Clinical practice guideline and pathway for the evaluation and management of children with diarrhea in family and community practice

Background@#Diarrhea is among the common causes of morbidity and mortality in children. It is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). It does not include frequent passing of formed stool and passing of loose, pasty stools by breastfed babies. It is usually a symptom of an infection in the intestinal tract, caused by variety of organisms, which is spread through contaminated food or drinking water, or from person-to-person as a result of poor hygiene. Diarrhea can last several days and can leave the body without the water and salts that are necessary for survival causing significant number of mortality and morbidity among children. At the level of primary care, diagnosis, management and treatment of food- and waterborne-diseases, which commonly present as diarrhea, lack the necessary protocols and standards, thus, the creation of this clinical pathway. @*Objective@#The main goal of this clinical pathway was to provide guidance to family and community physicians, and other primary care physicians in managing acute diarrhea among immunocompetent pediatric patients.@*Methods@#ADAPTE process was used in CPG development. Existing guidelines on acute diarrhea among pediatric patients were retrieved and appraised using the AGREE II tool. Recommendation statements from the guidelines that passed the AGREE II tool were reviewed. Recommendation statements that will help answer the clinical questions posed in the creation of the clinical pathway were adapted. For clinical questions were not answered by the available guideline recommendations, a de novo method was conducted. The adapted recommendation statements and the supporting summary of evidences were sent for external review prior to consensus development. Suggestions provided in both steps were discussed and incorporated in the final manuscript, as appropriate.@*Key Recommendation Statements@#These key recommendation statements addressing the clinical assessment, diagnosis, interventions (pharmacologic and nonpharmacologic), and patient outcomes that are relevant in the outpatient or primary care setting in the Philippines were based on the summarized key evidences from the systematic review of literature conducted using the ADAPTE process. Clinical Assessment Recommendation 1. A focused medical history that includes questions on duration, frequency, characteristics, associated symptoms, consumption of raw, ill-prepared, or rotten food; intake of antibiotics, contaminated food or water; and history of travel should be obtained. (Strong recommendation, High quality evidence) Recommendation 2. Physical examination should be done to assess the nutritional status, degree of dehydration, severity of disease, and presence of complications and comorbid conditions. (Strong recommendation, High quality evidence) Recommendation 3. Degree of dehydration should be classified into No Dehydration, Mild to Moderate Dehydration, or Severe Dehydration. (Weak recommendation, Moderate quality evidence) Recommendation 4. Children with acute infectious diarrhea who have any of the following conditions should be admitted to the hospital: severe dehydration, inability to tolerate fluids orally, suspected electrolyte abnormalities, altered consciousness, abdominal distention, respiratory distress, pneumonia, meningitis/encephalitis, sepsis, moderate to severe malnutrition, suspected surgical condition, or conditions for safe follow-up and home management are not met. (Strong recommendation, High quality evidence) Diagnostic Tests Recommendation 5. Routine diagnostic tests are not necessary among children with acute diarrhea. (Strong recommendation, Low quality evidence) Recommendation 6. Stool examination may only be requested if the patient present with moderate to severe condition, bloody diarrhea, or amoebiasis and parasitism is being considered at time of epidemic. (Strong recommendation, High quality evidence) Recommendation 7. Diagnostic tests may be requested if concomitant conditions like pneumonia, urinary tract infection, sepsis or meningitis are suspected; or if abdominal distension is observed post-hydration. (Strong recommendation, High quality evidence) Recommendation 8. Stool culture, serologic test, rapid diagnostic test, PCR determination and serum biomarkers are not recommended in family and community practice. (Strong recommendation, High quality evidence) Pharmacologic Treatment Recommendation 9. Reduced osmolarity oral rehydration solution (ORS), commercial or home-made is recommended to replace previous and ongoing losses. (Strong recommendation, High quality evidence) Recommendation 10. The volume and frequency of reduced osmolarity oral rehydration solution (ORS) should be dependent on patient’s age or weight, severity of dehydration and ongoing losses. (Strong recommendation, High quality evidence) Recommendation 11. Severe dehydration should be managed in the hospital with intravenous hydration. (Strong recommendation, High quality of evidence) Recommendation 12. Routine empiric antibiotic treatment is not recommended in children with acute infectious diarrhea. (Strong recommendation, Very low quality evidence) Recommendation 13. Antibiotic treatment may be given to children with Cholera, Shigella, typhoidal Salmonella, amoebiasis, and giardiasis. The choice of antibiotic must be guided by the local Antibiotic Surveillance Program. (Strong recommendation, High quality evidence) Recommendation 14. In general, antibiotic treatment should not be given in children with non-typhoidal Salmonella. It may be given in children with underlying conditions i.e., immunodeficiency, corticosteroid or immunosuppressive therapy. (Strong recommendation, Very low quality evidence) Recommendation 15. Among children older than six months, zinc supplementation of 10-20 mg per day for 10-14 days may be offered to reduce the duration and severity of diarrhea, and recurrence in the next two to three months (Strong recommendation, High quality evidence) Recommendation 16. Racecadotril may be offered to reduce ongoing loss of water and electrolytes. (Strong recommendation, High quality evidence) Recommendation 17. Probiotics may be offered to reduce the duration of diarrhea. Lactobacillus rhamnosus GG (LGG), Saccharomyces boulardii and Lactobacillus reuteri are strains with evidence of effectiveness. (Strong recommendation, High quality evidence) Recommendation 18. Anti-emetics and antidiarrheal drugs are generally not recommended because of their side-effects. (Strong recommendation, High quality evidence) Non-pharmacologic Interventions Recommendation 19. Among children with acute diarrhea, age-appropriate feeding should be continued. There is no need to modify or restrict diet. (Strong recommendation, Moderate quality of evidence) Recommendation 20. Among infants with diarrhea, breastfeeding must be continued. (Strong recommendation, High quality evidence) Recommendation 21. If diet was restricted because of frequent vomiting, early refeeding must be done. (Strong recommendation, Moderate quality evidence) Recommendation 22. All members of the family must be encouraged regular hand washing with soap and water. (Strong recommendation, Moderate quality evidence) Recommendation 23. Family members must observe proper food handling, have access to safe drinking water, and observe proper waste disposal. (Strong recommendation, Low quality evidence) Recommendation 24. Community level intervention that encourages hand washing, proper food handling, appropriate waste disposal and ensuring safe drinking water must be done. (Strong recommendation, Low quality evidence) Expected Patient Outcomes Recommendation 25. After each encounter the patient or guardian must understand the nature of acute diarrhea, its management and potential complications. (Strong recommendation, Low quality evidence) Recommendation 26. The management plan must be a mutual agreement between the family physician and the guardian. (Strong recommendation, Low quality evidence) Recommendation 27. For the management of a child with acute diarrhea, the family physician must target for resolution of dehydration, resolution of diarrhea, prevention of relapse, hospitalization, complications and early detection of adverse events. (Strong recommendation, High quality evidence) @*Dissemination and Implementation@#This clinical pathway will be published in the “The Filipino Family Physician” journal, which is accessible in the PAFP journal website. PAFP’s Committee on Research will disseminate the clinical pathway through distribution to its subspecialty and affiliate societies, chapters, training programs, and primary care practitioners; and continuing development sessions of the PAFP. Monitoring of the uptake of the clinical pathway will be through the number of downloads at the website and requests for copies. This clinical pathway may be used as a guide by family and community physician and primary care physicians in a primary care setting. Tabular presentation of the clinical pathway was included as a tool for implementation. Monitoring of implementation will be via continuous quality improvements activities, which can be a self-initiated activity of the member as recommended in the Universal Healthcare, or as a chapter or group activity.

Non-healing ulcers as an atypical presentation of Lupus Vulgaris in an adult Filipino: A case report

@#Cutaneous tuberculosis (TB) occurs rarely, comprising only approximately 1% of all extrapulmonary TB cases worldwide. This report presents an atypical clinical manifestation of Lupus vulgaris, the most common form of cutaneous TB. Typically, Lupus vulgaris presents as chronic erythematous plaques over the head and neck area. The patient, a 24-year-old male with limited support and financial resources, presented with chronic painful, non-healing ulcerated lesions on his left upper extremity. Diagnostic tests specific to TB infection, including culture, all turned out negative for TB. No improvement in the lesions was noted with antibacterial and antifungal therapies. Clinical course of the condition and histopathologic findings, though non-specific to TB, became the basis for diagnosis and treatment. Patient currently is on the 3rd month of anti-Koch’s treatment with noted gradual improvement in the character and appearance of the lesions. Lupus vulgaris could appear as ulcers and over the extremities though much less common, posing challenges in both diagnosis and treatment. Malignant transformation could develop if left untreated. Thus, careful and thorough examination of the patient and diligent follow-up and re-evaluation of lesions while considering the patient’s values, concerns and financial capacity, were necessary in successfully addressing both the biomedical and psychosocial aspect of the illness.

A validation study of the tagalog version of mental health literacy scale among community health workers

Background@#Mental Health Literacy (MHL) is considered a vital determinant of mental health and has the ability to benefit both individual and public mental health. To thoroughly measure the different aspects of mental health literacy and determine level of knowledge in the community, a MHLS-Filipino version is required.@*Objective@#This study aimed to validate the Mental Health Literacy Scale – Filipino (MHLS-F) version among Community Health Workers in a rural and an urban health center in CaLaBaRZon.@*Study Design@#This is a methodological study that was conducted among rural and urban health workers@*Patients and Methods@#The guidelines provided by Beaton was used as template for the process of translation and crosscultural adaptation. The first phase involved Translation and Cross- cultural Adaptation of the Mental Health Literacy Scale from English to Filipino Version (MHLS-F). The instrument was simultaneously forward translated from English to Filipino by two independent translators from the Sentro ng Wikang Filipino. Back translations into English were done by two independent translators. The expert review committee discussed discrepancies found between the original items and the back-translated version of the questionnaire through a small group discussion and evaluated the content validity. Judgement on each item was made based on the computed i- CVI. The pre-final translated questionnaire was pre-tested on 5 rural and 5 urban community health workers with similar characteristics to the study population. Suggestions or alternative wording were documented and forwarded to Sentro ng Wikang Filipino for editing and proofreading. After synthesis of all reviews, the Mental Health Literacy Scale – Filipino Version was finalized. The final version was administered to 220 Community Health Workers from the Santa Rosa CHO and San Juan MHO. Psychometric properties on internal reliability using Cronbach’s Alpha was used as complementary procedure for determining the final structure of the instrument.@*Results@#All six domains of MHLS were translated into Filipino without any major problems. The Final Mental Health Literacy Scale- Filipino Version has 26 items under 3 subscales. It has an acceptable content validity and satisfactory internal consistency (Cronbach’s alpha 0.730).@*Conclusion@#MHLS was successfully cross-culturally adapted into Filipino. The MHLS-F has good validity and reliability in assessing knowledge and attitude in mental health among community healthcare workers

Effectiveness of patient-centered intervention in post-stroke patients in the family and community practice setting: A meta-analysis

Background@#According to the American Heart Association, post- stroke patients often have neurologic deficits which can lead to a variety of complications. Patient-centered approach to care promotes shared decision-making between physicians and patients regarding treatment plan and may lead to better health outcomes for these post-stroke patients@*Objective@#The effectiveness of patient-centered intervention in improving physical functioning among adult post-stroke patients with residual neurologic deficit was determined. Secondary outcomes such as improvement in social functioning, activities of daily living, quality of life and prevention of negative events such as death, re-hospitalization and depression were also evaluated@*Method@#This systematic review included comparative randomized clinical trials involving humans as the clinical subjects, diagnosed to have had a stroke and appropriately evaluated to be in recovery with residual neurologic deficit, with the intervention described labeled as ‘patient-centered care’, and reporting an outcome on the improvement of physical functioning. Online search was done in Pubmed, CENTRAL, NICE, and the grey literature. Three reviewers independently conducted the search, appraisal and data extraction@*Results@#Results varied depending on the outcome measurement tool utilized by the included studies. There was no difference between groups in terms of overall physical functioning and ADL as measured by SIS 16 and SIS 3.0. However, significant improvement was noted in the following subscales of SIS 3.0: hand movement (0.45,3.18, p=0.009, I2=0%), communication (0.86,2.16, p<0.00001, I2= 0%), and memory and thinking (0.13, 1.74, p=.02, I2= 33%). Physical function, ADL and social functioning using RNLI as an outcome (1.44-3.70] p<0.00001, I2= 0%), and physical functioning, social functioning, ADL and QOL as measured by participation (1.48, 3.74, p<0.00001, I2= 0%) and perception of recovery (2.22, 4.00, p<0.00001, I2=0%) also showed significant improvement@*Conclusion@#Patient-centered approaches have potential benefit in improving specific components of physical and social functioning, ADL and quality of life. However, differences in the type of patient-centered intervention and outcome measurement tools warrant further investigation into the specific interventions which will provide the most benefit to post-stroke patients

Factors associated with COVID-19 vaccine acceptance among adult patients in primary care clinics in Laguna, Las Piñas and Parañaque: A cross sectional study

Background@#Since its surfacing in 2019, COVID-19 has spread all over the world and became an international concern. Vaccines against COVID-19 are expected to be the key in controlling this pandemic. To achieve this, studying factors that affect COVID-19 vaccine acceptance is crucial in order to increase the vaccine uptake rate of Filipinos to attain herd immunity.@*Objective@#The study aimed to determine the factors affecting COVID-19 vaccine acceptance among adult patients in primary care clinics in Laguna, Las Piñas and Parañaque.@*Methods@#This cross-sectional study was conducted last June 2021 with 137 adult patients from 6 clinics. The participants were given self-administered questionnaires containing items on sociodemographic profile and perception on vaccines. MS Excel and IBM SPSS were used for statistical analysis. Categorical variables were summarized as frequencies and percentages and continuous variables as means and standard deviations. Chi square was used to compare outcomes. Variables with statistically significant differences (p-value of <0.05) were included in multinomial regression analysis to determine association with vaccine acceptance.@*Results@#Residence (p=0.0166), educational level (p=0.017), perceived effectiveness of vaccines to prevent and control COVID-19 (p=0.001), safety (p=0.001), doctor’s recommendation (p=0.039), risk of being infected (p=0.025) and refusal of any type of vaccine in the past (p=0.003) were associated with COVID-19 vaccine acceptance.@*Conclusion@#Through this study, the authors found that most of the respondents are willing to get vaccinated regardless of their sociodemographic characteristics. Concerns about vaccine availability and accessibility can hinder the promotion of vaccine uptake in the future. This study can be used as a basis for development and planning of COVID -19 vaccination programs.

Considering the probable differential diagnosis

@#Differential diagnosis is the method of limiting the possible causes of the patient’s symptoms before making a final diagnosis. For experienced clinicians, it is the process of using clinical experience alongside the patient’s symptoms and test results to prioritize the list of possibilities until the diagnosis can be identified with confidence.

Diagnosis and management of Dyslipidemia in family practice

Background@#Atherosclerotic cardiovascular disease (ASCVD) is a top cause of mortality in the Philippines. A known modifiable risk factor for ASCVD is dyslipidemia. Thus, proper diagnosis and management of dyslipidemia in family practice clinic could significantly decrease the burden of cardiovascular disease in the country@*Objectives@#This clinical pathway was developed to guide family and community physicians on the diagnosis and management of dyslipidemia.@*Methods@#To develop evidence -based recommendations, the authors searched for the latest guidelines of reputable international and local societies. They also searched PubMed using the terms “dyslipidemia”, “diagnosis”, “therapeutics”, “family” and “community medicine”. The more rigorous meta-analysis of clinical trials and observational studies were prioritized over lowquality trials in the formulation of the recommendations.@*Recommendations@#Thorough ASCVD risk assessment for all adults should be done during initial visit in family practice. The physician should review patient’s present medication; probe regarding lifestyle habits; conduct complete physical examination; use family assessment tools; and assess risk for ASCVD using calculators or risk factor counting method. For patients ≥ 45 years old and all adult patients regardless of age at increase ASCVD risk the following should be requested: lipid profile, urinary albumin- creatinine ratio/ urinary dipstick test, alanine transaminase (ALT), 12-lead electrocardiography (12-L ECG) and fasting blood sugar (FBS). During subsequent visits, re-assessment of ASCVD risk; checking compliance to non-pharmacologic intervention; and review of medication adherence and adverse effects should be performed. Repeat measurement of lipid profile should be done 6-8 weeks after initiation of statin therapy; 8-12 weeks after dose adjustment; and biannually for patients with controlled lipid levels. For individuals on statin therapy who have already achieved their low-density lipoprotein cholesterol (LDL-C) goal, compute for non- high density lipoprotein cholesterol (non-HDL C). Repeat ALT 6-8 weeks after initiation of statin therapy for those at high risk of statin-induced liver injury. Request creatine kinase (CK) if with development of muscle symptoms while on statin therapy. For primary prevention, start low-moderate intensity statins for following: individuals with diabetes mellitus (DM) Type 2 without ASCVD; individuals with mild-moderate chronic kidney disease (CKD); and individuals without ASCVD aged ≥ 45 years old with LDL -C ≥ 130 mg/dl AND with ≥ 2 risk factors. Start high intensity statins for individuals diagnosed with Familial Hypercholesterolemia. Give high intensity statins as secondary prevention for individuals with established ASCVD. For individuals with ASCVD on maximally tolerated statin therapy not meeting target LDL-C, ezetimibe could be added to their regimen. Low saturated fat diet rich in fruits and vegetable; regular exercise; and smoking cessation should be advised for all adult patients. The physician should also engage other family members to adopt healthy lifestyle. Formation of a community-based lifestyle intervention program to reduce cardiovascular risk should also be supported by the family physician.@*Implementation@#Adherence to pathway recommendations that are graded as either A-I, A-II or B-I is strongly advised. However, the authors also recommend using sound clinical judgment and patient involvement in the decision making before applying the recommendations.

Diagnosis and management of acute Tonsillopharyngitis in family practice

Background@#Acute tonsillopharyngitis is a common reason for consult in the primary care setting. Although most cases are viral in etiology, more than half of patients with acute tonsillopharyngitis still receive antibiotic therapy for group A beta-hemolytic streptococcal infection. Streptococcal throat infection may lead uncommonly to suppurative complications like peritonsillar abscess and non-suppurative complications like acute rheumatic fever. It is with this consideration that streptococcal throat infection must be distinguished from viral infections. Clinical practice guidelines have focused their efforts on how it can be accurately diagnosed to prevent complications while reducing unnecessary antibiotic prescribing.@*Objective@#This clinical pathway was developed to serve as guidance for family and community medicine practitioners in making clinical decisions regarding the diagnosis and management of acute tonsillophrayngitis.@*Methods@#After defining the scope of the pathway, the PAFP Clinical Pathways Group first identified the key issues in managing patient with acute tonsillopharyngitis. These key issues were then translated to review question. The group then reviewed the published medical literature to identify, summarize, and operationalize the evidence in clinical publication. Databases were first searched for existing clinical practice guidelines from reputable medical organizations. Further search for evidence was also conducted using the terms “tonsillopharyngitis” or “tonsillitis”, “diagnosis” and “treatment”. Evidence was then summarized and its quality assessed using the modified GRADE approach. From the evidence-based summaries, the CPDG then developed general guideline and pathway recommendations which are stated as time-bound tasks of patient-care processes in the management of acute tonsillopharyngitis in family and community practice. The recommendations were then presented to a panel of family and community practitioners in both urban and rural settings, for a consensus agreement on the applicability of the recommendations to family and community practice. Lastly, the final clinical pathway was written and developed to include the recommendations, the clinical pathway tables, and an algorithm. The clinical pathway can be used as a checklist or standards of care. The algorithm can be used to explain the process of care to the patient.@*Recommendations@#This clinical pathway contains updates on recommendations in the 2010 clinical practice guidelines on acute tonsillopharyngitis. Recommendations on the utilization of clinical scoring and rapid antigen tests as basis for deciding on need for antibiotic therapy comprise the major changes from the previously published guidelines. Penicillin remains as the first-line antibiotic therapy for streptococcal throat infection.@*Implementation@#Implementation of the clinical pathway will be at the practice and the organizational levels. The pathway may be used as a checklist to guide family medicine specialists or general practitioners in individual clinic and community medicine practice. It may also be used as reference for exams by the training programs and the specialty board. In the commitment to achieve the goal of improving the effectiveness, efficiency and quality of patient care in family and community practice, the clinical pathway may also be implemented through quality improvement activities in the form of patient record reviews, audit and feedback. Audit standards will be the assessment and intervention recommendations in the clinical pathway. Organizational outcomes can be activities of the PAFP devoted to the promotion, development, dissemination and implementation of clinical pathways.

Catharsis-Education-Action (CEA) method as adjunct to family planning education in the utilization of contraceptives among women of reproductive age: A randomized controlled trial

Introduction@#For the past decades, issues on Population Control have been raised. The Philippine government has been addressing these issues for quite some time. However, on the other end of the spectrum on population control, the end users have seldom been asked, understood and talked about.@*Objective@#The study aimed to determine the effectiveness of Catharsis-Education-Action (CEA) Method with Family Planning Education in improving the uptake of artificial contraceptive use compared to Family Planning Education alone among women of reproductive age.@*Methods@#This randomized controlled trial was conducted in a primary health center in Batangas City among 176 women of reproductive age with unmet need in family planning. Participants were randomized into either CEA counseling with Family Planning Education (intervention group) and Family Planning Education alone (control group). CEA was conducted individually with the study participants in the intervention group, following a Family Planning Education lecture provided by a midwife trained to disseminate information on family planning methods. The control group received Family Planning Education lecture alone. Outcomes were determined one month after using a Follow-up Questionnaire. Categorical variables were expressed in frequency and percentage. Chi square was used to compare the utilization rate of artificial contraceptive use between the two groups.@*Results@#Baseline characteristics were similar except for the participants’ age (p-value 0.025). There was statistically significant difference in the uptake of artificial family planning method between the CEA group and control group (43% vs 27%; p-value 0.014@*Conclusion@#Catharsis-Education-Action (CEA) Method as adjunct to Family Planning Education is effective in improving the uptake of artificial contraceptive use among women of reproductive age. Utilizing CEA will strengthen existing primary healthcare services and establish a reproductive health plan that will enhance the overall health and well-being of women, their families and the community.

Effectiveness of community-based interventions among patients with Osteoarthritis in family and community practice: A meta-analysis

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> Osteoarthritis (OA) is a debilitating disease that impedes activities of daily living and negatively impacts the quality of life of affected patients. With an increasing elderly population in the Philippines and across the globe, the incidence and prevalence of OA is expected to rise, and thus, will continue to pose a significant burden to patients, caregivers and the society in general. Community-based programs are practical, easily accessible and potentially sustainable and often involve educational programs aiming at lifestyle changes from which patients suffering from osteoarthritis may benefit.<br /></p><p style="text-align: justify;"><strong>OBJECTIVE:</strong> This study aimed to determine the effectiveness of community-based interventions in the management of OA, specifically in terms of improving symptoms and physical functioning among patients who are diagnosed with this condition.<br /></p><p style="text-align: justify;"><strong>METHODS:</strong> This meta-analysis only included randomized, parallel clinical trials involving patients diagnosed to have osteoarthritis. The authors searched for studies in peer reviewed journals of PubMed, clinical trials registered in Cochrane Central Register of Controlled Trials and the grey literature. Clinical trials where the intervention described involved the community or labelled as 'community-based' delivered as face-to-face or web-based, were identified. The main categories of approaches considered were: 1) community screening; 2) health education and advocacy; 3) community exercises; and 4) monitoring of treatment by community health workers. standard care. The primary outcome considered was reported improvement of pain, stiffness and physical function based on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). The authors also looked at the patients' quality of life as a secondary outcome. They used the RevMan 5.4 software in the analysis of their data. Assessment of bias, subgroup analysis and sensitivity analysis were done. The overall results were evaluated using GRADE.<br /></p><p style="text-align: justify;"><strong>RESULTS:</strong> A total of 543 studies were initially identified based on the inclusion criteria, from which 12 studies were eventually included in the review. Community interventions identified in the review included 3 publications on water-based exercises, 5 on strengthening exercises, 2 on behavioral intervention and 3 on physiotherapy. Two studies included QOL as part of the outcomes. Meta-analysis was done using the Revman 5 software and revealed that the studies were heterogeneous based on p values 50%. Subgroup analyses of specific variables were done to further assess the impact of the interventions. Results revealed that while there was no statistical difference between intervention and control, a positive trend in favor of strengthening exercises versus control in improving WOMAC pain scores, stiffness scores and physical function scores were noted. There was a statistically significant difference noted in favor of community-based intervention in the impact on quality of life, specifically for mental and social aspects based on SF-36<br /></p><p style="text-align: justify;"><strong>CONCLUSION:</strong> Based on these findings, we conclude that community-based interventions, specifically strengthening exercises, physiotherapy and behavioral intervention are effective in the management of OA and may be implemented whenever feasible. These interventions will help address the burden of OA and serve as an adjunct to existing hospital or health institution-based management.</p>