Most patients want to play an active role in their own health care. There is now a movement from medical paternalism to patient-centered care in the consultation process that is based on the therapeutic alliance and negotiation between the doctor and patient, aptly named “shared decision-making” (SDM). It is a process where doctors work together with patients, including their families and caregivers, to select tests, treatments, management, or support packages, based on clinical evidence and personal informed preferences, health beliefs, and values. Successful implementation of SDM is associated with improved quality of consultations, favorable patient-reported health outcomes, and increased patient and doctor satisfaction. Patients are empowered to make proactive health decisions resulting in decreased anxiety, faster recovery, increased treatment compliance, and reduced unnecessary health care expenditure. There are multiple existing models in facilitating SDM. Two simple and easyto-follow models are the “three-talk model” and “S.H.A.R.E. approach.” The three-talk model endorsed by the NICE divides the SDM consultation into three steps, namely: team talk (explaining the need to consider treatment options as a team), option talk (describing the alternatives in more detail, and making use of patient decision aids [PDA] whenever appropriate), and decision talk (helping patients explore and form their personal preferences). On the other hand, the S.H.A.R.E. approach promoted by the Agency for Healthcare Research and Quality (AHRQ) is a five-step SDM consultation process that includes exploring and comparing the benefits, harms, and risks of each treatment option through meaningful dialogue about what matters most to patients.
Decision Making, Shared

In Evidence-based Family Practice, requesting a diagnostic test should be based on two issues. First is whether the test is accurate and thus will significantly help in clinical decision making. Second is whether the test is appropriate and acceptable for the patient. This involves careful discussion of risks and benefits based on the physician’s knowledge and experience and the patient’s values and preferences.
Diagnostic Tests, Routine

A systematic review summarizes the results of a number of individual studies that address a focused clinical question. It may be accompanied by a meta-analysis, which is a quantitative method of combining the results of all these studies in order to come up with a summary statistic of the overall effect of an intervention. Single studies may be unrepresentative of the total body of evidence, that is why combining the results of several studies in a systematic review increases precision, provides better estimates of effect, and includes a greater range of patients thus facilitating better clinical decision making. This must be done in a systematic and reproducible manner.
Systematic Review ; Meta-Analysis

Background and Objective: The family plays an important role in the management of patients with Diabetes Mellitus. In this study, the authors determined the association between family function using the APGAR questionnaire with glycemic control among Type 2 diabetic patients. Association between demographic and clinical characteristics with glycemic control was also assessed. Methods: This was a cross-sectional study of 237 adults ages 18 years old and above with Type 2 Diabetes Mellitus seen in Healthway clinics in Las Piñas between April 2021 to May 2021. Data from participants were obtained through a self-administered questionnaire and review of recent HbA1c results. The questionnaire contained 3 sections which included sociodemographic and clinical characteristics of the participants, their recent HbA1c result, and Family APGAR score. Multiple logistic regression analysis was done to determine the association of glycemic control with family function, demographic, and clinical factors. Results: Four variables were noted to be significantly associated with glycemic control- family function (p<0.0001), duration of being diabetic (p=0.021), diabetes regimen (p=0.013), and comorbidity status (p=0.021). Respondents with functional families as evaluated from their Family APGAR scores were 6 times more likely to have good glycemic control (OR 6.204) compared to those with dysfunctional families. Respondents with ≤10 years duration of diabetes (OR 4.051) and on both oral and insulin therapy (OR 9.639) are more likely to have good glycemic control. Respondents with comorbidities (OR 0.465) are less likely to achieve good glycemic control Conclusion Family APGAR score, duration of diabetes, type of diabetes regimen, and presence of comorbidities should be highlighted in diabetic management as they may influence glycemic control. This supports the need to include family assessment (especially family function) in the routine care of diabetic patients, and to address family issues which may hinder achievement of glycemic targets.
Glycemic Control ; Diabetes Mellitus

Introduction: Uncontrolled hypertension can lead to increased morbidity and mortality secondary to end-organ damage. Community-based health interventions promote health changes in a community setting and have been shown to promote better and more cost-effective healthcare. Existing meta-analyses on community-based interventions in hypertension control are confined to a certain country, have high risks of bias, and have shown heterogeneous results. A gap in the applicability of these conclusions necessitates the present study Objective: Synthesize available evidence on the effectiveness of community-based interventions in addition to standard of care in the control of blood pressure among hypertensive adults. Methods: A meta-analysis of randomized and non-randomized controlled trials among hypertensive adults was conducted. A literature search from various search engines and electronic databases such as PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, Google Scholar, Proquest, medRvix, and Grey literature was done by the investigators. Separate forest plots were generated for each desired outcome. Results: Six studies were included. The pooled estimates showed a trend in favor of community-based interventions in the control of blood pressure [RR = 0.86, 95% CI 0.62 to 1.19, p = 0.37], reduction of systolic blood pressure, reduction of diastolic blood pressure [MD = -2.52, 95% CI -3.64 to -1.28, p < 0.001] and medication adherence [RR = 0.82, 95% CI 0.72 to 0.93, p = 0.0025]. However, there was high heterogeneity across studies. Subgroup analysis showed a favorable trend with lower heterogeneity in decreasing diastolic BP in particular, among community health worker-led interventions, and those involving health education and/or physical activity Conclusions/Recommendations Adherence to the current standard of care in the management of hypertension is still advised. There appears to be a trend towards control of blood pressure with community-based interventions; and a reduction of diastolic blood pressure with interventions that are led by community health workers involving health education and/or physical activity. There is a need to empower community health workers and conduct additional studies on the specific community-based interventions targeting communities as a whole whenever resources and current health restrictions allow
Hypertension ; Systematic Review ; Meta-Analysis

Background: The recent inclusion of the pediatric population aged 12-17 years old in the rollout of COVID-19 vaccines in the country is necessary in order to increase vaccine coverage, and eventually achieve herd immunity. Vaccination of those in this age group is dependent on the vaccine acceptance of their parents or respective caregivers. Objective: The study’s primary aim was to determine factors associated with parents’ intent to vaccinate their children against COVID-19. Specifically, this study aims to determine: 1. parent and child factors that influence the parents willingness to have their children vaccinated, 2. external factors in the decision to vaccinate their children, that is, if it is recommended by the doctor or school, and 3. concerns of parents regarding vaccination Methods: A multi-clinic cross-sectional analytic study design was used. Respondents were parents in select Healthway Family Clinics in Cavite. Data were gathered via self-administered questionnaires, adapted and modified with permission from the authors of The COVID States Project. Data were analyzed using Epi Info 7. Results: Among 350 respondents, 73.71% are most likely to vaccinate their children against COVID-19 once the vaccine becomes available to them. The major parental concerns are: long term health effects (56.29%), whether it has been tested enough (54.86%), immediate side effects (54.57%), and whether the vaccine actually works (54%). There is an association between the willingness of parents to vaccinate their children with the age and COVID-19 vaccination status of parent, and age and EPI immunization status of the child. Parents consider doctors’ and school’s recommendations to be very important factors in their decision to vaccinate their children Conclusion Majority of participants are likely to have their children vaccinated. Knowledge of associated factors and parental concerns gives the researchers better understanding of vaccine hesitancy amongst parents. This is vital to promote vaccination in the clinic setting, and on a much larger scale, in the local and national government’s public health strategies.
COVID-19 Vaccines

Background: Chronic obstructive pulmonary disease (COPD) is one of the contributors to the burden of non-communicable disease. Health education is a key component in COPD management. Effective health education interventions directed to patient, family and community are necessary to prevent exacerbations, emergency room visits, hospitalizations and improve quality of life for patients with COPD. The general objective of the study was to determine effectiveness of health education interventions directed to patient, family and community. Specifically, to determine the effect on the number of acute exacerbations, COPD related emergency room visits and hospitalizations, improvement in the quality of life and patient satisfaction. Methods: This study only included comparative clinical trials randomized or non- randomized, parallel or cross-over clinical trial design, cohort study involving humans as the participants. It also includes published studies in peer reviewed journals of PubMed, clinical trials registered Cochrane Central Register of Controlled Trials, and the grey literature. There were no foreign language studies included relevant to this review. The non-comparative clinical trials, outcomes research or real-world data, animal experiments, reviews and case reports were excluded. The study population of reviewed literature has an established diagnosis of Chronic Obstructive Pulmonary Disease based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for diagnosis of COPD. Studies involving COPD patients who have other co morbidities were also included. The patients with COPD in the study were similar to patients consulting in family and community medicine practice clinics in the Philippines. Data synthesis was done separately for each type of intervention, i.e., patient directed, family directed, community directed health education intervention on Chronic Obstructive Pulmonary Disease. Quantitative analysis was only possible for studies reporting similar outcomes and units of measures such as number of COPD-related hospitalizations and emergency room visits for health education intervention directed to patient and improvement in the quality-of-life scores for health education intervention directed to family and community. Narrative synthesis was done when it was not feasible to include studies to do pooled analysis due to any of the following reasons such as different outcomes and when outcomes not reported as means with standard deviation. The Review Manager 5 software was used in the analysis of the data. Sensitivity analysis was done by restricting the analysis to published studies and with low risk of bias. Results: A total of ten studies were included. Health education interventions directed to patient has no benefit in decreasing the number of COPD related emergency room visits (1.84, 95% CI 0.94,2.74) and insufficient evidence to decrease the number of COPD related hospitalizations (4.33,95%CI-4.69,13.34). Health education intervention directed to family have insufficient evidence to improve the quality of life among patients with COPD (0.35,95% CI -0.49,1.19). Community directed health education intervention have significantly improved the quality of life among patients with COPD (-1.95,95% CI -3.37, -0.53).The studies had low risk for bias in terms of random sequence generation, allocation concealment and blinding of outcome assessment except for one study that was a non-randomized trial (Tabari et al, 2018). The highest risk for bias across the studies was the non-blinding of the participants. The withdrawals or dropouts in one study exceeded 20%. Three studies reported non possibility of blinding the assessor (Marques et al 2015, Nguyen et al 2019, Tabari et al 2018). Furthermore, five studies (Gallefos, 2004, Hernandez et al 2015, Tabari et al 2018, Van Wetering et al 2010, Marques et al, 2015) did not report the use of intention to treat analysis Discussion Effective health education interventions directed to patient, family and community in conjunction with standard of care may decrease exacerbations, hospitalizations, emergency visits, better quality of life and patient satisfaction. The studies included for this review were heath education interventions solely directed to patient, to family and to community and not a combination of the interventions directed to patient and family, or patient and community, or patient and family and community. Overall, health education interventions are integrated in a patient centered family focused community-oriented care for COPD. Health education is just one of the components of the integrated care on COPD. Better control of COPD is likely due to the combined effects of the different care components. Hence, there is a need for more randomized controlled trials on health education interventions directed to patient and family. Inclusion of COPD related hospitalizations, emergency room visits, acute exacerbations as outcome measures in health education interventions directed to patient, family and community is useful to provide evidence in effectiveness of the intervention. The authors declare no financial or funding involvement in the development and implementation of this study. This protocol was registered with Research Grants Administration Office (RGAO) with Registration No. RGAO-2020-1276, Research Implementation Development Office (RIDO) and to the Research Committee of the Philippine Academy of Family Physicians. The study was given Certification of Exemption from Ethical Review by the University of the Philippines Research Ethics Board (UPMREB CODE: UPMREB 2020-783-EX
Pulmonary Disease, Chronic Obstructive

Human ; Physicians, Family ; Practice Guideline

Background: Uninvestigated dyspepsia is a common complaint in family practice in the Philippines. Patients usually seek consult due to severity of symptoms which affect their quality of life. The goals of management are short- and long-term symptom control, with reversal of possible underlying mechanisms, achievable through a combination of pharmacologic and non-pharmacologic interventions. Objective: The main objective of this pathway is to guide family physicians and primary care physicians in the assessment, diagnosis and management of adult patients with uninvestigated dyspepsia through a shared decision-making process. Method: This clinical pathway is an update of the PAFP’s Clinical Pathways for the Management of Dyspepsia in Adults (2016). The current panel utilized the ADAPTE method and prioritized reviewing relevant clinical practice guidelines from 2017 to present. Grading of recommendation was achieved through a mixture of strength of available evidence and a consensus from a panel of experts. Summary of Recommendations: The main changes in the recommendations in this update are as follows: symptom-based classification of dyspepsia, screening for anxiety and depression, family and SCREEM assessment; initiation of therapeutic trial for most patients to whom H. pylori testing is not available; extension of initial PPI treatment to 4-8 weeks, consideration of antacids/alginates for immediate symptom relief, consideration of tricyclic antidepressants for non-responders to initial treatment; symptom-based non-pharmacologic advice, consideration of counseling and other psychosocial interventions; empowerment for self-treatment and as-needed therapy for those who have completed the initial treatment regimen Dissemination and Implementation This guideline shall be disseminated and implemented at the clinic and organizational level. It will be published in the “The Filipino Family Physician” journal, social media platforms and will be disseminated through PAFP local chapters, training institutions and during the national convention. Non-FCM primary care physicians will also be reached through relevant agencies. It shall be included in the references required during training activities and national exams of accredited training institutions, in coordination with the PAFP committee on Residency Training. It shall be incorporated in checklists for compliance in audits and QA cycles, with support from the PAFP committee on Quality Assurance and that on Standards for Family Practice. Feedback on utility and applicability will be actively sought from the intended users and other stakeholders.
Dyspepsia ; Community Health Services ; Critical Pathways

Background: Coronavirus disease 2019 (COVID-19) was first identified in Wuhan, China in December 2019. This has rapidly spread worldwide, causing a pandemic. The Philippines ranks 3rd in Southeast Asia with more than 15,000 confirmed cases, and a case fatality rate of 6.01%, close to the global average of 6.33%. Objective and Methods: This review aims to provide Family and Community Physicians the latest updates on epidemiology, pathogenesis, clinical manifestations, diagnosis, treatment options, and prognosis of COVID-19. Online literature search was done with WHO and DOH websites prioritized for epidemiologic data, and MEDLINE for the most recent and relevant journal articles. Pathogenesis: SARS-CoV-2, the etiologic agent of COVID-19, is an enveloped, positive sense single-stranded RNA virus which triggers immune-mediated responses responsible for most of the clinical manifestations of the disease. Angiotensin Converting Enzyme 2 appears to play a critical role in viral entry and disease severity. Clinical Manifestations: There have been reports of asymptomatic cases. Majority have mild illness, with common symptoms of fever, cough, headache and fatigue. Those who progress to the critical stage of the disease present with Severe Acute Respiratory Syndrome, sepsis or Multiple Organ Dysfunction. Diagnostic Evaluation: The definitive diagnosis of SARS-CoV-2 requires an analysis of respiratory specimens collected through oropharyngeal and nasopharyngeal swabs. The reverse transcriptase-polymerase chain reaction (RT-PCR) is considered the confirmatory test. Serological rapid detection test (RDT) for SARS-CoV-2 IgM and IgG may be done, but as an adjunct only because antibodies appear later in the course of disease. Imaging studies and other tests are used to monitor the severity of the condition, but not for diagnosis. Treatment and Prognosis: Supportive therapy is the cornerstone of management. Currently, there is no FDA-approved drug or agent specifically for the treatment of COVID-19. Drugs being investigated for treatment are those that are currently used for other viral infections or indicated for other conditions. A vaccine is yet to be developed. Old age, the presence of comorbidities such as hypertension, diabetes, cardiovascular and lung diseases, and smoking history are risk factors that lead to severe complications and death. Conclusion COVID-19 has caused a global public health crisis. In the Philippines, cases are still on the rise. Majority of cases are mild. More severe and fatal disease is associated with old age and the presence of comorbidities. Definitive diagnosis is through RT-PCR. Supportive therapy is the cornerstone of management. The search continues for a proven, effective drug for treatment and vaccine for prevention of COVID-19.