Bridging the Gap: Reducing Health Inequities in Access to Preventive Health Care Services in Rural Communities in the Philippines.

INTRODUCTION: We used an implementation science framework to investigate perceived health inequities in preventive health care initiatives in rural communities in the Philippines. We also identified health equity-focused quality improvement strategies. METHODS: Three health care providers and 12 barangay clinic patients were interviewed. RESULTS: Patient interviews showed that social determinants of health, respect, and attitudes toward health care providers affected patient empowerment to engage in self-management for noncommunicable diseases (NCDs). Health care providers identified six challenges in managing NCDs: (a) inefficient work processes; (b) staffing shortages; (c) insufficient access to low-cost medications; (d) inadequate primary preventive health education from the schools; (e) health care not considered a priority; and (f) lack of local government support. DISCUSSION: Inadequate preventive health care and education intensify health access and resource inequities in rural communities in the Philippines. A multi-sectoral plan may improve rural health infrastructure and education toward improving health care access and decreasing care disparities.

Feasibility of Nurse-Facilitated Advance Care Planning Among Older Veterans in a Dialysis Unit and an Oncology Infusion Center.

INTRODUCTION: Many veterans with serious illnesses, such as end-stage kidney disease requiring dialysis and advanced cancer requiring treatment infusions, must make complex decisions about their current and future medical care. Advance care planning (ACP) is a process where individuals identify, express, and communicate their personal values, life goals, and preferences for care. ACP may be feasible in chemotherapy infusion centers or chronic dialysis centers during patient treatment. MATERIALS AND METHODS: We assessed the feasibility of a licensed vocational nurse (LVN) facilitator to help veterans review the PREPARE for Your Care program (www.prepareforyourcare.org) and complete an advance directive (AD) in an outpatient hemodialysis unit or a chemotherapy infusion center. PREPARE For Your Care is an evidence-based online program with written pamphlets and ADs that prepares patients to participate with clinicians in making medical decisions. We measured the time to complete a session and the level of assistance required from LVNs via LVN self-report. Self-reported ease-of-use, comfort, and helpfulness were assessed on a 10-point Likert scale from 1 (not at all) to 10 (very). RESULTS: Twenty-eight patients were enrolled (mean age ± SD: 67 ± 11 years); all (100%) completed PREPARE and the AD within 1 session. The mean completion time was 100 (±40) minutes. Most of the patients required considerable assistance from the LVN. The mean scores were 8.0 of 10 for ease-of-use (±2.3), 7.7 of 10 (±2.8) for comfort, and 8.2 of 10 (±2.3) for helpfulness. CONCLUSIONS: This pilot study demonstrates that using PREPARE as an ACP tool for veterans may be feasible for patients during hemodialysis and chemotherapy infusion. Patients required considerable assistance from the LVN to complete PREPARE. Hemodialysis and chemotherapy infusion are opportunities when patients have time and space to consider ACP.

A Comparative Study on Health Risks, Lifestyle Behaviors, Health Perceptions, and Health Seeking Patterns between Older and Younger Filipinos in the Rural Areas.

Background: Worldwide trends in health risks, lifestyle behaviors, health perceptions, and health-seeking patterns suggest alarming disparities among individuals from low- and middle-income countries. Such international comparisons are particularly troubling for older individuals (≥ 60 years). Objectives: This study aims to compare health risks, lifestyle behaviors, health perceptions, and health-seeking patterns between younger (<60) and older (≥60) Filipinos from rural communities in the Philippines. Methods: A comparative cross-sectional study was employed with 863 younger and 427 older Filipinos. Data were analyzed using frequencies, chi-squares, and T-tests. Results: Older participants were more likely to be single/widowed, ≤ high school education and had higher rates of hypertension, high cholesterol, diabetes, and depression. They reported poorer health status and went to the village health center when sick. Furthermore, they were less likely to drink alcohol and see a physician. Conclusion: There were significant differences in modifiable health risks and lifestyle behaviors and differences in health perceptions between younger and older cohorts of Filipinos living in rural areas in the Philippines. Our findings suggest the need to design separate health promotion interventions that target older and younger Filipinos' unique needs from rural communities.

Facilitators and Challenges to Exergaming: Perspectives of Patients With Heart Failure.

BACKGROUND: Few investigators have explored challenges and facilitators to exergaming, essential factors to exergaming adherence, among patients with heart failure. OBJECTIVES: In this qualitative study, we explored facilitators and challenges using a home-based exergame platform, the Nintendo Wii Sports, in patients with heart failure. METHODS: Semistructured face-to-face interviews were conducted in 13 participants given a diagnosis of heart failure (age range, 34-69 years). Participants were asked about their experiences with exergaming. Transcribed interviews were analyzed with content analysis. RESULTS: The following 4 facilitators were identified: (1) enjoyment and competition motivated gaming, (2) accessibility at home gave freedom and lowered participants' barriers to exercise, (3) physical benefits when decreasing sedentary lifestyle, and (4) psychosocial benefits on stress, mood, and family interactions. Challenges included (1) diminished engagement over time due to boredom playing similar games and (2) frustrations due to game difficulty and lack of improvement. CONCLUSION: Exergaming can increase individuals' physical activity because of easy accessibility and the fun and motivating factors the games offer. Participants initially found exergaming enjoyable and challenging. However, engagement diminished over time because of boredom from playing the same games for a period of time. Participants' preferences and capacities, participants' past experiences, and social support must be considered to avoid boredom and frustrations. Future studies are warranted to determine adherence to exergaming among patients with heart failure and, ultimately, increased overall well-being and healthcare delivery in this patient population.

An effective in-hospital chaplaincy-led care program for nurses: Tea for the soul a qualitative investigation.

Tea for the Soul (TFS) is an understudied care model, addressing bereavement and other emotional needs of nurses related to impactful patient care experiences. Nurses are at high risk for compassion fatigue, moral distress, and burnout. Facilitated by a Chaplain, the TFS program provides participants a venue to express their feelings and explore ways of adapting effectively with the death of a patient, and other traumatic workplace experiences. In this qualitative grounded theory study, hospital nurses (N = 7) who participated in TFS were interviewed. IRB approval was obtained. Questions were constructed within the context of the medical center research council and asked if TFS: (a) was personally beneficial, (b) helped nurses feel better about their work, and (c) affected job satisfaction. Four core themes emerged: (a) Nurses' Self-Care, (b) Professional Practice, (c) Community, and (d) Improved Patient Care Outcomes. The Roy Adaptation Model, Group Identity Mode was applied to the content analysis. Overarching themes were Compassionate Service, Ministry of Presence, Reflective Practice, and Sacred Encounters. Nurses reported that TFS facilitated a spiritual respite and a sense of enhanced community and was a source of strength and coping, thus may aid in the promotion of nurse well-being and the amelioration of moral distress, compassion fatigue, and burnout.

Effectiveness of an educational intervention in improving the patient medication reconciliation in the emergency department.

AIMS: This study aimed to evaluate the effectiveness of an educational intervention in improving the patient medication reconciliation process. METHOD: This was a cross-sectional study that was conducted at St. Jude hospital, California (CA), United States. An educational intervention was provided to the healthcare team working in the emergency department (ED) to explore its effectiveness in improving their patient medication reconciliation practices. A survey was administered to explore the healthcare staff's views on where responsibility lay in their team concerning the fulfilment of appropriate medication reconciliation procedures. Additionally, we identified the barriers facing the completion of appropriate medication reconciliation using open-ended question provided to healthcare staff at the hospital. RESULTS: In the pre-intervention phase, the percentage of patients who received medication reconciliation was statistically significantly higher during the day shift (71.0% compared with 51.3%). In the postintervention phase, the percentage of patients who received medication reconciliation was statistically significantly higher during the night shift (96.7% compared with 75.8%). Overall, the percentage of patients who received medication reconciliation was statistically significantly higher in the postintervention group (81.3%) compared with the pre-intervention group (64.7%) (P < .001). CONCLUSION: Educational intervention is an effective tool in improving medication reconciliation practices in inpatient settings. The process of medication reconciliation should be conducted based on shared responsibility between healthcare providers and aimed at reducing medication errors and improving patient safety.

Health determinants and risk factors for coronary artery disease among older Filipinos in rural communities.

AIMS: Lifestyle modifications and healthy behavioural regimens are critical in preventing coronary artery disease (CAD) and other important health conditions. Little is known about the risk for CAD and health behaviour among older adults (>60 years) living in rural areas in the Philippines. Compare risk profiles and health behaviours of Filipinos at low- vs. moderate-to-high-risk for CAD and examine the association between demographic variables, risk profiles, and health behaviours. METHODS AND RESULTS: A comparative, cross-sectional study was conducted using a convenient sample of 427 Filipinos (≥60 years old). Data on sociodemographic characteristics, risk profiles, and health behaviours (e.g. diet, physical activity, smoking status, and alcohol use) were collected. Ten-year CAD risk was estimated using the non-laboratory-based Framingham algorithm. Of the 427 participants [mean age was 69.2 ± 6.7 years, primarily women (65%), married (52.8%)], 319 (75%) were at low risk, and 108 (25%) were at moderate-to-high-risk for CAD. Filipinos at moderate to high risk were more likely to have cardiometabolic diseases (e.g. hypertension, hyperlipidaemia, diabetes, and obesity, all P's < 0.001). Health behaviours did not differ between the two groups except for the consumption of ≥5 servings of fruit, higher in the low-risk group. CONCLUSION: Data showed highly consistent and convergent evidence among older Filipinos living in rural areas at high risk for CAD and other health conditions. These findings underscore the need for culturally sensitive guidance to improve CAD outcomes for moderate to high-risk older adults living in rural areas, including education and counselling on risk and risk-reducing strategies.

Effect of exergaming on health-related quality of life in older adults: A systematic review.

INTRODUCTION: Exercise through video or virtual reality games (i.e. exergames) has grown in popularity among older adults; however, there is limited evidence on efficacy of exergaming on well-being related to health in this population. This systematic review examined the effectiveness of exergaming on health-related quality of life in older adults. METHODS: PRISMA guidelines for this systematic review. Several databases were searched using keywords to identify peer-reviewed journal articles in English. Randomized control trials that evaluated the effect of exergaming on health-related quality of life in older adults when compared to a control group and published between January 2007 to May 2017 were included. RESULTS: Nine articles that in total included 614 older adults with varying levels of disability, mean age 73.6 + 7.9 years old, and 67% female were analyzed. Significant improvements in health-related quality of life of older adults engaged in exergaming were reported in three studies. Sample sizes were small in 7 of the studies (N < 60). The study participants, exergaming platforms, health-related quality of life instruments, study settings and length, duration and frequency of exergaming varied across studies. CONCLUSION: Exergaming is a new emerging form of exercise that is popular among older adults. However, findings from this analysis were not strong enough to warrant recommendation due to the small sample sizes and heterogeneity in the study participants, exergaming platforms, health-related quality of life instruments, length, duration and frequency of the intervention and study settings. Further research is needed with larger sample sizes and less heterogeneity to adequately explore the true effects of exergaming on health-related quality of life of older adults.

Direct-Acting Oral Anticoagulants and Warfarin-Associated Intracerebral Hemorrhage Protocol Reduces Timing of Door to Correction Interventions.

BACKGROUND: Intracerebral hemorrhage (ICH) is a life-threatening complication of oral anticoagulant therapy that sometimes results in hematoma expansion after onset. Our facility did not have a standardized process for treating oral anticoagulant-associated ICH; this resulted in lag times from order to reversal agent administration. PURPOSE: The aim of this study was to examine the impact of a rapid anticoagulant reversal protocol, combined with warfarin and direct-acting oral anticoagulant therapy, in decreasing door to first intervention times. METHODS: This study used a retrospective quality assessment research approach in examining an oral anticoagulant reversal protocol to compare the control and intervention groups. Phytonadione was the first intervention treatment for most study participants diagnosed with warfarin-associated ICH with an international normalized ratio greater than 1.4. Factor IX was the first intervention treatment for all but one study participant with DOAC-associated ICH. RESULTS: Findings were statistically significant (P < .05) for door to first intervention treatments. Door to phytonadione in minutes decreased from 232.7 (SD, 199.4) to posttest findings of 111.4 (SD, 64.6). Door to factor IX in minutes decreased from 183.9 (SD, 230.2) to posttest findings of 116.6 (SD, 69.1). CONCLUSION: Study findings support the hypothesis that the new protocol was associated with lower door-to-treatment times for eligible patients.

Are Health Behaviors and Risk Factors for Altherosclerotic Cardiovascular Disease Interrelated Among Older Filipinos in Underserved Communities?

Introduction: Moving individuals toward ideal cardiovascular health through adoption of healthy lifestyle behaviors is critically important for prevention of atherosclerotic cardiovascular disease (ASCVD) and other important health conditions. However, associations between health behaviors and risks for ASCVD is poorly understood among older adults (≥ 60 years) living in rural areas in the Philippines. Likewise, their access to healthcare and health-seeking practices are unknown. Purpose: To 1) compare risk profiles of Filipinos at low- vs. moderate to high-risk for ASCVD; and 2)examine the relationships befiveen demographic variables, risk profiles, and health behaviors. Methods: A convenient sample of 427 Filipinos (≥ 60 years old) were recruited to participate in this comparative, cross-sectional study. Data on sociodemographic characteristics, risk profiles, and health behaviors (e.g., dietary patterns, physical activity, smoking status,and alcohol use)were collected. Results: Of the 427 participants (mean age was 69.2± 6.7 years, primarily women [65%], married [52.8%]), 319 (75%) were at low-risk and 108 (25%) were at moderate to high-risk for ASCVD. Those at moderate to high-risk were more likely to have cardiometabolic diseases(e.g., hypertension, hyperlipidemia, diabetes, and obesity, all p's < .001).Health behaviors did not differ between the two groups except for consumption of≥ 5 servings of fruit which was higher in the low-risk group. Conclusion: Findings showed that there is highly consistent and convergent evidence that older Filipinos living in rural areas are at high risk for ASCVD and other health conditions. Much of this is attributable to the suboptimal implementation of prevention strategies, uncontrolled ASCVD risk factors, and poor access to effective and equitable healthcare services commonly observed in low-income countries. Clinicians, researchers, policy makers, and other stakeholders need to address these issues to improve primary and secondary prevention and disease management in this population.

PREVALENCE AND CORRELATES OF DEPRESSION, ANXIETY, AND DISTRESS AMONG FILIPINOS FROM LOW-INCOME COMMUNITIES IN THE PHILIPPINES.

INTRODUCTION: More than one billion people worldwide are affected by mental health disorders, making up 16% of the world's population. However, psychological morbidity has been understudied and disparately estimated among Filipinos living in low-income communities in the Philippines. PURPOSE: The specific aims of this descriptive, cross-sectional study were to 1) describe depression, anxiety, distress, and quality of life in a large sample of Filipinos from low-income communities in the Philippines; and 2) determine the prevalence and correlates of depression, anxiety, and distress in this sample. METHODS: A convenient sample of Filipinos (⩾ 18 years old) were recruited to participate in the study and asked to complete a general health survey. Only one person per household was eligible to participate in the study to avoid biases based on the prevalence of mental health disorders. RESULTS: One thousand two hundred three participants, mean age, 49.5 ± 17.6 years, primarily women (64.6%) and married (58.4%) reported the following cardiometabolic disorders: overweight/obesity (29%), hypertension (43%), hyperlipidemia (21%), type 2 diabetes (14%), and current smoker (19%). The mean physical and mental quality of life was 46.2 ± 8.1 and 48.6 ± 7.7, respectively. Depression (21%), anxiety (39%) and distress (82%) were prevalent in the sample. Depression was associated with older age, higher distress and anxiety, and lower quality of life. Anxiety and distress were associated with younger age, female gender, higher depression, and lower quality of life. CONCLUSION: Mental health disorders are prevalent in Filipinos from low-income communities. Findings provide empirical support for the provision of mental health services consistent with the World Health Organization's action plan in this understudied population. The high association between psychological morbidity and perceived physical and mental quality of life signifies the need to screen for depression in older adults and anxiety and distress in younger adults and women.

Dose-Response Relationship Between Exercise Intensity, Mood States, and Quality of Life in Patients With Heart Failure.

BACKGROUND: We conducted a secondary analysis to (1) compare changes in mood disorders and quality of life (QOL) among 4 groups of patients with heart failure in a home-based exercise program who had varying degrees of change in their exercise capacity and (2) determine whether there was an association between exercise capacity, mood disorders, and QOL. METHODS: Seventy-one patients were divided into 4 groups based on changes in exercise capacity from baseline to 6 months: group 1showed improvements of greater than 10% (n = 19), group 2 showed improvements of 10% or less (n = 16), group 3 showed reductions of 10% or less (n = 9), and group 4 showed reductions of greater than 10% (n = 27). RESULTS: Over time, patients in all 4 groups demonstrated significantly lower levels of depression and hostility (P < .001) and higher levels of physical and overall quality of life (P = .046). Group differences over time were noted in anxiety (P = .009), depression (P = .015), physical quality of life (P < .001), and overall quality of life (P = .002). Greater improvement in exercise capacity was strongly associated with lower depression scores (r = -0.49, P = .01). CONCLUSIONS: An improvement in exercise capacity with exercise training was associated with a decrease in depression and anxiety and an increase in QOL in patients with heart failure.

Hospital staff nurse perceptions of competency to care for patients with psychiatric or behavioral health concerns.

Disruptive behaviors are common among hospitalized patients with psychiatric and substance abuse behaviors. Nurses working on nonpsychiatric units, however, may lack competencies to care for patients with such behaviors. A survey was developed and administered to 844 nurses across three hospital settings that revealed a lack of nurse confidence to intervene in situations that require de-escalation techniques and crisis communication. This study provides direction for further research and interventions in hospital settings with similar professional development needs.