2.1 Setting

This was a multi-site multi-phase study on health literacy for select Philippine communities. The communities were chosen based on the human development index (HDI) per geographic zone (i.e., Luzon, National Capital Region or NCR, Visayas, Mindanao). The province closest with the whole zone's median HDI was selected, with HDI values from 2009 as reported by the Philippine Statistics Authority (PSA) with ranking done in 2018.⁶ The choice to select the median HDI province was to achieve representativeness of the zone by the province in the absence of random sampling. The province of the median HDI per zone was chosen to represent each of the four zones. NCR and the province in Luzon had the high HDI classification while the areas in Visayas and Mindanao assumed the low HDI classification. After identifying the case provinces, the municipalities were purposively chosen by considering the established political support in the area. In each of LGU, population groups were tapped through organisations (e.g., schools, livelihood centres, and primary health centres). Stages were purposive since the Ophelia process relies on the participation of the community. The sampling also took into account the recommendation of the DOH Health Promotion Bureau (DOH HPB) based on their knowledge of community statuses.

2.2 Participants

Representatives from the different life stages: breastfeeding mothers (for newborns), children, adolescents, adults, and seniors were included. Practitioners from the DOH, and the Department of Education (DepEd), local government officers representing each life stage, city health officers, nurses, midwives and nutrition officers were invited in the study.

2.3 Sampling

The samples for phase 1 survey respondents for HLQ (Leyte) and ISHAQ (Mindoro and Surigao) were computed using the formula for proportion.⁷ The prevalence estimates used were from existing surveys done in the Philippines. Estimates for behaviour were used, and not the prevalence of health literacy, since the study was focused on the change in health behaviours. The sample ranged from 54 to 91 participants per life stage. This yielded a minimum of 270 per area. Random sampling would be counterproductive to the research objectives given the interventional nature. Hence, the study used purposive sampling in the selection of community settings. The willingness criteria did not pose a problem of selection bias because: (i) the study does not aim for representativeness; (ii) there is no control group; and (iii) this was supposed to be a paired sample design (i.e., before and after comparisons will be done for each community). Informed consent forms (ICFs) were translated into local dialects, disseminated, and accomplished ICFs were collected from the participants or their guardians prior to inclusion in the study. A total of 1578 survey respondents for all three areas participated in phase 1 of the study.

Several focus group discussions (FGDs) were also conducted in phase 1. The first FGD round was to get an initial profile of the communities through 8–10 community members, based on the qualitative sampling rule of thumb for FGDs.⁸ The second phase also involved FGDs with one session for each life stage representing community members, while cocreation workshops were conducted for organisational representatives and health practitioners.

2.4 Data collection

2.5 Analysis

2.5.2 Cocreation: Thematic analysis and rapid realist review

The vignettes were written using the cluster analysis results and the narrative data, creating hypothetical personas who had the same health issues and abilities as the people who were in the clusters. A specific template was used for both the background and the vignette itself. For the background, a short profile of the typical person in the cluster is shown, including the age, gender, education level, health card status and common health ailments. At the end, the highest and lowest scales for the specific cluster were identified. Once a background of the cluster was written out, the vignette was then made with one persona used as a representative of the entire cluster of respondents. The persona was described based on a common name in the community, age, marital status, educational level, number of dependents, and any identified health ailments. Afterwards, by using the identified highest and lowest scales, a common situation was written out wherein the persona practices health literacy (using the highest scale) and also a scenario wherein the person may have difficulty in practicing health literacy (focusing on their lowest scale).

Separate cocreation workshops were conducted for different groups of stakeholders. The first group consisted of health practitioners and organisation representatives or leaders such as school nurses, municipal health officers, midwives, barangay health workers, Office for Senior Citizen Affairs representatives, Livelihood Training officers, teachers, and nutrition officers. The second group consisted of representatives from the community members, with each life stage having a separate FGD to discuss vignettes representing their life stage using the Ophelia template and resources for cocreation.² This separation of groups was also recommended by the Ophelia creators to ensure that the community members would not have difficulty expressing their opinions and ideas, since they might not be comfortable to share if health practitioners and organisation representatives or leaders were present.

The aims of the FGDs were to present the vignettes that were translated into the local language to the different stakeholders and discuss possible interventions to help the person described in the vignettes. For each vignette, the following questions were asked to the stakeholders:

1. Do you see people like this or do you know people like this?
2. What sort of issues is this person facing?
3. What strategies or solutions could help this individual overcome the issues?
4. Is the intervention idea likely to be equitable (can they be applied to a lot of people?)
5. Is the intervention idea sustainable?
6. Is the intervention idea exciting?
7. Are there major risks (negative effects or problems the person or the community might encounter) if this idea was implemented?
8. What are the available resources in the community that could help in the implementation of the intervention?

Content analysis of the FGD results was done to show the most common interventions suggested by practitioners and community members per life stage, as illustrated in Table 2. Organisation and health practitioner representatives were heavily involved in the health program planning, design, and impact evaluation for monitoring and sustainability of the interventions chosen. The team of reviewers also conducted the secondary data collection for phase 3a (see Figure 1). This part of the process reflected steps four to eight of the 10 steps of the RRR Method discussed previously. For each top intervention per life stage, the reviewers produced the following.

TABLE 2. Top interventions based on content analysis.

Top interventions per life stage
Mothers	Children	Adolescents	Adults	Seniors
Seedling distribution per household or backyard gardens	Proper solid waste management including trash offence in barangay and clean-up program	Family counselling. Includes normalise family bonding for strong foundation of support system; Division of Labor/Scheduling of house works and other responsibilities. Application of proper time management principles for household chores with parents	Provide job opportunities and livelihood trainings like garments and food processing to alleviate stress and provide income	Monthly doctor's visit or other health personnel for check-up, counselling, and health related updates to the home or health centre (Community Health Counseling—to motivate people to visit RHU/hospital for health consultation)
Home visit by nurses for check-up and health information dissemination; encourage her to seek health care services in the health facility	Practice and promotion of healthy eating habits (lessen sweets and street foods, eat nutritious food) in schools and homes. This includes selling of nutritious foods in canteens	Sex Education and Health Awareness (importance of check-ups and management) Campaign in school or community; includes online workshops	Gardening and beautification per house (with evaluation)—Assembly meeting for backyard gardening campaign, free seeds from DA	Promote Herbal Gardening in the backyard
Health Information and Education Campaign per barangay using IEC materials	Free medicine and health check-up (annual) from barangay or medical missions	Home visitation—Health staff household visit for free check-up and health update and pandemic news dissemination	Health assistance for free consultation in barangay health centres with different doctors with different specialties; designated health workers for each barangay (doctors, midwives, nurses)	Provision of free personal health protection during pandemic
	Assign more nurses and doctors in the community and barangay health centres for barangays without one		Family health counselling with committee on health, including couple counselling. Topic can also include financial literacy promotion

• Note: For Surigao, there were a total of three top interventions for breastfeeding mothers, four top interventions for children, three top interventions for adolescents, four top interventions for adults, and three top interventions for seniors.

Literature review database

There were four reviewers involved in coding using a Literature Review (LR) database. For each life stage, there were two reviewers. The review answered questions about how the interventions worked in other countries with similar profile, the population, context, and how they succeeded in implementation.

The reviewers were assigned the top three to four interventions for each life stage based on the list of interventions collected during Ophelia phase 2 in the cocreation FGDs. These top interventions were those suggested by both the community members and the health practitioners. In the event that interventions were not agreed upon by the two different groups, the ones suggested by the community were prioritised. The reviewers used an iterative approach in searching for the concepts.¹⁵

The research team started with the intervention list from the cocreation FGDs in Ophelia phase 2. From the list, the researchers iterated more search terms with the studies found. A table containing search terms were formed for each intervention, which follows the PICOS (Population (P), Intervention (I), Comparator (C), Outcome (O), and Study Design (S)) method¹⁶:

1. Population—specific life stage (breastfeeding mothers, children, adolescents, adults, seniors).
2. Intervention—the top intervention resulting from the co-creation, described using Medical Subject Headings or MeSH terms.
3. Comparator—not applicable.
4. Outcome—Improved health and wellbeing or Improvements or increase in health literacy outcomes.
5. Study Design—impact studies, effectiveness studies.

Countries located in the WHO WPRO region were prioritised and papers written in the English and Filipino language were considered. The documents should also have been published within the last 10 years. The research team used databases like Google scholar and Pubmed to search for sources. Individual LR database for each life stage was created based on a uniform template. Each article found was categorised under each intervention that initially came from the list of top interventions gathered during the co-creation FGDs.

Chains of inference charting tool and rapid realist review synthesis

The LR database was then downloaded and auto-coded into themes using NVIVO software. The resulting themes and sub-themes were used to create the Chains of Inference (COI) theories. These were then validated by the field team. Contrary evidence was already included, if found at all by the reviewers, even before the themes were made.

The connections or COIs across extracted data and themes were sought. This is an iterative process and connections were updated as needed. There was no formal rule of which should be filled up first—COI theory level, COI sub-theory level, or themes from the literature—given the iterative process, so the Qualitative consultant prescribed the intervention ideas from the FGDs as the sub-theory coming from the co-creation FGD members, since it was still too generic and needed to be broken down further by the reviewers using the literature.

Hypothesis formation was the last step and was done using the filled-up COI theories, sub-theories, and themes. At this stage, the hypotheses reflect the intervention ideas that came from the co-creation FGDs with additional details from the thematic analysis of the literature database. The reviewers were able to identify possible relationships and health outcomes for the interventions, along with specific activities for the health intervention in the COI theories. Since the interventions have yet to be implemented and the actual health outcome is yet to be seen, the evidence-based interventions are called hypotheses.

Rapid realist review synthesis report containing CIMO diagrams and summary tables

The research team used Google Sheets for the LR database, Chains of Inference and Hypothesis statements, NVIVO software for thematic analysis, and Google slides for the Context-Intervention-Mechanism-Outcome (CIMO) diagrams (see Figure 2). These CIMO diagrams were used to present the top evidence-based intervention ideas along with the context and mechanisms needed for it to work, and the final health outcome desired, to the health practitioners and leaders that were invited for the program planning workshop during phase 3.

3.1 Phase 1

Prior to any data collection conducted in partner communities, a Health Literacy Workshop was done for local health practitioners, including school nurses, and organisation representatives. The training focused on providing community stakeholders with a better understanding of health literacy and to give an overview of the Ophelia process. Due to the health literacy seminars given at the start of each site entry, the Ophelia process helped local stakeholders understand the implications of health literacy on their experience with their health system. Workshop participants from Mindoro expressed that the training enabled them to gain health literacy skills to manage their health better even just from their own home.

This phase included two methods: (i) a health literacy questionnaire via the HLQ or the ISHAQ and (ii) an FGD with stakeholders from the community to create a community profile. The total number of respondents per area are as follows: Leyte (578), Mindoro (565), Surigao (514), while the total number of community profiling FGD participants per area are: Leyte (47), Mindoro (40), Surigao (40).

Below is an example of a cluster analysis results with its corresponding vignette.

3.2 Phase 2

For Leyte, a total of 23 participants attended the co-creation workshops designed for health practitioners and organisation representatives. Mindoro had a total of 37 co-creation workshop attendees while Surigao had a total of 14. For the separate co-creation FGDs for community members that was divided per life stage, Leyte had a total of 51 participants, Mindoro had a total of 155 participants, while Surigao had a total of 40 participants.

3.3 Phase 3

4.1 Practical use of ISHAQ for Philippine country profile

The ISHAQ was created specifically for LMIC settings so this was used for Surigao and Mindoro. The 14 scales of the ISHAQ take into account collective or community decision making for health which is a better fit for the culture of the Philippines. The ISHAQ is also offered free of charge for use by governments as opposed to the HLQ which comes with a high administration fee for LMICs. By understanding health literacy needs, effective interventions can be developed and existing interventions can be improved.¹⁷

4.2 Why co-creation is important and practical

There have been other initiatives in improving health literacy such as digital health literacy initiatives in Europe,¹⁸ assessment toolkits in the United States¹⁹ and various other assessment and information toolkits. Similarly, there have been initiatives in creating tools for co-creation for health.^20-22 However, Ophelia is currently the only existing framework specifically for assessment and co-creation of health literacy interventions through co-creation. In the second phase, collaboration with all the relevant stakeholders was done through the co-creation process. Representatives from the different organisations and practitioners of each life stage participated in the co-creation workshops to create solutions or interventions that address the needs assessment results. These were compared with the solutions or interventions that came from the community representatives of each life stage, ensuring that community wisdom was also included as seen in Table 2. The vignettes presented during these workshops were practical tools for lay people to understand the needs assessment results in the form of a story about a person that they can relate to. The successful implementation of Ophelia phases 1 and 2, needs assessment and co-creation, are important steps towards increasing access to health services and also increasing health literacy. These are systematic and efficient approaches that ensure the use of available resources in the community to improve population health.²³ A similar project by Loignon et al.²⁴ which involved co-creating solutions with the different stakeholders in the community also showed how this kind of participatory approach can help “increase their access to health services.”²⁴

Since the study was done on a large scale with all the life stages represented in several communities at the same time, the researchers added activities to complement the Ophelia process as needed in the Philippines' unique setting. This includes capacity building workshops and the adoption of RRR to ensure evidence-based interventions will be proposed to the communities in a timely manner.

4.3 Capacity building of stakeholders

The principles of Ophelia Philippines are aligned with that of the Universal Health Care (UHC) Law, which aims to “ensure that all Filipinos are health literate” and to “provide all Filipinos access to a comprehensive set of quality and cost-effective, promotive, preventive … health services.”²⁵ Beginning with a needs assessment and community profiling to gain a more comprehensive understanding of each community is strongly in line with taking a people-oriented approach which recognises the context of different communities.²⁵ Similarly, several training workshops were conducted at the start of each phase to help contribute to the basic understanding of health literacy among participants for each life stage. These included health literacy training workshops, co-creation workshops, program planning workshops, and impact evaluation workshops. Aside from health practitioners, organisation representatives, and community leaders, local area coordinators and research staff fluent in the local language were also trained to ensure that the Ophelia process is shared and disseminated to all the stakeholders.

4.4 Rapid realist review as a practical approach for policy makers

Results of Ophelia Philippines may aid the Philippine DOH HPB by providing locally-tailored, evidence-based interventions that may be piloted and evaluated for refinement and potential scaling up, with a focus on health literacy, health promotion, and preventive care, as recommended in the UHC Law. The rapid turn-around of the results generated using the rapid realist review approach ensures the timely release of potential interventions reflecting the actual needs of the communities.

4.5 Using the Ophelia process as a tool for generating health promotion interventions

Ophelia is a feasible approach to develop interventions tailored to the health literacy needs of a specific population and a specific focused disease. Ophelia implementation in Europe, Australia, Asia, and the Philippines encountered different factors contributing to the success or failure of implementing the method in full scale. Similar challenges encountered are time constraints, barriers in the implementation, continuity of an intervention, and organisation's flexibility to accommodate interventions.²⁶ Past Ophelia implementations in the mentioned countries recommended a longer time-frame for capacity building, intervention trials and impact evaluation. Overall, Ophelia has enabled all study sites to generate health-literacy informed interventions.

While there was variation to the co-created interventions across areas, as they were tailored to each community's specific needs, it may be noted that many interventions were not solely medical or clinical, and in fact used a multidisciplinary approach that involved environment, financial, and social aspects of the community. Examples of these are livelihood skills training programs, health insurance literacy training, setting up a waste segregation program and materials recovery facility and gardening and beautification programs. These may be said to be aligned with a “whole of society approach,” promoted in the UHC Law as well, as they involve families, local government, and local organisations and businesses.²⁵

The WHO initiated National Health Literacy Demonstration Projects (NHLDPs) in Denmark, France, Ireland, the Netherlands, Norway, Portugal, and Slovakia where Ophelia was used to inform evidence-based interventions in schools, communities, and hospitals for noncommunicable diseases (NCDs) like rheumatic conditions, COPD, Type 2 Diabetes Mellitus, and renal diseases.²⁶ In contrast, Ophelia Philippines focused on the promotion of breastfeeding among mothers, nutrition and WASH among school age-children, sexual and reproductive health among adolescents, healthy diet and exercise among working adults, and mental health or prevention of dementia among the elderly.

It is hoped that by their experience and participation in Ophelia Philippines, local stakeholders gain knowledge and skills in health literacy and health promotion. The project aims to have provided local partners with the capacity to be able to replicate the process or otherwise use the related skills in new or existing programs related to local health promotion. Though the study was not able to conduct the trial of interventions, interventions were chosen based on available health and social resources to ensure sustainability and scalability. By doing so, a decrease in operating costs, increase in staff availability and an empowered local community should be expected.¹

Similar key challenges have been observed across LMICs, and suggested action points reflected the interventions in Ophelia Philippines. Globally, women in LMICs often have “less personal autonomy, and less access to information about their health than do their male counterparts.”¹ Key barriers to their health include long distances from facilities, lack of trust and quality provided by the health system, and other limited number of trained health care providers and properly-equipped facilities.¹ Thus, solutions such as making information and services for family planning, pre- and postnatal care, immunisation, and child health more available and accessible were also suggested by the WHO.¹ In Leyte, community support groups aim to increase health literacy to empower mothers. Information on services will also be available through mass media to increase family planning practices. For Mindoro, nutritional knowledge will help achieve the goals identified. Lastly, community health workers will be engaged in Surigao to increase health care accessibility for breastfeeding mothers as long-distance facilities were reflected to be problems for both maternal and child health.

Evidence shows that those in LMICs carry a greater disease burden.¹ Interventions such as fitness programs, information sessions and activity engagement, home care visits and surveillance across the three areas answers the current problems and challenges to increase access and availability of information and services. Overall, Ophelia Philippines reflected common strategies found in other LMICs and identified similar challenges to health literacy and existing problems for developing countries.

4.6 Limitations

Since this was the first time Ophelia was implemented in the Philippines, Leyte was chosen as the pilot area while the other areas were added only after the first phases were done in Leyte. This resulted in the implementation schedule of the other areas coinciding with the COVID-19 pandemic and why only the first part of phase 3 was completed. The fourth site, Parañaque City (designated as the high HDI area) suffered from an extended strict lockdown, therefore research activities could not be implemented and the area removed from the study. The team was able to instead conduct a program planning workshop (see Table 3), create impact evaluation plans for the top interventions, and conduct an impact evaluation training workshop. These training workshops equipped the areas in conducting their own impact evaluation even after the Ophelia study ends, promoting sustainability.

4.7 Bias

Such biases and confounding are expected to minimally affect the internal validity of the results. The methodology of Ophelia does not aim external generalizability but to contextualise results in a specific community.