Examining the Status of Primary Health Care in A Highly Urbanized and Densely Populated Village in Quezon City, Philippines: A Basis of Integrating Universal Health Care in the Community Health Nursing Education

Examining the Status of Primary Health Care in A Highly Urbanized and Densely Populated Village in Quezon City, Philippines: A Basis of Integrating Universal Health Care in the Community Health Nursing Education

Kevin L. de Vera*, Mylene B. Pacris, Josery F. Cariño, Michael John P. Agustin

College of Nursing, World Citi Colleges, Quezon City, Philippines

*Correspondence Author

DOI: https://doi.org/10.51244/IJRSI.2024.11150073P

Received: 07 December 2024; Accepted: 10 December 2024; Published: 15 January 2025

ABSTRACT

This study documents the country’s current status of primary health care (PHC) through a case village. It examines Barangay Bagong Silanagan Quezon City’s local health system’s approaches to promoting health and providing services. It also identifies challenges health workers face in delivering basic health services to diverse clients. The study involved supply- and demand-side participants, including city health officials, barangay representatives, healthcare workers, and community members from four subgroups, namely mothers, elderly, youth, and adult males. Purposive sampling was used to select a total of 28 demand-side and 12 supply-side participants, with data gathered through meticulously crafted instruments adhering to the World Health Organization and Department of Health guidelines, aiming to evaluate primary healthcare services’ status comprehensively. The data collection process included document review, focus group discussions, key informant interviews, and observational studies, ensuring ethical considerations and cultural sensitivity while providing nuanced insights into primary healthcare delivery. Additionally, it seeks to explore the health-promotive practices of individuals and families in Bagong Silangan, examine their experiences accessing health services from the local health unit, and identify challenges they encounter in accessing these services. In advancing community health nursing practice, understanding the landscape of PHC delivery is crucial for informed interventions. The current situation in the Philippines highlights the need for accessible, responsive, and equitable PHC. Existing practices demonstrate multifaceted approaches, including digital technology and collaboration. Trends reveal emerging health issues, while gaps underscore the need for innovative strategies and policy reforms. Communication emerges as critical, emphasizing person-to-person interactions and tailored education. Integrating evidence-based interventions and promoting health equity is essential for community health nursing to enhance health outcomes nationwide.

Keywords: primary health care, community health nursing, public health, universal health care, nursing education

INTRODUCTION

Primary Health Care

Imagine a community where every individual has access to affordable, high-quality healthcare close to their doorstep—where health services are not only curative but also preventive, promotive, and empowering. This vision lies at the heart of Primary Health Care (PHC), a globally recognized approach to health that puts communities at the center of their well-being. First introduced through the Alma-Ata Declaration in 1978, PHC has been instrumental in shaping equitable health systems worldwide, including the Philippines.

This study looked into the state of PHC in the Philippines and examined Bagong Silangan, Quezon City, as a case village to understand the experiences of health workers and various sectors as recipients of primary-level healthcare. The Alma-Ata Declaration defined PHC as essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination (WHO, 2021). The declaration emphasized the importance of PHC as the foundation of a strong and equitable health system, recognized health as a fundamental human right, and highlighted the need for social and economic development to improve health outcomes. It also called for active community participation and the integration of health services with other sectors to address the broader determinants of health.

Moving forward, PHC is geared towards universal access to health for all individuals and families and public active participation in health to ensure they meet local needs and priorities. PHC focuses on preventive measures, health education, and health promotion to reduce the burden of illness on Filipinos and improve the overall well-being of Filipino families.

In the Philippines, the Department of Health (DOH) is the principal government agency responsible for planning, implementing, and regulating health policies, programs, and services. To advance health for all Filipinos, the DOH ensures that primary healthcare services are integrated within the Philippine health systems through various healthcare delivery models such as Barangay Health Stations (BHS), Rural Health Units (RHUs), and Health Centers. These facilities offer various primary healthcare services, including preventive, promotive, curative, and rehabilitative care (DOH 2020). PHC in the Philippines also includes essential health packages, including immunization, prenatal and postnatal care, family planning, child health services, and management of common illnesses.

Another PHC strategy employed by the DOH is health promotion and disease prevention programs and activities, including public health campaigns and programs to raise awareness about healthy lifestyles, disease prevention, and regular check-ups. These efforts aim to provide information and education to Filipinos to empower individuals and communities to take charge of their health and well-being. The DOH is also involved in the training, deployment, and capacity building of healthcare professionals, including doctors, nurses, midwives, and community health workers, to ensure a skilled and competent workforce at the primary healthcare level (DOH 2023).

Nurses are the backbone of health systems across the planet. They play a pivotal role in ensuring the health and well-being of all individuals, families, populations, and communities. Community health nurses’ vital role in PHC includes health promotion and education, disease prevention and screening, assessment and diagnosis, evidence-based management and treatment, facilitation of collaboration, health advocacy, and community engagement and organizing. In this backdrop, student nurses’ skills development must be responsive to the trends and current demands of the country’s ever-changing political and health landscape.

 Community Health Nursing

The Community Health Nursing (CHN) course deals with concepts, principles, theories, and techniques for providing basic health care regarding health promotion, disease prevention, restoration and maintenance, and rehabilitation at the individual, family, and community levels. In CHN practice, the client is the community, and the recipients and partners of nursing care are the individuals, families, and people in the community.

CHN courses are expected to enable student nurses’ skills development of nursing skills which can be utilized in advancing primary health care to provide holistic care to clients, such as facilitating health-promotive activities to individuals and families, evaluating the existing public health policies of the government, and creating a program that will educate the people of the community regarding common illnesses in their area, collaborating with other community health workers in enforcing the programs set for the community, and advocating for change through policies.

Barangay Bagong Silangan, Quezon City: The Scoping Site

This study looked into the past and recent developments of PHC in the country and examined the situation of a village, namely Bagong Silangan, Quezon City. Barangay Bagong Silangan is a dynamic barangay in the 2nd district of Quezon City, the most populous city in the Philippines.  It has at least 100,000 people, according to the 2020 census. It is an urban poor community that is flood-prone and is the biggest sub-district of Quezon City, with 535.85 hectares of land area (Lim H.R. et al., 2017). It has an urban farm, the biggest farm of its kind in the National Capital Region, which serves as a food source and alternative source of income for some residents.

Bagong Silangan shares borders with four Quezon City barangays – Payatas, Pasong Putik, Batasan Hills, and New Era. Additionally, it connects with six barangays in San Mateo, Rizal Province, and Manggahan Barangay in Rodriguez, Rizal Province. Originally part of San Mateo Municipality, Bagong Silangan was ceded to Quezon City in 1930. It is demarcated into high and low zones by the Markina Valley fault system, which runs parallel to the Marikina River. Situated on the western high area, adjacent to the Guadalupe plateau, the eastern low area lies along the west bank of the Marikina River. Bagong Silangan is exposed to a heightened risk of earthquakes due to its direct positioning on the Marikina fault line. Many nearby structures are either directly on or close to the fault. Additionally, the lower region of Bagong Silangan, near the riverbank, is susceptible to severe flooding. Despite its predominantly urban landscape, approximately a quarter of the barangay’s terrain comprises farmland—the last vestige of agricultural space in Quezon City.

Quezon City’s government health programs aim to promote its constituencies’ well-being as outlined in the city’s Citizen’s Charter. The Quezon City Health Department provides various health programs to the city’s residents, including primary health care, maternal and child health and nutrition services, integrated non-communicable disease prevention, dental health services, community-based mental health services, and care for the elderly. Specific health programs for specific concerns include cancer, tuberculosis, nutrition, family planning, adolescent and epidemiology programs in case of outbreaks. Assurance activity programs in the city include issuing health certificates and permits for establishments, facilities, healthcare and food preparation workers, and other certifications such as death certificates and pre-marriage counseling certificates.

Quezon City’s primary-level facilities are the super health centers (SHC) and the health centers. Super Health Centers serve as health centers, have 24-hour operating lying-in clinics, and provide basic health services. They have basic features to cater to clients’ medical needs, such as a laboratory, dental services, breastfeeding services, a lying-in clinic, and an ambulance. Health Centers are community patient-directed establishments that deliver comprehensive, culturally competent, high-quality primary healthcare services to the nation’s most vulnerable individuals and families.

The city’s primary healthcare service points are the “Sundown or Klinika.” These are a type of social hygiene clinic that provides free consultation, treatment, and counseling services for men who have sex with men (MSM) and those men vulnerable to the human immunodeficiency virus (HIV). It also encourages females to seek consultation and treatment counseling. Prevention and control are the top priority programs of this type of facility. While general social hygiene clinics of the city are responsible for the management, prevention, and control of sexually transmitted diseases (STDs). The clinic’s services include providing diagnostic assessment, treatment, and care; promoting health and preventing STD and skin diseases through individual counseling and other health education activities; contact tracing for investigation and defaulters for treatment and follow-up. The clinic encourages male and female patients to avail of its services, such as free testing and screening, treatment, free HIV counseling, and other support services.

 Objective

This study aims to examine PHC in the Philippines in a case village, Bagong Silangan, Quezon City, to pursue evidence-based and enhanced quality of community health nursing education. Specifically, it sought to find answers to the following research questions:

1. Supply side (public health workers and local officials)
2. What is the current situation of PHC in the country?
3. What are local health system approaches to a) promoting health and b) providing services?
4. What challenges do health workers face regarding providing basic health services to different clients?
5. Demand side (mothers, youth, adult males, and elderly population)
6. What are the health-promotive practices of the individuals and families in Bagong Silangan?
7. What trends and challenges do individuals face when accessing health services from the local health unit?

METHODOLOGY

Research Design

Qualitative methods used in this study include reviewing reports and published studies, observation and focus group discussion (FGD), and key informant (KI) interviews—the reviewed reports comprised health policies, promotion materials, performance statistics, and related literature. Observation focused on the health facilities and the processes of promoting and administering primary health services to various clientele. Key informants and participants in FGDs from the supply side included nurses, local officials, and community health workers, while the demand side involved mothers, youth, adult males, and the elderly. Interview guides were developed for the key informant interviews.

Research Locale

The research locale for this study is characterized as a highly populated and dense urban village, Barangay Bagong Silanagan, Quezon City, Metro Manila. A pilot study in a high-density and populous urban village offers a rich context for exploring the complexities of PHC to reshape community health nursing education and test the feasibility and effectiveness of evidence-based teaching interventions in real-world settings.

Research Participants

The participants from the supply side were a city health physician, a city health office representative, two barangay officials (barangay chairperson, and councilor – social welfare focal person), a nurse, a midwife, and six community health workers. The participants from the demand side were eight mothers, six youths, seven adult males, and seven senior citizens. All participants were selected through purposive sampling.

 Research Instrument

The research instrument was meticulously crafted to evaluate the status of primary health care services in adherence to the guidelines established by the World Health Organization (WHO) and the Department of Health (DOH). It encompasses a comprehensive scoping guide meticulously designed to encompass indicators aligned with the principles of universal healthcare. The guide questions, formulated based on the research inquiries, have been thoughtfully translated into Filipino to ensure accessibility and effective utilization by the target population. This instrument aims to provide a thorough qualitative assessment of primary healthcare delivery while incorporating culturally sensitive approaches to enhance the gathered data’s understanding and utilization.

 Data Gathering Procedure

The data-gathering process commenced with thoroughly examining relevant documents and reports about primary healthcare. The FGDs and KIIs were conducted to delve deeper into the nuances of primary healthcare delivery. Before initiating data collection activities, a series of consultative meetings were convened by the researchers with the selected site, adhering to established protocols. These preliminary engagements included a courtesy call meeting to introduce the research team, secure necessary permissions from local authorities, and seek stakeholder assistance to identify participants and facilitate data collection efforts.

During the FGDs and KIIs, meticulous attention was paid to ethical considerations, ensuring participants provided explicit consent for audio recording. Guided by the principal investigator, a skilled facilitator conducted the interviews, while a dedicated documenter recorded the discussions in detail. Both the facilitator and documenter are graduate students commissioned to assist in data collection by the research team. This collaborative approach ensured comprehensive coverage of insights shared by the participants. Furthermore, an observational study was conducted alongside the interview process to observe activities within the selected site closely. This firsthand examination provided valuable context and enriched the understanding of operational dynamics within the primary healthcare setting. Secondary data was retrieved from the local health office to further understand the status of PHC and provide a clearer picture of the situation on the ground to help answer the research objectives. Through these meticulous steps, the data-gathering procedure was designed to yield comprehensive and nuanced insights into the current state of primary healthcare, guided by the principles of primary healthcare.

 Ethical Considerations

A steadfast commitment to ethical conduct, integrity, and respect for all participants and stakeholders’ rights and well-being guides this research endeavor. The researchers’ commitment to ethical conduct begins with the engagement of stakeholders and the respect for their autonomy and rights throughout the data-gathering process. Prior to the commencement of FGDs and KIIs, comprehensive consultative meetings were held with the selected site. These meetings served as a platform to establish mutual understanding, secure necessary permissions, and ensure transparency in our research endeavors.  Participants were provided with clear explanations of the research objectives, procedures, and potential risks. Informed consent was obtained from all participants prior to their involvement in the FGDs and KIIs. Furthermore, measures were implemented to guarantee the confidentiality and anonymity of participants, with audio recordings made only after explicit consent was obtained. Participants were assured of their right to withdraw from the study at any point without repercussion. In addition, the observational study conducted as part of the research process was carried out with the utmost respect for privacy and dignity. Observations were conducted discreetly without disrupting the normal flow of activities within the selected site. Any identifiable information gathered during observations was handled carefully to maintain confidentiality and protect individuals’ rights.

RESULTS AND DISCUSSION

This section presents a comprehensive analysis of the supply and demand sides of PHC in Bagong Silangan. By examining the perspectives of healthcare providers and community members, it offers insights into the strengths, weaknesses, and areas for improvement within the local health system. Through a nuanced exploration of the challenges and opportunities, this chapter aims to inform Community Health Nursing educators on the practice interventions to enhance PHC delivery and improve community health outcomes.

Supply Side

This section delves into the intricacies of Primary Health Care (PHC) within the nation by examining the health system’s current state and efficacy locally in Bagong Silangan, Quezon City. It explores the multifaceted strategies health workers and officials employ to promote health and deliver services while confronting the challenges they encounter in catering to diverse client needs. Through a comprehensive analysis, this chapter aims to shed light on the operational realities of PHC and the persistent efforts to optimize health outcomes.

Current Situation of Primary Health Care

Community-level health workers, such as public health physicians, nurses, midwives, and barangay health workers, are essential to primary health care. The health service providers in the three areas have identified that the principles of universal healthcare guide primary health. They recognized that they play a critical role in providing a range of essential health services to improve the health and well-being of their communities, especially those who face barriers to accessing health care. Similarly, WHO (2019) highlighted the essential role of community health workers in improving health equity and access in both urban and rural areas.

Table 1 presents the thematic analysis of the current situation of PHC. The public health physicians, nurses, midwives, and barangay health workers are the service providers primarily involved in ensuring health promotion strategies by the DOH and the LGUs. A city or municipal health officer serves as the chief of the rural health unit and also plays a role as a public health physician. As duty-bearers, including the front liners down in the barangay level, it is of prime importance that they know what primary health care is. The service provider participants in the study were able to describe their understanding of PHC as both delivery of PHC to their constituencies and ensuring equitable access to health services.

Table 1: Thematic Analysis of Current Situation of PHC

Themes	Subthemes
Delivery of primary health care	– Education and information for health empowerment
	– Equitable access, especially for the vulnerable
	– Responsive programs and policies
Uptake and challenges of vaccine-preventable infections	– Free commodities as attractive
	– Accessibility as a driver
	– Misconceptions as a deterrent
Health issues in the communities	– Lifestyle diseases
	– Sexual and reproductive health concerns
	– Respiratory diseases
	– Emerging demand for mental health

Delivery of primary health care. The duty-bearers described their understanding of primary health as their duty to facilitate health promotion. Most participants described primary health as public health services that are available in the rural health units (RHUs) at the barangay level and massive efforts in conducting health education activities. The findings drawn from the participants, along with the delivery of PHC, highlighted the importance of education and information for health empowerment, equitable access, especially for the vulnerable, and responsive programs and policies. The UHC Act or R.A. 11224 mandates LGUs to provide health care delivery that shall afford every Filipino a primary care provider. Likewise, with the assistance of the DOH and PhilHealth, LGUs are expected to register their respective constituents with a primary care provider and identify health financing sources (DOH, 2019).

Education and information for health empowerment. Most duty bearers recognized the principle of PHC as ensuring that all have access to health. Public health workers viewed PHC as a health promotion strategy that enables people to seek health services while they are healthy and not when their health condition has worsened. Most health workers, such as BHWs, nurses, and midwives, described PHC as ensuring access to health by giving people access to health education and information to enable them to make sound decisions about their health. This can be achieved by ensuring that communities become more aware of the services offered in the RHUs or health centers.

Equitable access, especially for the vulnerable. In addition, to ensure universal access to health, nursing staff and the BHWs expressed that PHC refers to the primary health care services Filipinos should enjoy. One healthcare worker expressed that it is most important to the vulnerable sector of the community, such as the poorest of the poor. A few BHWs verbalized that PHC ensures that no one is left behind. Hence, one way is ensuring that the poorest can also access health services. Mechanisms enable vulnerable groups to be registered in PhilHealth programs under the LGUs, a shared belief of the health officers.

Responsive programs and policies. Similar Duty-bearers from the social sector, such as the local social welfare and development sector and local elected officials, viewed PHC as ensuring delivery services aimed at cultivating people’s health condition by focusing on health programs that can improve people’s physical well-being and mental health. Hence, social welfare assurance activities and local policies, along with health, should also be responsive to the needs of vulnerable groups.

While we have national-level policies, enacting localized policies was also identified as a catalyst for ensuring PHC for the people. A number of participants expressed that policies and programs that ensure the provision of free services empower communities to access health services and commodities easily.

These factors affect the motivation and retention of BHWs, as well as their performance and impact, among service providers. Therefore, there is a need to understand the lived experiences and roles of BHWs in different contexts and to identify ways to enhance their capacity and empowerment.

Under the IRR of RA 7160, Section 24(a) Rule V states that delivering essential services and facilities shall be devolved from the National Government to provinces, cities, municipalities, and barangays (Official Gazette, 2022). This enables the LGUs to be responsible for the minimum services and facilities under existing national policies, guidelines, and standards. While RA 11223 expects the LGU to commit to ensuring the integration of the UHC Law in their city-wide health system, whose main function is the management of health service delivery operations of primary care provider networks, hospitals, and other health facilities, clinical facilities, and public health programs.

Uptake and challenges on vaccine-preventable infections. Most service providers shared that the pandemic-induced disruption to routine immunization programs for children and free vaccines for senior citizens are now coming back to normal as it was pre-pandemic. It is an interesting observation by most BHWs and public health workers that more people have become conscious about their health than before the pandemic. The service providers described the current trend and demand for vaccination as free vaccines as attractive, misconceptions as deterrents, and accessibility as a driver.

Free commodities as attractive. General insight among health workers and advocates for the population’s access to vaccines as “free.” In communities, different subgroups and social strata always value free services and commodities. PHC, in principle, enables communities to become healthier by ensuring that services and commodities are accessible and affordable, if not free. However, not all commodities are free, specifically medicines. Service providers highlighted that they can only dispense free vitamins and medicines when supplies are available. Most in-demand essential medicines are those for elderly people and those with chronic conditions, such as maintenance medications for hypertension and diabetes.

A few BWHs shared that when patients are sick if there are no free medicines, they have to pay out of pocket for their medications. However, if the patient is indigent, they can seek assistance from the social welfare officer stationed in the RHU for their medications.

The public health physician expressed that there is also a sufficient supply of free human papillomavirus (HPV) vaccines, which are given to adolescent girls, 9-14 years old, enrolled in public schools. However, a good uptake of this service has yet to be seen due to parents’ hesitancy and challenges in involving schools in participation. Overall, in the case of the COVID-19 pandemic, the significant uptake of the number of COVID-19 vaccinated individuals is attributed to the vaccines being “free,” apart from the fact that COVID-19 infection terrified most of the communities.

In comparing the HPV vaccine drive and the COVID-19 vaccine drive, international and national efforts were invested in the latter compared to mainstreaming the HPV vaccine. While the narratives of the health workers showed high regard for free commodities, one study revealed that despite some services and commodities being accessible, especially for the indigents, the indigent members are not well informed about their rights to free access to health care offered by LGU health centers (El Omari S., et.al., 2021).

Accessibility as a driver. During the imposed community quarantine, the routine immunization program shifted from scheduled shots in the centers to bringing the shots to where the children were. Health workers’ experiences, as shared by BHWs, the situation called for ensuring that health services and commodities, hence services such as vaccines, were delivered to where the clients were. Accessibility to increasing vaccinated individuals was also true in the case of COVID-19.

Health workers in Bagong Silangan shared that COVID-19 took several residents’ lives. This scenario was the same in many other localities in the country. Apart from the imposed community restrictions, this situation unfortunately also deterred people from going to health facilities. While other services halted amid the pandemic disruptions, COVID-19 vaccines were made available in public areas like shopping centers, malls, and town plazas.

In addition, the COVID-19 pandemic made routine health programs inaccessible due to patients’ hesitancy to visit health facilities (Maravilla J. et al., 2022). During the onset of the COVID-19 pandemic, when community quarantine was strictly observed, certain groups were barred from access to most activities. Such as those with co-morbidities, but more were observed among young people below 20 and senior citizens. Contrary to the literature, significant disparities in access to healthcare services remain, with differences observed among socio-economic groups, geographical regions, and rural/urban residences (Siongco K., 2020). The country’s experience in 2020 was worsened by the pandemic-induced lockdowns when senior citizens and young people 21 and below were not allowed outside their homes as part of the Enhanced Community Quarantine (ECQ) (Official Gazette, 2020).

Misconception as a deterrent. While most health workers shared that COVID-19 vaccination and other immunization programs are seemingly doing well, some health workers expressed that the Dengvaxia (dengue vaccine) scare still negatively affects some of their residents’ perceptions about vaccines.

Most BHWs shared that they have experienced clients who are apprehensive about getting COVID-19 vaccines due to information found on online sources and stories they heard in the community. Young people, especially, get information about COVID-19 from online sources. The general observation is that adults, especially the heads of the household, significantly influence their family members’ uptake of health programs and services, such as vaccines. One BWH participant emphasized that despite anxiety about vaccines, the policy on who is allowed outside their homes compelled many clients to get vaccinated. Similarly, a study by Migriño J. et al. (2019) found that immunization hesitancy among parents is caused by harmful exposure. The study highlighted that one of the main reasons for vaccine hesitancy was exposure to negative media information and concerns about vaccine safety.

Health issues in the communities. According to health workers, the most common health issues that surfaced across all areas for the elderly are diabetes and hypertension. For young people, it is teenage pregnancy and mental health. While the overall population, hypertension, diabetes, and tuberculosis (TB) were consistent in all three areas. In terms of health issues in the communities, the following themes surfaced: lifestyle diseases, sexual and reproductive health concerns, respiratory diseases, and emerging demand for mental health.

Lifestyle diseases. Most health workers pointed out that hypertension and diabetes are the most common non-communicable diseases in all three areas. Health officers shared that their cases of cardiovascular problems, especially hypertension, are getting younger and younger. In Bagong Silangan, one public health worker shared that the demand for dialysis is becoming problematic, especially since such a procedure is not available in the health center.

Most health service providers and the BHWs affirmed that the most commonly dispensed free medicines are for hypertension and diabetes. Clients with hypertension are primarily adults and senior citizens or the elderly. These medicines are free and accessible in public health facilities until supplies last.

Sexual and reproductive health concerns. The most common services received by mothers are related to their pregnancy, delivery, and postnatal concerns. Public health workers affirmed that they follow a certain schedule weekly to ensure these concerns are met. Maternal and child health and nutrition are among the basic health programs implemented at the barangay level. This includes prenatal and postnatal care for mothers and child immunization.

While for young people, teen pregnancy remained a concern across all areas. The youth participants also recognized that teen pregnancy is a problem common in their respective communities. Health workers confirmed that adolescent reproductive health remained a top concern due to cases of teenage pregnancy.

Nurses also highlighted sexual harassment and isolated reported cases of rape. Security and social sector service providers also recognized that sexual violence remained a concern in the communities. They also shared that cases of violence against women and children increased during the pandemic when most people were locked in their homes following the COVID-19 protocols. While the health sector takes care of the health needs of the survivors, the social sector looks after social protection and provides necessary assistance to them, including seeking legal support. Women and girls remained in a disadvantageous position in situations of sexual abuse.

Respiratory diseases. Tuberculosis (TB) is the highlighted communicable disease as most prevalent in all three areas. Moreover, due to COVID-19, acute respiratory concerns remained on the chart of prevalent health concerns. BHWs shared that all of them were tasked with monitoring communities, especially households at risk of tuberculosis infection and cross-infection. They also put significant effort into advocating for communities’ importance of getting screened and adhering to treatment.

Key informants from the SHC and health center reaffirmed that local efforts are invested in addressing TB. The DOH’s TB Directly Observed Treatment Short-course (TB DOTS) is a regular program that is accessible and free for everyone concerned. The treatment includes screening and free medicines throughout the treatment period. There is a vaccine available against TB, the Bacillus Calmette–Guérin (BCG) vaccine; however, it is only given to children. There is no BCG available for adults.

Emerging demand for mental health. Specific to the youth group, mental health was raised as a concern. Most participants recognized that depression is a concern they faced but often neglected by adults.

Local Health System Approaches to Promote Health and Provide Services

The Bagong Silangan Super Health Center (SHC), strategically situated on Bonifacio Street within Barangay Bagong Silangan, Quezon City, is a beacon of accessible healthcare services. Officially inaugurated on March 16, 2018, this facility embodies the essence of primary healthcare, serving as a cornerstone in the local healthcare landscape. With a comprehensive array of medical services, the SHC is designed to alleviate the strain on hospitals while catering to the diverse healthcare needs of the community. One study highlights the importance of strategic site selection for healthcare facilities in achieving universal access to essential services, particularly in low and middle-income countries like the Philippines (Flores LJY, Tonato RR, dela Paz GA, Ulep VG 2021).

Table 2: Summary of Health Programs Services in Bagong Silangan SHC

Themes	Services
General Services	-Telemedicine
	-Database management
	-Outpatient care
Reproductive and Maternal Health	-Birthing or lying-in service
	-Family planning (education & commodities)
Diagnostics	-Laboratory services
	-X-tray examinations
	-Ultrasound imaging
Long-term Treatment Care	-TB DOTS
Vaccination and Immunization	-Routine vaccines for children
	-Routine vaccines for pregnant mothers
	-Vaccines for the elderly population
	-HPV vaccine for girls
Social and Health Emergencies	-Isolation/quarantine facilities
	-Ambulatory surgical unit

Table 2 shows the scope of services offered at the SHC. The services are extensive, encompassing essential medical provisions and specialized care units. Its key offerings include database management, outpatient care, TB DOTS (Directly Observed Treatment, Short-course), a dedicated birthing or lying-in clinic, isolation facilities, and diagnostic services, including laboratory testing, x-ray examinations, and ultrasound imaging. Moreover, the SHC houses a fully equipped pharmacy and an ambulatory surgical unit, enabling prompt and efficient treatment for various medical conditions. Additionally, embracing technological advancements, the center incorporates telemedicine services to facilitate remote diagnosis and treatment, ensuring accessibility for patients in remote areas. Primary health care goals align closely with universal health coverage, which seeks to provide essential health services and medications to everyone. Achieving universal health coverage requires prioritizing reforms that bolster primary health care, ensuring fairness and controlling costs (Van Weel C, Kidd MR. 2018).

Central to its maternal and child health mission, the lying-in clinic operates within a separate building, staffed by an obstetrician-gynecologist and a team of four midwives. This specialized unit is pivotal in providing comprehensive delivery services to expectant mothers, catering not only to residents of Barangay Bagong Silangan but also extending assistance to women from neighboring barangays. Furthermore, recognizing the importance of family planning in promoting reproductive health, the SHC offers various family planning services and commodities, fostering informed decision-making and empowering individuals to exercise control over their reproductive choices.

The Bagong Silangan Super Health Center epitomizes a holistic approach to healthcare delivery, blending state-of-the-art medical technologies with compassionate and culturally sensitive care. By addressing the multifaceted healthcare needs of the community and fostering partnerships with local stakeholders, the SHC plays a pivotal role in promoting health and well-being, thereby contributing to the realization of universal healthcare access for all.

The Bagong Silangan SHC operates a vital service by providing free vaccinations to various clients daily. The center prioritizes the vaccination needs of children and senior citizens, particularly those residing in remote areas or distant sitios.

The Bagong Silangan Super Health Center epitomizes a holistic approach to healthcare delivery, blending state-of-the-art medical technologies with compassionate and culturally sensitive care. By addressing the multifaceted healthcare needs of the community and fostering partnerships with local stakeholders, the SHC plays a pivotal role in promoting health and well-being, thereby contributing to the realization of universal healthcare access for all.

Fieldwork Observation. A seamless process is in place to accommodate the influx of clients, starting with the early morning queue where individuals obtain numbered tickets and index cards. Upon receiving their (clients) numbered tickets, clients fill out index cards, providing essential information for record-keeping purposes. Concurrently, vital signs are recorded to ensure the safety and suitability of vaccination for each individual. Once these preliminary steps are completed, clients advance to the second floor of the SHC, where a comprehensive array of healthcare services awaits.

The second floor of the SHC serves as a hub for essential healthcare services, including consultations with medical professionals and immunization procedures. Here, clients can engage in meaningful discussions with nurses and doctors (if available), addressing health concerns and receiving personalized medical advice. Furthermore, in situations where clients’ needs, along with immunization and long-term treatment, the process is efficiently administered, ensuring that clients receive necessary interventions on time.

The Bagong Silangan Super Health Center is committed to promoting community health and well-being through this streamlined process. By offering free primary health care such as health checks, consultations, and vaccinations and facilitating access to essential healthcare services, particularly for vulnerable populations such as children and senior citizens – the SHC plays a pivotal role in safeguarding public health and promoting universal healthcare access for all residents.

Similar processes are observed in providing health care services at Sitio Veterans, with health personnel, including the medical doctor, extending services on certain days.

Outreach work is scheduled, especially in Sitio Bakal, the smallest and rural sitio in Bagong Silangan. Scheduled outreach activities are crucial in extending healthcare services, particularly to underserved areas like Sitio Bakal, the smallest and most rural enclave within Bagong Silangan. Creative social innovation approaches improved access and quality of health services for vulnerable rural populations and increased agency among people in the community. These endeavors are integral components of the primary health care system, designed to bridge the gap between communities and essential medical services (Van Niekerk, L., Bautista-Gomez, M.M., Msiska, B.K. et al. 2023)

Outreach initiatives are meticulously planned to ensure maximum reach and impact. Before the outreach session, BHWs announce the impending arrival of the healthcare team. This proactive approach mobilizes community members, raises awareness about the available services, and encourages active participation.

The multi-purpose hall serves as a central hub for the outreach session, where assigned nurses are stationed to deliver a spectrum of healthcare interventions tailored to the community’s specific needs. Priority is accorded to vaccinations for children, safeguarding them against preventable diseases and laying the foundation for a healthy future. At the same time, mothers are provided with comprehensive family planning services, empowering them with the knowledge and tools to make informed decisions regarding their reproductive health.

The significance of outreach work in primary healthcare cannot be overstated. These initiatives enhance access to essential healthcare services and foster community engagement and empowerment. By proactively reaching out to remote and marginalized areas, PHC practitioners can address healthcare disparities, promote preventive measures, and strengthen the overall health infrastructure. Ultimately, outreach activities serve as a cornerstone of PHC, embodying the principle of equitable access to healthcare for all members of society.

Existing Practices in PHC Delivery. The practices on the ground are responsive health services, population-based health programs, family-focused interventions, and the emergence of e-health. These practices reflect a shift towards more client-centered health promotion, disease prevention, and technology-driven approaches in healthcare. They emphasize the importance of addressing the health needs of populations, involving families in health interventions, and leveraging digital tools to improve healthcare delivery and outcomes. These are shown in Table 3.

Table 3: Thematic Analysis of Existing PHC Practices (Supply Side)

Themes	Subthemes
Responsive health services	– Regular health missions
	– Satellite health stations
	– Intensified referral system
Population-based health programs	-Adolescent and youth health
	-Health for the senior citizens
	-Maternal and child health
Family-focused interventions	-Integrated social and health sector approaches
Emerging E-health	-Telemedicine/telehealth
	-Digitalization of database and processes
	-Emergence of the use of social media

Responsive health services. Regular health missions, satellite health stations, and intensified referral systems aim to provide accessible and timely healthcare to the population. Regular health missions involve organized healthcare campaigns that target specific areas or communities, providing essential health services, screenings, and treatments. These missions often include medical professionals, support staff, and necessary equipment and supplies.

Regular health missions. According to most health workers, they hold diverse health promotion activities to get more people to participate in activities led by the local health department. The most common activities are health education sessions during village town halls and health sessions while clients line up in the queue for consultations. It was also noted that other health activities are conducted if there are development partners or sponsors from the private sector and civil society groups.

However, one concern raised regarding the conduct of medical missions is that people are conditioned to receive food supplements or even medications without proper health checks or medications.

Satellite health stations. Given that the country is prone to typhoons and Baong Silangan is a flood-prone area, satellite stations and mobile health services have been practiced. The local government also invested in evacuation sites, and health workers were also prepared to respond to calls for disaster response.

In addition, responding to the impact of COVID-19 on hospital clogging due to communicable diseases created a space for the isolation of clients with COVID-19. The evacuation center can also serve as an evacuation site during calamities and an isolation area on regular days in case the same scenario as the pandemic occurs again.

Intensified referral system. Most health workers shared that if clients require secondary and tertiary care, they refer them to the appropriate facilities. However, in cases where the client may require a primary level of care, upon getting screened at the community level, they refer the client to health professionals such as nurses or primary health facilities like health centers.

The barangay health workers closely monitor identified clients. Typical cases that may require close monitoring are those of TB patients, pregnant, infants, and the elderly. Most health workers shared that they follow through efforts to this identified clientele and ensure that they follow their treatment or course of care. An intensified referral system is an enhanced approach to the traditional referral process aimed at increasing the effectiveness and efficiency of generating referrals. Transporting the clients as part of the referral practice has also been integrated into the local health system.

Population-based health programs. These health programs are designed to address the specific health needs of different population segments. Maternal and child health programs ensure pregnant women’s and children’s well-being, including prenatal care, immunizations, nutrition support, and access to safe deliveries and postnatal care. Adolescent and youth health programs aim to address the unique health challenges faced by this age group, including sexual and reproductive health, mental health, substance abuse prevention, and education on healthy lifestyle choices. Also, health programs for senior citizens focus on promoting healthy aging, managing chronic conditions, providing social support, and ensuring access to appropriate healthcare services tailored to their needs.

Maternal and child health. All participants who are mothers are well aware of the essential health services intended for their maternal health and that of their children. These health services are available in their health centers and are included in services provided by barangay health workers during home visits. It includes prenatal and postnatal care, maternal and child health and nutrition education and counseling, immunization, newborn screening, and referral to a tertiary facility for complicated cases.

Also included are family planning services.

Adolescent and youth health. Adolescent and youth health programs aim to address the unique health challenges faced by this age group, including sexual and reproductive health, mental health, substance abuse prevention, and education on healthy lifestyle choices. Many youth participants recalled that they had attended forums on teenage pregnancy, HIV awareness, drug prevention, and healthy lifestyle.

One participant shared that teenagers who are pregnant receive support from the local health office during their pregnancy and that their schools allow them to continue their schooling through modular modalities.

Health for the senior citizens. Health programs for senior citizens focus on promoting healthy aging, managing chronic conditions, providing social support, and ensuring access to appropriate healthcare services tailored to their needs.

Most of the elderly participants shared about their participation in physical wellness activities facilitated by their respective barangays or communities, like “Zumba.” While it was intended for the elderly, it also allowed all age groups interested in participating to join, hence becoming a social activity that one participant found healthy for their social well-being.

All participants shared that they get free health check-ups, such as regular monitoring of blood pressure and blood sugar levels, and medical check-ups when needed. One participant shared about a free eye check-up.

Maintenance medications for the elderly are lifesaving commodities. All participants shared that they can get medicines for hypertension, high blood sugar, and other essential medicines from their respective health centers, including vaccines for the elderly, such as flu and anti-pneumonia.

Along with social support, senior citizens of the older population shared that they have an organization for seniors and the elderly. Their usual activities include information dissemination of activities and programs for senior citizens. They have regular town hall meetings, wherein it also serves as a space for conducting health education activities led by the local health department.

Family-focused interventions. Family-focused interventions recognize that various social determinants influence health and require a collaborative approach between the health and social sectors. Integrated social and health sector approaches involve coordinated efforts to address health and social issues simultaneously. In the case of participants, addressing the healthcare needs of a family also involves providing support for education and access to social welfare programs.

Integrated social and health sector approaches. The stories of health workers based on their experiences in the field showed that despite the availability of health programs and services, some clients cannot attend to their health needs due to inequities. Few health workers shared that they needed to support their clients financially, from their own pockets, to ensure they could buy medicines or pay for their transportation to the health facility. This situation is common in poor barangays that do not have vehicles, compared to other higher-income barangays and in barangays that are too distant from the center of the city.

However, there are social security programs available. Financial assistance is granted to those who qualify for it. It requires proof or certification of indigency, which is issued by the barangay-level government. In case of hospitalization and other medical-related financial needs, there are social welfare officers in tertiary hospitals to provide assistance.

In situations where the expenses incurred by the indigent individual exceed the minimum grant available from the financial aid by the social welfare, the workaround is to assist the client in finding other sources.

Emerging E-health, including telemedicine/telehealth, digitalization of databases and processes, and the use of social media, has transformed healthcare delivery and accessibility.

Telemedicine/telehealth. Although telemedicine/telehealth is new, according to most health worker participants, it allows patients to consult with healthcare professionals remotely, overcoming geographical barriers and increasing access to medical expertise. However, the major problem of maximizing technology is people’s poor connectivity, especially in geographically isolated areas.

Digitalization of database and processes. In the rolling out of the UHC Law, all areas are now in the process of facilitating the registration of households in the eKonsulta. The local officials who participated in the study revealed that this is a part of the transition to integrating UHC in the local health system, wherein eKonsulta is a process to register Filipinos to the PhilHealth system to be able to access the “PhilHealth Konsultasyong Sulit Tama” (Konsulta), which is a comprehensive outpatient benefit as mandated by the

This transition to eKonsulta is followed by information dissemination to the communities. When they need medical or health services, they are encouraged to visit their primary level of care facility, such as the health centers, and be screened for appropriate intervention or proper referral.

Emergence of use of social media. The emergence of social media has provided platforms for health education, awareness campaigns, and support networks, enabling communities to access health information and resources easily.

In addition, most duty-bearers now communicate through social media platforms, such as messenger group chats. According to most duty-bearers, this channel enables them to respond more attentively and quickly, especially if there is urgency.

Challenges faced by Health Workers

Table 4 presents the thematic analysis of challenges health workers face regarding providing basic health services to different clients. The practices on the ground are responsive health services, population-based health programs, family-focused interventions, and the emergence of e-health. These practices reflect a shift towards more client-centered health-promotive, disease-preventive, and technology-driven approaches in healthcare. They emphasize the importance of addressing health needs. Despite these efforts, the challenges nurses and other health front liners face relate to human health resources (HHR), service delivery, and the health system.

Table 4: Thematic Analysis of Challenges Health Workers face regarding providing basic Health Services to different clients

Themes	Subthemes
Issues on Health Human Resources (HHR)	– Training needs
	– Political support needed
	– Overbearing situation on HHR
Issues on Service Delivery	-Fund sources for UHC
	-Exploring non-state actors’ roles in UHC
Issues in the Health System	-Access to health services
	-Need for more active participation of the private sector

Issues on Health Human Resources (HHR) in the Public Health Sector. Issues on HHR in the public health sector include training needs, political support, and an overbearing situation.

Training Needs. Many health workers lack the necessary skills and knowledge to address the complex healthcare needs of the population. Most BHWs shared that despite the efforts of their respective city governments and the DOH to provide learning sessions, they need specific skills to build.

Along with primary health care and universal health care implementation, many participants shared that they know what PHC and UHC are. However, this awareness does not translate to actual skills. Hence, additional training may be required.

Public health is an ever-changing field of practice. Regular training, orientation, and re-orientation are needed to provide responsive health services, population-based health programs, and family-focused interventions and to face the emerging e-health technologies that play vital roles in ensuring accessible and effective healthcare delivery.

In particular, BHWs are also closely involved in conducting psychosocial assessments, including those of violence against women cases; however, they are not trained for this. Public health nurses can advocate for BHWs, representing their interests at various decision-making and policy development levels. By addressing these barriers collaboratively, public health nurses can help strengthen the capacity and effectiveness of BHWs in delivering essential healthcare services to their communities (Reyes et al., et al. 2023). The BHWs, along with other health workers, are involved in sexual and reproductive health. Hence, training on dealing with sensitive issues or topics was also noted. BHWs are involved explicitly in assessing, planning, implementing, monitoring, and evaluating health programs; hence, technical skills training was raised as needed.

Political Support is needed. Improving HHR in the Philippines requires strong political support. Adequate funding, policy reforms, and effective program implementation are essential to addressing the challenges the public health sector faces. Political commitment is crucial for developing and implementing policies that promote the recruitment, retention, and equitable distribution of healthcare professionals.

Political skill plays a significant role in driving health services change, with five critical dimensions of leadership identified: personal performance, contextual awareness, interpersonal influence, stakeholder engagement, and influence on policy processes. Nurses’ involvement in public policy is crucial for promoting public health initiatives effectively (International Council of Nurses 2021; Clarke et al., et al. 2021).

The overbearing situation on HHR. The public health system in the Philippines is often burdened with an overbearing situation on HHR. Limited healthcare infrastructure and resources in specific areas contribute to this problem. The overburdened situation strains the existing healthcare workforce, leading to increased workload, burnout, and compromised quality of care. The overburdened situation strains the existing healthcare workforce, leading to increased workload, burnout, and compromised quality of care. The literature emphasizes the broader implications of nursing shortages on public health outcomes. Insufficient staffing levels may compromise the effectiveness of disease prevention efforts, response to public health emergencies, and delivering essential health services to vulnerable populations. This, in turn, could lead to adverse health outcomes within communities and hinder progress toward achieving public health goals (Smith et al., 2020)

Issues in the Health System. Primary health care and the Philippine health system face various challenges. Findings showed issues in the health system related to access to health services and the need for increased private-sector participation.

Access to health. A number of participants shared that one factor that bars people from access to health is transportation. The lack of transportation infrastructure available at the barangay level, difficult terrain in some situations, and long distances to health facilities limit people’s access to care.

Limited health literacy and lack of awareness about available services and preventive measures pose barriers to accessing primary health care. Health workers shared that they are actively going around the community to inform every household of the city’s and barangay’s health programs and health promotion activities; however, a number of youth participants were not aware of these programs and services.

The private sector needs to participate more actively. While the public sector plays a significant role in providing health services, increased private sector participation can contribute to addressing a number of challenges, such as indigents’ access to medicines, where pharmacies or drugstores can partner with the LGU.

While it is being recognized that the private sector contributes to health promotion activities through their corporate social responsibility and non-government organizations’ capacity to provide technical support to the LGUs, there is a need to harmonize the effort. Considering that the LGU city health office remains the direct contact point of the people, it is helpful if private and non-government actors coordinate activities with the LGU, hence, with a harmonized effort. There is an idea of exploring potential partnerships with private pharmacies or drug stores as part of the service delivery network in pursuit of implementing the UHC Act. Similarly, at the national level, pharmaceuticals and supply chains play a crucial role in ensuring the availability and delivery of health services to the population. Supply chain management that can ensure access to health commodities is indispensable to successfully implementing UHC (Enriquez A. et al., 2022). UHC Act devolves the national health system and places the accountability to meet the demands for health and responsibility for financial management and supply chain authority on local government units (LGUs) for select health commodities and technologies.

 Demand Side

 Health-Promotive Practices of the Individuals and Families

From the point of view of the claim holders or recipients of PHC (demand side), the participants from different sub-groups shared common knowledge of the health services their barangay health centers and RHUs are providing. The most common, in groups, are free commodities and free services. It is important to note that the availability and range of free commodities in primary health care can vary between barangay health centers, LGUs, and levels of care. Additionally, certain practices were noted to ensure efficient allocation of resources and prioritization of high-risk groups. Shown in Table 5 is the thematic analysis of existing practices on the demand side.

Accessing Free commodities. In primary health care, several commodities are often provided for free or at subsidized rates to promote equitable access to essential health services. While most common are vaccines but these are only for selected population groups. Medicines are free, but the elderly population and those with chronic conditions are a priority, while contraception and vaccination against COVID-19 are universal, which means for all.

Vaccines for selected population groups. All mother participants shared that they are getting free vaccines for their children. The barangay health workers ascertained that it is a must that they ensure that all children in their respective barangays will receive routine immunization for children. On the other hand. most elderly participants also discussed that they can get free vaccines, such as flu and anti-pneumonia vaccines, from the health center.

Table 5: Thematic Analysis of Existing Practices of Demand Side

Themes	Subthemes
Accessing Free commodities	– Vaccines for selected population groups
	– Universal vaccination against COVID-19
	– Medicines for the elderly and with chronic conditions
	– Contraception commodities
Accessing Free services	-Health checks and referral
	-Dental Health
	-Home visit

In the Philippines, routine vaccines for children from zero to one year old are free in barangay health centers. Booster doses for measles, rubella, tetanus, diphtheria, and vaccine against Human Papilloma Virus- cervical cancer-causing disease are also provided in schools during School Based-Immunization (UNICEF Philippines, 2022). In addition, the vaccination of senior citizens with the pneumococcal conjugate vaccine (PCV) and influenza vaccines was also mandated in the program through Republic Act No. 9994 – the “Expanded Senior Citizens Act of 2010” (Reyes MS. et al. 2021).

The Quezon City Health Office provided the following EPI performance statistics of Barangay Bagong Silangan SHC to the documentation team on November 29, 2023.

Table 6: Number of fully immunized children (FIC), HPV (girls 9-14 years old), pregnant women (Tdap), and senior citizens (influenza and pneumococcal vaccines) from 2018 to 2022

Barangay Bagong Silangan	2019	2019	2020	2021	2020
Fully Immunized Children Under 1	2,749	1,865	1,060	1,294	1,241
HPV	0	31	18	0	0
Pregnant Women	1,363	998	1,443	1,578	124
Senior Citizens (Pneumo & Flu)	0	247	102	886	1,723

Table 6 displays the number of clients who received vaccines from SHC from 2018 to 2022. It does not provide information about the eligible population for each type of vaccine for each year. Thus, the proportions or percentages of eligible children under one, girls between the ages of 9 and 14, pregnant women, and senior citizens who obtained the vaccines could not be determined.

Despite this limitation, it can be gleaned from the table that the number of FIC in 2022 was less than half (45 %) of the FIC in 2018.  There was no uptake of HPV vaccines in 2018, 2021, and 2022. The SHC nurses claimed that they had administered the HPV vaccine to schoolgirls in 2022, but they could not understand why there was no recorded SHC data in the Quezon City Health Office.  Tdap vaccines for pregnant women dropped immensely in 2022 due to shortages. The only increase in the number of vaccinations from 2019 to 2022 was from senior citizens. However, the results of administering the two vaccines are aggregated in this report.  This dismal vaccine performance of Barangay Bagong Silangan may change in 2024 because of Barangay Resolution No. 076 Series of 2023, which allocated a considerable amount from the barangay’s development fund to augment vaccine shortages in 2024 in the village.

Universal vaccination against COVID-19. In response to the global COVID-19 pandemic, primary healthcare centers often play a crucial role in administering COVID-19 vaccines at no cost to the population, aiming to protect individuals and communities from the virus. All participants were vaccinated for COVID-19.

Most participants shared that getting vaccinated is a must to prevent COVID-19 from spreading inside their homes. Along with the recommended precautions, such as wearing masks and washing hands, getting vaccinated is also important. They verbalized that COVID-19 vaccines are free in their locality regardless of brand. Access to COVID-19 vaccines is not a problem for all participants.

Medicines for the elderly and with chronic conditions. This support ensures that essential medications, such as those for hypertension, diabetes, renal problems, or heart disease, are accessible to vulnerable populations, especially those who may face financial constraints. Most of the elderly participants shared that they are getting their regular supply of hypertensive medications from the health center. Those who have diabetes also get their medications from their health center.

Contraception commodities. All healthcare centers in three areas provide free contraception to individuals seeking family planning services. Access to free contraception helps individuals make informed choices about their reproductive health and prevent unintended pregnancies. Most mothers shared that their family planning commodities are from the health center. However, a few mothers said that due to side effects, they prefer to get their brand of pills over drugstores, as it is not available in the health center.

On the other hand, one adult male participant, while recognizing that contraception commodities are free, shared that in their case, they prefer to buy family planning commodities, especially condoms. Getting free condoms was described as an embarrassing experience. Hence, buying is preferable.

Accessing Free services. It is important to note that the availability and extent of health services may vary depending on the local government, government support, and resources allocated to health programs. In the three areas, health checks and referrals, dental health, and home visits surfaced as the most common free services received and experienced by participants from the community.

Health checks and referrals. Most participants across subgroups shared that health consultations, including needed referrals, were provided at the primary-level healthcare facility in their locality. Few participants identified their knowledge about getting health checks when they were sick. In contrast, one participant shared that in case the required diagnostic laboratory was not available in the health center, they were referred to a facility where it was.

According to health workers, in their experience, most of the clients who visit the health center for check-ups are those who may require health certification issued by the City Health Department.

Dental Health. Many participants in all areas expressed awareness of the free dental health services provided in their health centers. One participant shared that they had their tooth extraction in the center for free.

Home visit. Most participants recall that they got a health worker conducting a home visit at their respective homes. One participant highlighted that home visits became more frequent during the pandemic since people cannot go out due to quarantine restrictions. Conducting home visits for both elderly individuals and children under one year old plays a crucial role in promoting vaccination acceptance and improving healthcare outcomes. These personalized approaches address barriers to access and provide tailored information and services, ultimately contributing to better public health outcomes for these populations.

Conducting home visits to provide information and administer free vaccines for the elderly is a proactive approach to improving vaccination rates and promoting health among this vulnerable population. Home visits offer a personalized and convenient way to reach seniors with limited mobility or access to healthcare facilities. By bringing vaccinations to their homes, healthcare workers can address barriers such as transportation issues or concerns about visiting medical facilities.

The personalized nature of home visits allows healthcare providers to tailor information about influenza and pneumococcal vaccines to the needs and concerns of each elderly person. This targeted approach helps to increase acceptance and uptake of vaccines by addressing any misconceptions or fears they may have.

Similarly, home visits for children under one year old have been identified as effective methods for improving healthcare outcomes. Health center workers can use these visits to provide reminders about vaccination schedules and offer additional services such as X-rays or consultations for older children. This comprehensive approach ensures that children receive timely vaccinations and access necessary healthcare services, ultimately contributing to their overall health and well-being.

According to participants, home visits are to provide health education regarding COVID-19, share announcements on the vaccination schedule, and follow up with pregnant women and children due for immunization.

The Philippine government, health departments, and LGUs provide free health check-ups and referrals to Filipinos through primary health care centers and rural health units. These services typically include general medical consultations, basic laboratory tests, and health education (DOH, 2021).

 Challenges Faced When Accessing Health Services

The trends in community activities and pandemic-driven health behaviors reflect the evolving landscape of public health practices and priorities in response to various societal factors, including changes in lifestyle, emerging health threats, and cultural influences. These trends underscore the dynamic interplay between individual behaviors, community practices, and broader societal factors in shaping public health outcomes. By recognizing and harnessing these trends, public health practitioners can tailor interventions and strategies to promote health and well-being effectively within diverse communities.

In addition, selective health-seeking behavior and attitudes require a multi-faceted approach that addresses barriers to access, promotes health literacy, and fosters trust in healthcare providers. Strategies may include improving healthcare infrastructure to reduce wait times, implementing community-based health education programs to raise awareness about the importance of preventive care, and fostering patient-provider communication to address misconceptions and build trust. By understanding and addressing the underlying factors driving selective health-seeking behavior, healthcare systems can work towards ensuring equitable access to quality care for all individuals.  Table 7 presents the thematic analysis of trends and challenges in the community.

Community activities. Health promotion activities in the community encompass many initiatives to improve the overall health and well-being of individuals and communities. Findings highlighted two key areas of focus within health promotion: wellness and physical activities and health education activities.

Wellness and physical activities. One highlighted by the participants is the conduct of group exercise classes, the most common activity being “Zumba.” Among male participants, adults and youths have a higher appreciation for sports leagues, such as basketball tournaments.

Table 7: Thematic Analysis of Trends and Challenges in the Community

Themes	Subthemes
Community activities	– Wellness and physical activities
	– Health education activities
Pandemic-driven health behaviors	-Improved hygiene practices
	-Geared up against COVID-19
	-Spirituality and other rituals
Selective health-seeking behavior and attitude	-Seeking health services when in poor health
	-Visiting health centers as a companion of the patient
	-“No doctor or no meds” mindset
	-“Long queue” mindset

Unique among young people, the healthy lifestyle campaign, specifically on smoking cessation, is well recognized by the participants. Most participants could recognize the city government’s initiatives toward a smoke-free community. Young people described ‘no smoking’ posters in areas where young people are, such as basketball courts. Other adult participants recalled ‘no smoking’ messages posted in public spaces and local officials talking about it.

Health education activities. Such activities aim to provide individuals and communities with the knowledge and skills to make informed health decisions. Some health promotion activities highlighted by the participants include substance abuse, sexual health, COVID-19 prevention, mental health, and healthy lifestyle. According to some participants, there are several seminars and training on HIV/AIDS prevention, teenage pregnancy prevention, and drug prevention. While a few shared discussions about mental health and healthy lifestyles. However, most of the adult male participants shared that, although they were aware that such health education activities exist, they were unable to participate due to conflicts in their work schedules.

Health promotion enables individuals, families, populations, and communities to adopt and/or adapt lifestyles that promote and improve health. It helps community members make the right choices that can improve their health. Each individual, population, and community has factors that positively or negatively influence their health (Onal AE, 2021).

Pandemic-driven health behaviors. The findings showed individuals’ conscious choices to engage in specific actions or adopt particular attitudes towards their health. The selective health-seeking behaviors and attitudes include improved hygiene practices, being geared against COVID-19, and engaging in spirituality and other rituals.

Improved hygiene practices. Most participants articulated many behaviors, especially protecting oneself from communicable infections and ensuring cleanliness and hygiene. Key informants also shared that most community people developed better health management practices to prevent acquiring or contracting COVID-19. With the emergence of the COVID-19 pandemic, there has been a heightened focus on personal hygiene to prevent the spread of the virus. Hygiene practices include the use of alcohol and hand sanitizers, proper hygiene, and regular handwashing.

Geared up against COVID-19. Most of the participants expressed an understanding of the importance of taking preventive measures against COVID-19. They stay informed about the latest updates on the pandemic, follow guidelines and recommendations provided by health authorities, and proactively seek vaccination against the virus.

Additionally, they may prioritize maintaining a healthy lifestyle, including a balanced diet, regular exercise, and adequate rest, to strengthen their immune systems and enhance their overall resilience against infections.

Spirituality and other rituals. Few participants, however interestingly, shared about believing in God and divine will in matters of life and death, health and sickness. Also, “suob” practices and other tonic and herbal rituals.

Health promotion enables individuals, families, populations, and communities to adopt and/or adapt lifestyles that promote and improve health. It helps community members make the right choices that can improve their health. Each individual, population, and community has factors that positively or negatively influence their health (Onal AE 2021).

Selective health-seeking behavior and attitude. The findings showed individuals’ practices in engaging in activities specific to their health. Selective health-seeking behavior and attitudes can vary among individuals based on their beliefs, experiences, and need for healthcare services. Findings highlighted seeking health services when in poor health, visiting health centers as a companion of the patient, the “no doctor or no meds” mindset, and the “Long queue” mindset.

Seeking health services when in poor health. Some participants shared that they only visit health centers when they need to get their medicines or are already sick. Some participants would seek out a health professional when unwell or experiencing a health condition, such as pregnancy or fever.

One participant shared that they proactively sought healthcare services to address their health concerns promptly. However, when they are better, despite being advised to return, they no longer see going back for follow-up care as critical.

Most participants across all subgroups visit the RHU to secure documents as a requirement for school, employment, or any other purpose that the RHU can provide.

Visiting health centers as a patient companion. In connection to seeking health services when in poor health, many participants expressed that when they visited the health centers, it was not because they wanted to be there; instead, they needed to accompany a family member who was sick.

Other lived experiences by young people are that they get to visit a health center when they are told to or that they need to accompany someone to go there.

“No doctor or no meds” mindset. According to the participants’ experiences, this attitude stemmed from various reasons, such as distrust, cost concerns, and previous negative experiences with healthcare providers and facilities.

“Long queue” mindset. According to a number of participants, this attitude refers to individuals who are deterred from seeking healthcare services due to long waiting times or overcrowded healthcare facilities. They may perceive the waiting time as inconvenient or anticipate spending excessive time in the queue, which can discourage them from seeking care.

Furthermore, along with trends, table 8 shows the status of communication as a strategy in PHC delivery. Communication is a vital strategy in primary health care and public health settings. It helps to inform, educate, and empower people about their health and well-being. It facilitates dialogue and collaboration among stakeholders, such as health workers, communities, and policymakers. By understanding the communication status in these settings, we can identify the gaps, challenges, and opportunities for improvement. This will enable the duty-bearers to design and implement effective and responsive communication interventions to enhance health outcomes and reduce health disparities.

Conventional means included using traditional media such as bulletin boards and radio broadcasts, putting up posters, and door-to-door strategies to communicate important health education information and announcements. Digital modalities included utilizing social media platforms.

Table 8: Thematic Analysis of Status of Communication as a strategy in PHC delivery

Themes	Subthemes
Person-to-person communication	– Face-to-face where the people are
	– A known personality behind the message
Readily made materials as a source	-Perceived as inadequate by population groups
	-Tailor fitting to the target audience
Conventional modalities are effective sources of information	-Participation
	-Visibility

Person-to-person communication. LGU and the barangay leadership utilized conventional and digital means to communicate within and among their peers, clientele, and the broader community. However, according to most participants across all subgroups, person-to-person communication surfaced as most appreciated. This includes face-to-face communication where the people are and a known personality behind the message.

Face-to-face where the people are. All subgroups highly recognize home visitation done by BHWs and other volunteer healthcare workers. This allows the service provider and the client to interact and facilitate direct answers in case questions arise. Likewise, it enables healthcare service providers to provide information and health education if needed.

A known personality behind the message. At the barangay level, communicating announcements and updates and advocating for people’s health happens during community/town hall forums and barangay general assemblies. This approach enables people to participate in the discussion on how to keep individuals, families, and the community healthy. It also enables individuals to be more actively engaged in health activities in the community. In Bagong Silangan, there are the “ikat boys” who roam around the community to inform the residents about the health programs and activities in the barangay.

Likewise, even in social media, who is behind the message also matters. All youth participants shared that they follow and get information from the FB posts made by their barangay leaders, like the SK Chairperson. They also value announcements posted by their local leaders through their accounts.

Readily made materials as a source. All duty-bearer participants shared that their messages were from materials, training guides, instructions, and tools provided by the DOH. At the same time, those from the social sector said that theirs were from the Department of Social Welfare and Development (DSWD). The BHWs and public health workers shared that they received training from the DOH. Likewise, they would often cascade announcements as instructed by those with higher authority. Subthemes related to this theme are: perceived as inadequate by population groups, and; tailor fitting to target audience.

Population groups perceive it as inadequate. Most subgroup participants find conventional means of communication more effective. However, mothers and youth groups emphasized that they find the content insufficient to give them the information they need, including what services and where to get them. This is contrary to how most duty-bearers, the health workers, perceive their communication strategies as effective.

Tailor fitting to target audience. One common mistake in communicating health advocacy is not considering the audience’s needs, preferences, and barriers. Health educators and advocates should tailor their messages and strategies to the specific context and culture of the people they want to reach. In the case of Quezon City, they ensure that the materials and messages are aligned to their health program objectives. By doing so, they deliver the message using the audience’s language to build trust and rapport and address the needs of its target. Therefore, they can increase the effectiveness and impact of their health communication efforts.

Conventional modalities are effective sources of information. BHWs put great effort into conducting home visits to ensure that individuals and families receive the health information and education they need. This approach is highly impactful, as most participants from different sectors have experienced it. Participation – in activities like family development sessions and family counseling, participants appreciated the opportunity to improve their health literacy and expected care for their family. Visibility is also essential for most participants, and health services and programs become more visible to them as they enjoy it firsthand in their homes. In addition, posters in visible areas around the community reinforce the expected behavioral change to complement the counseling and health teaching provided by the health care workers. One example is the smoke-free campaign, in which violations may result in penalties. A related study on primary care highlights that effective counseling typically requires multiple structured visits to deliver a behavior change theory–driven comprehensive, multicomponent intervention program. It also highlights the importance of assisting patients in setting health behavior goals and arranging follow-up support, including referrals to evidence-based behavioral counseling programs in primary care or community settings (Laddu D. et al., 2021).

CONCLUSION AND RECOMMENDATION

 Conclusion

In the context of Advancing Community Health Nursing Practice, understanding the current situation, existing practices, trends, gaps, and challenges in primary healthcare (PHC) delivery is essential for informing evidence-based interventions and promoting population health.

The current situation of PHC in the Philippines underscores the importance of accessibility, responsiveness, and equity in delivering essential health services to individuals, families, and communities. Despite efforts to improve PHC, challenges persist, particularly in addressing prevalent health issues, ensuring universal access to quality healthcare services, and advancing primary healthcare through implementing the Universal Health Care Act of 2019 and rolling out other public health programs and policies.

Existing practices in PHC highlight the multifaceted approaches healthcare providers adopt to promote health, prevent diseases, and address the diverse needs of communities. From the delivery of basic health services to the utilization of digital technology and collaboration with various sectors, these practices reflect the evolving landscape of community health nursing and the commitment to delivering comprehensive care.

Trends, gaps, and challenges in PHC delivery underscore the need for innovative strategies, policy reforms, and intersectoral collaboration to address emerging health issues, strengthen health systems, and overcome barriers to access. The recognition of communication as a critical strategy in PHC delivery highlights the importance of person-to-person interactions, tailored health education materials, and community engagement in promoting health literacy and behavior change.

Lastly, advancing community health nursing practice requires a holistic approach that integrates evidence-based interventions, promotes health equity, and engages communities as partners in health promotion and disease prevention. By addressing the current challenges and harnessing emerging opportunities, community health nurses can play a pivotal role in improving health outcomes and enhancing the well-being of individuals and communities across the Philippines.

Recommendations

To advance community health nursing practice, nursing education must prioritize curriculum enhancements that integrate the Philippines’ Universal Health Care Act principles, emphasizing equitable healthcare access, strengthened health systems, and case studies on prevalent health challenges. Educators should also develop training modules on interprofessional and intersectoral collaboration to equip nurses with teamwork, policy advocacy, and community organizing skills.

To ensure the delivery of community health programs and improve demand generation efforts, health communication, and literacy training must be strengthened by investing in training for community health workers on how to create tailored education materials and effectively engage communities to promote behavior change. Additionally, the integration of digital health tools, such as telemedicine, mobile applications, and electronic health records, into nursing education will ensure that future nurses are prepared to utilize emerging technologies for efficient healthcare delivery.

Additionally, future research should focus on evaluating innovative primary healthcare strategies, such as the use of telehealth, mobile clinics, and community-driven approaches, to address emerging health issues. Studies should also examine barriers to health equity and healthcare access, particularly among marginalized populations while assessing the role of nurses in implementing public health programs and advancing policy reforms. Research into the effectiveness of communication strategies in improving health literacy and fostering behavior change at the community level is equally important. Furthermore, exploring the preparedness and responsiveness of primary healthcare systems during public health crises and assessing the contributions of community health nurses to health system resiliency will provide valuable insights for strengthening healthcare delivery. By addressing these research gaps, future educators and public health nursing practitioners can advance evidence-based practices, inform future training programs, and improve population health outcomes in the Philippines.

FUNDING

This study received funding support from the Philippine NGO Council for Population, Health, and Welfare Inc., and the World Citi Colleges – Quezon City.

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