ASIAN/PACIFIC ISLAND NURSING JOURNAL Reyes et al

Original Paper

Using the Socioecological Model to Explore Barriers to Health

Care Provision in Underserved Communities in the Philippines:
Qualitative Study

Andrew Thomas Reyes1*, PhD; Reimund Serafica1*, MSN, PhD; Jennifer Kawi1*, MSN, PhD; Miguel Fudolig2*, PhD;
Francisco Sy2*, MD, DrPH; Erwin William A Leyva3*, PhD; Lorraine S Evangelista1*, PhD
1
School of Nursing, University of Nevada Las Vegas, Las Vegas, NV, United States
2
School of Public Health, University of Nevada Las Vegas, Las Vegas, NV, United States
3
College of Nursing, University of the Philippines, Manila, Philippines
*
all authors contributed equally

Corresponding Author:
Andrew Thomas Reyes, PhD
School of Nursing
University of Nevada Las Vegas
4505 S Maryland Parkway Box 453018
Las Vegas, NV, 89154-3018
United States
Phone: 1 702 895 5094
Email: andrewthomas.reyes@unlv.edu

Abstract
Background: The Philippines’ primary care is delivered via local health centers called barangay health centers (BHCs). Barangays
are the most local government units in the Philippines. Designed to promote and prevent disease via basic health care, these BHCs
are staffed mainly by barangay health workers (BHWs). However, there has been limited research on the social and environmental
factors affecting underserved communities’ access to health care in underserved areas of the Philippines. Given the importance
of BHCs in disease prevention and health promotion, it is necessary to identify obstacles to providing their services and initiatives.
Objective: This study aimed to explore multilevel barriers to accessing and providing basic health care in BHCs.
Methods: We used a qualitative approach and the socioecological model as a framework to investigate the multilevel barriers
affecting basic health care provision. A total of 18 BHWs from 6 BHCs nationwide participated in focus group interviews.
Traditional thematic content analysis was used to analyze the focus group data. After that, we conducted individual semistructured
interviews with 4 public health nurses who supervised the BHWs to confirm findings from focus groups as a data source
triangulation. The final stage of thematic analysis was conducted using the socioecological model as the framework.
Results: Findings revealed various barriers at the individual (lack of staff motivation and misperceptions of health care needs),
interpersonal (lack of training, unprofessional behaviors, and lack of communication), institutional (lack of human resources for
health, lack of accountability of staff, unrealistic expectations, and lack of physical space or supplies), community (lack of
community support, lack of availability of appropriate resources, and belief in traditional healers), and policy (lack of uniformity
in policies and resources and lack of a functional infrastructure) levels.
Conclusions: Examining individual-, interpersonal-, institutional-, community-, and policy-level determinants that affect BHCs
can inform community-based health promotion interventions for the country’s underserved communities. Given the multidimensional
barriers identified, a comprehensive program must be developed and implemented in collaboration with health care providers,
community leaders, local and regional health care department representatives, and policy makers.

(Asian Pac Isl Nurs J 2023;7:e45669) doi: 10.2196/45669

KEYWORDS
health care delivery; health care access; socioecological model; Philippines; community; barriers; health care; Asian and Pacific
Islander; focus group; Tagalog; thematic analysis; socioecological framework

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barriers to basic health care from the perspectives of BHWs and

Introduction public health nurses, as direct supervisors of BHWs, in several
In the Philippines, women, older adults, low-income households, underserved communities in the Philippines. The socioecological
and people with disabilities face barriers to basic health care, model is well established and can investigate how social and
particularly in underserved areas [1]. The Local Government environmental factors across ecological levels (ie, individual,
Code of 1991 (Republic Act no. 7160) decentralized public interpersonal, institutional, community, and policy) influence
health care, assets, liabilities, equipment, workers, and records basic health care provision or lack thereof in underserved
to local governments in the country [2]. By decentralizing care communities [12]. This model assists in identifying
to local government units (called barangays), the country aims context-specific factors, which are typically overlooked in
to improve health care services by bringing them closer to research, that either reduce or promote access to basic health
consumers [3]. Decentralization allowed local governments to care.
form organizations, improve and standardize services, and offer This qualitative study is significant because many countries,
a platform for best practices and new laws [4]. The barangay’s particularly low- and middle-income countries, use decentralized
decentralized local government budget specifies the number of health care services, and the grassroots level of health care
barangay health workers (BHWs), responsibilities, and salaries accessed by the communities of these countries is those
or allowances [3]. programs provided by community health workers (CHWs) [13],
As a result of decentralization, health centers in barangays (the such as the Filipino BHWs in this study. An explorative study
smallest administrative division in the Philippines) were tasked investigating factors that facilitate and hinder health care
with providing basic health care (eg, vaccines, health and provision by CHWs at all levels (ie, individual, interpersonal,
nutrition education, family planning services, treatment for institutional, community, and policy) is imperative. Therefore,
minor illnesses and injuries) to the individuals residing in the we conducted this qualitative study to explore factors affecting
communities they served [5]. These barangay health centers the health care provision of BHWs in the Philippines using a
(BHCs) are the cornerstone of the country’s public health system socioecological framework. The study’s findings will provide
and were designed to promote health and prevent disease by nuanced evidence on the commonly identified challenges of
providing basic health care [3]. Unfortunately, barely half of community health care programs in low- and middle-income
Filipinos can access a BHC within 30 minutes of travel time countries, such as inadequate government funding, lack of
[6]. Also, previous research has demonstrated that supervision and training of community health care providers,
decentralization does not always lead to greater equality, insufficient focus on health promotion and prevention, and
efficiency, and effectiveness in health care delivery. Instead, it fragmented programming [14-16]. The study’s findings can
can worsen inequality, erode local commitment to critical health also provide the basis for helping local, national, and
issues, and reduce the efficiency and efficacy of health care international stakeholders maximize their support for various
delivery to underserved populations [2]. Decentralization has community health programs, particularly in countries that use
also decreased health care quality in some of the country’s decentralized health care services. The comprehensive approach
poorest local government units [6]. (ie, socioecological framework) and the qualitative focus of the
study will provide findings that can further clarify ambiguous
The Philippines’ BHCs and their corresponding BHWs have and fragmented challenges that interface between broader health
been considered longer in operation as local government–trained systems and point-of-care services; hence, the results of the
health care providers than in other countries [7]. Therefore, study can provide a multilevel basis for overcoming challenges
exploring factors that facilitate and hinder the health care service with decentralized health care services in order for community
delivery of BHWs may offer interesting insights into improving health programs to reach their full potential. Therefore, the
the health care services provided by local government–trained purpose of the study is to explore the multilevel barriers to
health care providers in countries that provide decentralized accessing and providing basic health care in community health
health care services. To enhance health outcomes on all fronts, centers in the Philippines called BHCs.
BHWs are employed at the barangay level as a bridge between
health care institutions and local communities to increase access Methods
to care [8]. Because most BHWs come from the communities
they serve, they are well versed in the issues that the community Study Design
members face and can tailor their care accordingly. In addition The study team employed a qualitative descriptive approach
to taking vital signs, BHWs can advise on maintaining a healthy using focus group sessions and individual interviews. We
lifestyle, administering basic treatments, and making referrals followed the COREQ (Consolidated Criteria for Reporting
when necessary [9]. However, there is a lack of knowledge of Qualitative Research) guidelines [17]. We used 2 sets of
the motivational factors that make these primarily unpaid semistructured interview guides—one for focus groups and one
volunteers work and the challenges they face in providing access for individual interviews—to explore our study topic; the
to basic health care to these vulnerable populations [10]. conceptual underpinnings of both sets were derived from a
Recognizing these problems is crucial to the country’s primary literature review. Textbox 1 outlines sample questions included
health care success and sustainability [11]. in the semistructured interview guide. The interview guides
To address this gap in the literature, we used the socioecological were provided in Tagalog (the local language) and English. The
model as a conceptual and organizing framework to investigate focus group discussions focused on assessing the experiences

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and perspectives of BHWs in delivering basic health care at individual interviews had the same goals but focused on the
their BHCs and the obstacles they faced in providing health public health nurses’ perspectives of the BHWs’ attitudes and
care and using community resources for community members. work conditions and the community’s response to the BHWs’
The focus groups also explored how different levels of roles in the BHCs they served.
government-provided health care to the population. The
Textbox 1. The semistructured interview guide.
Sample questions for focus groups and individual interviews

• In your opinion, what was the situation of basic health care in your community, or how accessible was basic health care in your community?
Please explain.

• In your observation or experiences, how were you or people in your community using basic health care before the pandemic?

• Please share your experiences or efforts in delivering basic health care in your community. (Only ask health workers, female community health
volunteers, and local elected authorities.)

• In your observation or experiences, how are the different levels of governments responding to providing health care to community people?

• Please feel free to share if you have any suggestions or anything you would like to say or think you missed during our conversation.

Interviews were in Tagalog or English based on the participants’

Study Setting and Participants request. All interviews were held at the BHCs. All individual
A total of 6 focus groups were interviewed. Each focus group interviews and focus groups, which lasted an average of 45 to
comprised 3 BHWs from the Philippines’ 6 regions, including 60 minutes, were recorded, transcribed, and translated into
the National Capital, Cordilleras, Ilocos Region, Central Luzon, English. All data were deidentified before transcription and
Western Visayas, and Central Visayas (N=18). The BHCs of analyses. Two days after transcribing, the interviewer and
these regions of the Philippines served between 20,000 and research team convened to review the transcripts; they did not
25,000 people [6]. The majority of BHWs (15/18, 83%) were find any ambiguous questions or topics from the transcripts
older than 40 years (mean 50.8, SD 9.6 years), and 78% (14/18) requiring follow-up interviews.
had spent more than 6 years in their current occupation (mean
17.1, SD 10.3 years) and workplace (mean 12.9, SD 9.6 years). Data Analysis
Additionally, 4 public health nurses (all female, average age We used a deductive thematic analysis to identify the service
23.6, SD 5.6 years) assigned to supervise BHWs from 3 to 5 gaps, challenges, and constraints to providing health care in the
BHCs participated in the individual interviews to confirm barangays. The gathered data were structured and analyzed
preliminary findings from our focus group data analysis. using a socioecological framework [12] frequently used as a
foundational framework for research in health promotion
Sampling and Data Collection behavior interventions.
Purposive sampling was used to interview BHWs through focus
groups. After all 6 focus group interviews were completed, an ATLAS.ti (ATLAS.ti Scientific Software Development GmbH)
initial thematic analysis was conducted to arrive at emerging [20] was used to analyze transcripts for themes and patterns.
categories and preliminary themes. After data source Two bilingual researchers (EWAL and LSE) trained in
triangulation [18,19], these preliminary themes were forwarded qualitative research compared transcriptions with original
to the public health nurses supervising the BHWs through recordings to verify accuracy. Subsequently, these 2 researchers
in-person individual interviews. To protect the identity of the coded the first few transcripts and met with a senior researcher
BHWs, personal identifying information was not disclosed to discuss discrepancies and new topics. After comparing and
during the individual interviews. Additionally, the individual contrasting the coding, we obtained consensus on the emerging
interviews did not discuss information from the preliminary codes and categories and implemented these as a template for
themes that could directly refer to the identity of the BHWs. coding on the remaining transcripts.
For example, information was more expressed in general terms The female master’s-prepared nurse who originally conducted
(eg, information related to the punctuality of a particular BHW the interviews reviewed the emerging code and categories with
was shared in general terms applicable to a larger group of the 2 bilingual researchers to organize the themes for the
BHWs, such as “Some BHWs in some clinics were often late individual follow-up interviews with the nurses (data source
in coming to work” as opposed to referring to a particular triangulation). Statements that could have direct reference to a
BHW). BHW or could reveal the personal identifying information of
A female master’s-prepared nurse who was not part of the study the BHW were highlighted to omit them from the discussions
team but was trained and skilled in qualitative research in the individual interviews. After all individual interviews were
conducted all focus group discussions and individual interviews. conducted, the final stage of thematic analysis was conducted
The interviewer introduced herself and gave an overview of the to include insights from the individual interviews. In the final
research before each interview or group discussion. All analysis stage, all identified themes were grouped and
individuals were allowed to ask questions and provided consent. categorized into a socioecological model level with no emerging
themes outside the socioecological framework.

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Ethics Approval underserved communities in the Philippines. Using the

The University of California Irvine Institutional Review Board socioecological model framework, we organized the concepts
and the University of the Philippines Ethics Review Board (IRB we found into five broad categories: (1) individual, (2)
approval number: UPMRED #2016-496-01) approved this study. interpersonal, (3) institutional, (4) community, and (5) policy
Before conducting any interviews, each participant was informed (Figure 1). The socioecological model is a system model based
of the purpose of the study, and we ensured that all participants on the notion that social contexts determine the actions and
provided written informed consent. reactions of individuals and that multiple factors influence and
are influenced by the behavior of individuals [12]. It highlights
Results the importance of addressing the interaction between individuals
and their sociocultural environment at all system levels and the
Levels of the Socioecological Model interdependence of influencing factors within and across all
health problems and behaviors. Themes are presented according
This study aimed to examine barriers to basic health care from
to the 5 levels of the socioecological model and augmented with
the viewpoints of BHWs and public health nurses in several
illustrative quotes (see Table 1).
Figure 1. Barriers to health care provision in barangay health centers.

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Table 1. Themes with representative quotes.

Levels and themes Sample quotes
Individual-level barriers
Lack of staff motivation “Sometimes, we don’t want to go to the center because there aren't any people to see or because we can’t do anything
about their health problems.” (Christina, BHWa)
Misperceptions of health “People in our community don’t go to the center because they don’t think it’s necessary to be seen for their high
needs blood pressure. Instead, they go to the city or provincial hospital when they are really sick.” (Lolita, BHW)
Interpersonal-level barriers
Lack of training “Because not everyone got the same training to become a BHW, some of us are less skilled than others. Then there
is experience. For example, some of us have worked with local midwives, while others have not.” (Melinda, BHW)
Unprofessional behaviors “One of the BHWs working at our center was rude to the patients and their families. Because of this, the center
had to close because the people it served went to a nearby BHC for basic care.” (Josephine, BHW)
Lack of communication “We never see the nurses, so if we aren’t sure what to do, we have to send them a text message, which they may
not answer for several days. So, we send patients home without taking care of them.” (Luninging, BHW)
Institutional-level barriers
Lack of human resources for “There are just days when it is busy, and I can’t take care of all the people coming in. We just need more manpower.”
health (Magnolia, BHW)
Lack of accountability of “No one is held responsible for being at work, so no one sticks to the schedule, which slows things down. At the
staff centers, we sometimes work alone, which is frustrating because we can’t get everything done.” (Gwendolyn, BHW)
Unrealistic expectations “What we do as BHWs changes from day to day. If community leaders need us, sometimes for personal reasons,
we have to leave the center. The nurses who watch over us don’t know what we can do, and some let us do what
we feel comfortable with. However, some nurses will ask us to do things we shouldn't, clean wounds.” (Delia,
BHW)
Lack of physical space or “The space in our BHC is so small that only the BHW, the patient, and one family member can be there at once.
supplies Because of this, more people who need healthcare must wait outside, often for long periods. We also don’t have
electric fans, so it gets very hot. Our mayor promised to build a bigger and better facility to replace the one we
have, but that has been a plan for several years.” (Carmelita, BHW)
Community-level barriers
Lack of community support “With the help of our community leaders, we have done projects to reach out to the community. But this is not
consistent, and we often feel unsupported.” (Marilou, BHW)
Lack of availability of appro- “Our wealthier members will go to hospitals in the city, while those with less money will go to an herbalist or a
priate resources quack doctor. Most say that the centers don’t have enough resources or supplies for their needs.” (Tomasa, BHW)
Belief in traditional healers “Our herbalists and quack doctors have everything they need to treat common illnesses and can give them to sick
people for free. Therefore, they are more trusted than we (BHWs) are.” (Amelia, BHW)
Policy-level barriers
Lack of uniformity in poli- “Depending on how much money the local government spends on healthcare, some BHCs may have more supplies
cies and resources and resources than others. Also, they have more space and supplies. But we can’t be like them if we do not have
funds.” (Jocelyn, BHW)
Lack of a functional infras- “Donors sometimes make donations, but they are very infrequent and local leaders will make promises but not
tructure carry them out.” (Marilyn, BHW)

a
BHW: barangay health worker.

Interpersonal-Level Factors
Individual-Level Factors
Participants frequently brought up interpersonal concerns such
Participants shared several individual-level factors that they
as a lack of training, unprofessional behavior among peers, and
deemed were barriers to providing basic health care at the BHCs.
poor communication. BHWs, for instance, have reported feeling
These individual characteristics were BHW’s self-motivation
unprepared for their roles because of a lack of formal training.
and community members’ misperceptions of their health care
The nurses confirmed this BHW’s concern that they could not
needs. In addition, individual-level characteristics reported by
support the BHWs as much as possible because of their scope
participants were influenced by determinants at all other
of responsibilities of managing more than one BHC. During the
socioecological model levels, particularly those linked to
confirmatory interviews, nurses also expressed their need to
interpersonal and institutional factors.
provide closer supervision of the BHWs to help the BHWs
develop more confidence in performing basic health care
services. Other BHWs reported the opposite, citing informal

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training with more seasoned peers (BHWs) in their BHCs as selection of services and items they could avail themselves of
the source of a better understanding of their roles and a renewed during their visit to the BHC. Free access to essential medical
sense of motivation to perform at their best within the limits of items such as medication, contraception, and water was only
their job. However, BHWs voiced concerns that not all nurses offered at a select number of BHCs.
(considered as their supervisors) could be contacted for advice
when necessary. As a result, the nurses’ lack of access to
Community-Level Factors
supervise and mentor the BHWs contributed to the BHWs’ At the community level, thematic clusters emerged with
ongoing frustration and decreased job satisfaction. Lastly, the environmental elements such as the lack of community support,
BHWs rarely had someone check in on their progress because usually demonstrated by informal networks like community
the nurses were often unavailable to supervise them and oversee leaders influencing basic health care delivery. For example,
their performance at the clinics. During the confirmatory some BHCs benefited from donations from wealthier community
individual interviews with the nurses, it was evident that there members, but this was uncommon. Another environmental
were differences in perceived priorities between the nurses and consideration was the availability of community resources.
the BHWs. For example, BHWs prioritized improving their Furthermore, despite efforts to encourage community members
ability to provide basic health care services. At the same time, to seek basic treatment at BHCs, affluent members would go
the nurses wanted to expand the BHWs’ scope of responsibilities to city or provincial hospitals related to the lack of appropriate
so they could function even without the presence of the nurses health resources available at the BHC level. On the other hand,
in the clinics. Nurses often found resistance from BHWs in their the poorer members sought treatment from traditional healers
attempts to expand BHW’s scope of practice; this perceived such as an herbalist or quack doctors.
resistance often resulted in more distant communication between
Policy-Level Factors
the BHWs and the nurses. Therefore, this poor (often
nonexistent) communication was detrimental to their functions Policy topics that emerged were a lack of uniformity in policies
as primary health care providers. governing the provision of essential health care by individual
local government bodies. Different towns have varied
Institutional-Level Factors requirements for providing citizens with basic medical care.
Participants said that a BHC’s ability to provide basic health Another theme evident among the participants’ interviews was
care primarily depends on the availability of health workers and the lack of functional health infrastructure. The health care
the quality of care delivered by staff. Despite this, there was a resources made accessible by each jurisdiction influence the
lack of accountability among BHWs such as only a handful of accessibility of basic health care services (such as personnel,
dedicated BHWs working at the BHCs, with some employees supplies or equipment, and medications). Consequently, there
regularly missing work and others complaining about how much was an inadequate understanding of the benefits and expected
they had to do and how little help they got. In addition, basic health care coverage offered by the public and private health
health care was difficult to deliver for various reasons, such as care sectors.
conflicting and unrealistic expectations from community leaders
and members, supervisors, and local government entities. For Discussion
example, BHCs were promised by community leaders (eg, city
mayors and barangay leaders) more funding, but BHWs Principal Findings
continued to wait for these plans to be realized; therefore, basic The provision of primary health care in low- and middle-income
medical supplies were limited, resulting in challenges with countries has been the subject of prior research that used the
delivering basic health care services. In another example, nurses socioecological model [21-24]. However, no study has examined
and BHWs were expected to deliver more community outreach the perspectives of BHWs and public health nurses who work
programs by local government entities; however, they expressed in BHCs to provide basic health care in underserved regions in
frustration with the incongruence between the lack of public the Philippines using the socioecological model as a framework
funding and the increasing expectation to deliver more outreach [12]. Our research indicates that basic health care provision in
programs. BHWs voiced that they largely depended on BHCs across the Philippines is influenced by factors at all levels
volunteers from private organizations for their outreach of the socioecological model. The premise of the socioecological
programs, and they also articulated that the support they received model is that health policy decisions and practices affect not
from these private volunteers was inconsistent and infrequent. only individuals but also the social networks in which they
participate and the institutions and communities in which they
During the group sessions, accessibility to the BHCs (ie, the
reside [25].
physical distance between the center and the people it serves)
and transportation costs determined whether community There are several similarities between this study’s findings and
members would come for basic health care. It was also other studies on primary health care services provided by CHWs
emphasized that the infrastructure and resources varied from in low- and middle-income countries. Findings from our study
center to center. Patients frequently had to wait outside the that are consistent with previous research include the influence
center in the heat and occasionally rainy weather due to a lack of the lack of physical space and adequate ventilation on the
of physical space within the BHCs. Individuals were less quality of health care services provided by the CHWs [26], the
inclined to seek preventative treatment at the BHCs because of impact of the quality of the partnership between the local health
the absence of functioning fans and air conditioning. When the system and the CHWs on the community perceptions of the
patients obtained the help they needed, there was a limited quality of services provided by the health centers [27], the
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relationship between the community’s pervasive traditional Our research reveals that poor working conditions and limited
beliefs of non-Western medical care and the lack of trust of resources significantly hinder providing high-quality basic health
CHWs [9,28], lack of consistent funding from local health care in underserved areas. These findings are consistent with
systems [29,30], variability of basic and supplementary training earlier research examining health care delivery in underserved
of CHWs among health centers [8], and inconsistent and areas in the country [1,5,9,11,25]. Given the magnitude of the
infrequent funding from private and nongovernmental problems afflicting the health care system in the Philippines,
organizations [8]. an interdisciplinary and cross-sectoral approach is required to
improve the quality of health care provided in BHCs by
However, the area in which our findings are distinct from
enhancing their staffing, clinical resources, and access to
previous studies on primary health care services provided by
life-saving drugs [33,34]. The vital role of BHWs within the
CHWs in low- and middle-income countries is the interactional
larger health system should be reflected in resource allocation
processes between the BHWs and the public health nurses who
as the Philippines and other contexts make strides toward
oversee the work of the BHWs. Although previous studies
universal health coverage.
highlighted the importance of a collaborative working
relationship between CHWs and higher-level health workers The absence of supervision and proper training for BHWs
[15,31-33], these studies did not specifically explore the prevented them from playing their full role in providing primary
supervisory role of public health nurses in the work of the care to their communities. BHWs are employed and trained by
CHWs. Our findings specifically demonstrate that the local government units to support various health programs.
collaboration between the public health nurses and the BHWs Unfortunately, not all BHWs get the training they need. Some
is crucial in providing health care services to the BHWs. BHWs claim that they were not provided with a formal training
Because the scope of responsibilities of BHWs is mostly based program and were educated by experienced BHWs on how to
on nursing functions, supervision, training, and mentoring of perform their duties; if the training was provided at all, its scope,
BHWs by public health nurses are imperative. Nursing depth, and duration varied across different local communities.
perspectives in the partnership between public health nurses Given the disparity in training, BHWs may have difficulty
and BHWs are incumbently necessary. The lack of confidence understanding and consistently carrying out their tasks.
and competence of BHWs in performing their assigned nursing Moreover, lack of adequate training may lead to the
tasks in the clinics was attributed to the lack of formal training, communities’ lack of trust and hesitancy to seek care from
supervision, and mentoring by their nursing supervisors (ie, the BHWs, as revealed in our findings. Our results are consistent
public health nurses). with other studies performed in the Philippines [1,9] and
elsewhere [35] on BHW initiatives in low- and middle-income
Additionally, our study’s findings show that community
countries. For this reason, the Philippine Department of Health
members were not maximizing the use of the services offered
must attempt to standardize the training of BHWs throughout
by the clinics because the services provided by the BHWs were
the country. The effectiveness of BHC programs and safe,
limited. The limited scope of practice of BHWs was mainly
quality health care in the communities depend on BHWs
related to the lack of availability and limited accessibility of
receiving high-quality initial and continuous training.
public health nurses to train, supervise, and monitor the progress
of their performance. The BHWs required the supervision of In addition to standardizing the initial and ongoing training of
the public health nurses to carry out their nursing tasks to expand BHWs, another widely discussed option in the country is to
their scope of responsibilities and be able to perform nursing accredit BHW programs that can significantly improve the
functions more independently, especially when the nurses are usefulness of BHC programs, both for their communities and
not able to promptly respond to the needs of the clinics (eg, the BHWs. The Philippines’ BHW Act (1995) demanded BHW
public health nurses were responsible for overseeing several accreditation as a viable tool to increase BHWs’ morale, job
clinics or health centers). Our findings provide the basis for security, career chances, legitimacy, and social standing [8].
developing nursing-specific standards and policies in monitoring Accreditation for BHW programs has been shown to protect
the progress of BHWs’ performance and expanding their scope them from acquiescing to the agenda of local political leaders,
of responsibilities to perform more independent functions and ensuring their continued existence [8]. Furthermore,
respond to rapidly changing and complex clinical situations. accreditation can increase reliability in executing BHW
Our findings also demonstrate the need to integrate nursing programs in various settings by improving oversight and
perspectives in training CHWs to deliver point-of-care health standardizing BHW performance [8]. However, previous
care programs to the communities. For example, the type of initiatives to support the accreditation of BHW programs were
services and coordination provided by the BHWs are mainly unsuccessful at the local level in the Philippines.
based on nursing; therefore, public health nurses are the most
More research is needed to explore the governance challenges
appropriate supervisors, mentors, and coaches for the BHWs.
and opportunities of BHW programs in various decentralized
More importantly, the limited resources provided to the BHCs
health systems to realize the full role BHW programs can play
and the increasing scope of responsibilities of public health
in achieving universal health care. This includes the ability of
nurses in managing multiple health centers require BHWs to
programs to extend the reach of formal health care providers,
expand their scope of practice; the public health nurses are the
enhance access and equity of health care, and improve
main drivers in the professional development of BHWs to
individual- and community-level health outcomes. In the
provide timely and safe health care services to the populations
decentralized Philippines, BHWs could be “local” health experts
they serve.
in multistakeholder talks on planning, financing, implementing,
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managing, and monitoring community health care. Our research underserved communities in the Philippines. Our findings can
indicates that BHC programs and BHWs can be more effectively be used to develop comprehensive and effective interventions
leveraged in efforts to achieve universal health care by to address the various barriers to health care access and
increasing the capacity of local governments to provide provision and to inform “task shifting” programs and policies
sufficient resources to BHC programs and BHWs [8]. Providing in the Philippines and other low- and middle-income countries
BHWs a voice in policy decisions that pertain to their work that aim to encourage and empower communities to take a more
might increase transparency and accountability by involving active role in health management with the help of BHWs.
more government agencies (ie, local communities and regional
or national health authorities) [36].
Conclusions
Health professionals, communities, and stakeholders must think
Our study has some limitations. Using a convenience sample, outside conventional medicine to improve health [8]. This
for example, increases the possibility of selection bias. In comprehensive approach must encourage multisectoral
addition, the findings represent the viewpoints of numerous cooperation to improve public policy and long-term health care
BHWs and nurses working in underserved areas in the delivery [10]. National, state, and local institutions must
Philippines. However, they were mainly from Luzon and coordinate health policy making [4]. In the decentralized
Visayas (the northern and mid-regions of the country), making Philippines, BHWs could be “local” health experts in
generalization difficult. Moreover, our participants were female, multistakeholder dialogues on planning, financing,
highlighting a crucial gendered aspect of BHWs in the implementing, managing, and monitoring community health
Philippines. In societies where care is feminized, it is crucial to care [9]. Underserved areas need better health education so
recognize and address gender inequalities to ensure that the community members can adopt healthier lifestyles. BHWs need
work and time of BHWs are adequately appreciated [8]. superior training and supervision to provide basic services,
Nevertheless, the study has numerous merits, such as the health education, and patient referrals. The Philippine
iterative process of developing a framework of barriers that Department of Health must provide greater resources to reduce
hamper the delivery of basic health care to BHCs in the local health promotion barriers [6]. These elements are crucial
Philippines. Furthermore, this is the first known and documented to health promotion, which creates personal accountability to
study to use the socioecological model to investigate how social improve people’s health. Individual and community efforts must
and environmental factors at different ecological levels modify people’s ideas and habits to enhance health outcomes
(individual, interpersonal, institutional, community, and policy) [9].
influence the provision or lack thereof of basic health care in

Conflicts of Interest
None declared.

References
1. Siongco KLL, Nakamura K, Seino K, Moncatar TJRT, Tejero LMS, De La Vega SAF, et al. Improving community health
workers' attitudes toward collaborative practice in the care of older adults: an in-service training intervention trial in the
Philippines. Int J Environ Res Public Health 2021;18(19):9986 [FREE Full text] [doi: 10.3390/ijerph18199986] [Medline:
34639285]
2. Lakshminarayanan R. Decentralisation and its implications for reproductive health: the Philippines experience. Reprod
Health Matters 2003;11(21):96-107 [FREE Full text] [doi: 10.1016/s0968-8080(03)02168-2] [Medline: 12800707]
3. Banaag MS, Dayrit MM, Mendoza RU. Health inequity in the Philippines. In: Batabyal AA, Nijkamp P, Higano Y, editors.
Disease, Human Health, and Regional Growth and Development in Asia. Singapore: Springer; 2019:163-174
4. Siongco KLL, Nakamura K, Seino K. Reduction in inequalities in health insurance coverage and healthcare utilization
among older adults in the Philippines after mandatory national health insurance coverage: trend analysis for 2003-2017.
Environ Health Prev Med 2020;25(1):17 [FREE Full text] [doi: 10.1186/s12199-020-00854-9] [Medline: 32517677]
5. Dela Rosa JGL, Ornos EDB, Sianoya AC, Tantengco OAG, Guinaran RC. Social determinants of health inequities in
indigenous children in the Philippines. J Paediatr Child Health 2022;58(8):1493-1494 [FREE Full text] [doi:
10.1111/jpc.16103] [Medline: 35770475]
6. Philippine health facility development plan 2020-2040: investing in resilient and sustainable health facilities towards
universal health care. Philippine Department of Health. URL: https://drive.google.com/file/d/1eahmozW6PYADnBfm57cc
M0XhKN19HXp7/view?ths=true [accessed 2022-08-01]
7. Matsumoto-Takahashi ELA, Kano S. Evaluating active roles of community health workers in accelerating universal access
to health services for malaria in Palawan, the Philippines. Trop Med Health 2016;44:10 [FREE Full text] [doi:
10.1186/s41182-016-0008-7] [Medline: 27433129]
8. Dodd W, Kipp A, Nicholson B, Lau LL, Little M, Walley J, et al. Governance of community health worker programs in a
decentralized health system: a qualitative study in the Philippines. BMC Health Serv Res 2021;21(1):451 [FREE Full text]
[doi: 10.1186/s12913-021-06452-x] [Medline: 33980209]

https://apinj.jmir.org/2023/1/e45669 Asian Pac Isl Nurs J 2023 | vol. 7 | e45669 | p. 8

(page number not for citation purposes)
XSL• FO
RenderX
 ASIAN/PACIFIC ISLAND NURSING JOURNAL Reyes et al

9. Mallari E, Lasco G, Sayman DJ, Amit AML, Balabanova D, McKee M, et al. Connecting communities to primary care: a
qualitative study on the roles, motivations and lived experiences of community health workers in the Philippines. BMC
Health Serv Res 2020;20(1):860 [FREE Full text] [doi: 10.1186/s12913-020-05699-0] [Medline: 32917203]
10. Katigbak C, Van Devanter N, Islam N, Trinh-Shevrin C. Partners in health: a conceptual framework for the role of community
health workers in facilitating patients' adoption of healthy behaviors. Am J Public Health 2015;105(5):872-880 [doi:
10.2105/AJPH.2014.302411] [Medline: 25790405]
11. Dodd W, Brubacher LJ, Kipp A, Wyngaarden S, Haldane V, Ferrolino H, et al. Navigating fear and care: the lived experiences
of community-based health actors in the Philippines during the COVID-19 pandemic. Soc Sci Med 2022;308:115222 [FREE
Full text] [doi: 10.1016/j.socscimed.2022.115222] [Medline: 35930848]
12. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q
1988;15(4):351-377 [doi: 10.1177/109019818801500401] [Medline: 3068205]
13. Zulu JM, Perry HB. Community health workers at the dawn of a new era. Health Res Policy Syst 2021;19(Suppl 3):130
[FREE Full text] [doi: 10.1186/s12961-021-00761-7] [Medline: 34641904]
14. Angwenyi V, Aantjes C, Kondowe K, Mutchiyeni JZ, Kajumi M, Criel B, et al. Moving to a strong(er) community health
system: analysing the role of community health volunteers in the new national community health strategy in Malawi. BMJ
Glob Health 2018;3(Suppl 3):e000996 [FREE Full text] [doi: 10.1136/bmjgh-2018-000996] [Medline: 30498595]
15. Kok MC, Dieleman M, Taegtmeyer M, Broerse JEW, Kane SS, Ormel H, et al. Which intervention design factors influence
performance of community health workers in low- and middle-income countries? A systematic review. Health Policy Plan
2015;30(9):1207-1227 [FREE Full text] [doi: 10.1093/heapol/czu126] [Medline: 25500559]
16. Zulu JM, Kinsman J, Michelo C, Hurtig AK. Integrating national community-based health worker programmes into health
systems: a systematic review identifying lessons learned from low- and middle-income countries. BMC Public Health
2014;14:987 [FREE Full text] [doi: 10.1186/1471-2458-14-987] [Medline: 25245825]
17. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for
interviews and focus groups. Int J Qual Health Care 2007;19(6):349-357 [FREE Full text] [doi: 10.1093/intqhc/mzm042]
[Medline: 17872937]
18. Carter N, Bryant-Lukosius D, DiCenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncol Nurs
Forum 2014;41(5):545-547 [doi: 10.1188/14.ONF.545-547] [Medline: 25158659]
19. Patton MQ. Enhancing the quality and credibility of qualitative analysis. Health Serv Res 1999;34(5 Pt 2):1189-1208 [FREE
Full text] [Medline: 10591279]
20. Soratto J, de Pires DEP, Friese S. Thematic content analysis using ATLAS.ti software: potentialities for research in health.
Rev Bras Enferm 2020;73(3):e20190250 [FREE Full text] [doi: 10.1590/0034-7167-2019-0250] [Medline: 32321144]
21. Soola AH, Davari M, Moghaddam HR. Determining the predictors of self-management behaviors in patients with type 2
diabetes: an application of socio-ecological approach. Front Public Health 2022;10:820238 [FREE Full text] [doi:
10.3389/fpubh.2022.820238] [Medline: 35462803]
22. Khuzwayo N, Taylor M. Exploring the socio-ecological levels for prevention of sexual risk behaviours of the youth in
uMgungundlovu district municipality, KwaZulu-Natal. Afr J Prim Health Care Fam Med 2018;10(1):e1-e8 [FREE Full
text] [doi: 10.4102/phcfm.v10i1.1590] [Medline: 29781679]
23. Uchendu C, Windle R, Blake H. Perceived facilitators and barriers to Nigerian nurses' engagement in health promoting
behaviors: a socio-ecological model approach. Int J Environ Res Public Health 2020;17(4):1314 [FREE Full text] [doi:
10.3390/ijerph17041314] [Medline: 32085607]
24. Zulkiply SH, Rosliza AM. Application of socio-ecological model in developing preventive strategies against suicidal
ideation and suicidal attempt among youth in low and middle-income countries: a scoping review. Med J Malaysia
2022;77(6):755-763 [FREE Full text] [Medline: 36448396]
25. Duante CA, Austria REG, Ducay AJD, Acuin CCS, Capanzana MV. Nutrition and health status of Indigenous Peoples
(IPs) in the Philippines: results of the 2013 national nutrition survey and 2015 updating survey. Philipp J Sci
2022;151(1):513-531 [doi: 10.56899/151.01.39]
26. Olaniyan A, Isiguzo C, Hawk M. The socioecological model as a framework for exploring factors influencing childhood
immunization uptake in Lagos state, Nigeria. BMC Public Health 2021;21(1):867 [FREE Full text] [doi:
10.1186/s12889-021-10922-6] [Medline: 33952252]
27. Kowitt SD, Emmerling D, Fisher EB, Tanasugarn C. Community health workers as agents of health promotion: analyzing
Thailand's village health volunteer program. J Community Health 2015;40(4):780-788 [doi: 10.1007/s10900-015-9999-y]
[Medline: 25744815]
28. Sacks E, Morrow M, Story WT, Shelley KD, Shanklin D, Rahimtoola M, et al. Beyond the building blocks: integrating
community roles into health systems frameworks to achieve health for all. BMJ Glob Health 2018;3(Suppl 3):e001384
[FREE Full text] [doi: 10.1136/bmjgh-2018-001384] [Medline: 31297243]
29. Burnett-Zieman B, Abuya T, Mwanga D, Wanyugu J, Warren CE, Sripad P. Community-based postnatal care services for
women and newborns in Kenya: an opportunity to improve quality and access? J Glob Health 2021;11:07006 [FREE Full
text] [doi: 10.7189/jogh.11.07006] [Medline: 33763220]

https://apinj.jmir.org/2023/1/e45669 Asian Pac Isl Nurs J 2023 | vol. 7 | e45669 | p. 9

(page number not for citation purposes)
XSL• FO
RenderX
 ASIAN/PACIFIC ISLAND NURSING JOURNAL Reyes et al

30. Chipokosa S, Pattnaik A, NEP Malawi Technical Task Team, Misomali A, Mohan D, Peters M, et al. How strong are
Malawi's family planning programs for adolescent and adult women? Results of a national assessment of implementation
strength conducted by Malawi's National Evaluation Platform. J Glob Health 2019;9(2):020901 [FREE Full text] [doi:
10.7189/jogh.09.020901] [Medline: 33282227]
31. Kok MC, Ormel H, Broerse JEW, Kane S, Namakhoma I, Otiso L, et al. Optimising the benefits of community health
workers' unique position between communities and the health sector: a comparative analysis of factors shaping relationships
in four countries. Glob Public Health 2017;12(11):1404-1432 [FREE Full text] [doi: 10.1080/17441692.2016.1174722]
[Medline: 27133127]
32. Mundeva H, Snyder J, Ngilangwa DP, Kaida A. Ethics of task shifting in the health workforce: exploring the role of
community health workers in HIV service delivery in low- and middle-income countries. BMC Med Ethics 2018 04;19(1):71
[FREE Full text] [doi: 10.1186/s12910-018-0312-3] [Medline: 29973217]
33. LeBan K, Kok M, Perry HB. Community health workers at the dawn of a new era: 9. CHWs' relationships with the health
system and communities. Health Res Policy Syst 2021;19(Suppl 3):116 [FREE Full text] [doi: 10.1186/s12961-021-00756-4]
[Medline: 34641902]
34. Vaughan C, Gill-Atkinson L, Devine A, Zayas J, Ignacio R, Garcia J, et al. Enabling action: reflections upon inclusive
participatory research on health with women with disabilities in the Philippines. Am J Community Psychol
2020;66(3-4):370-380 [FREE Full text] [doi: 10.1002/ajcp.12468] [Medline: 33078846]
35. Plowright A, Taylor C, Davies D, Sartori J, Hundt GL, Lilford RJ. Formative evaluation of a training intervention for
community health workers in South Africa: a before and after study. PLoS One 2018;13(9):e0202817 [FREE Full text]
[doi: 10.1371/journal.pone.0202817] [Medline: 30248100]
36. Abimbola S, Baatiema L, Bigdeli M. The impacts of decentralization on health system equity, efficiency and resilience: a
realist synthesis of the evidence. Health Policy Plan 2019;34(8):605-617 [FREE Full text] [doi: 10.1093/heapol/czz055]
[Medline: 31378811]

Abbreviations
BHC: barangay health center
BHW: barangay health worker
CHW: community health worker
COREQ: Consolidated Criteria for Reporting Qualitative Research

Edited by H Ahn; submitted 12.01.23; peer-reviewed by A Nguyen, EG Oh; comments to author 10.05.23; revised version received
29.06.23; accepted 10.07.23; published 22.08.23
Please cite as:
Reyes AT, Serafica R, Kawi J, Fudolig M, Sy F, Leyva EWA, Evangelista LS
Using the Socioecological Model to Explore Barriers to Health Care Provision in Underserved Communities in the Philippines:
Qualitative Study
Asian Pac Isl Nurs J 2023;7:e45669
URL: https://apinj.jmir.org/2023/1/e45669
doi: 10.2196/45669
PMID:

©Andrew Thomas Reyes, Reimund Serafica, Jennifer Kawi, Miguel Fudolig, Francisco Sy, Erwin William A Leyva, Lorraine
S Evangelista. Originally published in the Asian/Pacific Island Nursing Journal (https://apinj.jmir.org), 22.08.2023. This is an
open-access article distributed under the terms of the Creative Commons Attribution License
(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work, first published in the Asian/Pacific Island Nursing Journal, is properly cited. The complete bibliographic
information, a link to the original publication on https://apinj.jmir.org, as well as this copyright and license information must be
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