Community Health Workers' Concept and Understanding of Diabetes: A Qualitative Study.

Objectives: Community health workers (CHWs) fill in the insufficiency of health professionals in low-income countries. The CHWs' roles include health education of their constituents whose health they likewise take care. This study aimed to describe the concept and understanding of diabetes among CHWs in the Philippines. Methods: Fifty female CHWs currently working in rural and urban areas participated in six focus group discussions with guidance from Kleinman's eight questions. With the written informed consent of the participants, discussions were recorded and transcribed by the Research Assistant. A multi-disciplinary team manually analyzed the data. Disagreements were discussed among them and the physicians provided clinical analyses and explanations on the results. Quotations of an important point of view were also presented. Pseudonyms were utilized to uphold anonymity. Results: CHWs were aged 32 to 72 years; older participants reside in rural areas. Majority were married, housekeepers, and high school graduates. Some CHWs and their family were suffering from diabetes or dyabetis, the disease of the rich according to them. Its causes were food and lifestyle, and believed to be hereditary. Complications lead to death. Amputation was feared the most. Diabetes is incurable. Persons with diabetes should take maintenance medicines, and seek physicians' and family's help. Together with the patient, the family must decide on its management. Balanced diet, healthy lifestyle, maintenance medicines, food supplements, and herbal plants were perceived treatments. The internist should lower blood sugar level as well as prolong life span. Proper diet and regular check-up prevent diabetes. Conclusions: CHWs' concept and understanding of diabetes reflect some of the biomedical causes, effects, treatment, and prevention of diabetes as well as its social determinants. The efficacy and safety of herbal plants in the treatment of diabetes, however, should be further studied. Training on diabetes care should be provided to address their fears of amputation, insulin injection, and complications.

The rs1458038 variant near FGF5 is associated with poor response to calcium channel blockers among Filipinos.

ABSTRACT: Genetic variation is known to affect response to calcium channel blockers (CCBs) among different populations. This study aimed to determine the genetic variations associated with poor response to this class of antihypertensive drugs among Filipinos.One hundred eighty one hypertensive participants on CCBs therapy were included in an unmatched case-control study. Genomic deoxyribonucleic acid were extracted and genotyped for selected genetic variants. Regression analysis was used to determine the association of genetic and clinical variables with poor response to medication.The variant rs1458038 near fibroblast growth factor 5 gene showed significant association with poor blood pressure-lowering response based on additive effect (CT genotype: adjusted OR 3.41, P = .001; TT genotype: adjusted OR 6.72, P < .001).These findings suggest that blood pressure response to calcium channels blockers among Filipinos with hypertension is associated with gene variant rs1458038 near fibroblast growth factor 5 gene. Further studies are recommended to validate such relationship of the variant to the CCB response.

The Klotho Variant rs36217263 Is Associated With Poor Response to Cardioselective Beta-Blocker Therapy Among Filipinos.

A common drug used for hypertension among Filipinos is beta-blockers. Variable responses to beta-blockers are observed, and genetic predisposition is suggested. This study investigated the association of genetic variants with poor response to beta-blockers among Filipinos. A total of 76 Filipino adult hypertensive participants on beta-blockers were enrolled in an unmatched case-control study. Genotyping was done using DNA from blood samples. Candidate variants were correlated with clinical data using χ2 and logistic regression analysis. The deletion of at least one copy of allele A of rs36217263 near Klotho showed statistically significant association with poor response to beta-blockers (dominant; odds ratio (OR) = 3.89; P = 0.017), adjusted for diabetes and dyslipidemia. This association is observed among participants using cardioselective beta-blockers (crude OR = 5.60; P = 0.008) but not carvedilol (crude OR = 2.56; P = 0.67). The genetic variant rs36217263 is associated with poor response to cardioselective beta-blockers, which may become a potential marker to aid in the management of hypertension.

Cardiac events occurred commonly among apparently healthy Filipinos with the Brugada ECG pattern in the LIFECARE cohort.

BACKGROUND: Brugada syndrome is the mechanism for sudden unexplained death. The Brugada ECG pattern is found in 2% of Filipinos. There is a knowledge gap on the clinical outcome of these individuals. The clinical profile and 5-year cardiac event rate of individuals with the Brugada ECG pattern were determined in this cohort. METHODS: This is a sub-study of LIFECARE (Life Course Study in Cardiovascular Disease Epidemiology), a community based cohort enrolling healthy individuals 20 to 50 years old conducted in 2009-2010. ECGs of all enrollees were screened independently by three cardiologists. The prevalence of the coved Brugada ECG pattern was ascertained, and the 5-year cardiac event rate was determined among those individuals with this pattern. The participants were contacted to determine the occurrence of cardiac events, which included syncope, presyncope, seizures, cardiac arrest and unexplained vehicular accidents. RESULTS: A total of 3072 ECGs were reviewed, and 14 subjects (0.4%) with the coved Brugada ECG pattern were identified. Four had a cardiac event on follow-up at 5 years, but all remained alive. Most of these 14 coved Brugada individuals were healthy and asymptomatic at baseline. CONCLUSION: Cardiac events occurred commonly among initially asymptomatic Filipinos with the coved Brugada ECG pattern. Such patients need to be followed up closely.

Chronic Heart Failure Clinical Practice Guidelines' Class 1-A Pharmacologic Recommendations: Start-to-End Synergistic Drug Therapy?

BACKGROUND: Chronic heart failure (HF) disease as an emerging epidemic has a high economic-psycho-social burden, hospitalization, readmission, morbidity and mortality rates despite many clinical practice guidelines' evidenced-based and consensus driven recommendations that include trials' initial-baseline data. OBJECTIVE: To show that the survival and hospitalization-free event rates in the reviewed chronic HF clinical practice guidelines' class I-A recommendations as initial HF drug therapy (IDT) is possibly a combination and 'start-to-end' synergistic effect of the add-on ('end') HF drug therapy (ADT) to the baseline ('start') HF drug therapy (BDT). METHODOLOGY: The references cited in the chronic HF clinical practice guidelines of the 2005, 2009, and 2013 American Heart Association/American College of Cardiology (AHA/ACC), the 2006 Heart Failure Society of America (HFSA), and the 2005, 2008, and 2012 European Society of Cardiology (ESC) were reviewed and compared with the respective guidelines' and other countries' recommendations. RESULTS: The BDT using glycosides and diuretics is 79%-100% in the cited HF trials. The survival rates attributed to the BDT ('start') is 46%-89% and IDT ('end') 61%-92.8%, respectively. The hospitalization-free event rate of the BDT group: 47.1% to 85.3% and IDT group 61.8%-90%, respectively. Thus, the survival and hospitalization-free event rates of the ADT is 0.4%-15% and 4.6% to 14.7%, respectively. The extrapolated BDT survival is 8%-51% based on a 38% estimated natural HF survival rate for the time period109. CONCLUSION: The contribution of baseline HF drug therapy (BDT) is relevant in terms of survival and hospitalization-free event rates compared to the HF class 1-A guidelines initial drug therapy recommendations (IDT). Further, the proposed initial HF drug ('end') therapy (IDT) has possible synergistic effects with the baseline HF drug ('start') therapy (BDT) and is essentially the add on HF drug therapy (ADT) in our analysis. The polypharmacy HF treatment is a synergistic effect due to BDT and ADT.

Prediction of Symptomatic Embolism in Filipinos With Infective Endocarditis Using the Embolic Risk French Calculator.

BACKGROUND: Cardioembolic events are life-threatening complications of infective endocarditis (IE). The embolic risk French calculator estimates the embolic risk in IE computed on admission. Variables in this tool include age, diabetes, atrial fibrillation, prior embolism, vegetation length, and Staphylococcus aureus on culture. A computed risk of > 7% was considered high in the development of this tool. Knowledge of this risk applied in our local setting is important to guide clinicians in preventing such catastrophic complications. Among patients with IE, we aim to determine the efficacy of the embolic risk French calculator, using a computed score of > 7%, in predicting major embolic events. METHODS: All adults admitted from 2013 to 2016 with definite IE were included. The risk for embolic events was computed on admission. All were monitored for the duration of admission for the occurrence of the primary outcome (any major embolic event: arterial emboli, intracranial hemorrhage, pulmonary infarcts, or aneurysms). Secondary outcomes were: 1) composite of death and embolic events; and 2) death from any cause. RESULTS: Eighty-seven adults with definite IE were included. Majority had a valvular heart disease and preserved ejection fraction (EF). The mitral valve was most commonly involved. Embolic events occurred in 25 (29%). Multivariate analysis identified a high embolic score > 7% (relative risk (RR): 15.12, P < 0.001), vegetation area ≥ 18 mm2 (RR: 6.39, P < 0.01), and a prior embolism (RR: 5.18, P = 0.018) to be independent predictors of embolic events. For the composite of embolic events and death, independent predictors include a high score of > 7% (RR: 13.56, P < 0.001) and a prior embolus (RR: 13.75, P = 0.002). Independent predictors of death were a high score > 7% (RR: 6.20, P = 0.003) and EF ≤ 45% (RR: 9.91, P = 0.004). CONCLUSION: Cardioembolic events are more prevalent in our study compared to previous data. The embolic risk French calculator is a useful tool to estimate and predict risk for embolic events and in-hospital mortality. The risk of developing embolic events should be weighed against the risks of early preventive cardiac surgery, as to institute timely and appropriate management.

Economic Burden of Community-Acquired Pneumonia among Adults in the Philippines: Its Equity and Policy Implications in the Case Rate Payments of the Philippine Health Insurance Corporation.

OBJECTIVES: To determine 1) the cost of hospitalization, the 1-week postdischarge cost, the total cost, and the economic burden of community-acquired pneumonia among patients aged 19 years or older in the Philippines and 2) the difference between the estimated costs and the Philippine Health Insurance Corporation (PhilHealth) pneumonia case rate payments. METHODS: The study involved two tertiary private hospitals in the Philippines. Using the societal perspective, both health care and non-health care costs were determined. A base-case analysis and sensitivity analyses were performed, and the economic burden of pneumonia was determined using PhilHealth claims. RESULTS: The estimated cost of hospitalization for community-acquired pneumonia-moderate risk (CAP-MR) ranged from Philippine peso (PHP) 36,153 to 113,633 (US $852-2678) and its 1-week postdischarge cost ranged from PHP1450 to 8800 (US $34-207). The cost of hospitalization for community-acquired pneumonia-high risk (CAP-HR) ranged from PHP104,544 to 249,695 (US $2464-5885) and PHP101,248 to 243, 495 (US $2386-5739) using invasive and noninvasive ventilation, respectively. The postdischarge cost for CAP-HR ranged from PHP1716 to 10,529 (US $40-248). If only health care cost was considered, the cost ranged from PHP24,403 to 89,433 for CAP-MR and PHP92,848 to 213,395 for CAP-HR. The present PhilHealth case rate payments are PHP15,000 (US $354) and PHP32,000 (US $754) for CAP-MR and CAP-HR, respectively. Based on the number of PhilHealth claims for 2012 and the estimated health care cost, the economic burden of pneumonia in 2012 was PHP8.48 billion for CAP-MR and PHP643.76 million for CAP-HR. CONCLUSIONS: The estimated health care cost of hospitalization is markedly higher than the PhilHealth case rate payments. As per the study results, the economic burden of pneumonia is, thus, significantly higher than PhilHealth estimates.

Smoking-attributable burden of lung cancer in the Philippines.

BACKGROUND: In the Philippines, smoking is highly prevalent and tobacco control policies fail to fully implement the WHO Framework Convention on Tobacco Control provisions. To aid in policy change, intervention implementation, monitoring and evaluation, this study aimed to provide the first internally consistent and latest Philippine estimates of the following: disability-adjusted life-years (DALYs) lost due to lung cancer; population-attributable fractions (PAFs) of smoking; and smoking-attributable lung cancer DALYs. METHODS: This study applied the Global Burden of Disease and Comparative Risk Assessment frameworks to secondary data, supplemented by expert opinion. A comprehensive internally consistent assessment of disease epidemiology was conducted using DISMOD II and disease impact was quantified as DALYs. PAFs were calculated using the smoking impact ratio and Monte Carlo uncertainty analyses were conducted. RESULTS: For 2008, lung cancer incidence and mortality estimates were 10 871 cases and 9871 deaths respectively. Lung cancer accounted for an estimated 267 787 DALYs lost, 99% of which were due to years of life lost. Overall, the PAF of smoking was 65% and a total of 173 103 DALYs were smoking-attributable. There were increasing trends in incidence, mortality and DALY rates with age. The majority of incidence (72%), mortality (71%) and disease burden (72%) occurred among men, who also had higher PAF estimates. CONCLUSIONS: Considerable health gains could be achieved if smoking exposure were reduced in the Philippines. Strong enforcement of measures like increasing taxation to the WHO-endorsed rate, expanding smoke-free environments, and requiring large graphic warnings within a comprehensive tobacco control programme is recommended.

Socio-demographic factors and the prevalence of metabolic syndrome among filipinos from the LIFECARE cohort.

BACKGROUND: Metabolic syndrome(MetS) is an aggregation of multiple metabolic risk factors shown to lead to the development of cardiovascular disease. The International Diabetes Federation(IDF) and the modified National Cholesterol Education Program Adult Treatment Panel Ⅲ(mNCEP) criteria are used in identifying MetS. This report will determine the prevalence of MetS and its component risk factors of the Philippine cohort of the LIFE course study in CARdiovascular disease Epidemiology(LIFECARE). METHODS: Our study recruited 3,072 participants aged 20-50 years old from Metro Manila and four nearby provinces. Baseline anthropometric and clinical parameters were measured. Prevalence of MetS and its component factors were determined. Associations with socio-demographic factors were determined. RESULTS: The prevalence of MetS was 19.7% and 25.6% by IDF and mNCEP, respectively(kappa 0.83). Both were associated with increasing age, urban residence, and employed status. It was higher in females by IDF and in males by mNCEP. IDF missed 40% of males and 10% of females identified with MetS by mNCEP. More males were identified by the mNCEP as MetS despite relatively normal waist circumference. CONCLUSION: MetS is common in the Philippines among older, educated, and urban residents. The mNCEP criteria identified more MetS than the IDF criteria.

A community-based validation study of the short-form 36 version 2 Philippines (Tagalog) in two cities in the Philippines.

OBJECTIVE: To evaluate the validity and reliability of the Philippines (Tagalog) Short Form 36 Health Survey version 2 (SF-36v2(®)) standard questionnaire among Filipinos residing in two cities. STUDY DESIGN AND SETTING: The official Philippines (Tagalog) SF-36v2 standard (4-week recall) version was pretested on 30 participants followed by formal and informal cognitive debriefing. To obtain the feedback on translation by bilingual respondents, each SF-36v2 question was stated first in English followed by Tagalog. No revisions to the original questionnaire were needed except that participants thought it was appropriate to incorporate "po" in the instructions to make it more polite. Face-to-face interviews of 562 participants aged 20-50 years living in two barangays (villages) in the highly urbanized city of Makati City (Metro Manila) and in urban and rural barangays in Tanauan City (province of Batangas) were subsequently conducted. Content validity, item level validity, reliability and factor structure of the SF-36v2 (Tagalog) were examined. RESULTS: Content validity of the SF-36v2 was assessed to be adequate for assessing health status among Filipinos. Item means of Philippines (Tagalog) SF-36v2 were similar with comparable scales in the US English, Singapore (English and Chinese) and Thai SF-36 version 1. Item-scale correlation exceeded 0.4 for all items except the bathing item in PF (correlation: 0.31). In exploratory factor analysis, the US two-component model was supported. However, in confirmatory factor analysis, the Japanese three-component model fit the Tagalog data better than the US two-component model. CONCLUSIONS: The Philippines (Tagalog) SF-36v2 is a valid and reliable instrument for measuring health status among residents of Makati City (Metro Manila) and Tanauan City (Province of Batangas).