Effects of the COVID-19 pandemic on the implementation of NCD Care at the Primary Care Level in the Philippines: A qualitative inquiry

Background and Objective@#The focusing of resources to COVID-19 response hampered and disadvantaged primary care services including that for Non-Communicable Diseases (NCDs), compromising continuity of care and hence, patients’ disease status. However, studies from low- and middle-income countries (LMICs) remain sparse; therefore, evidence generation on how the pandemic impacted the provision of these primary care services in LMICs will help further understand how policies can be reframed, and programs be made more efficient and effective despite similar crises. To bridge this gap, the study investigated how the pandemic affected the implementation of NCD care at the primary care level in the Philippines.@*Methods@#Thirty-one online focus group discussions via Zoom Meetings were conducted among 113 consenting physicians, nurses, midwives, and community health workers from various facilities — community health centers and stations, free-standing clinics, infirmaries, and level 1 hospitals — located within two provinces in the Philippines. All interviews were video-recorded upon participants’ consent and transcribed verbatim. Inductive thematic analysis was employed through NViVo 12® to generate themes, identify categories, and describe codes. @*Results@#The impact of COVID-19 on NCD care at the primary care level revolved around heightened impediments to service delivery, alongside worsening of pre-existing challenges experienced by the healthcare workforce; subsequently compelling the public to resort to unhealthy practices. These detriments to the primary healthcare system involved resource constraints, discontinued programs, referral difficulties, infection, overburden among workers, and interrupted training activities. Citizens were also observed to adopt poor healthcare seeking behavior, thereby discontinuing treatment regimen. @*Conclusion@#Healthcare workers asserted that disadvantages caused by the pandemic in their NCD services at the primary care level possibly threaten patients’ health status. Besides the necessity to address such detriments, this also emphasizes the need for quantitative studies that will aid in drawing inferences and evaluating the effect of health crises like the pandemic on such services to bridge gaps in improving quality of care.

Economic evaluation of oral ivermectin, alone or in combination with permethrin, versus permethrin, in the treatment of classic scabies in the Philippine Setting

Background and Objective@#Oral ivermectin is recommended as an alternative to topical permethrin in Japanese, European, and CDC-STI guidelines for treating classic scabies. The combination of oral ivermectin and topical permethrin is also used in some settings. Partial economic evaluations conducted in India and Egypt have conflicting results, and no cost-effectiveness analysis in the Philippines has compared ivermectin-based regimens to permethrin for scabies treatment. We aimed to determine the cost-effectiveness of oral ivermectin, alone or in combination with permethrin, compared to permethrin, in the treatment of Filipino adult patients with classic scabies.@*Methods@#We used a decision tree model to estimate the cost-effectiveness of two regimens, oral ivermectin alone or in combination with permethrin, compared with permethrin to treat adults and children aged five years and older with classic scabies in the outpatient setting from the household perspective in the Philippines. We estimated total costs and disability-adjusted life years (DALYs) over a one-month follow-up. Input parameters were obtained from secondary data, such as effect estimates for probabilities of clinical outcomes from a network meta-analysis, DALYs from the Global Burden of Disease 2019, and prevailing market cost in the Philippines (DPRI 2022 with recommended markup by DOH, and leading drugstores) as of August 2022. We computed for incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB) to determine which of the interventions are cost-effective. Univariate and probabilistic sensitivity analyses, and scenario analyses were conducted to assess the impact of parameter and structural uncertainty.@*Results@#Ivermectin-based regimens are suggested to be likely cost-saving compared to permethrin in the Philippine outpatient setting. Base case analysis showed that oral ivermectin had higher cost-savings (change in cost, -1,039.31; change in DALYS, 0.00027), while combination oral ivermectin/permethrin had higher DALYs averted (change in cost, PhP -1,019.78; change in DALYs, 0.00045), compared to permethrin. Combination oral ivermectin/permethrin (56%) was the most cost-effective, followed by oral ivermectin (44%) compared to permethrin (0%) through probabilistic sensitivity analysis. Estimates for ivermectin were sensitive to risk of cure for ivermectin vs permethrin using 1-way deterministic sensitivity analysis. Oral ivermectin was favored over combination oral ivermectin/permethrin at all thresholds based on the cost-effectiveness acceptability curve.@*Conclusion@#Both ivermectin-based regimens seem to be cost-saving compared to permethrin in the treatment of classic scabies in the Philippine outpatient setting. Clinicians may consider oral ivermectin, alone or in combination with permethrin as an alternative first-line or second-line treatment depending on patient preference, adverse event risk profile, availability, and economic capacity. This needs to be confirmed using primary data from Filipino patients to enhance the robustness of the findings and support evidence-based local decision-making in different settings. Less uncertainty in modelled parameters can give greater confidence in the results, which can be adopted for budget impact analysis and allow more rational resource allocation. Value of information analysis can be done to determine whether the expense of future RCTs or surveys in Filipinos to collect primary data is worth it. The cost of reducing uncertainty, if deemed worth the cost of further studies, may facilitate population-level decision-making and budget planning. Findings may further inform practice guideline development, coverage decisions, and national control program planning by providing the most cost-effective scabies intervention.

Association of comprehensive knowledge on HIV/AIDS and discriminatory attitudes towards people living with HIV/AIDS (PLWHA) among Filipino women

Background@#The Philippines is among the countries with the fastest growth rate of HIV cases in the Asia-Pacific Region. HIV/AIDS stigma and discrimination are recognized as major barriers, directly and indirectly inflicting harm to people living with HIV/AIDS (PLWHA). Despite this, there is a lack of studies regarding HIV/AIDS discrimination in the Philippines. This study aimed to assess the association between comprehensive knowledge on HIV/AIDS and discriminatory attitudes towards PLWHA among women in the Philippines. @*Methodology@#Secondary data analysis was done using the Philippine National Demographic Health Survey (2017). Twenty two thousand eight hundred thirteen (22,813) Filipino women aged 15-49 years old were included in this study. Multiple logistic regression was performed to determine the association between comprehensive knowledge and discriminatory attitudes. The final model was built using the change in estimate criterion and sampling weights were applied. @*Results@#More than 3 out of 4 (76.87%) had discriminatory attitudes towards PLWHA, whereas only 1 out of 4 (26.24%) had comprehensive knowledge on HIV/AIDS. Results of multiple logistic regression reveal that women without comprehensive knowledge are 2.53 times more likely to have discriminatory attitudes towards PLWHA (OR= 2.53, 95% CI =2.26-2.84). @*Conclusion@#Given that women without comprehensive knowledge are more likely to have discriminatory attitudes, HIV/AIDS campaigns may be strengthened by integrating necessary concepts in comprehensive sexual education and conducting more active nationwide information and education campaign efforts. Moreover, there is a need to formally evaluate the overall effectiveness of existing interventions.

The effect of a two-day training and refresher program on the basic emergency obstetric and newborn care knowledge and skills of health workers in Legazpi City, Albay

@#<p style="text-align: justify;"><strong>Objectives:</strong> The availability of emergency obstetric and newborn care (EmONC) services is one of the key strategies in improving maternal health and achieving Sustainable Development Goal 3. Health staff knowledge and competency on these interventions are crucial to ensure the effective handling and management of obstetric and newborn emergencies. Health workers, despite having undergone formal training, require regular refresher courses to keep up with new, evidence-based information on EmONC intervention; and to ensure compliance with national and local referral guidelines. A two-day workshop was implemented to assess the knowledge and skills of health workers in Legazpi, Albay, regarding obstetric emergency cases and referral guidelines.</p><p style="text-align: justify;"><strong>Methods:</strong> A pretest was conducted on the first day to assess the knowledge of the participants. A series of lectures were given before administering a posttest at the end of these lectures. An Objective Structured Clinical Examination (OSCE) was conducted on the second day, which aimed to assess the skills of the participants.</p><p style="text-align: justify;"><strong>Results:</strong> The pretest findings indicated that the participants are generally knowledgeable about areas such as handwashing and prenatal care. Results of the posttest show that participants had difficulty with the category of referrals. Moreover, comparing the pretest and posttest scores, there is strong evidence that there is a difference in the median values of the pretest scores as compared to the posttest scores. The results of the OSCE also indicate the need for further training on partograph use and adherence to an EINC protocol. More than half of the participants passed all five parts of the OSCE.</p><p style="text-align: justify;"><strong>Conclusion:</strong> The workshop contributed to an improvement in the knowledge of health care workers in obstetric emergency cases. Skills-wise, more frequent training may need to be conducted to improve other competencies such as partograph utilization and the practice of EINC interventions.</p><p style="text-align: justify;"><strong>Key Words:</strong> emergency obstetric care, training, skilled birth attendants, knowledge, skills</p>

Financial assistance for the treatment of schizophrenia in select institutions in the Philippines

@#<p style="text-align: justify;"><strong>Objective:</strong> This paper aims to characterize existing financial assistance available to patients with schizophrenia. Specifically, we described (1) the funding mechanisms for the treatment of patients with schizophrenia; (2) the process for accessing financial assistance; and (3) the experiences of consumers of services of these support mechanisms.</p><p style="text-align: justify;"><strong>Methods:</strong> We employed qualitative techniques using key informant interviews (KII) and focus group discussion (FGD). Key informants were officials from institutions providing or offering financial assistance for patients with any health-related concerns, including schizophrenia. Focus group participants were support group members or caregivers of patients with schizophrenia. Purposive sampling was used to select participants for both providers and consumers of financial assistance or scheme. Topic guides for KII and FGD were used for data collection. Thematic analysis was performed on the qualitative data gathered from the informants and focus group participants.</p><p style="text-align: justify;"><strong>Results:</strong> Securing financial assistance for schizophrenia followed a generally similar process, whether the source is from government offices or civil society organizations, and can be grouped into three main stages: (a) pre-application, (b) application, and (c) post-application. While the process of seeking financial assistance appears to be straightforward, issues were encountered in all of the stages by both providers and recipients alike, namely: (a) Financial assistance as an augmentation to patient resources; (b) Mismatch between demand and service capability; (c) Measures of organizational effectiveness; (d) Health professionals and support groups as "bridges" / "facilitators" to financial assistance providers; (e) Financial and non-financial costs incurred by caregivers in applying for financial assistance; and (f) Recipient-provider relationship as a barrier to the feedback process.</p><p style="text-align: justify;"><strong>Conclusion:</strong> This study provides a glimpse of available financial and other relevant assistance to clients, including clients suffering from schizophrenia. More extensive research covering more organizations, support groups, and caregivers from different parts of the country is recommended.</p>

Factors associated with hypertension and diabetes among risk-assessed patients in a Pasig City health center

Background@#Non-communicable diseases (NCDs) are among the growing public health problems globally which cause premature and preventable deaths. They remain as leading causes of mortality in the Philippines, specifically hypertension and Type 2 Diabetes Mellitus (T2DM). @*Objective@#This study aimed to determine the factors associated with high risk for hypertension and T2DM among patients who were risk-assessed in the Center for Dialysis, Healthy Lifestyle, Ambulatory Surgery, Maternity Clinic and Newborn Care of Pasig City (CHAMP) Health Center from January to December 2020. @*Methodology@#An analytical cross-sectional study design was utilized to determine the factors associated with hypertension and T2DM among risk-assessed patients. Secondary data from the NCD registry of the City Health Department of Pasig was obtained through a one-time collection. @*Results@#Among the 77 patients included in the study, 19.48% were classified as high-risk for hypertension and T2DM. Through a simple logistic regression, no variable was statistically significant at a 5% level of significance which means there is no sufficient basis to conclude that there is an association between the factors with high risk for hypertension and T2DM. Looking at the characteristics of the participants, 74% were obese and more than half had no regular exercise; they may still be at risk for NCDs because being at non-high-risk does not eliminate risk completely.@*Conclusion@#Policies or strategies regarding access to health centers for risk assessment should not be neglected even during a communicable disease pandemic because this may lead to a misreporting of high-risk individuals.

Analysis of trends in maternal mortalities in Bicol region using national health surveys and maternal death reviews / Philippine Journal of Obstetrics and Gynecology

Background@#Since 1976, Bicol Region had higher maternal mortality ratio (MMR) than the Philippine average and became the fourth region with the highest MMR in 2012. Looking at trends of maternal health outcomes and determining risk factors among mothers who died may guide interventions to reduce MMR.@*Objectives@#To determine the changes in maternal mortality ratio (MMR) in the Bicol region from 2004 to 2017 and determine the sociodemographic profile of pregnant women who died from 2015 to 2018. @*Materials and Methods@#A records review of Bicol?s Regional Field Health Services Information System from 2004 to 2017 and maternal death review reports from 2015 to 2018 was done. Changes in MMR was determined using Poisson regression. The sociodemographic characteristics and causes of maternal deaths were analyzed using frequencies and proportion. @*Results@#From 2004 to 2017, MMR of 100.9 remained higher than the regional target of 31.6. Significant reductions in MMR were achieved in 2007 to 2008 and in 2011 to 2012 wherein MMR ranged between 75.3 to 89.3. However, by the end of 2012, maternal deaths again increased which reached 122.5 in 2017. From the maternal death reviews, it was observed that 29.5% of maternal deaths were aged 35 years and above and 7.5% were less than 20 years old. Mothers who had more than five pregnancies were 30.1% of total deaths. In terms of place of death, 15.7% died at home or in-transit to referral facilities. Hemorrhage or hypertension-related causes were the leading reasons for maternal deaths. @*Conclusion@#Significant reduction in MMR was not sustained after 2012 and higher deaths were reported in the succeeding years. Maternal deaths can be further reduced by using a systems approach, by promoting family planning, and by strengthening service delivery networks to effectively manage hemorrhage and hypertension-related emergencies.