Therapeutic Itinerary of Elderly People

1Rev Bras Enferm. 2021;74(3): e20200788 8of

ABSTRACT Objective: to describe the therapeutic itinerary of elderly people with diabetes mellitus registered at Family Health Strategy units. Methods: qualitative and descriptive study carried out with 15 elderly people with diabetes mellitus between February and April 2019 by applying semi-structured interviews with the participants. Data were submitted to analysis of Minayo’s operational proposal. Results: in the folk care subsystem, the use of medicinal herbs, healers, and faith was emphasized by the participants. In the professional care subsystem, Family Health Strategy units were the services with the strongest bond to elderly people, but these patients still had to resort to the private healthcare network. Family proved to be the main source of support in the popular care subsystem. Final considerations: nursing must acknowledge the different types of knowledge, coping strategies, beliefs, and the culture of elderly people with diabetes mellitus to guarantee the delivery of comprehensive care. Descriptors: Aged; Diabetes Mellitus; Nursing Care; Primary Health Care; Family Health Strategy.

RESUMO Objetivo: descrever o itinerário terapêutico de pessoas idosas com diabetes mellitus cadastradas em unidades de Estratégia Saúde da Família. Método: estudo qualitativo, descritivo, realizado com 15 pessoas idosas com diabetes mellitus, entre fevereiro e abril de 2019, por meio de entrevista semiestruturada. Os dados foram submetidos à análise da proposta operativa de Minayo. Resultados: no subsistema de cuidado folclórico, foi evidenciado o uso de plantas medicinais, de benzedores e fé. No subsistema de cuidado profissional, as equipes de Estratégia Saúde da Família são os serviços de maior vínculo com as pessoas idosas que, porém, ainda precisam recorrer à rede privada de saúde. A família mostra-se como principal fonte de apoio no subsistema de cuidado popular. Considerações finais: faz-se necessário que a enfermagem reconheça a pluralidade de saberes, estratégias de enfrentamento, crenças e cultura das pessoas idosas com diabetes mellitus, para garantir um cuidado integral. Descritores: Idoso; Diabetes Mellitus; Cuidados de Enfermagem; Atenção Primária à Saúde; Estratégia Saúde da Família.

RESUMEN Objetivo: Describir el itinerario terapéutico de personas ancianas con diabetes mellitus registradas en unidades de Estrategia Salud de la Familia. Método: Estudio cualitativo, descriptivo, realizado con 15 ancianos con diabetes mellitus entre febrero y abril de 2019 utilizando entrevistas semiestructuradas. Datos sometidos a análisis de la propuesta operativa de Minayo. Resultados: En el subsistema de cuidado folclórico, fue evidenciado el uso de plantas medicinales, de curanderos y fe. En el subsistema de atención profesional, los equipos de Estrategia Salud de la Familia son los de mayor vínculo con los ancianos que, aún, precisan recorrer la red privada de salud. La familia se muestra como fuente de apoyo principal en el sistema popular. Consideraciones finales: Es necesario que la enfermería reconozca la pluralidad de saberes, estrategias de enfrentamiento, creencias y cultura de los ancianos con diabetes mellitus para garantizar una atención integral. Descriptores: Anciano; Diabetes Mellitus; Atención de Enfermería; Atención Primaria de Salud; Estrategia de Salud Familiar.

Therapeutic itinerary of elderly people with diabetes mellitus: implications for nursing care

Itinerário terapêutico de pessoas idosas com Diabetes Mellitus: implicações para o cuidado de enfermagem

Itinerario terapéutico de personas ancianas con diabetes mellitus: implicancias para la atención de enfermería


Francine Feltrin de OliveiraI

ORCID: 0000-0002-5105-7053

Margrid BeuterI


Maria Denise SchimithI

ORCID: 0000-0002-4867-4990

Marinês Tambara LeiteII

ORCID: 0000-0003-3280-337X

Carolina BackesI

ORCID: 0000-0002-2504-9105

Eliane Raquel Rieth BenettiI

ORCID: 0000-0003-1626-5698

Larissa VenturiniI

ORCID: 0000-0002-5401-3849

I Universidade Federal de Santa Maria. Santa Maria, Rio Grande do Sul, Brazil.

II Universidade Federal de Santa Maria. Palmeira das Missões, Rio Grande do Sul, Brazil.

How to cite this article: Oliveira FF, Beuter M, Schimith MD, Leite MT, Backes C,

Benetti ERR, et al. Therapeutic itinerary of elderly people with diabetes mellitus: implications for nursing care.

Rev Bras Enferm. 2021;74(3):e20200788.

Corresponding author: Francine Feltrin de Oliveira


EDITOR IN CHIEF: Antonio José de Almeida Filho ASSOCIATE EDITOR: Priscilla Broca

Submission: 08-11-2020 Approval: 11-01-2020



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Therapeutic itinerary of elderly people with diabetes mellitus: implications for nursing care Oliveira FF, Beuter M, Schimith MD, Leite MT, Backes C, Benetti ERR, et al.


Aging is a process marked by individual rhythm and evolution and is influenced by biopsychosocial factors. Noncommunicable chronic diseases are not intrinsically related to aging, but when people get old they become more likely to develop some diseases, including diabetes mellitus (DM). This disease is a public health problem. In 2017, Brazil occupied the fourth place in the global ranking of a number of people who live with DM(1), and global projections indicated that approximately 463 million people in the age group from 20 to 79 years had this morbidity in 2019 and that this number can increase to 700 million people in 2045. Additionally, it is estimated that one out of five people older than 65 years has DM(2).

Studies have shown that, when present in elderly people, DM interferes with quality of life, since it increases the risk of impair- ment of the motor function, the incidence of sarcopenia, and the chances of developing the frailty syndrome, characteristics that are not observed in people with the same chronological age who do not have DM. This suggests that the disease leads to early biological aging(3-4).

Therapeutic itinerary (TI) is one of the central concepts of socio- anthropological health studies(5) and aims to interpret the process by which people or social groups choose certain forms of health treatment. The initial studies on TI originated from the expression “illness behavior” and were based on the logic of individual con- ducts in the search for health services, guided by cost-benefit(5). The concept expanded its analytical scope from the 1980s onwards, especially with the studies by Arthur Kleinman, who began giv- ing more emphasis to the different medical notions of health and disease and their interaction with the healthcare system(5).

When faced with the establishment of a disease, people seek different therapeutic resources, which offer different trajectories in the attempt to solve the problem that bothers them(5). One of the paths to obtain assistance is primary health care, which materializes as the Family Health Strategy (FHS) and is the first level of health care(6). The Brazilian National Health Policy to Elderly People (Política Nacional de Saúde da Pessoa Idosa – PNSPI, in Portuguese) considers FHS the main gateway to access health services, and it is the care organizer and coordinator(7). Conse- quently, FHS(8) teams are given the responsibility to follow the population with DM. They also have to promote care practices that take into account people’s individuality and complexity.

Given the nature of nursing interventions, it becomes relevant that nurses know the knowledge of elderly people with DM and the trajectory taken by them in their attempt to obtain care, considering the sociocultural context in which they are inserted and their experience with the disease. Therefore, acknowledg- ing the specificity of the aging process and the care possibilities regarding elderly patients with DM’s beliefs and own ways to understand life, health, and disease contributes to nursing care in gerontological follow-up.

Aiming to elucidate the TI of elderly people with DM, the pres- ent study adopted the healthcare system proposed by Kleinman as a guide(9). This author intended to clarify the influence of the social and cultural matrix on the understanding of the process of health, disease, and care based on the interaction of three subsystems: folk, professional, and popular. The first admits

inclusion of nonprofessional healing specialists, such as healers and prayers. The professional subsystem represents scientific care, including traditional medical systems. The popular seg- ment encompasses the family sphere and social and community networks(9). People circulate in these subsystems based on the interpretation of their health or disease status and seek actions that can provide treatment or healing. These subsystems are responsible for the development of different therapeutic realities designed as sociocultural constructs, linked to beliefs about the disease and the experience with the symptoms, leading to the establishment of a systemic and interconnected relationship(9).

From the information above, it can be inferred that the number of studies on the healthcare practices of elderly people with DM who follow their TI is still limited, which justified the development of the present study. This limitation calls for the need to design studies that can deepen the knowledge of gerontological nurs- ing in primary health care for professionals to understand the care strategies and the trajectories taken in the different care subsystems. Given this context, the following question was asked: What is the TI put into practice by elderly people with DM who receive care by means of the FHS? It is expected that knowing the TI of elderly people with DM allows to expand the knowledge on the subject to provide professionals with resources to nursing practice and actions oriented toward elderly people to guarantee care comprehensiveness.


To describe the TI of elderly people with DM registered at FHS units.


Ethical aspects

The proposal was approved by the Research Ethics Committee at the Federal University of Santa Maria. The ethical principles involved in human research were observed, in conformity with Resolution no. 466/2012. Data were produced after the partici- pants signed free and informed consent forms. Each interview was identified with the letter “I” followed by a number that indicated its position in the sequence of interviews (I1, I2, etc.).

Study type

This is a qualitative and descriptive study. Its methodological details were based on the Consolidated Criteria for Reporting Qualitative Research checklist(10).

Methodological procedures


The present study was carried out with elderly people with DM registered at FHS units in a municipality in the South Region of Brazil between February and April 2019. The authors opted to choose two FHS units in the same municipality to be the study setting because these places held the multiprofessional residency



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Therapeutic itinerary of elderly people with diabetes mellitus: implications for nursing care Oliveira FF, Beuter M, Schimith MD, Leite MT, Backes C, Benetti ERR, et al.

of a federal university and developed a work oriented toward the elderly population with noncommunicable chronic diseases.

Data source

The sample was 15 elderly people with DM. This number of participants allowed information repetition and data saturation(11). Participant selection occurred with the collaboration of nurses and community health workers at the health units, who helped find elderly patients with DM. After that, the main researcher went to these patients’ houses in person to invite them to participate in the study. Once the invitation was accepted, a new visit was scheduled, according to the patients’ day and time availability and at the place that was most convenient for them.

The participants were elderly people with DM who were intentionally selected after meeting the following inclusion criteria: having preserved cognitive capacity as per evaluation in the Mini-Mental State Examination(12); having an established DM diagnosis for at least two years; and being registered at a FHS unit. This two-year period was chosen because the authors understood that it would be enough for the elderly people to have explored the possibilities available in the healthcare systems and, consequently, for them to be able to describe a proper TI.

Data collection and organization

Data collection occurred by interviewing the participants using a semi-structured script. The interview had two parts: the first had questions related to the characterization of the participants, and the second had five open-ended questions formulated by the re- searchers which allowed to obtain a description of the TI of elderly people with DM. These questions were: (1) Can you tell how you found out that you that DM?; (2) Who helps you when you need care?; (3) What type of bond do you have with these people?; (4) What services do you seek for treatment or care?; and (5) Have you ever sought or have you been seeking any alternative form of treatment?. All the interviews were carried out in the participants’ houses, privately, observing secrecy and privacy during data col- lection. The interviews had an average duration of 60 minutes and had their audio recorded after the participants authorized it. Before the data collection step, a pilot test was conducted with three elderly people with DM whose data were not included in the study.

Data analysis

Data analysis was grounded on Minayo’s operational proposal(13), for which the following steps are recommended: data ordering, data classification, data analysis, and report drafting. The inter- views were transcribed and exported to the NVivo® software to facilitate data ordering and classification.


The participants of the present study were 15 elderly people with DM, of whom six were men and nine were women. Their age ranged from 61 to 74 years, and their average level of education was incomplete middle school. Twelve participants lived with

their partners and three were widows or widowers. Regarding profession, 13 were retired people, one received the Continuous Provision Benefit, and one had no financial sources and was waiting to reach the minimum age to receive this benefit. The DM diagnosis time was between five and 23 years.

To understand the TI dimension of elderly people with DM, data were organized into three thematic categories:

Folk practices and their implications for the care of elderly people with DM

The information on use and preparation of medicinal herbs originated in the social relationships with friends, neighbors, and relatives, who made up a support network that contributed to the treatment for DM, which is a development found in the folk subsystem.

[…] I have a liana called monkey liana. It was the husband of my cousin, from the colony, who sent it to me […] my brother taught me. You get a piece of liana and put it in one liter of water and boil it. And then you drink it over the day, it is very good. (I7, 62 years old)

The participants reported success in the use of teas to control glycemia and vouched for the hypoglycemic effect of medicinal herbs because of the result they obtained in the self-monitoring of capillary glycemia.

[…], but if you drink java plum tea, you can measure and you will see, your glucose will be lower. I ran a test a couple of days ago, I skipped metformin, which I take daily, for a few days, and I drank the tea only and felt nothing, it was all the same. (I6, 68 years old)

It was observed that some participants interrupted their medica- tion to validate the effectiveness of the tea. In addition to drinking teas, other care practices were adopted by the elderly people with DM in their TI, including faith and prayers chanted by healers.

I have a lot of faith, I always pray. If faith does not heal, it soothes or controls the disease […] I feel good and it gives you strength in life, we get stronger spiritually and it impacts our life and our body. (I8, 65 years old)

These practices emerged as care elements and were used with a broad perspective to seek a better health condition and support in the coping with the disease.

There is a healer here in the city, in the neighborhood […] she says a prayer with everybody in a room and then she gets close to everyone’s head. We went there to see if this disease can be healed […] I have always gone to these places believing that I was going to get better […] we get well and feel better. (I11, 64 years old)

The therapeutic care entrusted to the ritual of submitting to the procedures of a healer was mentioned as a help to control and heal the disease, and consequently offered the feeling of well-being. The finitude perception was identified in the accounts of the participants, who asked God for longer survival.

We think: why this inside me, this disease? Will I go before the due time? I have to help myself. They work and they are all well, I have



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Therapeutic itinerary of elderly people with diabetes mellitus: implications for nursing care Oliveira FF, Beuter M, Schimith MD, Leite MT, Backes C, Benetti ERR, et al.

to get well too, I do not want to depend on anyone, and may God help me! (I10, 66 years old)

The way people experience the development of DM, com- bined with the losses inherent in aging, affects the subjective dimension of care, which encompasses emotions, desires, and the confrontation with finitude and death.

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