healthcare

Article
The Experiences of Community Health Workers in Preventing
Noncommunicable Diseases in an Urban Area, the Philippines:
A Qualitative Study
Yuko Yamaguchi 1, * , Lia M. Palileo-Villanueva 2 , Leonor Sanchez Tubon 3 , Eunice Mallari 2
and Hiroya Matsuo 4

1 Department of Nursing, Graduate School of Health Sciences, Kobe University, Kobe 654-0142, Japan
2 Department of Medicine, College of Medicine, University of the Philippines Manila, Manila 1000, Philippines;
[email protected] (L.M.P.-V.); [email protected] (E.M.)
3 City Health Department of Muntinlupa, Muntinlupa 1770, Philippines; [email protected]
4 Department of Nursing, Osaka Shin-Ai College, Osaka 538-0053, Japan; [email protected]
* Correspondence: [email protected]; Tel.: +81-796-4541

Abstract: (1) Background: Barangay health workers (BHWs) play important roles as community
health workers in preventing noncommunicable diseases (NCDs), where the shortage of health pro-
fessionals is felt more acutely in the Philippines. However, there is little research on the experiences
of BHWs as community health workers in preventing NCDs. This study aimed to clarify the roles and
difficulties of BHWs in conducting activities for the prevention of NCDs. (2) Methods: Qualitative
data were collected from 25 BHWs. (3) Results: The mean age of the participants was 50.4 ± 9.5 years,
23 were women, and the mean length of time as a BHW was 9.1 ± 7.7 years. Three major themes
about the role of BHWs in preventing NCDs—“screening for NCDs”, “assisting patients with man-
agement of their conditions”, and “promoting healthy behaviors”—and four major themes about
the difficulties—“insufficient awareness of preventative behaviors”, “economic burdens”, “lack of
resources for managing NCDs”, and “difficulty of access to medical care facilities”—were identified.
(4) Conclusions: Through the findings of this study, focusing interventions aimed at addressing the
Citation: Yamaguchi, Y.; Palileo- difficulties for the prevention of NCDs among BHWs may help reduce health inequities.
Villanueva, L.M.; Tubon, L.S.; Mallari,
E.; Matsuo, H. The Experiences of
Keywords: noncommunicable diseases; health volunteers; low-income countries; primary health
Community Health Workers in
care; qualitative study
Preventing Noncommunicable
Diseases in an Urban Area, the
Philippines: A Qualitative Study.
Healthcare 2023, 11, 2424. https://
doi.org/10.3390/healthcare11172424
1. Introduction
Noncommunicable diseases (NCDs), such as cardiovascular diseases, diabetes, cancer,
Academic Editor: Yao Jie Xie
and chronic lung diseases, are the leading causes of morbidity and mortality in low- and
Received: 2 August 2023 middle-income countries (LMICs) [1]. This rise in NCDs has been driven by changing
Revised: 23 August 2023 lifestyles coupled with rapid urbanization [2]. Previous studies have reported that LMICs
Accepted: 29 August 2023 have a high burden of undiagnosed and poorly controlled NCDs, unhealthy lifestyles,
Published: 30 August 2023 and under-resourced and inaccessible health care [3–5]. Primary health care (PHC), as the
cornerstone in health systems, is regarded as the most inclusive, equitable and cost-effective
approach to achieve health for all [6]. PHC is a key approach to strengthening health
system response for NCD prevention and control in LIMCs by promoting healthy lifestyles,
Copyright: © 2023 by the authors.
reducing premature NCD deaths, and improving access to NCD care [7–10]. NCDs are
Licensee MDPI, Basel, Switzerland.
largely preventable and treatable within PHC settings in a cost-effective manner [11].
This article is an open access article
However, some systematic reviews have showed that many LIMCs are unlikely to provide
distributed under the terms and
universal access to essential intervention of NCDs [12,13].
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).

Healthcare 2023, 11, 2424. https://doi.org/10.3390/healthcare11172424 https://www.mdpi.com/journal/healthcare

Healthcare 2023, 11, 2424 2 of 10

In the Philippines, a low-income country in Asia, NCDs are responsible for 70% of all
deaths [5]. The high mortality and morbidity from NCDs are associated with health care
systems and services and socioeconomic conditions [12–14]. The Philippine Department of
Health (DOH) has made addressing NCDs one of its priorities. The Philippine Package
of Essential Noncommunicable Disease Interventions (PhilPEN), based on World Health
Organization recommendations, focuses on identifying and managing overall cardiovas-
cular risk at the PHC level [15]. Interventions include screening for cardiovascular risk
factors such as smoking, hypertension, and diabetes, which can be done at the community
level. However, many Filipinos are unable to participate in the prevention of NCDs owing
to lack of resources and investment. Moreover, the gaps between current policies and
implementation for NCD prevention could increase the burden of NCDs. Indeed, many
Filipinos reportedly have undiagnosed NCDs and the prevalence of NCDs progression
such as hypertension and overweight/obesity are high because of insufficient fruit and
vegetable intake, high amounts of salt, and smoking [4,16–18]. However, there is little
community-based research on lifestyle behaviors that affect the progression of NCDs or on
the hindrances to NCD prevention.
The Philippines was one of the first countries to adopt the 1979 Alma Ata Declaration
on PHC, launching the barangay health worker (BHW) program in 1981 [19]. Operating at
the level of barangays, the smallest political unit in the Philippines, volunteer BHWs play
important roles as community health workers. The eligibility criteria to become BHWs is
people who has voluntarily rendered at least five years of continuous active and satisfactory
service in the community [20]. BHWs function as a link between the community and the
local health centers, especially in health promotion and surveillance activities, and provide
support to health professionals in health service delivery [20]. In the NCDs program,
BHWs are in a unique position not only to identify citizens at risk but also to provide
culturally appropriate and acceptable health information about NCD prevention in the
community with poor resources and an inadequate supply of health professionals [21].
With the challenges that PHC systems face, the BHWs play key roles of co-production of
health in the community. Previous studies have proposed that co-production of health is
defined as the interdependent work of users and health professionals who are creating,
designing, producing, delivering, assessing, and evaluating the relationships and actions
that contribute to the individual health [22–24]. However, little is known about how BHWs
engage in the activities for the prevention of NCDs as community health workers and
the difficulties they face related to NCD prevention. The findings of this study ought to
contribute to development of the effective intervention to alleviate existing barriers and
enhance health promotion for the prevention of NCDs at the PHC in the Philippines.
The present study aimed to assess the roles and difficulties of BHWs in conducting
activities for the prevention of NCDs.

2. Methods
2.1. Study Design and Participants
This qualitative study included 25 BHWs in five barangays of Muntinlupa City, Manila,
Philippines. A qualitative study is an approach to generate data from the experiences
of a small number of participants to provide an in-depth understanding of the subject
matter [25,26]. We followed the Standards for Reporting Qualitative Research guidelines
for this study [26]. This study was carried out between February and March 2022. The
inclusion criteria were age 18 years or older and at least 1 year working as a BHW. The
exclusion criterion was illiteracy. Traditionally, BHWs are a primarily women-dominated
profession. Of the 25 BHWs included in this study, 23 were women, the mean age was 50.4
(SD = 9.5) years, and the mean length of time as a BHW was 9.1 (SD = 7.7) years (Table 1).
Healthcare 2023, 11, 2424 3 of 10

Table 1. Participant characteristics.

Participants Age (Years) Sex Education Experience as a BHW (Years)

P1 47 Female College 8
P2 45 Female High school 8
P3 50 Female High school 8
P4 35 Female High school 5
P5 52 Female Elementary school 8
P6 50 Female College 4
P7 61 Female College 29
P8 41 Male High school 5
P9 42 Male College 5
P10 62 Female Highschool 20
P11 62 Female Collage 21
P12 64 Female Vocational 31
P13 64 Female College 8
P14 32 Female Vocational 8
P15 42 Female College 2
P16 54 Female Elementary school 4
P17 53 Female High school 4
P18 49 Female College 5
P19 52 Female College 5
P20 38 Female High school 4
P21 60 Female College 4
P22 54 Female High school 8
P23 63 Female High school 8
P24 39 Female High school 8
P25 48 Female High school 7
BHW: Barangay health worker.

2.2. Recruitment and Sampling

Purposive sampling was used to choose the participants for this study. The research
team members made an appointment with the director of the health center to explain the
concept of this study. A sample of BHWs who were registered at the barangay health centers
was recruited from community health workers each barangay. Eligible participants were
identified with the help of the Muntinlupa City Health Office. Muntinlupa is classified as a
highly urbanized city and had a total population of 543,445 in 2020. It is the southernmost
city of the National Capital Region and is divided into nine districts [27]. Approximately
20% of households in Muntinlupa are below the minimum income required to meet basic
food needs [28], and the majority of citizens cannot afford private medical services because
these services cost approximately five times more than the public medical services [27].
Selected participants were contacted by a trained research assistant, who explained this
study, secured informed consent, and scheduled a date and time for the interview.

2.3. Data Collection

The semi-structured interviews were conducted over the phone. Each interview took
40–60 min (range = 21–53 min). Before the interview, participants provided their age,
sex, education, and years of experience as a BHW based on the face-sheet. The interview
covered how the BHWs perform their work and the difficulties they face in preventing
NCDs. English or Tagalog was used as preferred by the BHWs. When Tagalog was
chosen, the interviews were conducted by investigators who were fluent in both English
and Tagalog. Each interview was conducted on a date and time that was agreed upon
between the participant and the interviewer. All interviews were audio recorded, and the
interviewer took notes during the interview (Supplementary Materials S1).
Healthcare 2023, 11, 2424 4 of 10

2.4. Data Analysis

All data were transcribed verbatim by two trained investigators. Tagalog recordings
were simultaneously translated into English by investigators who were fluent English and
Tagalog speakers. An independent research assistant randomly selected some English
transcripts and checked their accuracy by matching them between the English and Tagalog
responses. Thematic analysis was performed as described by Braun and Clarke [25]. Six an-
alytic phases for thematic analysis were used: (1) familiarization of the data, (2) generating
initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming
themes, and (6) producing the report. Verbatim records were created from recorded in-
terviews. The verbatim records were read several times by several researchers to grasp
the content and data depending on the purpose were extracted. A total of 18 codes were
reductive. The data of an individual were analyzed, and similar data from the second and
subsequent individuals were summarized as a code. Semantic coding was used. After
extracting codes from all verbatim records, the level of abstraction and created new codes
were raised. After comparing and examining new codes repeatedly, the themes were
extracted. investigator triangulation was used during the analyses. The interviews were
analyzed by several investigators to identify major themes. Themes were agreed on by
consensus. Open coding was done independently by three investigators. To support the
analyses, NVivo 11.0 software (QSR International, Burlington, MA, USA) was used.

3. Results
3.1. The Roles of BHWs in Preventing NCDs
Three major themes and eleven sub-themes regarding the roles of BHWs in preventing
NCDs were identified from the interviews (Table 2). The three major themes identified
were: Theme 1. screening for NCDs, Theme 2. assisting patients with management of their
conditions, and Theme 3. promoting healthy behaviors.

Table 2. Themes relating to the roles of the BHWs and the difficulties in NCD prevention.

Theme Sub-Theme
Assisting with health checkups at the health center
Screening for NCDs
Home visits for blood pressure screening
Monitoring people with NCDs
Delivering medicines to people with NCDs
Assisting patients with management of their conditions Home visits to monitor blood pressure to assess patients’ conditions
Supplying free medicine to control NCDs
Reminding people with NCDs to take medicines
Conducting exercise programs
Encouraging them to refrain from smoking
Promoting healthy behaviors
Giving lectures to promote healthy diets
Consultation about maintenance of NCDs
Neglect of their health until their condition gets worse
Insufficient awareness of preventative behaviors Lack of knowledge about NCDs
Lack of desire for regular checkups
Not enough money to buy medicine
Not enough money for transportation to go to the health center
Economic burdens
Few chances to receive nutritious food because of poverty
No money for laboratory tests
Healthcare 2023, 11, 2424 5 of 10

Table 2. Cont.

Theme Sub-Theme
Shortage of supply of medicines from the government
Lack of resources for managing NCDs
Shortage of health professionals for managing NCDs
Difficulty of access to the health center because it is too far
Difficulty of access to medical care facilities
Difficulty of access to the health center because of hot weather
BHW: barangay health worker; NCD: noncommunicable disease.

3.1.1. Theme 1: Screening for NCDs

The BHWs encouraged citizens to receive regular health checkups at the health center.
If citizens had not received checkups for a long time due to disabilities, lack of desire, or
accessibility of the health center, the BHWs visited the patients at home to measure blood
pressure for screening.
“We check their blood pressure and assist them, and if they are no longer coming
to the health center, we remind them at house-to-house visits to receive checkups.
We help them to go to the health center. This checkup program is free.” (P9)

3.1.2. Theme 2: Assisting Patients with Management of Their Conditions

The BHWs supported patients with NCDs to manage their chronic conditions. They
have patients with NCDs that they regularly monitor. If patients had difficulty in visiting
the health center or with adherence to treatment, the BHWs visited the patients at home to
check their conditions and bring medicines from the doctors.
“As BHWs in the hypertension and diabetes program, we monitor the patients’
conditions and check whether they neglect their disease. If patients cannot visit
the health center, we also conduct home visits, rain or shine. Even when we are
chased by a dog. My assigned area is a squatter area. It is hard but we enjoy our
work.” (P16)
Additionally, BHWs reminded patients with NCDs to take medicine. For patients
with hypertension and diabetes, the DOH has a free medicine program based on the
PhilPEN [15]. The BHWs supplied medicines to patients with hypertension or diabetes in
accordance with the instruction of doctors.
“It is our role to remind patients in our assigned area to take their medicines
when they forget. . . We have programs like giving free medicines for those who
have diabetes and hypertension.” (P6)

3.1.3. Theme 3: Promoting Healthy Behaviors

The BHWs promoted healthy behaviors, such as regular exercise, encouraging refrain-
ing from smoking, and promoting a healthy diet.
“We promote eating healthy foods and doing exercises. We tell them to avoid
cholesterol and have at least some exercise for 15–30 min a day if they have high
blood pressure or hypertension.” (P8)
Additionally, BHWs consulted with patients to assist them in controlling their health
to prevent NCDs.
“When we tell our patients that they have high cholesterol, they ask us the reasons
why they have high cholesterol. We try to discuss it with the patients. We do not
try to make them afraid; it is a casual conversation.” (P7)

3.2. Difficulties for NCD Prevention

Four major themes and eleven sub-themes were identified as difficulties for NCD pre-
vention (Table 2). The four major themes identified were: Theme 4. insufficient awareness
Healthcare 2023, 11, 2424 6 of 10

of preventative behaviors, Theme 5. economic burdens, Theme 6. lack of resources for

managing NCDs, and Theme 7. difficulty of access to medical care facilities.

3.2.1. Theme 4: Insufficient Awareness of Preventative Behaviors

The BHWs were concerned about citizens’ lack of consciousness toward NCD preven-
tion, such as neglecting their health until their condition gets worse, lack of knowledge
about NCDs, and inattention to regular checkups.
“Many people do not pay enough attention to health checkups because they do
not currently have any health concerns. They would follow the doctor’s advice
only when they feel unwell.” (P2)
“They do not know that they are at risk even if their blood pressure is at 180/100
mmHg since they do not feel anything. They lack knowledge about why people
get sick” (P1)
“They get lazy about going to the health center. They are annoyed at the long
lines at the public health center.” (P18)

3.2.2. Theme 5: Economic Burdens

Many citizens living in poverty are vulnerable to NCDs owing to health behaviors and
disparities in access to a health center. They do not have enough money to buy medicine,
undergo laboratory tests, or take transportation to the health center. The BHWs dealt with
patients struggling with these economic burdens.
“They just do not come back again because they do not have money for the
laboratory.” (P1)
“They do not have money for transportation to go to the health center.” (P3)
“It is brought about by poverty. They sometimes do not have things. . . What they
eat, if they do not have money, they buy junk food. They buy food outside, which
is mixed with a lot of salt.” (P17)
“Laboratory tests are their problem. Most of my patients have problems in
relation to the laboratory. Some patients cannot come back to the health center
because they cannot afford laboratory tests.” (P20)

3.2.3. Theme 6: Lack of Resources for Managing NCDs

The BHWs faced limited resources for managing NCDs in the community. The BHWs
said that shortages of medicines and health professionals for managing NCDs were espe-
cially challenging.
“We have a lot of patients who get their medicines from the health center. We
are running out of supplies. Fewer supplies come to us. Patients run out of their
medical supplies. If we run out of medicine, we adjust and give them 15 doses of
medicine instead of 30 doses for 1 month. They just buy the other 15 doses.” (P1)
“Many citizens come to the health center every day. Sometimes when we schedule
them for an afternoon checkup, they come to visit us in the morning. Sometimes
checkups are cancelled when we have an emergency meeting or something. My
tasks are too much. We sometimes cannot handle.” (P4)

3.2.4. Theme 7: Difficulty of Access to Medical Care Facilities

The BHWs felt that accessibility to a health center was a barrier for citizens, especially
older adults, in preventing NCDs.
“There are senior citizens that are so far from the health center that the BHWs are
unable to visit.” (P21)
“Senior citizens are not going to the health center because of the hot weather.” (P6)
Healthcare 2023, 11, 2424 7 of 10

4. Discussion
The present study examined how BHWs in the Philippines perform their work and
face barriers as community health workers for the prevention of NCDs. The findings from
the qualitative analyses highlight that BHWs play a significant role as a bridge between
Filipino citizens and health care for the prevention of NCDs in the community. However,
the BHWs also had difficulties in providing adequate health services for NCD prevention
due to a lack of human, economic, and facility resources. Moreover, the BHWs struggled
against the lack of individual citizens’ consciousness toward preventative behaviors.
The present study indicated that BHWs are responsible for delivering health services,
such as promoting health checkups, assisting patients with management of their conditions,
and visiting homes for screening and monitoring NCDs, in the specific area in which they
are assigned. Our previous study showed that community-dwelling Filipinos had a high
prevalence of progression of NCDs such as hypertension and overweight/obesity [18].
Other studies found high incidences of undiagnosed NCDs and high loss to follow-up
in the Philippines, especially due to maldistribution of health staff and facilities [29,30].
BHWs play essential roles in administering person-centered health care that responds to
Filipino citizens’ needs [20], suggesting that BHWs can deliver health services at health
centers or home visits to identify NCDs early and administer preventive interventions and
timely treatment.
In the present study, the BHWs described promoting healthy behaviors and consulta-
tion for maintaining health as their major roles in the prevention of NCDs. However, the
BHWs struggled with individual citizens’ insufficient awareness of preventative behaviors.
Previous studies showed that socioeconomic inequalities related to education and wealth
affect health literacy and self-management of NCDs in LMICs [31–33]. Additionally, we
reported in a previous study that community-dwelling Filipinos have poor health-seeking
behaviors, which influences practices aimed at the prevention of NCDs [18]. Therefore,
BHWs could reduce these health disparities by providing continuous education on healthy
lifestyle behaviors and individual health guidance.
Universal health coverage (UHC) is defined as all people and communities having
access to quality health services where and when they need them without suffering financial
hardship [34]. The essential principles to achieving UHC include acceptability, affordability,
and availability [34]. However, many people still lack access to the comprehensive health
services required to prevent disease or maintain their health [35,36], which is consistent
with our findings. BHWs identified economic burdens, shortage of human resources
and medicines, and difficulty of access to institutions as factors that hindered Filipino
citizens from receiving health checkups or medical supplies and maintaining a healthy
lifestyle. The findings suggest that combining the work of BHWs and assessing whether the
characteristics of the current health services are aligned with the capabilities of communities
is important.
This study has some limitations that should be considered. First, all interviews were
conducted during the COVID-19 pandemic; therefore, this may reflect the narratives of
the participants. Second, language and cultural barriers could have affected the data
collection and interpretation. Third, this interview was conducted by the same interviewer,
which may not avoid confirmation bias. Fourth, male BHWs or illiterate BHWs could have
different perspectives that may not have been adequately considered in the findings of this
study. Last, this study was conducted in one urbanized city, so the findings may not apply
to rural areas of the Philippines. Future work will focus on adding interviews with BHWs
in different areas of the Philippines to solidify these arguments as well as adding interviews
with the citizens to grasp the difficulties for the prevention of NCDs in the Philippines from
a different point of view.
The findings of this study could contribute to the development of effective strategies
such as promoting equal health care access, improving early health checkup systems that
detect NCDs, and providing effective information or education for BHWs for the prevention
of NCDs.
Healthcare 2023, 11, 2424 8 of 10

5. Conclusions
NCDs are the large contributors to morbidity and mortality in LIMCs although most
NCDs are preventable. PHC systems have supported NCD prevention and control by
reducing premature NCD deaths, improving cost-effectiveness, and health promotion,
especially in LIMCs. Under the primary health care framework, BHWs play vital roles
to operate on the frontline with vulnerable health systems, helping to keep health conse-
quences in the Philippines. Due to a lack of studies, however, the roles and difficulties of
BHWs in conducting activities for the prevention of NCDs remain unclear.
The findings of this qualitative study indicate for the first time that the BHWs play
important roles as co-producers in preventing NCDs at the PHC setting in the Philippines.
BHWs contributed to screening for NCDs, assisting patients with management of their
conditions, and promoting healthy behaviors. On the other hand, the BHWs struggled
against inadequate health services for NCD prevention due to a lack of human, economic,
and facility resources. Moreover, the BHWs faced barriers as community health workers
due to the lack of individual citizens’ awareness of preventative behaviors. These findings
may provide insight into the development of effective health care systems that utilize
BHWs for the prevention of NCDs.

Supplementary Materials: The following supporting information can be downloaded at: https://www.
mdpi.com/article/10.3390/healthcare11172424/s1, S1. Interview Guide for Baragay Health Workers.
Author Contributions: Y.Y. and L.M.P.-V. designed this study; L.S.T. and E.M. collected data; Y.Y.
created the dataset; Y.Y. analyzed the data; Y.Y., E.M. and H.M. drafted the manuscript; all authors
contributed to revisions of the manuscript. All authors have read and agreed to the published version
of the manuscript.
Funding: This research was funded by Grants-in Aid for Scientific Research from Japan Society for
the Promotion of Science, grant number 20K19273.
Institutional Review Board Statement: This study protocol was approved by the institutional review
boards of Kobe University Graduate School of Health Sciences (no. 1016; 14 July 2021) and University
of the Philippines Manila (protocol code UPMREB 2021-0704-01; 3 November 2021), and this study
was conducted in accordance with the 2013 Declaration of Helsinki. Informed consent was obtained
from all participants before this study, and their confidentiality was preserved.
Informed Consent Statement: Written informed consent was obtained from all participants before
this study, and their confidentiality was preserved.
Data Availability Statement: The datasets analyzed during the present study are available from the
corresponding author on reasonable request.
Acknowledgments: The authors are deeply grateful to all participants in this study and the staff who
cooperated with this research in Muntinlupa City, Philippines.
Conflicts of Interest: The authors declare no conflict of interest.

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