Title: Tulong, Ugnayan ng Lingap At gabaY (TULAY):Co-designing Philippines' Community Physical Rehabilitation
Funder: Department of Health and Social Care

Abstract: The 2030 Agenda for Sustainable Development sets out the plan of action for people, planet and prosperity, building on the Millennium Development Goals. Goal 3 aims to ensure healthy lives and promote well-being for all at all ages. The TULAY project focuses on its specific goals and targets, namely: To reduce, by one third, early death from non-communicable diseases through prevention and treatment and promote mental health and well-being (SDG3.4); and achieve widespread health coverage, including access to quality essential health-care services (SDG3.8). Aim: To design, with the help of patients, carers and health workers, a self-managed programme of activities that helps people recover from physical illness, such as stroke. Background: Rehabilitation is a vital part of recovery from illness and yet, currently, in the Philippines, outside of large cities, there is little help provided. Unlike the UK, where there are very effective rehabilitation programmes, in the Philippines, these are almost non-existent. The Philippines is classified as a lower middle income economy (LMIC) with a population of almost 115 million. It is a collection of many islands, which are connected via boats, and other transport is limited. The need to provide community-based rehabilitation has been accepted by the national governmental. Local governments provide primary care through rural health units and barangay (village) health stations, led by municipal and barangay health workers in a mainly privately funded health care system. This programme will based on the successful Bridges scheme (https://www.bridgesselfmanagement.org.uk/workshop/). The joint team of researchers and health professionals from the UK and Philippines will work together with stroke survivors and families to improve recovery care delivery within the community setting. This programme can then be adapted for use in other LMICs and for other physical conditions in the Philippines. Method: we will use a mixture of methods to find out about current services, what people want and then co-design the programme, and train local health workers and village people to deliver it. The University of Plymouth and De La Salle University have spent time with policy makers, clinicians, and patient/carer groups, as well as the Philippine Academy of Rehabilitation Medicine (PARM) and national therapy organisations to involve them in this work. Dissemination: We will share the results of the research widely within the Philippines using social media and other resources. Papers will be published in journals and conference presentations made. Through the involvement of key people from regional and central government and the national insurance scheme, we aim to have this model approved as part of the Philippines’ Universal Healthcare Scheme, to help others to manage themselves after physical illness. The team of researchers have expertise in the practice and evaluation of rehabilitation; development of self-management programmes; Philippines-based telehealth and public health programmes; and research implementation and evaluation. The programme progresses the team’s research and clinical work, and will strengthen the health system, to improve patient and family health within 5 years, using an wide-ranging partnership model respecting diversity and culture.

Lay abstract: Research question: Transforming community-based physical rehabilitation services in the Philippines through co-design; is this achievable? Background: Physical rehabilitation programmes are urgently needed in the Philippines, as evidenced by the statistics for stroke. In 2014 it was estimated that about 500,000 Filipinos will be affected by stroke resulting in healthcare costs of up to $1·2 billion.[1] The age adjusted Death Rate for stroke is 130.85 per 100,000 of population; this ranks Philippines #22 in the world.[2] The Philippines’ healthcare system is largely private and in 54% of the population the cost of interventions are borne by out-of-pocket payments, with limited use of services by lower and middle-income groups. Rehabilitation is central to promoting independence, meaningful life goals and economic productivity. Although stroke unit numbers have risen recently from 2 in 1999 to nearly 50 in 2021,[3] they remain inaccessible to patients who live in remote areas. No established community-based care facilities in the Philippines exist, and qualified staff to deliver rehabilitation within the Philippines are scarce. Aims: To co-design and implement a sustainable self-management community-based programme for physical rehabilitation, using stroke as the test-case, and evaluate its impact on self-management skills, patient well-being and self-efficacy. Methods: A mix of methods, to co-design and implement a bespoke self-management programme, with contextualised training resources, within 3 targeted regions, for local health workers, supported by local people with stroke acting as village heroes. Informed by the Knowledge to Action (KTA) framework, and based on the ‘Bridges’ training programme, co-designed self-management tools used by rehabilitation providers to support self-management will be produced. This programme has been established in the UK and elsewhere, including Estonia. Normalisation Process Theory (NPT), alongside the KTA will be used to understand implementation, sustainability, and cost-effectiveness. We will adopt a pragmatic approach, facilitating co-production, tailoring, implementation and evaluation. These frameworks will enable us to capture necessary modifications ensuring that the evidence-based self-management programme for stroke rehabilitation has a pragmatic fit with the context of wider community health delivery in the Philippines. Timelines for delivery: • WP1: Management, communication and dissemination; including study set up (4 months); Q1/22 – Q1/26 • WP2: Clarification of Structures of Care; Q3/22 – Q2/23 • WP3: Quality of rehabilitation services in cities and rural settings; Q3/23 –Q4/24 • WP4: Co-production of TULAY stroke self-management programme; Q2/24 – Q1-26 • WP5: Implementation and evaluation of TULAY programme within targeted Municipalities; Q2/24 – Q1/26 Anticipated impact and dissemination: Regional and national system changes in community rehabilitation services; formal adoption with ordinances approved; and stakeholders from regional and central government and the national insurance scheme (PhilHealth) working together to embed the programme into the Universal Healthcare Scheme to contribute to the 2030 Sustainable Development Goal 3. Dissemination will be via peer reviewed publications, social media, news media, a website hosted by De la Salle University (DLSU), and links to data repositories to facilitate data sharing with other LMICs.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: STROKE