Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus, Brazil.
Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Brazil.
PLoS Negl Trop Dis. 2021 Mar 4;15(3):e0009245. doi: 10.1371/journal.pntd.0009245. eCollection 2021 Mar.
Access to antivenoms is not guarranteed for vulnerable populations that inhabit remote areas in the Amazon. The study of therapeutic itineraries (TI) for treatment of snakebites would support strategies to provide timely access to users. A TI is the set of processes by which individuals adhere to certain forms of treatment, and includes the path traveled in the search for healthcare, and practices to solve their health problems. This study aims to describe TIs of snakebite patients in the Brazilian Amazon. This study was carried out at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, state of Amazonas, Brazil. The itinerary from the moment of the bite to the patient's admission to the reference unit was analyzed. Sample size was defined by saturation. After an exploratory survey to collect epidemiological variables, in-depth interviews were conducted following a semi-structured guide. Patients originated from rural areas of 11 different municipalities, including ones located >500 kilometers from Manaus. A great fragmentation was observed in the itineraries, marked by several changes of means of transport along the route. Four themes emerged from the analysis: exposure to snakebite during day-to-day activities, use of traditional therapeutic practices, and personal perception of the severity, as well as the route taken and its contingencies. Access to healthcare requires considerable effort on the part of snakebite patients. Major barriers were identified, such as the low number of hospitals that offer antivenom treatment, poor access to healthcare due to long distances and geographic barriers, low acceptability of healthcare offered in countryside, lack of use of personal protective equipment, common use of ineffective or deleterious self-care practices, late recognition of serious clinical signs and resistance to seeking medical assistance. Health education, promotion of immediate transport to health centers and decentralization of antivenom from reference hospitals to community healthcare centers in the Brazilian Amazon are more effective strategies that would to maximize access to antivenom treatment.
偏远亚马逊地区的弱势群体无法保证获得抗蛇毒血清。研究治疗方案（TI）可支持为用户提供及时治疗的策略。TI 是指个人遵循某些治疗方式的一系列流程，包括在寻求医疗保健过程中所走的路径，以及解决健康问题的实践。本研究旨在描述巴西亚马逊地区蛇咬伤患者的 TI。本研究在巴西亚马孙州首府玛瑙斯的 Heitor Vieira Dourado 热带医学基金会进行。分析了从咬伤到患者被收入参考单位的整个过程。根据饱和度确定了样本量。在进行了一项探索性调查以收集流行病学变量后，采用半结构化指南进行了深入访谈。患者来自 11 个不同城市的农村地区，包括距离玛瑙斯 500 多公里的地区。路线存在很大的分散性，沿途多次更换交通工具。从分析中得出了四个主题：在日常活动中暴露于蛇咬伤、使用传统治疗方法以及对严重程度的个人认知，以及所采取的路线及其偶然情况。获得医疗保健服务需要患者付出很大的努力。发现了一些主要障碍，例如提供抗蛇毒血清治疗的医院数量较少、由于距离远和地理障碍导致获得医疗服务困难、农村地区医疗服务的接受程度低、缺乏使用个人防护设备、常见使用无效或有害的自我护理实践、对严重临床症状的识别延迟以及对寻求医疗帮助的抵制。在巴西亚马逊地区，健康教育、促进立即将患者送往医疗中心以及将抗蛇毒血清从参考医院分散到社区医疗中心是更有效的策略，可以最大限度地提高抗蛇毒血清治疗的可及性。
