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Research Protocol Tingao B, Ventigan JL I. Introduction A.

Statement of the Problem The provision of primary health care is a basic service designed to be cost effective and bring healthcare as close as possible to the population, particularly to those people of low economic status. It is a service which is provided free of charge by the Philippines government. It is intended that the service should be accessible to the populace and be effectively utilized. The Barangay Health Center at Cluster 10 of San Juan, Batangas has smaller number of consults. (Figures 1 and 2) An informal conversation with Health Care Personnel was held to determine the possible reasons for underutilization of health centers. Explanations given include: 1. 2. 3. 4. 5. smaller population, therefore, less number of sick community members, self-care employed for minor illnesses, some prefer consulting private practitioners for chronic and/or severe illnesses, distance of health center from home (especially in Imelda) some still prefer traditional healers (hilot).

Ideally, a formal study (through a well-planned survey) should be conducted to determine the reason for underutilization of the health centers. However, the midwife and BHWs do not consider the underutilization a pressing problem in the community.

Figure 1 Baranggay Imelda 2011-2012 census

Figure 2 Baranggay Barualte 2011-2012 census

B. Background of the Problem San Juan lies in the easternmost portion of Batangas, a province located in the southwestern part of mainland Luzon. . It has a total land area of 27,340 kilometers, approximately 120 kilometers south of Metro Manila. . Although most of the main roads are cemented, inner road networks are still unpaved and accessible only by foot or horseback. Most of the total land area is devoted to agriculture, fishing, and ecotourism. Cluster 10 is comprised of two barangays, Barualte and Imelda. Barangay Barualte has a total land area of 4,453,745 km2 and a population of 1,617. It is divided into seven sitios: Centro, Cumba 1, Cumba 2, CYO, Silangan Talaba and Tanglaw. The main health center is located in Sitio Centro and is managed by the midwife, Ms. Arlene Agudera and six barangay health workers. Barangay Imelda has a total land area 4,729, 967 m2 and a population of 912. It is divided into five sitios: Bagong Silang-Silangan, Bagong Silang-Kanluran, Bandera, Baluk-Baluk and Pandayan. It is also managed by Ms. Agudera and five barangay health workers. Outpatient clinics are held in Barualte on Tuesdays and Wednesdays, while clinics in Imelda are held during Mondays and Thursdays. The average number of consults in Barualte is 5-10, whereas consults in Imelda range from 0-2. C. Review of Literature Perceptions of quality of the local health system play a major role in determining utilization of health services. A review on the determinants of delivery service use found that quality of care was an important factor in all the studies reviewed. (Gabrysch S 2009) In a qualitative study in Uganda on peoples perceptions and attitudes that affect healthcare utilization, there was a negative assessment by the community of the local public health system, especially at the primary level. (Bakeera SK 2009) Some of the complaints were Lack of supplies and equipment, poor referral system,

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inadequate facilities, lack of trust in health worker qualifications. The same can be found in a study in Central Java, Indonesia on under-utilization of public primary health facilities. (Triratnawati 2006) Further identified were inadequate working hours for the health system, unavailability of doctors, limited facilities and inadequate equipment. People also tend to bypass the nearest health facility to go to a higher level and more remote one. A quantitative-qualitative study in Tanzania among pediatric patients assessed the main reasons for bypassing. (Kahabuka C 2011) The main reasons were lack of diagnostic facilities or drugs, facilities were closed and poor perception of quality among participants. On another study in Tanzania, this time with women giving birth, bypassing mothers were of the impression that local facilities were of poorer quality and that farther ones had better and more trustworthy doctors and staff. (Kruk ME 2009) Perceptions also play a role on peoples attitudes towards illness and how to deal with it. In the above study in Central Java, it was found that people perceived of local health centers as providing for only mild illnesses. If patients do not perceive their illness as serious, then they will not go to a local health facility. This of course could be due to a problem in education, as was concluded by a study in Nairobi, Kenya of health care seeking for childhood illnesses. (Taffa N 2005) This was also the observation of a study on utilization of antenatal care services in Indonesia. Lack of complications on previous pregnancies and lack of education about possible pregnancy complications were correlated with under-utilization. (Titaley CR 2010) The private sector also plays a major role in the health care of people in the developing world. In Uganda, a study found that up to 63% of people sought care from a private provider. (Konde-Lule J 2010) Private providers were not limited to private doctors and health facilities. They could be as simple as general merchandise stores selling medicine or local boutiques. Almost the same rates were found in a study in Vietnam, where participants used a private provider 60% of the time versus 10% for public providers. (Thuan NTB 2008) People were also willing to shell out large sums of money for private providers as it was found that 59.9% of healthcare payments were for private providers. Self treatment can be a part of this pattern and in the two studies above, self-treatment rates were found to be around 30-35%. In fact, in the Ugandan study above, participants identified self-care as the natural first step in health seeking. (Bakeera SK 2009) Distance also plays a role in utilization. A study on the utilization of rural health facilities for pediatric patients in Tanzania was able to quantify this distance decay effect. Clinic visits decrease progressively per 0.5 km distance from a clinic up to 4 km. Per 1 km increase in distance, visitation fell 34% from the previous kilometer. (Feikin DR 2009) The reviews by Gabrysch and Campbell and Shaikh and Hatcher (Shaikh BT 2004) reveal the same importance in other studies. Research Question Among the residents of Cluster 10 (Brgys. Imelda and Barualte) in San Juan, Batangas, what are the community-reported factors can contribute to under-utilization of the local primary healthcare system, using a qualitative design study?

III. IV. V.

Objectives 1. To determine the Conceptual Framework Methodology The research will use a qualitative design study with data collection using focus group discussions (FGDs) and in-depth interview. It is mainly used for eliciting information from population subgroups in a descriptive manner. (Bender DE 1994) A. Selection of Participants As there is no consensus in the literature on the ideal number of FGDs for a study, this number must be individualized by investigator. (Bender DE 1994) The selection process above can be extended and repeated as much as necessary until data saturation is reached, i.e. when no new responses or insights can be extracted anymore. Tentatively, the number of FGDs will be set to three. B. Focused Group Discussions C. In-Depth Interviews Semi-structured, in-depth interviews will also be conducted in order to supplement the information obtained from the FGDs. The BHWs, health secretary and midwife will be interviewed. The question will be open ended and will not serve to constrain and direct but merely act as starting points for discussion. The guide questions are as follows: D. Data Collection Data collection either in the FGDs or interviews will be by digital audio recording with handwritten notes and transcriptions. Debriefings will be held with interview and FGD participants to clarify the notes, transcriptions and recordings. E. Analysis Bibliography

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Bakeera SK, Wamala SP, Sandro G, State A, Peterson S, Pariyo GW. "Community perceptions and factors influencing utilization of health services in Uganda. ." International Journal for Equity in Health, 2009: 8:25. Bender DE, Ewbank D. "The focus group as a tool for health research: issues in design and analysis." Health Transition Review, 1994: 4:1. Feikin DR, Nguyen LM, Adazu K, Ombok M, Audi A, Slutsker L, et al. "The impact of distance of residence from a peripheral health facility on pediatric health utilization in rural western Kenya." Tropical Medicine and International Health, 2009: 14:54-61. Gabrysch S, Campbell OMR. "Still too far to walk: Literature review of the determinants of delivery service use." BMC Pregnancy and Childbirth , 2009: 9:34.

Kahabuka C, Kvale G, Moland KM, Hinderaker SG. "Why caretakers bypass Primary Health Care facilities for child care a case from rural Tanzania." BMC Health Services Research , 2011: 11:315. Konde-Lule J, Gitta SN, Lindfors A, Okuonzi S, Onama VON, Forsberg BC. "Private and public health care in rural areas of Uganda." BMC International Health and Human Rights, 2010: 10:29. Kruk ME, Mbaruku G, McCord CW, Moran M, Rockers PC, Galea S. "Bypassing primary care facilities for childbirth: a population-based study in rural Tanzania." Health Policy and Planning , 2009: 24:279-288. Shaikh BT, Hatcher J. "Health seeking behavior and health service utilization in Pakistan: challenging the policy makers." Journal of Public Health, 2004: 27:49-54. Slaughter P, Pinfold P, Flintoft V, Gort E, Thiel E, Blackstein-Hirsch P, et al. Focus groups in health services research at the Institute for Clinical Evaluative Sciences. Technical Report, Ontario: Institute for Clinical Evaluative Sciences, 1999. Taffa N, Chepngeno G. "Determinants of health care seeking for childhood illnesses in Nairobi slums." Tropical Medicine and International Health, 2005: 10:240-245. Thuan NTB, Lofgren C, Lindholm L, Chuc NTK. "Choice of health care provider following reform in Vietnam." BMC Health Services Research, 2008: 8:162. Titaley CR, Dibley MJ, Roberts CL. "Factors associated with the underutilization of antenatal care services in Indonesia: results of Indonesia Demographic and Health Survey 2002/2003 and 2007." BMC Public Health , 2010: 10:485. Triratnawati, A. "Underutilization of community health centers in Purworejo Regency, Central Java." Makara, Kesehatan, 2006: 10:1.