Self-care practices for common acute conditions in the Philippines: a scoping review

Introduction

Self-care encompasses health promotion, disease prevention and control, self-medication and self-management, seeking care from the formal health system and rehabilitation (World Health Organization, 2019). It has the potential to increase cost savings by USD 119bn, save time spent by patients and physicians, and improve quality of life (Bauer et al., 2022; Global Self-Care Federation, 2021). Its value for countries and health systems is in contributing to improved health outcomes while reducing unnecessary demands on the formal health system, and is recognized as a cost-effective strategy that is integral to Universal Health Coverage (UHC) (Amit et al., 2022; Lozano et al., 2020). This is especially necessary for health conditions commonly experienced such as low back pain, allergic rhinitis, general acute pain, cough, common colds, diarrhea, constipation, and stress. These contribute substantially to the burden of disease and loss of economic productivity (Department of Health, 2022; Dierick et al., 2020; Katelaris et al., 2011; Sanico, 2004), but can be managed by patients on their own with proper guidance. However given the low health literacy of the general population in the Philippines (Tolabing et al., 2022) and increasing global health threat of antimicrobial resistance (AMR) attributed to improper self-medication (Rather et al., 2017), a more systematic approach to empower people in caring for oneself is a key approach which needs to be implemented as early as childhood.

The increasing importance of self-care comes with the need to establish its evidence base concerning its safety and effectiveness (Jaarsma et al., 2020; Riegel et al., 2021). Methodological suggestions have been published to strengthen research on self-care (Jaarsma et al., 2020). Additionally, a research agenda for self-care has been proposed that identifies the following as priority areas: influence of habit formation on self-care behavior change; resilience in the face of stressful life events and social contexts that interfere with self-care; culture and self-care; difficulty performing self-care with multiple chronic conditions; self-care in persons with severe mental illness; and the influence of others on self-care (Riegel et al., 2021). Previous reviews have largely focused on self-care for chronic diseases and/or self-care in high-income settings (Hearn et al., 2019; O'Connell et al., 2018; Papadakos et al., 2018).

This scoping review aimed to map the literature of how Filipinos practice self-care to manage common acute conditions to answer the research question, “What examples of self-care practices for common acute conditions among Filipinos exist in the published local literature?” In doing so, we provide evidence on self-care practice and research for acute conditions in low- and middle-income countries (LMICs) using the Philippines as an example, where the implementation of the UHC has been impacted by the coronavirus disease 2019 (COVID-19) pandemic (Amit et al., 2022; Jaminola et al., 2022). This review will provide insights into the current evidence base: the culture and understanding of self-care, and specific self-care practices in managing acute health conditions in a low-resource setting.

Methods

Results

The search resulted in a total of 887 studies, with 209 duplicates removed. After screening, 623 were not relevant as these did not meet the criteria for inclusion based on their titles and abstracts and only 55 studies were eligible for full-text screening. A total of 55 full-text articles were retrieved and screened, of which 26 articles met the criteria for review (Figure 1).

The 26 included articles were published between 1987 and 2021, and employed mixed-methods (n = 5), quantitative (n = 11) and qualitative (n = 9) research designs and evidence synthesis (n = 1) (Balangcod and Balangcod, 2011; Balilla et al., 2014; Barber et al., 2017; Bernardo and Tolentino, 2019; Caringal-Go et al., 2021; Cleofas, 2021; Cordero and Alejandro, 2021; Cruz et al., 2011; Del Mundo et al., 2019; Hardon, 1987; Katelaris et al., 2011; Kim et al., 2014; Maglalang-Co et al., 1999; Marquez et al., 2020; McNee et al., 1995; Morfe and Lim, 2013; Nichter and Nichter, 1993; Obermeyer et al., 2004; Ong and Kim, 2014; Sato et al., 2018; Simon et al., 1996; Tupasi et al., 1989; Villanueva, 2021; Visaya-Ceniza, 2015; Yoder and Hornik, 1994; Zarsuelo et al., 2018). We were able to identify studies conducted in all island groups of the country (Luzon: 12 studies; Visayas: 8 studies; Mindanao: 1 study; and 3 nationwide studies). Study populations represented various groups: Filipinos with ages ranging from 15 years of age and above and parents/caretakers of infants and children under 18 months and above, both male and female and from the general population and indigenous groups (Aeta, Kalangua, Ati, Ga'dang) (Table 1). Our review included nine studies with infants and children with pneumonia-like episodes, diarrhea, acute respiratory illness, and allergic rhinitis as the population of interest, and how their parents and caregivers managed their symptoms (Hardon, 1987; Katelaris et al., 2011; Kim et al., 2014; McNee et al., 1995; Nichter and Nichter, 1993; Sato et al., 2018; Simon et al., 1996; Tupasi et al., 1989; Yoder and Hornik, 1994). A more detailed summary of the included articles is shown in Supplementary File Table S2.

Discussion

This scoping review provides insights into the current research landscape, understanding of self-care, and how self-care is practiced in managing acute health conditions. We found that Filipinos across different population groups and settings engaged in a variety of self-care practices – some of which can be potentially harmful: use of medicines with and without a prescription and antibiotics even for the common cough and cold, and delays in seeking adequate treatment from a health professional. Filipinos also engaged in recreational activities and adopted healthy habits and behaviors, which are recommended for the prevention of noncommunicable diseases. Additionally, they managed their own condition or sought care from a traditional healer or a health professional, influenced by various considerations. Specific to indigenous peoples, ceremonies and rituals are performed with traditional therapies because of passed on beliefs on the causes of sickness and disease.

This review is aligned with the proposed research areas on self-care (Riegel et al., 2021) and described how self-care is practiced among the general population and indigenous peoples. Studies on indigenous peoples showed that culture and knowledge play a role in how diseases and self-care are viewed, which are important in better understanding and promoting self-care (Riegel et al., 2021). Additionally, in managing stress, it showed Filipinos' resilience and how engaging in recreational activities helped. The role of social networks was also prominent across population groups and conditions, which highlights the need to involve them in promoting desired health behaviors and decision-making processes. More importantly, our review also shows the need to study self-care beyond chronic conditions as self-care practices for acute conditions are just as varied and have significant implications on AMR, T&CM, health, education and labor policy and economy. There may be a need, therefore, to include self-care for managing acute conditions in the research agenda since only chronic illnesses are spotlighted (Riegel et al., 2021).

Despite our finding that self-care practices are well-enculturated in the Philippines, some self-care practices have been described as harmful. In the Philippines, the lifetime prevalence of sharing antimicrobials is estimated to be 78% (Barber et al., 2017), contributing to AMR in the country. Inappropriate antibiotic use and prescription sharing have been reported even for the common cold or cough (Barber et al., 2017; Sato et al., 2018), and may be reflective of misconceptions that antibiotics are useful against all types of common cold and cough and can even be considered as vitamins (Barber et al., 2017). Furthermore, beliefs and practices about the ethnophysiology of diseases that are deeply rooted in tradition and culture have been demonstrated to cause delays in the decision to seek medical attention, sometimes with fatal consequences especially among children. Given that 1 in 2 Filipinos have limited health literacy (Tolabing et al., 2022), we need more information campaigns and inclusion of health literacy in the basic education curricula. Health professionals, together with community health workers, will need to actively engage with patients to emphasize responsible self-care and responsible use of medications (Amit et al., 2022; Robredo et al., 2022). On the other hand, our review also showed that Filipinos sought healthcare from the formal health system, instead of self-management at home or by a traditional healer, and engaged in prescription sharing or reuse based on several factors including the advice of their social networks. Seeking timely and appropriate care is a key component of self-care that needs to also be taught, given that significant delays can worsen the health status and increase risk of death (McNee et al., 1995). Equally important therefore is to empower individuals to evaluate information and make informed and timely health decisions, acknowledging their various considerations such as perceived severity of the condition, availability and perceived effectiveness of treatment, cost and advice from trusted sources of health information.

Indigenous peoples mainly used herbal and ethnomedicinal plants. However, one study reported use of Western medicines because of the establishment of a community pharmacy (Balilla et al., 2014). Traditional and ethnomedical knowledge in indigenous communities may be lost as a result of relocation to cities and shifting into Western medical practices (Dapar and Alejandro, 2020). Conversely, Western medicines are predominantly used but T&CM is still practiced by the general population and even among Filipinos in more urban areas. Despite the lack of strong evidence of T&CM effectiveness and safety, as well as potential interactions that may occur with their concurrent use with conventional medicines, Filipinos continue to engage in this practice (Othman and Farooqui, 2015; Peltzer and Pengpid, 2018) with 4 in 5 not informing their doctors (Cruz et al., 2011). As many as 125 plant species have been identified for use in managing acute health conditions (Balangcod and Balangcod, 2011), with only 10 herbal plants endorsed by the Department of Health (Balangcod and Balangcod, 2011; Marquez et al., 2020). Oregano is a popular herbal drug used by the general population and indigenous peoples, but it is not included in the list of herbal plants endorsed in the country (Marquez et al., 2020). House Bill No. 10059 (“An Act Strengthening the Traditional and Complementary Medicine System, Amending for the Purpose Republic Act No. 8423, Otherwise Known As the “Traditional And Alternative Medicine Act of 1997”) aims to modify provisions on the regulation and enforcement of T&CM in the country through the Philippine Institute of Traditional and Alternative Health Care (PITAHC) given its prevalent use (House of Representatives, 2021). Despite this legislation, the Philippines still has challenges to better integrate T&CM in the formal health system compared to other countries in the Western Pacific Region such as China, Japan, and the Republic of Korea that already have policies and regulatory systems in place (Park and Canaway, 2019). The lack of effectiveness and safety studies, despite the widespread use of T&CM highlight the need to invest in research that assesses their safety, effectiveness and interactions with other T&CM modalities and Western medications (Palileo-Villanueva et al., 2022). Data on these can be used to inform how T&CM should be integrated into the health system.

Among all the acute conditions studied, only stress was managed through social and recreational activities and other health behaviors including engaging in physical activity and eating a healthy diet. These types of self-care practices are commonly mentioned and more pronounced for chronic illnesses (Newbould et al., 2006; Willis, 2016). Additionally, social support has been a common and more pronounced theme for chronic conditions. For self-limiting conditions and among the general population, relatives, friends, health providers including community health workers influenced management and health decisions (Sato et al., 2018; Tupasi et al., 1989). While fathers considered themselves the main decision-makers, mothers were still identified as the main caregivers (Sato et al., 2018). Among indigenous peoples, families and social networks were similarly their main sources of health information and influenced the decision to seek an indigenous healer (Villanueva, 2021), with practices passed on from generation to generation. Traditional healers were also important in healthcare decisions as sick individuals or their children would first seek them for healing rituals, given that T&CM among indigenous peoples is tied with the belief that certain conditions are caused by spirits and supernatural beings (Balangcod and Balangcod, 2011; Balilla et al., 2014). In addition to being important facilitators to self-care, families and friends were also depended on for money for hospital and health expenses, brand preferences of medicine and even during prescription and antibiotic sharing (Barber et al., 2017; Sato et al., 2018). We also found that families and peers played an important role in maintaining social and mental well-being (Caringal-Go et al., 2021; Cleofas, 2021). Social networks should therefore be involved when promoting health behaviors and lifestyles to individuals, as they can serve as facilitators or barriers to responsible and evidence-informed self-care.

As self-care becomes recognized to play an integral role in advancing UHC goals, the different self-care dimensions including T&CM, self-medication and other health behaviors need to be better integrated in the health system (Bauer et al., 2022; Global Self-Care Federation, 2021; Park and Canaway, 2019). This means including self-care in health planning and health insurance mechanisms. The current financing model of the country is a case-based payment (Obermann et al., 2018) with the current benefit package called the “Konsultasyong Sulit at Tama” (“Konsulta”) encouraging access to primary care services. Other countries in the Americas and Europe are more advanced in institutionalizing self-care (Bauer et al., 2022), and the Philippines may draw lessons and insights to better regulate self-care practices towards UHC (Amit et al., 2022; Jaminola et al., 2022).

This scoping review is a comprehensive examination of self-care practices to manage common acute health conditions in the Philippines. Our review did not apply any restrictions to the population groups, and we were, therefore, able to capture the different self-care practices of Filipinos including indigenous peoples. Because of the nature of this review however, we did not conduct any quality and risk of bias assessments. To ensure we captured as many local studies as possible, we searched HERDIN, which is the Philippines' country-wide repository of health and health-related research. Our review only included 26 studies that captured different populations and settings including the young and old, female and male, general population and indigenous peoples throughout the Philippines. This low volume of studies may be due to the exclusion of articles that looked into self-care practices for chronic conditions, such that at least 90% excluded at the title and abstract level were studies on chronic illnesses. While we only studied practices to manage commonly experienced acute conditions, studies on self-care and self-management of chronic illnesses reported similar practices including use of medications and practice of healthy behaviors such as regular exercise and good diet (Newbould et al., 2006; Willis, 2016). In addition, some studies may still have been missed, especially those that are not published and registered in the local database. While one study estimated 8 in 10 Filipinos using any T&CM for acute health conditions, this study was published in 2013 but used data in 1999 (Morfe and Lim, 2013). This may therefore be an underestimate or overestimate of current practices based on more updated data (Peltzer and Pengpid, 2018). Finally, our review excluded intervention studies on the outcomes of self-care, which limits our ability to make conclusions on the effectiveness of different modalities of self-care.

Conclusions

This is the first published review of self-care practices for managing common acute health conditions and captured practices of various groups and populations including indigenous peoples. Filipinos engage in a variety of “safe” (or evidence-informed) and “unsafe” (or harmful) self-care practices including the use of medicines with and without a prescription, appropriate and inappropriate antibiotic use, T&CM, recreational activities and healthy behaviors and self-management or seeking care from a traditional healer or a health professional. Specific to indigenous peoples, ceremonies and rituals are performed with traditional therapies. A number of considerations influenced the decision on how to manage health conditions and symptoms including perceived severity of the condition, availability and perceived effectiveness of treatment, cost and advice from trusted sources of health information.

The prevalent use of T&CM requires investing in research that determines the effectiveness and safety of these modalities and products – their interaction with conventional and Western medicines – together with other priority areas (i.e. self-care and mental health, habit formation). The bill on strengthening the regulation of T&CM is an important step towards a better integration in the health system; but standards for monitoring quality and safety will also need to be established and implemented. Additionally, our review showed that self-care practices are already widely enculturated and accepted among individuals. Health professionals and social networks have an important role to play in encouraging responsible self-care: how and when to do self-care vis-à-vis when to seek a health professional. Further research is also needed on the role of pharmaceutical industries and other commercial determinants of health, self-medication and prescription sharing behaviors, and the effects of habit formation and behavior change as these will inform information, education and communication (IEC) and behavioral change interventions to promote responsible optimal self-care practices. The success of engaging with and educating the population will require involving a range of cultural and social actors and networks to effect change. Our study shows the importance of studying self-care for managing acute health conditions, and we propose that the research agenda include these and their effectiveness and not only chronic illnesses. Finally, we recommend a national strategy to promote health literacy and self-care pursuant to the mandate of the UHC Law (Department of Health, 2019). This self-care strategy should contain a legal framework for reforms to promote a culture conducive to responsible self-care, including policy directions to promote research, improve T&CM regulations and strengthen health literacy. Through responsible and evidence-informed self-care, cost savings and improvement in quality of life can be achieved (Bauer et al., 2022; Global Self-Care Federation, 2021).