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Linking Community-Based Linking Community-Based Participatory Research with Participatory Research with

Revitalized Primary Health Care Revitalized Primary Health Care in the Philippinesin the Philippines

Barbara C. Pence, PhD, CCRPBarbara C. Pence, PhD, CCRPProfessor of Pathology, School of MedicineProfessor of Pathology, School of Medicine

M. Christina Esperat, RN, PhD, FAANM. Christina Esperat, RN, PhD, FAANProfessor and Associate Dean for Clinical Services Professor and Associate Dean for Clinical Services

and Community Engagement, Perry School of Nursing and Community Engagement, Perry School of Nursing

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In 1898, during the Spanish-American War, Filipinos established the basic flag

in use today; it was officially adopted in 1936. The white triangle is for liberty.

The golden sun and stars are for the three main areas of the Philippines:

the Visayan Islands, Luzon, and Mindanao. The red color is for courage and

the blue color is for sacrifice.

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Philippines Demographics & Philippines Demographics & PoliticsPolitics

Population (2007 census) = 88,574,614Population (2007 census) = 88,574,614 Population is young: 0-14 yr = 33.8%, >65 yr = Population is young: 0-14 yr = 33.8%, >65 yr =

4.4%4.4% Life expectancy: Male = 64 yr; F = 70 yrLife expectancy: Male = 64 yr; F = 70 yr PH is a democratic and republican state with PH is a democratic and republican state with

three branches of govt.three branches of govt. 1991: devolution giving responsibility for basic 1991: devolution giving responsibility for basic

services, including health, to local govt units services, including health, to local govt units (LGU)(LGU)

LGUs include provinces, cities, municipalities, LGUs include provinces, cities, municipalities, barangaysbarangays

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Philippines Health TrendsPhilippines Health Trends

Communicable diseases: ASMR (2004 Communicable diseases: ASMR (2004 data): 285/100,000data): 285/100,000

Non-communicable diseases: ASMR Non-communicable diseases: ASMR (2004 data): 620/100,000(2004 data): 620/100,000

Health workforce, MDs: 12/10,000Health workforce, MDs: 12/10,000 Health workforce, RNs and midwives: Health workforce, RNs and midwives:

61/100,00061/100,000Major responsibility for revitalization of PHC Major responsibility for revitalization of PHC

will fall on nurses and other such as CHW.will fall on nurses and other such as CHW.

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Figure 1.The PHC reforms necessary to Figure 1.The PHC reforms necessary to refocus health systems toward health for allrefocus health systems toward health for all

Universal coverage reforms to Universal coverage reforms to improve health equityimprove health equity

Service delivery reforms to Service delivery reforms to make health-systems people-make health-systems people-centeredcentered

Public policy reforms to Public policy reforms to promote and protect promote and protect the the health of communitieshealth of communities

Leadership reforms to make Leadership reforms to make health authorities more reliablehealth authorities more reliable

WHO Health Report, 2008.Primary Health Care: Now MoreThan Ever, WHO, Geneva.

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What is CBPR?What is CBPR? ““Research” is a loaded word in many Research” is a loaded word in many

underserved communities, associated with underserved communities, associated with expectations of being examined or exploited.expectations of being examined or exploited.

CBPR is defined as “a collaborative approach to CBPR is defined as “a collaborative approach to public health research that involves community public health research that involves community members, organization representatives and members, organization representatives and researchers as equal participants in all phases researchers as equal participants in all phases of the research process”.of the research process”.

CBPR is especially useful in addressing health CBPR is especially useful in addressing health disparities and chronic disease management.disparities and chronic disease management.

CBPR is used in making communities healthier.CBPR is used in making communities healthier.

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CBPR DefinitionCBPR Definition

B. Israel et al. (1998) provide key principles of B. Israel et al. (1998) provide key principles of CBPR:CBPR:

““Recognizes community as a unit of identity;Recognizes community as a unit of identity; Builds on strengths and resources within the Builds on strengths and resources within the

community;community; Facilitates collaborative, equitable involvement Facilitates collaborative, equitable involvement

of all partners in all phases of the research;of all partners in all phases of the research; Integrates knowledge and action for mutual Integrates knowledge and action for mutual

benefit of all partners;benefit of all partners;

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CBPR, continuedCBPR, continued

Promotes a co-learning and empowering Promotes a co-learning and empowering process that attends to social inequalities;process that attends to social inequalities;

Involves a cyclical and iterative process;Involves a cyclical and iterative process; Addresses health from both positive and Addresses health from both positive and

ecological perspectives;ecological perspectives; Disseminates findings and knowledge Disseminates findings and knowledge

gained to all partners; andgained to all partners; and Involves a long-term commitment by all Involves a long-term commitment by all

partners.”partners.”Israel et al., Review of community-based research: assessing partnership approaches to improve public health. Ann Rev Pub Health 19, 173, 1998.

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Fogarty NCD-LIFESPAN GrantFogarty NCD-LIFESPAN Grant

““Chronic, Non-Communicable Chronic, Non-Communicable Diseases and Disorders Across Diseases and Disorders Across the Lifespan: Fogarty the Lifespan: Fogarty International Research Training International Research Training Award (NCD – LIFESPAN)” Award (NCD – LIFESPAN)” (D43)(D43)

Amount: up to $250,000 (total Amount: up to $250,000 (total cost) per year up to 5 yearscost) per year up to 5 years

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THE VISIONTHE VISION

We will need to develop a research agenda that:We will need to develop a research agenda that: Connects PHC with Community-Based Connects PHC with Community-Based

Participatory Research (CBPR) methodologies;Participatory Research (CBPR) methodologies; Define the research priorities for graduate study Define the research priorities for graduate study

in the above areas, to focus on NCDs; in the above areas, to focus on NCDs; Documents the process as we develop PHC and Documents the process as we develop PHC and

its associated research focus in chronic disease its associated research focus in chronic disease prevention and management, andprevention and management, and

Create a model to replicate in other LMIC of SE Create a model to replicate in other LMIC of SE Asia and then globally.Asia and then globally.

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PartnersPartners

LMICLMIC: Silliman University, Dumaguete : Silliman University, Dumaguete University of the Philippines, ManilaUniversity of the Philippines, Manila WHO Collaborating Center, Western WHO Collaborating Center, Western

Pacific Region OfficePacific Region Office Philippines Nurses Association and PRCPhilippines Nurses Association and PRC Philippines DOHPhilippines DOH

HICHIC: Texas Tech University Health Sciences : Texas Tech University Health Sciences Center Schools of Nursing and MedicineCenter Schools of Nursing and Medicine

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NCD-LIFESPAN Training Program NCD-LIFESPAN Training Program ObjectivesObjectives

To strengthen the capacity of LMIC institutions To strengthen the capacity of LMIC institutions to conduct NCD research;to conduct NCD research;

To support multidisciplinary research training in To support multidisciplinary research training in basic through translation and implementation basic through translation and implementation research science to address NCDs;research science to address NCDs;

To develop a cadre of research expertsTo develop a cadre of research experts To support training-related research (degree-To support training-related research (degree-

related or mentored research projects)related or mentored research projects) To strengthen the research and research To strengthen the research and research

training capacity required for success by building training capacity required for success by building on existing programs in the LMIC, andon existing programs in the LMIC, and

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Objectives, cont’d.Objectives, cont’d. To integrate with other efforts to strengthen core To integrate with other efforts to strengthen core

research support capabilities needed to manage research support capabilities needed to manage and research training grants at the LMIC and research training grants at the LMIC institution, including expertise in ethics and institution, including expertise in ethics and compliance issues, protection for human compliance issues, protection for human subjects, animal welfare, fiscal management, subjects, animal welfare, fiscal management, budgeting, program and grants administration, budgeting, program and grants administration, grant and report writing, preparation of scientific grant and report writing, preparation of scientific manuscripts, information technologies, manuscripts, information technologies, technology transfer and management of technology transfer and management of intellectual property, data management, and intellectual property, data management, and Internet connectivity.Internet connectivity.

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Disease Focus on NCD such as Disease Focus on NCD such as Obesity, HTN, DM) and Breast CaObesity, HTN, DM) and Breast Ca

Obesity and its consequences of HTN and Obesity and its consequences of HTN and DM, is rising in the Philippines as in the DM, is rising in the Philippines as in the rest of the world (WHO data)rest of the world (WHO data)

Major consequences of obesity are HTN Major consequences of obesity are HTN and diabetesand diabetes

Breast cancer is underdiagnosed and Breast cancer is underdiagnosed and undertreated resulting in a high mortality undertreated resulting in a high mortality compared to the US, and the highest compared to the US, and the highest incidence in Asiaincidence in Asia

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NCD-LIFESPAN Grant TimelineNCD-LIFESPAN Grant Timeline

Meetings in Dumaguete and Manila: August 18-Meetings in Dumaguete and Manila: August 18-20 and 24, 201020 and 24, 2010

Submit Letter of Intent to NIH due: October 2, Submit Letter of Intent to NIH due: October 2, 20102010

Application receipt date (electronic submission Application receipt date (electronic submission thru Grants.gov) November 2, 2010thru Grants.gov) November 2, 2010

Must be processed through TTUHSC Office of Must be processed through TTUHSC Office of Sponsored Programs 5 days prior to mailing Sponsored Programs 5 days prior to mailing application: October 22, 2010.application: October 22, 2010.