Chapter I

Introduction

Background of the Study

The right to health is protected under the Philippine Constitution in Article

II, Section 15 which states that “The State shall protect and promote the right to

health of the people and instill health consciousness among them.” Article XIII,

Sections 11-13 of the Constitution sets out further provisions related to health. In

the PDP for the 2017–2022 period, the State has committed to accelerating

Human Capital Development and this includes improvements to health.

According to the CRC and ICESCR, every child has the right to ‘the

highest attainable standard of physical and mental health’.464 The right to health

is an inclusive right, encompassing not only the right to appropriate and timely

health care, but also to the ‘underlying determinants’ of health, including access

to safe and potable water and adequate sanitation, an adequate supply of safe

food, nutrition and housing, healthy occupational and environmental conditions,

and access to health-related education and information, including on sexual and

reproductive health.

However, existing data suggest that child mortality rates are significantly

higher in rural areas compared to urban areas. According to the Philippines

National Demographic and Health Survey 2013 (NDHS) the neonatal mortality

rate was 9 deaths per 1,000 live births in urban areas, but stood at 18 deaths per

1,000 live births in rural areas. Moreover, the educational status of the mother

has an impact on child mortality in the Philippines. The highest rate of under-5
mortality in 2013 was found to be among those children born to mothers with no

formal education (61 deaths per 1,000 live births). For those children born to

mothers with elementary education the under-5 mortality rate stood at a lower 53

deaths per 1,000 live births, dropping to 30 deaths per 1,000 live births for those

children whose mothers went to high school, and again to 16 deaths per 1,000

live births for those whose mothers went to college.

Household wealth is also a significant predictor of child mortality in the

Philippines. Children born in the lowest wealth quintile have a higher level of

under-5 mortality, at 52 deaths per 1,000 live births, than those children in the

highest wealth quintile, where the rate stood at 17 deaths per 1,000 live births, as

of 2013.493 A similar association exists between household wealth and infant

mortality.

Nevertheless, health reforms in the Philippines build upon the lessons and

experiences from the past major health reform initiatives undertaken in the last

30 years. It emphasized the delivery of eight essential elements of health care,

including the prevention and control of prevalent health problems; the promotion

of adequate food supply and proper nutrition; basic sanitation and adequate

supply of water; maternal and child care; immunization; prevention and control of

endemic diseases; appropriate treatment and control of common diseases; and

provision of essential drugs.

In Isabela City, province of Basilan, one of the main concerns of the local

government is to ensure the health and welfare of its constituents especially the

children. It also embraces the advocacy on the promotion of inclusive health

reaching out those who are in the marginalized sector of the society as well as

the indigenous group of people. Isabela City has a diverse cultures and ethnicity.

Among others, it include the IPs such as the Yakan, Sama Balanguiguih and the

Sama Dilaut.

From the discussions stated herein, the researchers found it helpful to

hold a study which will determine the heath associated factors among the

children who belong to the indigenous group of people taking into account their

cultures and traditions.

Statement of the Problem

This study will determine the associated factors of the nutritional status of

indigenous children in Isabela City, Basilan. Specifically, it will seek to find

answers to the following questions.

Research Questions:

1. What is the demographic profile of the respondents in terms of

a. Family socio-economic status

b. Educational attainment of the parents

c. Parents’ age

d. Type of birth

e. Order of birth

f. Number of pre-natal check-up

g. Number of immunization received

 2. What is the health status of the children who belong to the indigenous

group in Isabela City, Basilan province?

3. Does the health status of indigenous children in Isabela City significantly

related to

a. Family socio-economic status

b. Educational attainment of the parents

c. Parents’ age

d. Type of birth

e. Order of birth

f. Pre-natal care

g. Number of immunization received

Hypotheses

This study will attempt to prove the following hypotheses.

Null Hypothesis

The health status of the indigenous children is not significantly related to

the family socio-economic status, educational attainment of the parents, parents’

age, type of birth, order of the birth, number of pre-natal check-up, and the

number of immunization received.

Alternative Hypothesis

The health status of the indigenous children is significantly related to the

family socio-economic status, educational attainment of the parents, parents’

age, type of birth, order of the birth, number of pre-natal check-up, and the

number of immunization received.

Scope and Delimitation

This research study will be bound by the purpose of exploring the

associated factors related to the nutritional status of the children who belong to

the indigenous group. It will only be conducted within Isabela City, Province of

Basilan whose respondents will include children aged three (3) to five (5) years

old belonging to the indigenous group of people such as yakan, Sama

banguiguih and sama dilaut.

Nutritional status of the children will be limited to the determined body

mass index (BMI) while the associated factors will only include the family socio-

economic status, educational attainment of the parents, parents’ age, type of

birth, order of the birth, number of pre-natal check-up, and the number of

immunization received. Body mass index refers to the child’s weight in kilograms

divided by the square of height in meters which will be determined through the

Children’s BMI for schools (Centers for Disease Control and Prevention, 2020)

readily made in Excel spreadsheet. BMI is classified according to the following

types, namely underweight, normal, overweight, obese and extremely obese.

Moreover, the socio economic status of the child’s family will be

determined using the Kuppuswamy’s socio-economic status scale (1976) where

the occupation of the head of the family, his or her education and monthly

income of the family are used to classify whether the family belongs to upper
class, upper middle class, lower middle class, upper lower class and lower class.

The educational attainment of the head of the family will only include did not

enter school at all, elementary undergraduate, elementary graduate, secondary

undergraduate, graduated secondary, college undergraduate, graduated college,

and graduate studies level. Parents’ age will refer to the both the mother and the

father whose age may fall within below 20 years old, 21 to 30 years old, 31 to 40

years old, 41 to 50 years old and 50 years old and above. The birth type will

involve whether the child was born through natural birth or cesarean while the

order of the birth will mean the order in which the child was born such firs,

second, third and soon.

On the other hand, prenatal care refers to the number of prenatal check-

up and testing which will be limited to the recorded visit and check-up of the

mother to the health care centers while the number of immunization will only

cover the required dosage and types of immunization received by the children up

to his or her present age.

Significance of the Study

Study findings will be beneficial to the following;

Child and the family: This study will bring empirically based information to

promote awareness among parents on how to take care of their children by

taking into accounts the specific factors associated with the well-being of their

children particularly on their health. Results will help them realize to consider
important factors in planning their family to maximize the children’s growth and

development which will help their children succeed in the future.

Health policy makers: Results of the study will support policy maker’s decision

in crafting provisions that will cater the health needs of the children who belong to

the indigenous group particularly the yakan, sama banguinguih and sama dilaut.

It will help support advocacies of the health agencies in promoting children’s

health, family planning and community health among indigenous group of people

and in their respective communities in such a way that cultures, traditions and

customs are still uphold. Given the findings, these advocacies will be streamlined

targeting the most associated factors associated with the health status of the

aforementioned children.

Community: Findings will help the community leaders educate its constituents to

address problems on children’s malnutrition, child’s mortality and morbidity as

well as other aspects of health such as mental, social and emotional instead of

only the physical dimension. They will be able to determine which aspect of the

family should be given the priority which could be education of the parents,

number of children, age of marriage, health services provided in the community

and the livelihood programs to alleviate socio-economic status.

Future researchers: Study results will support future researchers who are

proposing to do similar studies and explore on other related factors affecting

children and of the indigenous group of people.

Operational Definition of Terms

Child immunization: refers to the number of immunization that child-

respondents has been subjected to for strengthen immune system and

protection.

Indigenous Children: refers to the native people in the Philippines with culturally

distinct ethnic group specifically the yakan, sama banguinguih and sama dilaut

residing within Isabela City, Province of Basilan.

Nutritional status: In this study, nutritional status will refer to the body mass

index of the respondents who are the children aged 3 to 5 years of age which are

classified as underweight, normal, overweight, obese or extremely obese

(Centers for Disease Control and Prevention, 2020).

Order of birth: is defined as the order of the child when he or she was born such

as first, second, third and soon.

Prenatal care: is the health care received by the mother during pregnancy of the

child-respondent which include checkups and testing.

Socio-economic status: means the economic and sociological measure of

family’s position particularly the head of the family which are classified as upper

class, upper middle class, lower middle class, upper lower class and lower class.

Type of birth: means the type of birth delivery when the child was born such as

natural or cesarean.
Review of Related Literature and Studies

This section presents various literatures which enable the researcher

conceptualize the study and take into account the variables which may have

bearing in the focus of the research. It delves into the system of health care

provision both from the international perspective and the local policies which may

affect the condition of the quality of health among the children specifically, in this

study, those who belongs to the indigenous group. Moreover, it will compare,

critique and contrast related studies which explored on the health associated

factors among children.

The Health Care System and Situations in the Philippines

The right to health is protected under the Philippine Constitution in Article

II, Section 15 which states that “The State shall protect and promote the right to

health of the people and instill health consciousness among them.” Article XIII,

Sections 11-13 of the Constitution sets out further provisions related to health. In

the PDP for the 2017–2022 period, the State has committed to accelerating

Human Capital Development and this includes improvements to health. The

targets set out in the PDP are reflected in the Philippines Health Agenda 2016-

2022.466 There are a number of laws on health in Philippines, including

legislation of broad reach such as RA 10606, the National Health Insurance Act

of 2013, and legislation that is more targeted, such as RA 10152, the Mandatory

Infants and Children Health Immunization Act of 2011 and RA 8504, the
Philippine AIDS Prevention and Control Act of 1998. Additional ‘subject specific’

laws are set out in the relevant sub-sections within this Chapter.

The Philippine health care system has rapidly evolved with many

challenges through time. Health service delivery was devolved to the Local

Government Units (LGUs) in 1991, and for many reasons, it has not completely

surmounted the fragmentation issue. Health human resource struggles with the

problems of underemployment, scarcity and skewed distribution. There is a

strong involvement of the private sector comprising 50% of the health system but

regulatory functions of the government have yet to be fully maximized.

Health facilities in the Philippines include government hospitals, private

hospitals and primary health care facilities. Hospitals are classified based on

ownership as public or private hospitals. In the Philippines, around 40 percent of

hospitals are public (Department of Health, 2009). Out of 721 public hospitals, 70

are managed by the DOH while the remaining hospitals are managed by LGUs

and other national government agencies (Department of Health, 2009).

The health human resources are the main drivers of the health care

system and are essential for the efficient management and operation of the

public health system. They are the health educators and providers of health

services. Most are concentrated in urban areas such as Metro Manila and other

cities. In the 2008 National Demographic and Health Survey (NDHS), 50 percent

of the clients who sought medical advice or treatment consulted public health

facilities, 42 percent went to private health facilities, and almost 7 percent sought

alternative or traditional health care. Rural Health Units (RHUs) and Barangay
Health Centers (33 percent) were the most visited health facilities in almost all

the regions except for NCR and CAR, where most of the clients visited private

hospital/clinic for medical advice or treatment. The most common reasons for

seeking health care were illness or injury (68 percent), medical checkup (28

percent), dental care (2 percent), and medical requirement (1 percent) (NSO,

2008). With regard to child delivery, more than thirty-six percent of infants are still

delivered by hilots despite aggressive efforts of the Department of Health to

promote facility-based delivery (National Statistics Office, 2008).

The hospital sector in the Philippines is highly segmented in nature.

Utilization of hospitals may be driven by PhilHealth insurance coverage and

socio-economic determinants. People with PhilHealth insurance are more likely

to be confined in a private hospital (56 percent), than those without Philhealth

insurance (28 percent). Similarly, patients living in urban area (52 percent) and

belonging to the richest quintile (74 percent) are also more likely to be confined in

private hospitals (Lavado et al., 2010). PhilHealth benefits include inpatient care;

maternity and newborn care; outpatient treatment for tuberculosis, rabies and

leptospirosis. The catastrophic ‘z-benefit’ package includes coverage for certain

cancers, cardiovascular surgeries, dialysis and kidney transplants; primary care

benefits include screening for breast cancer and cervical cancer; and small

medicines benefit. Indigent PhilHealth members benefit from no-balance billing,

which prohibits providers from charging the poor any fees or charges over and

above what is reimbursed by PhilHealth. There have been initiatives to reduce

the price of drugs through the Cheaper Medicines Act 2008 and improve the
availability of cheap medicines through the Botikang Barangay, Botikang Bayan

and PhP100- treatment pack initiatives.

The projected average life expectancy of Filipinos in 2005 to 2010 is 68.8

years, with males having an average life expectancy of 66.11 years and females

with 71.64 years (National Statistics Office, 2010). It is projected that the average

life expectancy of Filipinos will increase to 70.38 years from 2010 to 2015 and

71.59 years from 2015 to 2020 (National Statistics Office). Deaths and births are

commonly measured to determine the status of health and fertility dynamics of an

area. The crude death rate (CDR) has been declining since the 1960s. However,

no significant change has been noted since 2000-2009. The number of deaths in

a particular population is influenced by various environmental factors. Global

experience suggests that decreasing CDR is a result of decreasing cases of

infectious diseases, improvement of perinatal practices and innovative health

interventions (National Statistics Office, 2009).

Seven of the ten leading causes of death are non-communicable in

etiology. Cardiovascular diseases (i.e. diseases of the heart, and

cerebrovascular diseases), cancers, chronic obstructive pulmonary disease and

diabetes are the leading non-communicable diseases. The lingering problems on

infectious diseases like pneumonia and tuberculosis are still evident as they

ranked 4th and 5th leading causes of death (National Statistics Office, 2009).

Infant and maternal mortality are the most useful indicators since they

reflect the general condition of the health system. The mortality rate among

infants dropped from 57 infant deaths per 1000 live births in 1990 to 25 infant
deaths per 1000 live births in 2008 (National Statistics Office, 2008). However,

disaggregating IMR by socio-economic quintiles and regions reveals

performance disparities. WHO defines maternal mortality as death of a mother

while pregnant or within 42 days after delivery. Risks attributable to pregnancy

and childbirth as well as from poor quality health care services make this a strong

indicator for health care status. In developing countries, hemorrhage and

hypertensive disorder are the major causes of maternal death. Infant (under-1

year) mortality also decreased over the last decades. The infant mortality rate

was 41 deaths per 1,000 live births in 1990481 and had reduced to 21 deaths per

1,000 live births in 2015.482 In the PDP, the goal is to reduce the infant mortality

rate to 15 deaths per 1,000 live births by 2020.483 The SDGs do not include an

explicit target linked to infant (under-1) mortality, but instead focus on under-5

mortality and neonatal mortality.

Nevertheless, health reforms in the Philippines build upon the lessons and

experiences from the past major health reform initiatives undertaken in the last

30 years. It emphasized the delivery of eight essential elements of health care,

including the prevention and control of prevalent health problems; the promotion

of adequate food supply and proper nutrition; basic sanitation and adequate

supply of water; maternal and child care; immunization; prevention and control of

endemic diseases; appropriate treatment and control of common diseases; and

provision of essential drugs.

The Philippines has made significant investments and advances in health

in recent years. Rapid economic growth and strong country capacity have
contributed to Filipinos living longer and healthier. However, not all the benefits of

this growth have reached the most vulnerable groups, and the health system

remains fragmented. Health insurance now covers 92% of the population.

Maternal and child health services have improved, with more children living

beyond infancy, a higher number of women delivering at health facilities and

more births being attended by professional service providers than ever before.

Access to and provision of preventive, diagnostic and treatment services for

communicable diseases have improved, while there are several initiatives to

reduce illness and death due to non-communicable diseases (NCDs).

Health Associated Factors among Children

Existing data suggest that child mortality rates are significantly higher in

rural areas compared to urban areas. According to the Philippines National

Demographic and Health Survey 2013 (NDHS) the neonatal mortality rate was 9

deaths per 1,000 live births in urban areas, but stood at 18 deaths per 1,000 live

births in rural areas. The region with the highest neonatal mortality was

SOCCSKSARGEN at 29 deaths per 1,000 live births. Lastly, the under-5

mortality rate was also found to be higher in rural areas, at 38 deaths per 1,000

live births, as of 2013, in comparison to 25 deaths per 1,000 live births in urban

areas. The region with the highest under-5 mortality rate was ARMM with 55

deaths per 1,000 live births. The lowest was the Cagayan valley with 21 deaths

per 1,000 live births.

 Existing data shows that the educational status of the mother has an

impact on child mortality in the Philippines. The highest rate of under-5 mortality

in 2013 was found to be among those children born to mothers with no formal

education (61 deaths per 1,000 live births). For those children born to mothers

with elementary education the under-5 mortality rate stood at a lower 53 deaths

per 1,000 live births, dropping to 30 deaths per 1,000 live births for those children

whose mothers went to high school, and again to 16 deaths per 1,000 live births

for those whose mothers went to college.

Household wealth is also a significant predictor of child mortality in the

Philippines. Children born in the lowest wealth quintile have a higher level of

under-5 mortality, at 52 deaths per 1,000 live births, than those children in the

highest wealth quintile, where the rate stood at 17 deaths per 1,000 live births, as

of 2013.493 A similar association exists between household wealth and infant

mortality.

According to a report by the Philippines Child Health Epidemiology

Reference Group (CHERG) in 2010, the main causes of death for children under

1 month were pre-term birth complications (39.3 per cent), intrapartum

complications (25.4 per cent), congenital abnormalities (14.6 per cent) and

sepsis, meningitis or tetanus (13.2 per cent). For children under 5 years, the

main causes of death in 2010 were pneumonia (27.4 per cent), injury (15.1 per

cent) and diarrhoea (10.7 per cent) according to the CHERG estimates.

More recent estimates from WHO Global Health Observatory (2015)

suggest that the main causes of death for children under 1 month were
prematurity (32.7 per cent), birth asphyxia and trauma (23.1 per cent), congenital

abnormalities (17.2 per cent) and sepsis and infections (13 per cent). For

children under 5 years, the main causes of death were acute lower respiratory

infections (29.5 per cent), injuries (15 per cent), diarrheal disease (13.6 per cent),

and other communicable, perinatal and nutritional conditions (12.2 per cent),

according to WHO estimates from 2015.

The Expanded Program on Immunization (EPI) was launched in the

Philippines in 1976 to ensure that all Filipino children and mothers have access

to routinely recommended vaccines. The current standard immunization

schedule includes BCG, OPV, DPT, Hepatitis B, Haemophilus Influenzae type B

(HiB), IPV and Measles (MMR) vaccines. This year has also seen a policy shift

from the provision of Tetanus (TT) to Tetanus and Diphtheria (Td) vaccines for

pregnant women and women of reproductive age. PCV, Rotavirus and Dengue

vaccines have been piloted in some regions. School-based immunization was

introduced in 2013 to deliver routine immunizations to school-aged children and

catch up on missed doses.

Low immunization coverage rates (and in some cases declining

immunization coverage rates) have resulted in increased incidence of vaccine-

preventable diseases in the Philippines with, for example, two major outbreaks of

Rubella in 2001 and 2011, and a measles outbreak in 2014.

On Child’s Nutritional Status

Childhood wasting (low weight for height or ‘acute malnutrition’) is

estimated to affect around 7 per cent of under-5 children in the Philippines, as of

2015, which is still above the WHO’s target of 5 per cent for the year 2025 and

also above the PPAN target of 5 per cent or less by 2022. Childhood wasting

prevalence rates in the Philippines also compare unfavourably with the regional

average for East Asia and Pacific which stood at 4 per cent as of 2015.

Disparities between genders, wealth and geographical divides appear to

be relatively minor in relation to childhood wasting prevalence in the Philippines.

The percentage of children under the age of five years who were wasted in 2015

was higher among male children (8.3 per cent) compared to female children (7.6

per cent). It also appears that children living in rural areas are only slightly more

likely to be wasted (7.2 per cent) than those living in urban areas (7.0 per cent).

2015 NNS data reveal that wasting prevalence rates are highest in MIMAROPA

(9.7 per cent), Eastern Visayas (8.4 per cent), and ARMM (8.2 per cent); and

lowest in Northern Mindanao (4 per cent) and CAR (4.5 per cent).

Low birth weight is closely associated with foetal and neonatal mortality

and morbidity. The WHO defines low birth weight as weight at birth of less than

2.5 kilograms. According to the 2013 NDHS, 21.4 per cent of children in the

Philippines had low birth weight.828 The low birth weight prevalence in the

Philippines compares unfavourably to the global average of 16 per cent as of

2015. According to NDHS data, a child is more likely to be born underweight if

the mother is under 20 years old (25.1 per cent) or aged 35–49 (24.2 per cent),

rather than aged 20–34 (20.2 per cent). There appears to be no significant

difference between rural and urban areas in relation to low birth weight

prevalence in the Philippines. The regions with the highest percentage of children
with a low birth weight are Central Visayas (25.5 per cent), MIMAROPA (25.3 per

cent) and Caraga (25.1 per cent). The lowest low birth weight prevalence was

found in Davao (16 per cent).

Meanwhile, overweight prevalence in children under 5 years has been

increasing in the Philippines since at least the early 1990s, albeit at a relatively

low level. While in 1989, overweight prevalence in under-5 children stood at only

1.1 per cent, this rose to 5.1 per cent by the year 2013. According to a 2015

report by the Special Rapporteur on the Right to Food, the gradual increase in

overweight and obesity levels (also among the adult population) corresponds to a

change in nutritional habits, with a move away from high-fiber healthier foods to

meat, dairy and canned and packaged foods. In addition, urban dwellers are

increasingly vulnerable to food price hikes and in such cases, opt for less

nutritious foods which are usually cheaper.

Conceptual Framework

Various factors may be associated to the health of the children which

when identified and given intervention will improve the health and well-being of

the children - the hope of the society. In aiming towards healthy citizens, it shall

include all children from all walks of life regardless of gender, race, color, ethnic

group and religion. It is in this idea that indigenous group rights have been put

onto the pedestal in the social services instead of focusing only to some known

and common people in a community.

Among the challenges of indigenous groups is the health and welfare of

their children which are still bonded and restricted by their own cultures and

traditions. In this study, health related factors such as the family socio-economic

status, educational attainment of the parents, parents’ age, type of birth, order of

the birth, number of pre-natal check-up, and the number of immunization

received are treated as the independent variables of the study while the health

condition or status of the child becomes the dependent variables. The figure

below shows how these variables interact with one another.

Figure 1 The Schematic Diagram