29.2 The Physician as Health Care Provider II: The Filipino Family and Family Assessment Tools, Health Education and Promotion, Behavior Change Models and Geriatric Medicine

Why this area matters

The TOS asks the physician as health care provider to:

• design a family health wellness program;
• educate patients, families and caregivers;
• monitor treatment outcomes;
• apply health education and promotion;
• apply geriatric medicine.

In the Philippines, illness is managed within the family. Decisions about care, money and caregiving are shared, so family-oriented care is a core skill. The population is also aging, and chronic disease, disability and caregiving demands are growing.

The Filipino family

• Structures:
  • nuclear (parents and children);
  • extended (with grandparents, relatives), common in the Philippines;
  • single-parent families;
  • blended families;
  • transnational families, with a parent working overseas as an OFW.
• Functions:
  • affection;
  • socialization;
  • reproduction;
  • economic support;
  • health care, since the family is the first source of care.
• Values that affect health behavior:
  • close family ties and respect for elders, so decisions are often made by the family;
  • utang na loob (debt of gratitude);
  • hiya (shame), which may delay consultation for stigmatized illness;
  • pakikisama (getting along);
  • bahala na (fatalism);
  • strong faith and religious coping.
• The family life cycle (Duvall's eight stages):
  1. married couple;
  2. childbearing;
  3. preschool children;
  4. school-age children;
  5. teenagers;
  6. launching children;
  7. middle-aged parents;
  8. aging family members.
  • Each stage has developmental tasks and health risks, such as adolescent risk behaviors or caregiver strain in the aging family.

Family assessment tools

The family health wellness program uses this assessment to set preventive goals for each member, such as:

• immunization for the children;
• Pap or VIA screening for the mother;
• BP and glucose checks for the father;
• fall prevention for the grandmother;
• shared lifestyle changes.

Health education and health promotion

• Health promotion (WHO, Ottawa Charter 1986) is the process of enabling people to increase control over their health. The charter has five action areas:
  1. build healthy public policy, such as tobacco taxes and smoke-free laws;
  2. create supportive environments;
  3. strengthen community action;
  4. develop personal skills;
  5. reorient health services toward prevention.
• Health education is planned learning that leads to voluntary change in knowledge, attitudes and practices (KAP). Methods include:
  • individual counseling;
  • group discussion and demonstration (for example, preparing ORS);
  • mass media and social media;
  • information, education and communication (IEC) materials in the local language.
• Behavior change models:
  • Health belief model: action depends on perceived susceptibility, perceived severity, perceived benefits and barriers, cues to action and self-efficacy.
  • Transtheoretical (stages of change) model: precontemplation, contemplation, preparation, action, maintenance, with possible relapse. Counseling is matched to the stage: raise awareness in precontemplation, and help plan in preparation.
  • Brief interventions, such as the "5 A's" (ask, advise, assess, assist, arrange), are used for smoking cessation in primary care.
• Effective health messages are simple, culturally appropriate and repeated. They use trusted messengers such as barangay health workers, teachers and religious leaders, and ask for a specific action.

Geriatric medicine

• Comprehensive geriatric assessment:
  • function: activities of daily living (ADL: bathing, dressing, toileting, transferring, continence, feeding; Katz index) and instrumental ADL (shopping, cooking, finances, medications, telephone, transport; Lawton scale);
  • cognition (Mini-Cog, MMSE, MoCA);
  • mood (Geriatric Depression Scale);
  • falls and gait (Timed Up and Go test);
  • nutrition;
  • vision and hearing;
  • continence;
  • medications;
  • social support and advance care wishes.
• The geriatric syndromes:
  • falls: multifactorial, from sedatives, orthostatic hypotension, poor vision, weakness and home hazards;
  • delirium: acute fluctuating confusion, often from infection or drugs, and frequently missed;
  • dementia;
  • urinary incontinence;
  • frailty;
  • pressure injuries;
  • polypharmacy.
• Polypharmacy and prescribing:
  • use the lowest effective doses ("start low, go slow");
  • review all medicines regularly and deprescribe;
  • avoid potentially inappropriate drugs listed in the Beers criteria: long-acting benzodiazepines, first-generation antihistamines and anticholinergics, NSAIDs with renal impairment or GI risk, and sliding-scale insulin alone.
• Prevention for older adults:
  • influenza (yearly) and pneumococcal vaccines;
  • Td, and herpes zoster where available;
  • BP, glucose and lipid screening;
  • cancer screening by life expectancy;
  • bone health;
  • vision and hearing checks;
  • fall prevention and physical activity;
  • advance care planning.
• Philippine laws for older persons:
  • the Expanded Senior Citizens Act of 2010 (RA 9994) gives citizens aged 60 and older a 20% discount and VAT exemption on medicines, medical and dental services, diagnostics and professional fees, and other benefits;
  • senior citizens are covered by PhilHealth as indirect contributors (RA 10645, RA 11223);
  • indigent seniors receive a social pension;
  • the Centenarians Act (RA 10868) grants cash gifts at age 100, extended by later law to earlier milestone ages.