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.

Factors affecting treatment adherence among leprosy patients: Perceptions of healthcare providers.

Background: Treatment adherence is a vital aspect in the management of chronic diseases like leprosy; however, most studies on treatment adherence focus on patients. This study aims to examine the perceptions of healthcare providers on factors that can promote or prevent patients from adhering to treatment. Methods: We conducted three focus group discussions (FGDs) with healthcare providers who have at least one year experience in managing leprosy in three large leprosy case-holding hospitals in Metro Manila, Philippines. We audio-recorded, transcribed, translated the FGD proceedings, and analyzed the transcripts thematically to identify patient-intrinsic and patient-extrinsic enablers and barriers to treatment adherence of leprosy patients. Results: Patient-intrinsic motivators to complete treatment include innate desire to be cured, fear of infecting family and friends, fear of disability, good knowledge about the disease, need for medical clearance to be considered fit to work, and experiencing leprosy reactions. Patient-extrinsic motivators to complete treatment include free treatment, immediate and sufficient counselling, flexibility in treatment, follow-up and motivation of healthcare workers, and presence of Hansen's Club and support groups. Patient-intrinsic barriers to good treatment adherence include distance between residence and hospital, financial and opportunity costs, adverse drug reactions, misconceptions about being cured, disabilities and presence of leprosy reactions, stubbornness and/or laziness, and undergoing clinical depression. Patient-extrinsic barriers to good treatment adherence include poor availability of MDT, transfer to other leprosy treatment facilities without informing current facility, and stigma. Conclusion: Healthcare providers perceive that patient-intrinsic and patient-extrinsic factors influence the treatment adherence of leprosy patients through different mechanisms. We highlight the role of healthcare provider attitudes, stigma, and support groups in promoting treatment adherence.

Evolving academic and research partnerships in global health: a capacity-building partnership to assess primary healthcare in the Philippines.

Building fair, equitable, and beneficial partnerships between institutions collaborating in research in low- and middle-income countries (LMIC) and high-income countries (HIC) has become an integral part of research capacity building in global health in recent years. In this paper, we offer an example of an academic collaboration between the University of California Los Angeles, Center for Health Policy and Research (UCLA CHPR) and the University of Philippines, Manila, College of Public Health (UPM CPH) that sought to build an equitable partnership between research institutions. The partnership was built on a project to build capacity for research and produce data for policy action for the prevention and care of non-communicable diseases (NCDs) through primary healthcare in the Philippines. The specific objectives of the project were to: (1) locally adapt the Primary Care Assessment Tool for the Philippines and use the adapted tool to measure facility-level primary care delivery, (2) conduct focus group discussions (FGDs) to gather qualitative observations regarding primary care readiness and capacity, and (3) conduct a comprehensive population-based health survey among adults on NCDs and prior healthcare experience. We describe here the progression of the partnership between these institutions to carry out the project and the elements that helped build a stronger connection between the institutions, such as mutual goal setting, cultural bridging, collaborative teams, and capacity building. This example, which can be used as a model depicting new directionality and opportunities for LMIC-HIC academic partnerships, was written based on the review of shared project documents, including study protocols, and written and oral communications with the project team members, including the primary investigators. The innovation of this partnership includes: LMIC-initiated project need identification, LMIC-based funding allocation, a capacity-building role of the HIC institution, and the expansion of scope through jointly offered courses on global health.

Patterns and determinants of treatment completion and default among newly diagnosed multibacillary leprosy patients: A retrospective cohort study.

BACKGROUND: Poor treatment adherence among leprosy patients contribute to relapse, development of antimicrobial resistance, and the eventual plateauing of the prevalence and incidence of leprosy not just in the Philippines, but also worldwide. For this reason, we aimed to identify the patterns and determinants affecting treatment completion and default among multibacillary leprosy patients. METHODS: We conducted a retrospective cohort study involving three large hospitals in Metro Manila, Philippines. Patients who started the World Health Organization - Multiple Drug Therapy for multibacillary leprosy between January 1, 2007 and December 31, 2013 were included in the study. Selected socio-demographic and clinical data were abstracted from the patient treatment records. Survival analysis and proportional hazards regression were used to analyze the data. RESULTS: Records of 1,034 patients with a total follow-up time of 12,287 person-months were included in the analysis. Most patients were male, younger than 45 years old, had an initial bacterial index between 1 and 4, and were residents of Metro Manila. Less than 20% had their treatment duration extended to more than 12 months. Treatment adherence of the patients was poor with less than 60% completing treatment. Most patients complete their treatment within 12 months, but treatment duration may be extended for up to three years. Patients who default from treatment usually do so a few months after initiating it. After adjusting for other variables, hospital, initial bacterial index, and non-extended treatment duration were associated with treatment completion. These factors, in addition to age, were also found to be associated with treatment default. CONCLUSION: This study provides quantitative evidence that there might be marked variations in how doctors in particular hospitals manage their patients, and these findings underscore the need to revisit and re-evaluate clinical practice guidelines to improve treatment outcomes and adherence.

Effectiveness of peer counseling and membership in breastfeeding support groups in promoting optimal breastfeeding behaviors in the Philippines.

BACKGROUND: The prevalence of early initiation of breastfeeding and exclusive breastfeeding (EBF) at 6 months remain low in the Philippines. To help meet the 90% early initiation of breastfeeding target and to improve infant and young child feeding practices in the Philippines, the Millennium Development Goals - Fund 2030 Joint Programme (JP) on Ensuring Food Security and Nutrition for Children 0-24 months old was implemented. We aimed to determine the effectiveness of visits by peer counselors during pregnancy and after delivery, and membership in breastfeeding support groups in promoting these optimal breastfeeding practices. METHODS: We used data from the Endline Survey of the JP to study the effects of prenatal and postnatal peer counselor visits, and membership in breastfeeding support groups, and their possible interactions with initiation of breastfeeding within 1 hour of birth among children aged 0 to 24 months and EBF at 6 months among children aged 6 to 24 months, while adjusting for confounding. We used logistic regression methods for survey data to assess these associations. RESULTS: Of the 2343 mother-infant pairs, only 1500 (63.1%) practiced early initiation of breastfeeding. Of the 1865 children aged 6 months or older, only 621 (34.7%) were exclusively breastfed at 6 months. After adjusting for confounding variables, there was no strong evidence that peer counselor visits were associated with early initiation or EBF at 6 months. However, members of breastfeeding support groups had 1.49 times higher odds of early initiation of breastfeeding (95% CI [Confidence Interval] 1.12, 1.98) and 1.65 times higher odds of EBF (95% CI 1.20, 2.24) compared to those who were not members of breastfeeding support groups. There was no interaction between the different exposure variables and early initiation and EBF at 6 months. CONCLUSIONS: Our findings suggest breastfeeding support groups may be institutionalized to promote both early initiation of breastfeeding and EBF in the Philippines, while the role of peer counselors in promoting optimal breastfeeding behaviors should be further reviewed. Our suggestion to integrate non-healthcare professionals to promote early initiation of breastfeeding and EBF could be tested in future intervention studies.

Prevalence of psychosocial distress among flood victims in selected urban barangays in Manila

OBJECTIVES: This study was conducted to estimate the prevalence of psychosocial problems among residents of four flood-prone barangays in Manila located along the Maricaban-Malibay creek in Pasay City and were reported to have experienced 10-15 feet-deep flood waters simultaneously caused by Typhoon Maring and the southwest monsoon in August 2013.METHODOLOGY: A stratified two-stage random cluster sampling method, adapted from the Community Assessment for Public Health Emergency Response (CASPER) Toolkit, was employed in the syudy. The first stage of sampling used street clusters, with more or less of the same size, as the primary sampling unites (PSU) and households as secondary sampling units (SSU) to select the households that will be included in the survey. Since the clusters were more or less of the same size, they ahd equal chances of being selected in the study if the probability of selection is proportionate to size (PPS). Seven houses were then randomly chosen from the 30 selected clusters. All of the househol heads from the 210 selected households were given several copies of the self-administered questionnairescalled the Self-Reporting Questionnaire-20 (SRQ-20), a screening tool developed by WHO, to determine the psychosocial condition of the household members 12-65 years.RESULTS: The prevalence of psychosocial distress in this population was estimated at 17% (95%CI=13.7-20.3%). The residents of the study barangays were in their rehabilitation phase i.e., three months post disaster when data was collected for this study. The study also characterized the households in the sample according to socio-economic status, presence of members with special needs, and presence of children 0-5 years ol. In the aftermath of the disaster, 46.84% of the respondents had positive answer on the group of questions about decreased energy, 49.8% on somatic symptoms,25.89% on depressive thoughts and 40.91% on depressive moods.There was a higher prevalence of these 4 factors among females, those separated, with low socioeconomic status and low educational attainment.CONCLUSION: The estimated prevalence of psychosocial distress was 17% (95%CI=13.7%-20.3%), In the aftermath of the disaster, 46.8% of the respondents had positive answer on the group of questions about decreased energy, 49.8% on somatic symptoms, 25.9% on depressive thoughts and 40.9% on depressive moods.

Mapping the Risk of Soil-Transmitted Helminthic Infections in the Philippines.

BACKGROUND: In order to increase the efficient allocation of soil-transmitted helminth (STH) disease control resources in the Philippines, we aimed to describe for the first time the spatial variation in the prevalence of A. lumbricoides, T. trichiura and hookworm across the country, quantify the association between the physical environment and spatial variation of STH infection and develop predictive risk maps for each infection. METHODOLOGY/PRINCIPAL FINDINGS: Data on STH infection from 35,573 individuals across the country were geolocated at the barangay level and included in the analysis. The analysis was stratified geographically in two major regions: 1) Luzon and the Visayas and 2) Mindanao. Bayesian geostatistical models of STH prevalence were developed, including age and sex of individuals and environmental variables (rainfall, land surface temperature and distance to inland water bodies) as predictors, and diagnostic uncertainty was incorporated. The role of environmental variables was different between regions of the Philippines. This analysis revealed that while A. lumbricoides and T. trichiura infections were widespread and highly endemic, hookworm infections were more circumscribed to smaller foci in the Visayas and Mindanao. CONCLUSIONS/SIGNIFICANCE: This analysis revealed significant spatial variation in STH infection prevalence within provinces of the Philippines. This suggests that a spatially targeted approach to STH interventions, including mass drug administration, is warranted. When financially possible, additional STH surveys should be prioritized to high-risk areas identified by our study in Luzon.

New endemic foci of schistosomiasis infections in the Philippines.

Schistosomiasis affects 28 provinces in the Philippines found along the southeastern part where there is continuous rainfall throughout the year. In 2002 and 2005 respectively, two new endemic foci were reported in the northernmost (Gonzaga, Cagayan) and central (Calatrava, Negros Occidental) parts of the country. This study conducted in March 2008-March 2009 confirmed the presence of the disease by determining its prevalence using four diagnostic tests - Kato-Katz, circumoval precipitin test (COPT), ELISA and ultrasonography. Oncomelania hupensis quadrasi was identified through snail surveys conducted in possible snail habitats in the seven new endemic villages. Animal surveys through stool examination confirmed the presence of schistosomiasis infection in animals in Gonzaga but not in Calatrava. Compared to Calatrava, Gonzaga demonstrated markedly higher prevalence of schistosomiasis using all four diagnostic methods. Proximity of snail habitats to human habitation including higher snail density and snail infection rate could be responsible for the high prevalence. Snail sites were more widespread in Gonzaga whereas those in Calatrava were confined only in areas not frequented by the general population except by farmers. GIS maps showing spatial distribution of snails in Gonzaga and Calatrava indicated differences in elevation among the snail sites. It is hypothesized that the snail intermediate host has been in these sites for sometime but discovered only lately. Migration of people from endemic provinces into Gonzaga and Calatrava brought in cases and in the presence of snail intermediate hosts, emergence of disease was just a matter of time.

Knowledge, attitudes, sexual behaviors and utilization of health services among Filipino men who have sex with men (MSM)

OBJECTIVES: The main objective of this study was to describe the knowledge, attitudes, sexual practices, and utilization of health services of the MSM population in the Philippines. METHODS: The study design was cross-sectional. Data was collected through an online survey of Filipino MSMs with accounts at any of the three (3) major MSM websites. This was supplemented by focus group discussions and key-informant interviews of informal MSM leaders. Only 682 men satisfied the eligibility criteria and were included in the analysis. RESULTS: Forty eight percent (48%) of the respondents had low levels of knowledge on Human Immunodeficiency Virus (HIV). Majority (54%) engaged in unprotected sex despite having positive attitudes toward condom use. MSMs had multiple sex partnerships to satisfy their "high libido" and get "sexual gratification." Only 17% had submitted themselves for HIV testing and knew their results. CONCLUSIONS: MSMs remain at high risk for HIV and Sexually Transmitted Infections (STI's). There is a wide gap between knowledge and actual sexual practices, and their health-seeking behavior remains poor. Thus, there is a need for programs that are tailored to the needs, cultural diversities, and unique practices of the MSM community.

Factors associated with non-compliance with anti-malarial treatment among malaria patients in Puerto Princesa, Palawan

OBJECTIVE: Malaria is a life-threatening, mosquito-borne disease that continues to cause numerous deaths worldwide. In the Philippines, malaria remains an important problem, with five provinces having >1000 cases of malaria a year. The objective of this cross-sectional analytical study was to determine the association of selected factors with non-compliance to anti-malarial treatment among malaria patients in Puerto Princesa, Palawan, specifically: perceived susceptibility to malaria, perceived seriousness and severity of malaria, perceived benefits of medication, perceived barriers to treatment compliance and cues to action.METHODS: Using an interviewer-administered structured questionnaire, 320 individuals diagnosed with and treated for malaria from January to October 2010 were interviewed regarding compliance to anti-malarial treatment and the factors related to compliance. Descriptive statistics and multiple logistic regression were used to analyze the data.RESULTS: The rate of non-compliance to anti-malaria treatment was 17% (95% Cl 12.1%-21.2%). After multivariate analysis using logistic regression, symptom perception as a cue to action and forgetfulness as a perceived barrier to treatment compliance were found to be significantly associated with non-compliance to treatment. The odds of non-compliance were three times higher for individuals who perceived that an improvement in symptoms implied cure of malaria. An individual who forgot to take at least one dose of medication was 17 times more likely to be non-compliant with treatment compared to someone who did not forget to take a single dose.CONCLUSION: Given the factors found to be associated with non­compliance to treatment, more effective ways of ensuring compliance with anti-malaria treatment may be explored e.g., doing directly observed treatment and utilizing treatment partners that may help address the problem of forgetfulness. The fact that symptom improvement is not equivalent to cure must be stressed when advising patients. Emphasizing compliance to treatment and the consequences of noncompliance when conducting patient education activities may also help boost treatment compliance.