Living with diabetes and hypertension in Tunisia: popular perspectives on biomedical treatment.

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Why look at this?

As with many other countries, Tunisia has seen a shift in the health of its population. The healthcare system, developed to treat and manage infectious diseases, is feeling the strain of the growing burden of long term, chronic conditions.

Methods

The aim was to see health policies & provision actually worked in selected clinical settings. To look from different angles, perspectives of both clinical staff, patients and family members were synthesised.

Interviews with patients, family members and clinical staff of public primary healthcare centres, one in Tunis and one rural. 24 patients were interviews, with an equal number of male and female participants, and an equal number of rural and urban participants. Patients ages between mid 40s and mid 80s, in more deprived neighbourhoods. Purposive sampling was used. 12 family members were also interviews, the majority were spouses but some were adult children.

What did they find out:

Primarily, all patients treated and managed their illness through healthcare. Some patients chose to supplement their medical treatment with herbs or foods like garlic or live leaves. A few found scarification (etching the skin) efficacious. No supplementary treatment supplanted the medical treatment. No one reported seeing a "traditional healer".

The causes given by patients for disease could be grouped into three, and patients did not exclusively give causes in one group. The first group was in line with the current dominant discourse in Public Health, i.e. inherited predispositions and the modern shift toward sedentary lifestyles and diets high in sugar and fat. 

What has caused the shift in diet and levels of exercise? Physical activity was perceived as something that was part of everyday life but not wasn't, and time constraints made it difficult to include in a supplementary fashion. The stress and pace of modern life, the industrialisation of food production were identified as causes. A gravitation toward the "nuclear" family rather than living with more extended family was seen to concentrate the domestic burden on women, and the pressure of being a breadwinner was felt by some men.

The second group spoke of a higher power as disease bringer and healer. This served as an explanation, as opposed to a way to treat disease.

The third group attributed their disease to hardship, trauma and great loss. 

Patients reported a transition, a change between before disease and after, and some indicated acceptance. Patients and family members reported higher levels of irritability, and strains on relationships.

Lack of communication from staff was a common theme. Doctors did not have enough time and did not explain the rationale behind their treatment, or listen to the patient. It was felt that clinicians did not display understanding or compassion, and therefore patients did not learn about their illness. There was a lack of continuity of care too, with patients not knowing their doctors. This was more pronounced in urban settings.

One patient said "A person is sick, not just physically but psychologically. If you are not patient and receptive, if you do not talk to her, you do not see what she has, how can she feel better? They go home feeling worse than before."

Staff opinions seemed to compound the views of the patients. The amount of time patients wanted for their appointments was unreasonable or impossible to them. Doctors and senior nurses thought patient adherence to treatment guidelines could be taught quickly in a didactic manner. Patients were considered wilfully non-compliant when they did not adhere to treatment as prescribed, even when using monitors to inform their decision.

The researchers identified two recurrent themes: "one relates to nostalgia  for what is seen to be lost with modern lifestyles: and the other concerns communication in the clinic." Alleviating the latter is not straightforward, as "it is rooted in structural arrangements which make [thwarted communication] all the more intractable"

Please read the article: 

Tlili F, Tinsa F, Skhiri, Zaman S, Phillimore P, Bem Romdhane H. Living with diabetes and hypertension in Tunisia: popular perspective on biomedical treatment. International Journal of Public Health 2014 Vol 59 (3) 425-574