in dietary patterns or physical activity ⁽⁸⁾.

One of the key elements to achieve disease control refers to the recognition of therapeutic itineraries (TIs), trajectories that people build in search of their health, going beyond the doctor-patient relationship, linking intersubjective aspects and interactions between the subjects, the community, and the health system ⁽⁹⁾. TIs are individual care practices with sociocultural content that include the choice of practices based on different conceptions of the disease according to the social context, circumstances, available resources, experiences, interests, and conflicts ⁽¹⁰⁾. These TIs are little recognized and assumed in health systems at present.

In TIs, most people resort to different strategies to recover their health. Addressing the sociocultural contexts where these strategies are mobilized allows us to analyze the dynamics of the different actors involved in the health/illness/care process and the relationships between them. This process corresponds to a universal one that operates in all the social groups that make up society, where illness and disease are part of the social and cultural action ⁽¹¹⁾, involving aspects of the political and economic order that explain the way in which care practices, behavior, and life habits are related. Thus, disease is defined by beliefs and values about health care and is circumscribed to cultural configurations where it is reproduced ⁽¹²⁾.

The objective of the study was to understand how migrant women with arterial hypertension configure their therapeutic itineraries in the search for health care within the health-illness-care process in Popayán, Colombia.

MATERIALS AND METHOD

The research adopted a qualitative design with a grounded theory (GT) approach, allowing for the identification of relationships between various categories that emerged from the participants' narratives. This method enables the interpretation of complex phenomena in the field of health, analyzing socially constructed experiences such as disease, access to and utilization of services, and therapeutic adherence ⁽¹³⁾. GT systematically collects data and continuously searches for relationships between them, adopting a historical hermeneutic approach that seeks to interpret and understand people's motivations through their daily actions. This approach facilitates the analysis of socio-historical facts to comprehend reality.

GT is based on symbolic interactionism, wherein people assume behaviors based on the meanings derived from their daily experiences ⁽¹⁴⁾, The researcher endeavors to define these meanings within the ways people relate to their context, approaching what individuals perceive as social reality. In this research, the GT process was pursued until the identification of relationships between emerging categories, without postulating a theory ⁽¹⁵⁾.

The research was conducted between October 2021 and June 2022 in Popayán, Colombia. Sixteen semi-structured interviews and two focus groups were conducted: one for data generation and the other for validation of the findings. A purposive theoretical sampling was carried out to collect empirical data, which were then analyzed and categorized by selecting internal migrant women from municipalities of the Department of Cauca with a diagnosis of AH. Interviews continued until reaching theoretical saturation and abstraction of emerging categories ⁽¹⁵⁾. The inclusion criteria were as follows: being an internal migrant woman due to forced displacement, being of legal age, having been diagnosed with AH, and having resided in Popayán for more than one year. The exclusion criteria were not suffering from cognitive or mental illnesses. All study participants were required to sign an informed consent form, wherein the purpose of the study and their rights in the research were explained verbally and in writing in detail. The custody and confidentiality of the information were in accordance with the Declaration of Helsinki ⁽¹⁶⁾. The study received approval from the Ethics Committee of the University of Cauca, as recorded in act No. 6.1-1.25/77 of June 2021. Both interviews and focus groups were recorded, transcribed in Microsoft Word®, copied to Microsoft Excel®, and analyzed using Atlas Ti ® version 8.1, while always preserving anonymity.

The analysis involved a process of coding and categorization carried out through three iterative moments: open coding, axial coding, and selective coding ^(15,17). As the information was collected, microanalysis was conducted, involving a line-by-line examination of what was expressed by the participants in each interview. Open coding was utilized to capture as much data as possible. The researchers independently applied the open coding system to the women's narratives and then reconciled the emerging categories. This exercise resulted in 1,135 codes, which were organized in an Excel ® matrix and classified by themes. In this stage, theoretical questions were formulated to select concepts and explore their relationships. The data were carefully examined and compared to identify related categories and subcategories, thereby linking coincident data.

According to the grouping of the codes, categories were constructed to indicate a series of practices, events, and situations that were similar and directly related by their meaning ⁽¹⁵⁾. From this input, we proceeded to categorization, which consisted of grouping the codes to establish more complex units and relate them to the data. In this way, categories emerged that made it possible to explain the practices and relationships that women had in their daily lives to meet their health needs. This coding, called axial, related categories and subcategories to achieve precise explanations of the phenomenon, which occurred around the axis of the categories, linking them according to their dimensions and properties. Next, a paradigmatic matrix was made containing emerging elements that supported the understanding of the phenomenon. The paradigmatic matrix was then refined by carrying out the process of analytical reading and re-reading of data and constant comparison that led to the realization of selective coding, a process that integrated and refined the categories according to theory and reality. From this exercise, the main category and related subcategories were obtained.

RESULTS

The process of analyzing the information to understand the therapeutic itineraries of migrant women with AH allowed us to interpret that these trajectories, routes or paths, are determined by the logic of the health system and the categorical influence of social, cultural, political and economic dynamics, defined by the context in which they live. This main category is supported by four interrelated subcategories: risks of becoming ill from AH in everyday environments; heterogeneity of formal and informal therapeutic resources to treat the disease; processes of access to health system scenarios; and practices for follow-up and control (Figure 1).

Source: authors' elaboration

Figure 1. Selective coding: main category and interrelated subcategories. 

DISCUSSION

Once AH is communicated as a disease to women, it is linked to the dynamics for the care of health and life, going beyond the actions of the biomedical scenario. The TI to achieve the control of AH allude to different processes circumscribed in the formal and traditional health system, integrating different curative resources available in the sociocultural fields where women live, as described by Lima et al. ⁽¹⁸⁾ from the logic of the health-disease-care process ⁽¹²⁾, in order to understand the trajectories assumed in the search for care to solve health needs.

The construction of trajectories, paths, routes, or itineraries links aspects related to culture, such as the adoption of healthy lifestyles that have shown a decrease in the risk of AH. However, their continuous and systematic adoption represents great challenges, as they go beyond personal decisions and depend on sociocultural, economic, and family dimensions. These findings are consistent with those described by Ferrer et al. ⁽¹⁹⁾ in studies on lifestyle dynamics. On the other hand, women perform therapeutic practices complementary to those offered in the state health model or in concomitance with it, including traditional, complementary, and alternative medicine. The use of these cultural practices has been associated with dissatisfaction with the conventional health system ⁽²⁰⁾, beliefs about the effectiveness of treatment, accessibility to therapeutics, and the accentuated use in populations living in contexts of poverty and in rural areas ⁽²¹⁾.

Aspects from the political point of view configure itineraries. The operation of the system from a hospitalocentric approach, characterized by restrictions in community action, limits women's care. These findings are consistent with those referenced by Mera et al. ⁽²²⁾ in the study of Colombian health policy. The participants express limitations from what would be the primary health care approach and the existence of organizational barriers to care. Similar results are related by Galindo et al. ⁽²³⁾ from administrative, financial, and geographical aspects, especially in populations living in contexts of vulnerability. These effects affect the therapeutic process to such an extent that women may give up treatment ⁽²⁴⁾. The multiple bureaucratic requirements for women's care complicate access and affect the itinerary within the health system. On the other hand, the limited access to the required health inputs and services coincides with the findings of García ⁽²⁵⁾ in the study of the conditions of health services in Colombia, where care is compromised by inadequate criteria of quality, timeliness, and accessibility.

The economic dynamics shape itineraries. Women's financial limitations do not allow them to meet all the therapeutic recommendations ⁽⁴⁾. The participants report having little money for transportation, payment of moderator fees, purchase of drugs and other out-of-pocket expenses, restrictions that end up disrupting care. These findings are consistent with those described by Bran et al. ⁽²⁴⁾ in their study of barriers to access to the Colombian health system. The migratory process per se generates changes in the itineraries when encountering inequities in health care, as described by Machado ⁽²⁶⁾, either due to lack of support in navigating the system, high cost of care, discrimination from health actors and women's expectations about the quality of treatment. Studies have also related the existence of less access to health care for the migrant population compared to the native population ⁽²⁷⁾.

From the social perspective, different categories are incorporated into the trajectories of the care process, including stigmatization for being a migrant and fear of discrimination ⁽²⁸⁾. On the other hand, fear of disability generates anxiety and joint symptoms of depression, anger, or hostility ⁽²⁹⁾ that exacerbate the presentation of cardiovascular events. Living with AH alludes to remaining with a silent disease that generates consequences in the social context, which becomes indifferent to the treatment of the condition ⁽³⁰⁾.

As strengths of the study, it is specified that the approach linked to the research refers to taking into account different categories that make it possible to deepen the analysis of the determinants that define the success or failure of AH treatment, incorporating elements between the daily dynamics and the management of health services.

Limitations of the study are related to the restriction to make statistical generalizations according to the findings presented or to make inferences in other populations; however, the categories described can contribute to the understanding of what happens in contexts with similar characteristics.

CONCLUSIONS

Migrant women with hypertension configure their therapeutic itineraries in the search for health care not only from the state health system, but also based on various social, cultural, political and economic elements. To this extent, AH goes beyond morbid nominations that are exclusive to biomedicine and the doctor-patient relationship, to focus on and transcend a condition that involves bureaucratic burdens, barriers to access, discontinuity in care, stigmas and limitations in obtaining adequate treatment.