OBJECTIVE: To evaluate the effectiveness of chart reminder flyers in increasing the appropriateness of coronary primary preventive care. DESIGN: Randomized controlled trial. SETTING: A university-based clinic in the period January-June, 2000. PATIENTS: 120 charts randomly selected from 256 patients in the intervention group were considered. Another 120 randomly chosen from 295 patients were selected for the control. These subjects were those who consulted from January-June 2000 at the university clinic. INTERVENTIONS: Each clinic day was randomized to be either "with reminder flyer day" or "without reminder flyer day." On "with reminder flyer days", a one-page flyer that contained a letter of reminder for physicians to perform coronary primary preventive care was placed on the charts of all patients consulting at the clinic. The reminder flyer was detached from the chart right after each consultation. On "without reminder flyers days", no intervention was done. At the end of the trial, 120 charts from each group were randomly selected for auditing for appropriateness of coronary primary preventive care. RESULTS: The proportions of charts that recorded appropriate history taking, physical examination and pharmacological and non-pharmacological interventions were all significantly greater in the intervention group than in the control group (p values 0.001, 0.005 and 0.0001). When coronary primary prevention was taken as a whole, the proportion of charts that reflected appropriate care was significantly greater in the intervention group than in the control group (25 percent vs. 5 percent, p 0.001). Reminder flyers reduced the relative risk of not being given appropriate coronary prevention to 0.79 (p, 0.001). MAIN OUTCOME MEASURES: Proportion of charts that documented appropriate primary coronary preventive care in the intervention and controlled groups were compared using the test for equality of proportions. The changes in appropriateness of the preventive care from baseline for each group was taken and compared. CONCLUSION: The proportion of charts that recorded appropriate coronary primary preventive care was significantly higher in the reminder flyer group.
Human ; DELIVERY OF HEALTH CARE ; PRIMARY PREVENTION ;

BACKGROUND: Ultraviolet radiation is a major modifiable risk factor for aging and skin cancer. Studies assessing knowledge, attitudes and practices towards sun exposure and protection should be conducted on high-risk groups like the triathlete community.
OBJECTIVES: To assess the knowledge, attitudes, and practices regarding sun exposure and protection among triathletes in Manila, Cebu and Davao City. To determine if these are associated with demographic characteristics, and if knowledge and attitudes are correlated with protective practices.
METHODS: This was a cross-sectional study conducted among adult triathletes evaluating their knowledge, attitudes and practices concerning sun exposure and protection, using a self-administered e-questionnaire.
RESULTS: There were 120 respondents. Almost half of the respondents had inadequate knowledge scores, while majority (83%) had desirable attitudes. Having at least a college degree significantly increased the odds ratio of having a desirable attitude (OR 6.0, 95% CI 1.36-26.45). Only 37.5% of the participants practiced good sun protection. Triathletes with Fitzpatrick III phototype had significantly increased odds ratio of having adequate sun protection practices (OR 2.22; 95% CI 1.04-4.72), while higher socioeconomic status was associated with poor protection practices (OR 0.42, 95% CI 0.19-0.90). Only 32.5% of the participants had adequate KAP scores combined.
CONCLUSION: Even though more than half of the respondents had limited knowledge scores, most of them had desirable attitudes towards sun protection. Athletes with adequate knowledge and desirable attitude were more likely to exhibit adequate practice. These findings indicate the pressing need for public health strategies on sun protection for the triathlete community.

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Athletes ; Attitude ; Demography ; Odds Ratio ; Philippines ; Public Health ; Risk Factors ; Skin Neoplasms ; Social Class ; Sunburn ; Ultraviolet Rays

Health Services

The patient-level experience of health care financing in the Philippines is complex and challenging. While almost all citizens of the Philippines are now covered by the Philippine Health Insurance Corporation (PhilHealth), in practice, not all health care expenses are covered during an episode of illness. Consequently, individuals facing illness might be compelled to seek alternative financial sources to pay for health care costs. This can result in high out-of-pocket (OOP) expenses for patients, which can be financially devastating, especially for those who are already struggling to make ends meet.1 In 2022, government schemes and compulsory contributory health care financing schemes accounted for 44.8% of the Philippines’ current health expenditure, while household OOP payments contributed a close 44.7%.2 Multiple studies evaluating PhilHealth coverage have highlighted the insufficiency of case rates to meet the complete cost of hospitalization.3 4 5 6 This is especially true for high-cost procedures and treatments. As a result, patients with large hospital bills may be left with a significant financial burden, even after they have received PhilHealth reimbursement. Beyond the OOP costs that admitted patients are required to settle, which are reflected in the hospital bill after applying discounts, PhilHealth coverage, and other financial aid, patients often incur additional health care expenses that are not included in the bill. These non-billed OOP costs can encompass a variety of expenses, such as those for medications and diagnostics that are not available in the hospital, and for living allowances, transportation fees, and salaries of private duty nurses, caregivers, and/or patient watchers. These costs are typically borne by the patients themselves and are not usually reimbursed by insurance or the hospital. To cope with these expenses, many patients seek financial aid from various government schemes designed to provide medical assistance. These include programs—such as the Malasakit Program7 and the Medical Assistance for Indigent Patients program8—and the services offered by medical social workers. However, these schemes often do not cover everything in the excess bill, and the distance between offices, coupled with extended waiting times, could discourage patients from pursuing financial aid. Moreover, the paperwork required for PhilHealth coverage and government assistance, especially for patients from outside the city, who must travel home to get the necessary documents, poses significant challenges. Despite seeking financial help, many patients continue to grapple with OOP expenses due to insufficient assistance. This can lead to financial hardship, debt, and even bankruptcy. In some cases, it can also push patients into poverty. In addition to the challenges of inadequate PhilHealth coverage and limited financial assistance, there is also the question of cost efficiency in health care delivery and the reasonableness of professional fees. Are the diagnostics requested really warranted? Is there judicious use of therapeutics? Are the professional fees fair and proportionate to the health care services provided, taking into account the complexity of the case, the time spent, the risks involved, the physician’s professional standing, and the patient’s financial capacity?9 Unwarranted or unjustified use of diagnostics and therapeutics, and disproportionate professional fees, increase health care spending and ultimately put the financial burden on patients. In practice, while the PhilHealth Z Benefit Packages do outline a list of acceptable diagnostic and therapeutic interventions, as well as professional fees for specific packages,10 11 12 much of the practice of determining diagnostics, therapeutics, and professional charges in health care is largely left to the discretion of the health care providers. There are a number of things that can be done to improve the patient-level experience of health care financing in the Philippines. First, there needs to be more research on the adequacy of PhilHealth case rates. These studies will help improve the financial protection that PhilHealth provides to patients. Second, interventions in clinical practice should be aimed at optimizing patient diagnostic and therapeutic management. These measures can both improve patient outcomes and reduce health care costs. Third, professional fees should be efficiently managed to ensure that they are balanced and equitable. A comprehensive and thoughtful approach to fee management can foster transparency in health care spending and greater public trust in the health care system. Fourth, the government should implement mechanisms to address the barriers in availing PhilHealth and other financial assistance schemes. These mechanisms should make it easier for patients to access the funds they need to pay for their health care. One such mechanism is the Malasakit Centers Act,7 13 which encourages public hospitals to establish one-stop shops within their premises, where patients and their families can seek medical assistance from various agencies. This law should be efficiently enforced, as it simplifies the process of obtaining medical assistance. Future interventions should be geared towards reducing OOP expenses. This can be done by making the diagnostic and therapeutic management of patients cost-efficient, ensuring that professional fees are justifiable, expanding the coverage of PhilHealth, and making it easier for patients to access affordable health care services. While PhilHealth and other government schemes have made strides towards universal health coverage, significant gaps in practice still exist. These need to be addressed in order to improve the experiences of patients procuring health care services and make health care truly universal and accessible to all.

Medical journals are meant to both reflect the science behind medical practice and facilitate the advancement of the discipline.1 They present newly generated knowledge in the field, with the general aim of improving health care. The effectiveness of a journal article to convey its messages can potentially affect the development of health care. Medical information from journals used to be designed for medical practitioners alone. Now, increasingly, publishers feel the need to package the same information to make it accessible to different types of readers. Almost always, readers go to journals to look for evidence that can support decisions about health. The common questions readers ask when looking for evidence in medical literature have something to do with incidence or prevalence of conditions, effectiveness of therapy or prevention, accuracy of diagnostic approaches, and associations of exposures and outcomes.

In this epoch of progress in health care, when systematic generation of knowledge is considered the cornerstone of health development, there is increasing focus on the need to demonstrate the ethicalness of doing research. Stories of harm inflicted on research participants and scientific misconduct in research are rife in the history of science, even within our immediate past.1 The lessons that we have learned from these stories have shaped the ethical research guidelines that we abide by and uphold today.2 3 Within the last 15 years, since the creation of the Philippine Health Research Ethics Board (PHREB) as the country's policy-making body on research ethics, numerous mandates have been issued to ensure human research participant protection and research integrity. Taken together, these mandates push for the ethical review of researches that are proposed to be done among humans or to use human data, the establishment of research ethics committees (RECs) in institutions that produce these researches, and the maintenance of quality standards in the operation of these RECs through accreditation by the PHREB.4 The enactment of Republic Act No. 10532 in 2013, formally institutionalized the Philippine National Health Research System and tied up all these mandates that pertain to research ethics.5 In effect, all institutions that generate human research一hospitals, health facilities, pharmaceutical companies, government and private agencies, universities, colleges, and even high schools一are expected to comply with these mandates. Many institutions that produce research involving humans or human data find it very challenging to set up a series of procedures for the review of these researches. For one, submitting research protocols一after they have gone through several revisions as directed by the technical research committee or panel一to a second committee for ethics review, approval, and implementation monitoring is a relatively new practice. The extra layer of scrutiny, the intellectual disagreements of technical committees and RECs, and the additional time and effort it takes to get an REC approval all figure in the arguments of those who are against the ethics review process. Research offices or training committees may have to put a system in place to incentivize submission or discourage non-submission of research protocols for ethics review. All in all, it takes administrative political will to incorporate a procedural pathway to ethics review into the usual research generation procedures of an institution. The institutions can arrange a mechanism for external ethics committees or, more commonly一and indeed more efficiently一they can create their own in-house RECs. The demands related to the establishment and operation of in-house RECs constitute an altogether different set of challenges for the institution. REC members and staff will have to be trained to competently do ethics reviews and perform administrative tasks within the REC office. There is also the difficulty of coming up with a good roster of trained reviewers who can dedicate time for committee work. The institution will also have to allocate physical space, and finance both the cost of REC operations and the remuneration of office personnel. The REC accreditation process is meant to reduce variation of procedures and maintain the quality of operations by way of recommending certain standards in the structures, processes, and outputs of RECs. On the part of PHREB as the accrediting body, the process requires careful organization of a well-trained accreditation team that can efficiently and scrupulously evaluate the REC operations and produce helpful recommendations. The process is inherently challenging for REC managers as well since, most of the time, it requires meticulous (re)engineering of REC operations. Above all these demands in complying with the mandates on research ethics is the pervasive call for us to generate trustworthy research results in ways that are beneficial and non-harmful to humans. An ethically produced piece of knowledge is a valuable contribution to scientific progress.
Ethics, Research

Research—or the production of new knowledge—needs to be done ethically. Why is it important to factor ethics into the practice of producing new knowledge? The word “ethics” refers to “moral principles that govern a person’s behavior or the conducting of an activity.”1 Moral principles are “principles of right and wrong that are accepted by an individual or a social group.”2 If we add “research” into the term “ethics,” the phrase “research ethics” would now refer to the principles of right and wrong that govern a researcher’s behavior or the conducting of research. “Research ethics” is the principles of right and wrong in action, in practice, or in the actual implementation of knowledge production. When we conduct human research, we produce new knowledge, often with development goals in mind, for instance—to be more efficient in work, to make clients more satisfied, to diagnose more accurately, to treat more effectively, to prevent illness, to predict outcomes, or to save lives. We ask questions and answer them to produce new knowledge, which we hope will eventually inform the actions that we take in order to meet our development goals. This is a very human pattern of behavior: question-answer-knowledge-action, to strive towards development. It is human nature to work towards development—towards making existence a better experience. This is the reason why we have the propensity to marvel and to introspect, and then to question and look for answers to our questions. This is the most fundamental reason for generating more and more knowledge, for doing research. And this is good—the intention is noble because it benefits us, the people around us, and even those who will exist after us. Generating new knowledge is a conscious effort to do something that gives benefit to oneself and to others. The problem with knowledge production is that it can cause harm, especially to research participants. Harm within the context of research can either be physical, psychological, economic, sociocultural, or legal. Many researches in the past have caused direct, indirect, intentional, or unintentional harm to the participants, or even to the public.3 Asking questions, collecting and analyzing data to answer these questions, and communicating findings and interpretations to others all involve harm. That is why we have international and national guidelines, state laws, and research implementation standards that support human protection systems in research. In the Philippines, many mandates pertaining to health research order the establishment of research ethics committees, the review of all researches involving humans or human data by these committees, and the accreditation of these committees by the Philippine Health Research Ethics Board, the policy-making body in health research ethics in the country.4 These mandates should guide academic and health institutions, as well as agencies that conduct researches involving humans or human data, in providing human protection in research. Deciding to do research is an ethical act. If we decide to pursue knowledge, we affirm and celebrate the human features of introspection, examination of our actions, and pursuit of excellence in the things we do as a society. Actually doing research—i.e., asking questions, recruiting participants, giving interventions, gathering and analyzing data, to reporting findings—offers several opportunities for more ethical acts because, when we perform the tasks involved in research, we are presented with opportunities to do good for others, to prevent harm from coming their way, to show respect for and to acknowledge others as fellow humans, to actively participate in restoring or maintaining justice, and to practice professionalism, honesty, and integrity. By properly applying ethical principles in doing research, and by ensuring that a system for the oversight and guidance of research implementation is in place, we can prevent harm, minimize the risk of harm, and avoid misconduct in research. From there on, we can pursue the ethical act of doing research and positively gain from seizing the opportunities that the act offers. That is why it is important to factor ethics into the practice of producing new knowledge.
Ethics, Research

The response of Southern Philippines Medical Center (SPMC), the largest tertiary government hospital in Davao Region, to the coronavirus disease 2019 (COVID-19) pandemic is detailed in the brief report of Astudillo.1 The guiding principles for implementing the structural and operational modifications made by SPMC in its health care services during quarantine were: to focus on the diagnostic and therapeutic management of patients with probable or confirmed COVID-19 and to limit the spread of SARS-CoV-2, the virus that causes COVID-19. As can be gleaned from the hospital's census before and during quarantine, extreme focus on COVID-19 health care, when sustained for a long time, can potentially compromise other essential, but non-COVID-19, health care services. On the other hand, restoring full-scale health care services to pre-COVID-19 amplitude can potentially increase the spread of the virus. Restoring hospital health care delivery to a more balanced state—comprehensive in scope, yet fully responsive to the epidemiological status of COVID-19—requires several rigorous cycles of planning, execution, and revision. Fortunately, the quarantine period has given SPMC—as a health care provider—an opportunity to maximize the efficiency of the delivery and utilization of health care services amid the extreme focus on infection control and management. It also compelled the institution to more frequently carry out certain procedures that were not often practiced before—teleconferencing, teleconsultations, operating on skeleton workforce, allowing work from home schemes, etc. As SPMC prepares to gradually reinstate health care services that were scaled down or put on hold during the quarantine period, some practices that need to be developed or sustained in the presence of the ongoing COVID-19 pandemic are worth pointing out for consideration. Like SPMC, hospitals that provide diagnostic and therapeutic managements of patients with COVID-19 are considered COVID-19 hotspots—where concentrations of patients with the disease are very high, and where most hospital staff who eventually get infected with SARS-CoV-2 have been initially exposed to the virus. Therefore, the goal of health care from this point on is to keep people away from hospitals that manage patients with COVID-19, as much as possible. Any task, transaction, operation, or essential person-to-person interaction that is not dependent on hospital facilities and equipment should be done outside the hospital.

Due to the long quarantine, with several levels of intensity and degrees of implementation, we all have, more or less, similar experiences with the COVID-19 pandemic. Starting early this year, we stayed home for a long time, we had ourselves tested, our friends or relatives had themselves tested, and some of us may even have tested positive for the infection. We listened to, or read, or watched the news, about the statistics of COVID-19 morbidity and mortality, lockdowns, reopenings, resurgence and reinfections. And then, we received all sorts of information—true, fake, inaccurate, anecdotal—and some were derived from systematically produced knowledge, i.e., properly conducted research or ongoing research.
COVID-19