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

Critical appraisal is the process of reading published research to make a judgement on its scientific value (validity), and to consider how its results can be applied in family and community practice (applicability). There are four main elements of critical appraisal in EBFP i.e., relevance, validity, results, and applicability. Some family practitioners are not so comfortable with appraisal because of their poor background in research. But we developed the guide questions for critical appraisal simple and provide advice on what and where to look for it in the published evidence.
Community Health Services ; Publications ; Reading ; Judgment

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

<p style="text-align: justify;">Background. The increasing prevalence of autism has significantly impacted the health care spending of many families worldwide. To date, families from low to middle-income countries are burdened with out-of-pocket spending as their local health care systems have yet to incorporate autism-related services into the health care infrastructure.p><p style="text-align: justify;">Objectives. This study aimed to determine the direct costs of diagnosing and caring for children with autism and analyze its impact on the Filipino family.p><p style="text-align: justify;">Methods. The cross-sectional study consisted of a self-administered questionnaire that looked at parents' employment status, family income, and the direct costs for consultations, diagnostic tests, therapy, education, and medications. Study participants were parents living with their child diagnosed with autism, ages 2 to 6 years old at the time of the study.p><p style="text-align: justify;">Results. One hundred fifty-eight parents participated in the survey for the cost of care for children with autism. Sixty-seven (42.4%) of parents received government or subsidized medical services for their children's consultation and/ or intervention, while the rest went to private centers or hospitals. The total costs for all evaluations that confirmed the autism diagnosis ranged from ?1,356 to ?44,634 and averaged ?7,411.80 per child. Overall, the mean cost of interventions post-diagnosis, including therapy, education, medications, and developmental evaluations for the first year, was ?38,868 or ?3,239 per month (21% percent of the monthly expenditures for a household with an income of ?15,000/month). The total cost of care per child was closely related to the family's revenue in the sample population. Families with higher incomes also had higher expenditures for autism-related services.p><p style="text-align: justify;">Conclusion. Autism imposes a significant economic burden on Filipino families, particularly the minimum-wage household earners who spent a higher proportion of their budget (21%) on autism-related services. The wide range of total costs for the care of the children in the study may be explained by the wide variability of the expenses for the services, differences in access to services, socioeconomic status, and the wide variation in needs of children with autism due to the nature of the condition.p>
Autistic Disorder