MAN Thesis JonaberTM PDF

EXTENT OF THE IMPLEMENTATION OF HEALTHCARE SERVICES
AMONG SAMA TRIBES OF SIBUTU, TAWI-TAWI
A Thesis
Presented to
The Faculty of the Graduate School Studies
College of Health Sciences
Mindanao State University
Marawi City
In Partial Fulfillment
of the Requirements for the Degree
Master of Arts in Nursing
(Nursing Administration)
JONABER TIANOK MOHAMMAD–SABIL, RN
OCTOBER 2018
Republic of the Philippines
Marawi City
The Faculty of the Graduate School of the Mindanao State University

at Marawi City accepts the thesis entitled
EXTENT OF THE IMPLEMENTATION OF HEALTH CARE SERVICES

AMONG SAMA TRIBES OF SIBUTU, TAWI-TAWI
Conducted and submitted by JONABER

JANISHA TIANOKRN,
M. MANDARA, MOHAMMAD-SABIL
MAN
in partial fulfillment of the requirements for the degree Master of Arts in
Nursing, Major in Nursing Administration
NAIMA D. MALA, RN, MN, MAN, PhD

Adviser
ATHENA JALALIYAH D. LAWI, RN, MN, MAN, PhD MINOMBAO R. MAYO, PhD
Panel Member Panel Member
RANDY IAN GALLEGO, RN, MAN HAMDONIE K. PANGANDAMAN, RN, MAN

Panel Member Panel Member
RANDY IAN GALLEGO, RN, MAN

Chairperson, Graduate Studies Department
College of Health Sciences
NAIMA D. MALA,
NAIMA MALA, RN,
RN, MN,
MN, MAN,
MAN, PhD
PhD
Dean, College of Health Sciences
MINOMBAO R.
MINOMBAO R. MAYO,
MAYO, PhD
PhD
Dean, Graduate School
ACKNOWLEDGMENTS
Above anything and everything, the researcher thanks the Almighty ALLAH
SWT for giving him the guidance, courage, strength, patience, wisdom and all means in
the preparation of this inquiry.
The researcher wishes to express his sincere thanks to all those who contributed in
many ways to the success of this study:
Dr. Naima Datumanong-Mala, Dean of the College of Health Sciences, his
thesis adviser, for being a great teacher and adviser, for inspiring him and instilling
determination when circumstances tended to be unfavorable, for reviewing and editing
his work and helping him learn the complexities in thesis writing. Her incomparable
generosity and tremendous optimism furnished the researcher ability to finish this thesis;
His thesis consultant during his proposal and dignified panel members Dr. Athena
Jalaliyah D. Lawi, Dr. Salmah M. Basher, and Prof. Ashley A. Bangcola for their
comments and suggestions they shared that is beneficial in the completion of this study;
His thesis panel members Dr. Athena Jalaliyah D. Lawi, Prof. Hamdonie K.
Pangandaman, and Prof. Randy Ian Gallego for their substantial contribution to the
organization of the study and for giving time for this piece of work;
Dr. Minombao Ramos-Mayo, Dean of the Graduate School, for her comments
and invaluable inputs which added substance and form to this research;
Mr. Blair Taylaran, for editing the grammar of this paper;
His Statistician, Prof. Hamdoni K. Pangandaman, of the College of Health
Sciences, for checking my statistics and tabulated data;
Their contribution facilitated much to survive an almost insurmountable task a
reality.
-THE RESEARCHER
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DEDICATION
In the Name of Allah, the Most Gracious, the Most Merciful.
This work is dedicated to my family, my advisors, and my friends. I thank and
give very special gratitude to my beloved parents whose words of encouragement ring in
my ears. To my sisters, Neneng, Lala, Sheila, Mina, Len and Indah, thank you for all the
things you have done for me. I know you will be proud of me in doing this
accomplishment.
I would like to sincerely thank my thesis adviser, Ma’am Naima D. Mala, for your
advice, guidance, support, and patience throughout this study. And to the thesis
committee, thank you for the comments and suggestions you shared that is beneficial to
this study.
My dear friend, Irene Lou O. Erazo, thanks for always being there and for always
lending me you laptop whenever I needed it.
To Auntie Ednabel L. Angeles, Jana, and Kano, thanks for welcoming me in your
family, for support, and for showing me that we can be family even if we’re not blood
related.
And last but not the least, I dedicated this work to the best person I ever had,
Chan, for always being there for me. Thank you for your endless support, care, and
attention. Thanks for being a person who always there beside me.
Above all, this work is dedicated to Allah, the Almighty. Thank you for guiding
me and giving me strength in my everyday life.
“No success gained without pain and effort”.
-Jonaber
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ABSTRACT
JONABER TIANOK MOHAMMAD-SABIL, RN, MAN. “EXTENT OF
THE IMPLEMENTATION OF HEALTH CARE SERVICES AMONG SAMA
TRIBES OF SIBUTU, TAWI-TAWI.”A Master’s Thesis. Master of Arts in Nursing,
College of Health Sciences, Mindanao State University, Marawi City, October 2018.
Thesis Adviser: Dr. Naima D. Mala, RN, MN, MAN
The Department of Health aims to provide quality health care services to all
Filipinos, and thus, implement programs that enhance the lives of the citizen. Expanded
Program on Immunization, Antenatal Care, and Family Planning are just some of
programs that the DOH provided that it gives importance in addressing the problems on
maternal and neonatal mortality and reducing child mortality rate.
This research used an inferential research design using both the qualitative and
quantitative approach in the interpretation of data. Data were gathered from 473
respondents comprising the Sama tribes of Sibutu, Tawi-Tawi. Problems soughed for
answers were: socio-economic profile of the respondents; barriers and factors affecting
the implementation of health care services; extent of the implementation of health care
services such as EPI, Antenatal Care, and Family Planning; the relationship between the
profile, barriers and factors to the extent of the implementation of health services.
Thematic results consisted of the following: (a) health care services such as the
EPI and antenatal care is always implemented; (b) there is a rare proper management of
pregnancy and delivery complications; (c) Family Planning is often implemented; (d)
personal attributes such as age, occupation and monthly income, barriers in the
implementation of health care services in terms of attitude, culture and beliefs, and family
and social dynamics, and factors affecting the implementation of health care services in
terms of accessibility of healthcare and availability of healthcare providers has significant
relationship to the extent of the implementation of health care services.
Most of the respondents belong to 5-7 members in the family, were high school
graduates, and mostly with an income of 2,501 to 5,000 pesos/month which implies that
the people belong to marginalized poor and that how can they afford to go to the health
facilities for consultation.
The researcher recommends a Multi-sectoral approach of addressing the problems

based on the findings of the study; a Population Education to the place should be done;
the tribe should reduce number of children depending on their income; there should be
adequate dispensing of the medicines/supplies intended for them; a conduct of Behavioral
Change Program to the respondents; to improve the attitude of the health care team in the
provision of health care; and to conduct a qualitative research for in-depth interview of
the Sama tribes to support the findings of the study and for further validation.
Key words: Expanded Program on Immunization, Antenatal Care, Family Planning,

implementation of health care services, Sibutu, Tawi-Tawi
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TABLE OF CONTENTS
Page
TITLE PAGE i
APPROVAL SHEET ii
ACKNOWLEDGMENTS iii
DEDICATION iv
ABSTRACT v
TABLE OF CONTENTS vi
LIST OF TABLES viii
LIST OF FIGURES ix
CHAPTER
1 THE PROBLEM AND ITS SCOPE
Rationale 1
Theoretical Framework 3
Conceptual Framework 6
Statement of the Problem 8
Null Hypotheses 9
Significance of the Study 9
Scope and Delimitations of the Study 11
Definition of Terms 12
2 REVIEW OF RELATED LITERATURE AND STUDIES
Review of Related Literature

The Philippine Health System Overview 16
Expanded Program on Immunization (EPI) 18
Antenatal Care 19
Family Planning (FP) 21
Review of Related Studies
Socio – Economic Profile and Health Care Services 24
Attitude as a Barrier 27
Culture and Beliefs as a Barrier 29
Family and Social Dynamics as a Barrier 31
Accessibility of Health Care Services as a Factor 32
Availability of Health Care Providers as a Factor 36
Provision of Care and Quality of Services as a Factor 37
3 RESEARCH METHODOLOGY
Research Design 42
Research Locale 42
Sampling Procedure 45
Respondents of the Study 46
vi
Research Instruments and Its Validity 47
Data Gathering Procedure 48
Statistical Treatment/Tools 48
4 DATA PRESENTATION, ANALYSIS, AND INTERPRETATION

OF FINDINGS
Profile of Respondents 54
Barriers in the Implementation of Health Care Services 65
Factors Affecting the Implementation of Health 80
Care Services
Extent of the Implementation of Health Care Services 85
Significant Relationship between Variables 91
5 SUMMARY, FINDINGS, CONCLUSION, AND

RECOMMENDATIONS
Summary 99
Major Findings 100
Conclusion 103
Recommendations 105
REFERENCES 108
APPENDIXES
A Sample Letter to the Respondents 115

B Sample Consent Form 116
C Research Questionnaire 117
D Proof or Certificate of Editing 127
E Proof of Statistical Analysis 128
F Curriculum Vitae 129
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LIST OF TABLES
Table Page
1 Stratified Sample of Research Respondents 46
2 Frequency and Percentage Distribution of Respondent’s Age 54
3 Frequency and Percentage Distribution of Respondent’s Sex 55
4 Frequency and Percentage Distribution of Respondent’s Civil Status 57
5 Frequency and Percentage Distribution of Respondent’s Religion 58
6 Frequency and Percentage Distribution of Respondent’s Family Type 59
7 Frequency and Percentage Distribution of Respondent’s Family Size 60
8 Frequency and Percentage Distribution of Respondent’s Highest 61

Educational Attainment
9 Frequency and Percentage Distribution of Respondent’s Occupation 63
10 Frequency and Percentage Distribution of Respondent’s Monthly 64

Family Income
11 Barriers in the Implementation of Health Care Services in terms of 66

Attitude towards Expanded Program on Immunization (EPI)

Attitude towards Antenatal Care

Attitude towards Family Planning

Culture and Beliefs towards Expanded Program on Immunization (EPI)

Culture and Beliefs towards Antenatal Care

Culture and Beliefs towards Family Planning

Family and Social Dynamics towards Expanded Program on
Immunization (EPI)

Family and Social Dynamics towards Antenatal Care

Family and Social Dynamics towards Family Planning
20 Factors Affecting the Implementation of Health Care Services 80

in terms of Accessibility

in terms of Availability of Health Care Providers

in terms of Provision of Care and Quality of Services
23 Extent of the Implementation of Health Care Services in terms of 86

Expanded Program on Immunization (EPI)

Antenatal Care

Family Planning
26 Relationship Between Respondents Socio-Economic Profile and 92

Extent of the Implementation of Health Care Services
27 Relationship Between Barriers in the Implementation of Health Care 95

Services and the Extent of its Implementation
28 Relationship Between Factors Affecting the Implementation of Health 97

Care Services and the Extent of its Implementation
viii
LIST OF FIGURES
Figure Page
1 A Schematic Diagram Showing the Interplay Between the 7

Independent and Dependent Variables of the Study
2 Map of Sibutu, Tawi-Tawi Highlighted 44

Chapter 1
THE PROBLEM AND ITS SCOPE
Rationale
The intention to provide the people’s rights to health has been the motivation on
the attempt to achieve universal health coverage. The right to health is not right to be
healthy, but the State must secure a citizen’s rights to access health care services and any
underlying determinants of health. Globally, reducing maternal mortality is the health-
related Millennium Development Goal whose progress has been considered to be the
most disappointing to date. This highly complex, system-level issue must be addressed
across the system rather than in isolation from it. By coordinating actions across different
parts of the health system, programs to improve maternal and neonatal health can
increase coverage and reduce barriers to the use of various services.
The Philippines faces unique challenges in aligning its health system with the
needs of its inhabitants, mainly because of the country’s geography and income
distribution. Many communities are located in isolated mountain regions of the country
or in coastal areas that are difficult to reach. There are also wide disparities in the use of
health services across income levels. A recent study found that 94% of women in the
richest quintile delivered with a skilled birth attendant, compared with 25% in the
poorest; and 84% of women in the richest quintile had a facility-based birth, compared
with 13% in the poorest. These discrepancies contribute directly to the country’s elevated
maternal mortality ratio (MMR). The MMR in the Philippines is higher than in other
middle-income countries in the region, such as Vietnam. The Government of the

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Philippines has placed health and maternal health high on its political agenda of reform.
(Philippines National Demographic and Health Survey, 2008)
Similarly, infant deaths or deaths of children below one year old decreased from
25 to 22 deaths per 1,000 live births – which is also close to the 2015 MDG target of 19
deaths per 1,000 live births. However, almost half of the infant deaths are neonatal
deaths, or fatalities occurring within the first 28 days of life, which show a slow decline
in reduction from 18 to 14 per 1,000 live births from 1993 to 2011.
The Department of Health aims to provide quality health care services to all
Filipinos, and thus, implement programs that enhance the lives of the citizens. Expanded
programs on immunization, antenatal care and family planning are just some of programs
that the DOH gives importance to address the problems on maternal and neonatal
mortality. Likewise, reducing child mortality rate (MDG 4) and improving maternal
health (MDG 5), are among the eight Millennium Developmental Goals (MDGs) that 192
United Nations member states and 23 international organizations have agreed to achieve
by the year 2015. To realize these goals, various government and non-government
institutions are encouraged to participate and cooperate.
The Island of Sibutu Tawi-Tawi has only one (1) rural health unit, one (1) district
hospital and two (2) barangay health stations. These facilities leniently serve 16
barangays with a total population of 28,532 according to the 2010 census of population.
As per observation, the researcher witnessed the complexity when it comes to access to
the health care services in the island. Despite of the governments’ effort to reduce
maternal and child mortality, a quite inevitable number of unreported cases of maternal
and neonatal death persist. With regard to immunization, there were still times that
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vaccines were scarce, the parents were non-compliant with the schedule of immunization,
and cases of vaccine preventable disease were relatively present in the island. On the
other hand, the family planning program had already been implemented. But it was
observed that only few couples have advocated and practiced it due to the misconception
that practicing family planning would cause sterility to the user. Those were just a few
identified problems that the researcher personally encountered, which subsequently
served as a motivation to look for solutions.
Hence, the researcher then conducted this study to identify the factors that affect
the implementation of health care services and as to what extent the DOH programs,
specifically the Expanded Program on Immunization, Antenatal Care and Family
Planning are being implemented among Sama Tribes.
Theoretical Framework
The study was anchored on the following theories: the Health Belief Model,
Andersen’s Behavioral Model of Health Service Utilization, and Bradshaw’s Need
Taxonomy.
Health Behavior, the Health Belief Model was developed by social
psychologists Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegeles, and
Howard Leventhal, (1950) at the U.S. Public Health Service to better understand and
explain why people failed to utilize health services. The Health Belief Model suggests
that “people’s belief about health problems, perceived benefits of action and barriers to
action and self-efficacy explains in the engagement in health promoting behaviour.” A
stimulus, or cue to action, must also be present in order to trigger the health-promoting
behavior. Recipients of heath care services have different views and perceptions as when
4
they seek health care services. Most of the time they, they primarily weigh the situation
based on their perceived advantages and disadvantages before they choose to take an
action or not. People’s belief systems shape their behavior towards health.
In this study, the health belief model is used as it could explain and predict the
individual changes in health behavior of the respondents. It is one of the most widely
used models for understanding health behaviors. As this model defines the key factors
that influence health behaviors as an individual’s perceived threat to sickness or disease,
belief of consequence, potential positive benefits of action, perceived barriers to action,
exposure to factors that prompt action and confidence in ability to succeed.
The Behavioral Model of Health Service Utilization by Ronald M. Andersen
(1968) was initially developed in the late 1960s. According to the model, usage of health
care services (including patient care, physician visit dental care and etc.) is determined by
three dynamics; predisposing factor, enabling factors and need factors. First, the
predisposing factors can be characterized such as race, age, and health beliefs. Second is
the enabling factor, which includes family support, access to health insurance, and one’s
community services. And, third and final factor is the need factor which represents both
the perceived and actual need for health care services.
In this study, the extent of implementation of healthcare services such as EPI,
antenatal care, and family planning also affected by almost the same factors as to what
Andersen, (1968) identified in his theory. Individuals tend to seek care if they perceive
that they need it. To some extent, people seek help when they are already in the state of
emergency. In general, people’s health seeking behavior varies according to their
perceived need considering the situation that they are currently facing. Second is their
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level of maturity and cultural practices. The last one is knowledge or information
regarding health care services being offered to the clients.
Bradshaw’s Need Taxonomy (Jonathan Bradshaw, 1972) believed that care is
best distributed based on the patients’ needs. The author also states that the entity can
only be needed if it is an important factor in achieving a goal. Moreover, Need
Taxonomy theory also distinguishes four varieties of need namely: normative, felt,
expressed, and comparative (Culyer and Wagstaff, 1993). The need for care is universal
to all human beings; the care the people need may come from other individuals, family,
community, country. In Community Health Nursing, care is being rendered to a group of
people in a community. A Health Care Provider’s main responsibility is to assess the type
of health care services that the community needs and to ensure that their needs are being
met. People are far more satisfied if their needs are being met.
In this study, Bradshaw’s Need Taxonomy was used as need is an important
concept in public health. It was used in the planning and management of health services
including health improvement, resource allocation, and equity. In this study, the example
of normative need was vaccinations; felt need were need perceived by an individual
which were limited by individual perceptions and knowledge of services; expressed need
were individuals’ help seeking behavior towards health; and comparative need were
needs identified by comparing the health services received by one group of individuals
with those received by another comparable group.

6
Conceptual Framework
In this study, there were three identified independent variables and these included
the following: First, the socio-economic profile of the settled Sama Tribe in Sibutu Tawi-
Tawi. Second, the perceived barriers in the implementation of health care services. And
the last were the factors affecting the implementation of health care services. The socio –
economic profile was indicated by age, gender, civil status, religion, family size/type,
educational attainment, occupation and family monthly income. Moreover barriers in the
implementation of health care services include; attitude, culture and beliefs, family and
social dynamics whereas factors affecting the implementation of health care services
were also identified in terms of accessibility and availability of health care services,
availability of health care providers, and provisions of care/quality service. On the other
hand, the dependent variable in this study was the extent of the implementation of health
care services /DOH programs, specifically the Expanded Program on Immunization,
Antenatal Care and Family Planning. Implementation of health care services/DOH
programs believed to be dependent on the socio economic profile of the respondents, the
barriers in the implementation of health care services as well as on the factors affecting
the implementation of health care services that the respondents encountered.

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INDEPENDENT VARIABLES DEPENDENT VARIABLES
I – Socio – economic profile:

• Age
• Sex
• Civil status
• Religion
• Family size/type
• Educational attainment
• Occupation
• Family income
IV - Extent of the implementation of

II – Barriers in the implementation
the health care services:
of HC services:
• Expanded Program on
• Attitude
Immunization
• Culture and Beliefs
• Antenatal Care
• Family and Social Dynamics
• Family Planning
III – Factors affecting the

implementation of HC services:
• Accessibility and
Availability of HC services
• Availability of Health Care
Providers
• Provision of Care and
Quality of Services
FIGURE 1 : A Schematic Diagram Showing the Interplay Between

The Independent and Dependent Variables of the Study
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Statement of the Problem
The study aimed to know the extent of implementation of health care services and
identify the factors that might affect the implementation of these health care services
among Sama Tribes of Sibutu, Tawi-Tawi. Specifically, it answer the following
questions:
1. What are the Socio – economic Profile of the Sama Tribe in terms of:
1.1. Age;
1.2. Sex;
1.3. Civil Status;
1.4. Religion;
1.5. Family Type/Size;
1.6. Educational Attainment;
1.7. Occupation; and
1.8. Family Income?
2. What are the barriers in the implementation of health care services in terms of:
2.1. Attitude;
2.2. Culture and beliefs; and
2.3. Family and Social dynamics?
3. What are the factors affecting the implementation of health care services in terms of:
3.1. Accessibility of health care services;
3.2. Availability of health care providers; and
3.3. Provision of care and quality of services?

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4. What is the extent of the implementation of the Health Care Services as to the
selected DOH Programs in terms of:
4.1. EPI;
4.2. Antenatal Care; and
4.3. Family Planning?
5. Is there a significant relationship between the socio – economic profile of the
respondents and the extent of the implementation of health care services?
6. Is there a significant relationship between the barriers in the implementation of the
health care services and the extent of its implementation?
7. Is there a significant relationship between the factors affecting the implementation of
the health care services and the extent of its implementation?
Hypothesis
On the basis of the specific research questions, the following null hypotheses
were formulated and were tested using 0.05 level of significance. Hence;
H01 There is no significant relationship between the respondents’ socio-economic
profile and the extent of its implementation.
H02 There is no significant relationship between the barriers in the implementation
of the health care services and the extent of its implementation.
H03 There is no significant relationship between the factors affecting the
implementation of the health care services and the extent of its implementation.
SIGNIFICANCE OF THE STUDY
The result of this research study had found to have significance to the following:
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Department of Health (DOH). The result of this study could be used as bases to
improve the delivery of quality, safe and efficient health services that the community
receives and will serve as a basis in creating and implementing resolutions to fully
support the implementation of Integrated Health Care Program.
College of Health Sciences (CHS). The findings of this study are vitally essential
that could broaden the understanding on the DOH health services and the status of its
implementation on rural or remote areas.
Local Government Units. Through the result of this study, it could serve as basis
and reference in creating and implementing resolutions to fully support the
implementation of Integrated Health Care Program.
Health Care Personnel. With the result and findings of this study, it should serve
as reference of relevant information that would help and guide them to formulate
solutions to improve and strengthen the implementation of DOH programs.
Community People. Such findings of this study, it could aid as an inquiry
improved the quality of safe and efficient health services that the community receives,
and increase their level of satisfaction as customers of healthcare.
Registered Nurses. The results of this research may broaden their awareness on
the impact of accessibility of public health care services. This study would also serve as a
basis for the improvement in the nursing practice, specifically the delivery of safe and
efficient health care services.

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Respondents. The result of this study may encourage the respondents to increase
their awareness on health care programs. Furthermore, this would make them value the
importance and benefits of the health care services being offered and thus cooperate as
the primary recipient of health programs.
Future Researchers. The study may serve as a reference for those who plan to
pursue researches on the extent of the implementation of health care services. The study
could guide in creating innovations in the delivery of safe and quality health care.
Scope and Delimitations of the Study
This study was conducted to determine the extent of the implementation of health
care services and the factors that may affect its implementation among Sama tribes of
Sibutu, Tawi – Tawi. Specifically, it focused on the selected DOH programs, which
included the Expanded Program on Immunization (EPI), Antenatal Care and Family
Planning (FP) only. Moreover, it determined the relationship between the socio –
economic profile (age, sex, civil status, religion, family size/type, family income,
educational attainment, and occupation) and the level or extent of implementation of
health care services among Sama tribes of Sibutu, Tawi – Tawi.
Participants of the study were the household heads of the family either the mother
or the father from Sama Tribe. It comprised approximately 473 respondents from 16
barangays. The location where the study conducted was in the Island of Sibutu under the
Province of Tawi-Tawi. Stratified Random and Simple Random Sampling were
employed. Self-constructed survey questionnaires were given to the participants of the
study to further assess the status of health care implementation in the Island. The
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selection of household head depend on the couple’s presence and its decision of whom
among them should participate during the course of data collection. Respondents below
18 years, who have their own families were included in the study. The hospital facilities,
type of patients, and staff nurses’ attitudes, were not included as variables of the study.
Hence, it was considered a limitation.
Definition of Terms
To facilitate better understanding of the reader, the following terms were defined
conceptually and operationally.
Accessibility of the Health Care Services. It means as "the timely use of personal
health services to achieve the best health outcomes" (IOM, 1993). Accessible. Able to be
used or entered. In the U.S., under the requirements of the Americans with Disabilities
Act (ADA), public places and places of employment must be accessible to the disabled
through architectural design (e.g., ramps, wheelchair-wide doorways) and/or the use of
assistive technologies (Taber’s Cyclopedic Medical Dictionary 21st Edition; 2009).
In this study, it refers to the opportunity to identify healthcare needs, to seek
healthcare services, to reach, to obtain or use health care services, and to actually have a
need for services fulfilled.
Antenatal Care. This refers to the regular monitoring and management of the
health status of the pregnant woman and her fetus during the period of gestation (Taber’s
Cyclopedic Medical Dictionary 21st Edition; 2009).

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For the purpose of this study, antenatal care refers to set of actions and services
administered by the Department of Health to aid women before, during and after
pregnancy.
Attitude. It pertains to a particular attitude may be a symptom of disease (e.g., the
stereotyped posturing assumed by catatonics) and it also means a long-standing point of
view that guides or influences one’s behaviors; a predisposition to think about things and
respond to them in internally consistent or patterned ways (Taber’s Cyclopedic Medical
Dictionary 21st Edition; 2009).
In this study, it is identified as one of the barriers in the implementation of health
care services; it also refers to the uncooperative behavior of the community people.
Availability of the Health Care Provider. Availability is the quality or state of
being available; an available person or thing (Merriam – Webster; 2006).
In this study, it refers to the health care provider’s availability to be reached by
the community people.
Culture. It is defined as shared human artifacts, attitudes, beliefs, customs,
entertainment, ideas, language, laws, learning, and moral conduct (Taber’s Cyclopedic
Medical Dictionary 21st Edition; 2009) while Beliefs is a nursing outcome from the
Nursing Outcomes Classification (NOC) defined as personal convictions that influence
health behaviors.
In this study, culture and beliefs refers to the beliefs and customs of the Sama
tribe appertaining to health.
Immunization. This refers to vaccination that works by stimulating the immune
system of the body to fight disease. A healthy immune system is able to recognize
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invading bacteria and viruses, and it produces antibodies to destroy or disable them.
Immunizations prepare the immune system to ward off a disease. To immunize against
viral diseases, the virus used in the vaccine has been weakened or killed. To immunize
against bacterial diseases, it is generally possible to use only a small portion of the dead
bacteria to stimulate antibodies against the whole bacteria. The effectiveness of
immunizations can be improved by periodic repeat injections, called boosters. For
information about specific immunizations, see the name of the disease (for examples,
DTP immunization, hepatitis B immunization, polio immunization) (Websters New
World Medical Dictionary; 2008).
In this study, the term refers to immunization or the vaccines expected to be given
to children ages at birth – 1 year old.
Family. This pertains to a group of individuals who have descended from a
common ancestor. And it means a group of people living in a household who share
common attachments, such as mutual caring, emotional bonds, regular interactions, and
common goals, which include the health of the individuals in the family (Taber’s
Cyclopedic Medical Dictionary 21st Edition; 2009).
In this study, the term refers to a group of individuals who have descended from a
common ancestor.
Family Planning. This refers to the spacing of conception of children according
to the wishes of the parents rather than to chance. It is accomplished by practicing some
form of birth control. (Taber’s Cyclopedic Medical Dictionary 21st Edition; 2009) The
practice of exercising some level of control over contraception. Birth control methods are
15
many, and they vary in effectiveness. The most effective method is abstinence from sex,
followed by oral, injectible, or implanted contraceptives; barrier methods used
consistently and with spermicidal gel; and the basal temperature method, if used carefully
and consistently (Webster’s New World Medical Dictionary; 2008).
In this study, the term refers to the couples’ use of different kinds of
contraceptives that the health care facilities offered in order to control birth.
Implementation. This means carrying out, accomplish; especially: to give
practical effect to and ensure of actual fulfilment by concrete measures. And it means to
provide instruments or means of expression for (Merriam – Webster; 2006).
Provision/ Quality of Services. This is an assessment of how well
a delivered service conforms to the client's expectations. Service business operators often
assess the service quality provided to their customers in order to improve their service, to
quickly identify problems, and to better assess client satisfaction
(http://www.businessdictionary.com/definition/service-quality.html).
Social Dynamics. It can refer to the behavior of groups that results from the
interactions of individual group members as well to the study of the relationship between
individual interactions and group level behaviors (wikipedia.org; 2002).
In this study, it refers to the Sama group behaviour (social interaction).

16
Chapter 2
REVIEW OF RELATED LITERATURE AND STUDIES
This chapter presents the different review of literature and studies which are
found by the researcher to have relevance to the present investigation.
Related Literature
The Philippine Health System Overview
The health status of Filipinos has improved dramatically in the Philippines over
the last forty years: infant mortality has dropped by two thirds, the prevalence of
communicable diseases has fallen and life expectancy has increased to over 70 years.
However, considerable inequities in health care access and outcomes between socio-
economic groups remain. A major driver of inequity is the high cost of accessing and
using health care. The Philippines has a national health insurance agency – PhilHealth –
since 1995 and incrementally increased population coverage, but the limited breadth and
depth of coverage has resulted in high-levels of out of pocket payments. In July 2010 a
major reform effort aimed at achieving ‘universal coverage’ was launched, which focused
on increasing the number of poor families enrolled in PhilHealth, providing a more
comprehensive benefits package and reducing or eliminating co-payments.
Attracting and retaining staff in under-served areas are the key challenges. The
Philippines is a major exporter of health workers, yet some rural and poor areas are still
facing critical shortages. Inefficiency in service delivery persists as patient referral
system and gatekeeping do not work well. Successive reform efforts in financing, service
delivery and regulation have attempted to tackle these and other inefficiencies and
17
inequalities in the health system. However, implementation has been challenged by the
decentralized environment and the presence of a large private sector, often creating
fragmentation and variation in the quality of services across the country. Never the less
the government health care system, is mostly directed towards the low-income groups. It
consists of Barangay Health Stations (BHS), with a midwife, and Rural Health Units
(RHU), which are supposed to be staffed by a team consisting of a physician, nurse, and
midwife. The ratio of health facilities to population continued to decline from 1982 to
1989 for all types of facilities.
Stressing the interrelationship between the hospital and other health and non-
health services, Solon et al. (1991, Vol. 1, p. 39), point out that hospitals have the
primary role of providing services for people who become ill from diseases that are not
readily preventable by non-health sector activities (e.g., use safe water sources). Thus,
expenditures for preventive health services should comprise a large component of the
total health expenditure. Health status may be significantly raised if all preventive
measures are exhausted so that the relatively high cost curative measures, those that
hospitals are meant to provide, can be minimized. It is therefore necessary to assess the
improvement in health status brought about by hospital services vis-a-vis field services.
Expounding along the same idea, Dr. Thelma Navarette-Clemente (1992), President of
the Philippine Hospital Association (PHA), in a newspaper article, wrote that the walls of
hospitals have disappeared by extending not only curative but also preventive (e.g.,
immunization, health education) and rehabilitative services to the communities.

18
Expanded Program on Immunization
The Expanded Program on Immunization (EPI) in the Philippines began in July
1979, and in 1986, made a response to the Universal Child Immunization goal. The four
major strategies include: (1) sustaining high routine of Fully Immunized Child (FIC) with
coverage of at least 90% in all provinces and cities; (2) sustaining the polio-free country
for global certification; (3) eliminating measles by 2008; and (4) eliminating neonatal
tetanus by 2008. Every Wednesday is designated as immunization day and is adopted in
all parts of the country. The standard routine immunization schedule for infants in the
Philippines is adopted to provide maximum immunity against the seven vaccine
preventable diseases in the country before the child's first birthday.
Thus the fully immunized child must have completed BCG 1, DPT 1, DPT 2,
DPT 3, OPV 1, OPV 2, OPV 3, HB 1, HB 2, HB 3 and measles vaccines before the child
is 12 months of age. EPI vaccines includes: Bacillus Calmette-Guérin given at Birth or
anytime after birth. BCG given at earliest possible age protects the possibility of TB
meningitis and other TB infections in which infants are prone; Diphtheria-Pertussis-
Tetanus Vaccine given at 6 weeks old – 3 doses. An early start with DPT reduces the
chance of severe pertussis; Oral Polio Vaccine given at 6 weeks old – 3 doses. The extent
of protection against polio is increased the earlier the OPV is given. An early start of
Hepatitis B vaccine reduces the chance of being infected and becoming a carrier. It also,
prevents liver cirrhosis and liver cancer which are more likely to develop if infected with
Hepatitis B early in life. For Measles Vaccine, it prevents up to 85% if given at 9 months
as part of the routine infant vaccination schedule. Moreover, if the vaccination schedule
19
is interrupted, it is not necessary to restart. Instead, the schedule should be resumed using
minimal intervals between doses to catch up as quickly as possible.
There are very few true contraindication and precaution conditions. Only two of
these conditions are generally considered to be permanent: severe (anaphylactic) allergic
reaction to a vaccine component or following a prior dose of a vaccine, and
encephalopathy not due to another identifiable cause occurring within 7 days of pertussis
vaccination. It is important to note that only the diluent supplied by the manufacturer
should be used to reconstitute a freeze-dried vaccine. A sterile needle and sterile syringe
must be used for each vial for adding the diluent to the powder in a single vial or ampoule
of freeze-dried vaccine.
Antenatal Care
The Maternal Health Program is a set of actions and services administered by
the Department of Health to aid women before, during and after pregnancy. The
Philippines is tasked to reduce the maternal mortality ratio (MMR) by three quarters by
2015 to achieve its millennium development goal. The overall goal of the Maternal
Health Program is to improve the survival, health and well being of mothers and unborn
through a package of services all throughout the course of and before pregnancy.
Pregnant women should have at least four prenatal visits with time for adequate
evaluation and management of diseases and conditions that may put the pregnancy at
risk. Postpartum care should extend to more women after childbirth, after a miscarriage
or after an unsafe abortion.
As a result, pregnancy poses a risk to the life of every woman. Pregnant women
may suffer complications and die. Every woman has to visit the nearest facility for
20
antenatal registration and to avail prenatal care services. This is the only way to guide her
in pregnancy care to make her prepare for child birth. The standard prenatal visits that
women have to receive during pregnancy are as follows: 1st visit - As early in pregnancy
as possible before four months or during the first trimester; 2nd visit - During the
2nd trimester; 3rd visit - During the 3rd trimester; and Every 2 weeks - After 8th month of
pregnancy till delivery.
Neonatal Tetanus is one of the public health concerns that people need to address
among newborns. To protect them from deadly disease, tetanus toxoid immunization is
important for pregnant women and child bearing age women. Both mother and child are
protected against tetanus and neonatal tetanus. A series of 2 doses of Tetanus Toxoid
vaccination must be received by a woman one month before delivery to protect baby
from neonatal tetanus. The 3 booster dose shots to complete the five doses following the
recommended schedule provides full protection for both mother and child. The mother is
then called as a “fully immunized mother” (FIM). When given to women of childbearing
age, vaccines that contain tetanus toxoid (TT or Td) not only protect women against
tetanus, but also prevent neonatal tetanus in their newborn infants. TT1 given at 20th
weeks AOG ensures protection for the mother for the first delivery. TT2 given at least 4
weeks later from TT1 ensures infants born to the mother will be protected from neonatal
tetanus and gives 3 years protection for the mother. TT3 given at least 6 months later
ensures infants born to the mother will be protected from neonatal tetanus and gives 5
years protection for the mother. TT4 given at least 1 year later from TT3 ensures infants
born to the mother will be protected from neonatal tetanus and gives 10 years protection
21
for the mother. TT5 given at least 1 year later from TT4 ensures gives lifetime protection
for the mother and all infants born to that mother will be protected.
Micronutrient supplementation is vital for pregnant women. These are necessary
to prevent anemia, vitamin A deficiency and other nutritional disorders. They are:
Vitamin A given twice a week starting on the 4th month of pregnancy and iron given
daily.
The presence of a skilled birth attendant will ensure hygiene during labor and
delivery. It may also provide safe and non traumatic care, recognize complications and
also manage and refer the women to a higher level of care when necessary. The necessary
steps to follow during labor, childbirth and immediate postpartum include the following:
1st Visit - 1st week post partum preferable 3-5 days and 2nd Visit - 6 weeks post partum. In
addition, proper counselling of couples on the importance of FP will help them inform on
the right choice of FP methods, proper spacing of birth and addressing the right number
of children. Birth spacing of three to five years interval will help completely recover the
health of a mother from previous pregnancy and childbirth. The risk of complications
increases after the second birth.
Furthermore, the launching and implementation of Basic Emergency Obstetric
Care or BEMOC strategy in coordination with the DOH entails the establishment of
facilities that provide emergency obstetric care for every 125,000 population and which
are located strategically. The strategy calls for families and communities to plan for
childbirth and the upgrading of technical capabilities of local health providers.
Family Planning
22
Family Planning (FP) is having the desired number of children and when you
want to have them by using safe and effective modern methods. Proper birth spacing is
having children 3 to 5 years apart, which is best for the health of the mother, her child,
and the family. It is a national mandated priority public health program to attain the
country and national health development: a health intervention program and an important
tool for the improvement of the health and welfare of mothers, children and other
members of the family. It also provides information and services for the couples of
reproductive age to plan their family according to their beliefs and circumstances through
legally and medically acceptable family planning methods.
Moreover, the program is anchored on the following basic principles: Responsible
Parenthood which means that each family has the right and duty to determine the desired
number of children they might have and when they might have them. And beyond
responsible parenthood is Responsible Parenting which is the proper upbringing and
education of children so that they grow up to be upright, productive and civic-minded
citizens. Respect for Life. The 1987 Constitution states that the government protects the
sanctity of life. Abortion is NOT a FP method: Birth Spacing refers to interval between
pregnancies (which is ideally 3 years). It enables women to recover their health improves
women potential to be more productive and to realize their personal aspirations and
allows more time to care for children and spouse/husband, and; Informed Choice that is
upholding and ensuring the rights of couples to determine the number and spacing of
their children according to their life aspirations and reminding couples that planning size
of their families have a direct bearing on the quality of their children and their own lives.
It is mandated by EO 119 and EO 102. Its vision is to empowered men and women living
23
healthy, productive and fulfilling lives and exercising the right to regulate their own
fertility through legally and acceptable family planning services. With mission: The DOH
in partnership with LGUs, NGOs, the private sectors and communities ensures the
availability of FP information and services to men and women who need them. Program
Goals include: To provide universal access to FP information, education and services
whenever and wherever these are needed.
Furthermore, family planning provides many benefits to mother, children, father,
and the family. For the mother: 1. Enables her to regain her health after delivery; 2.Gives
enough time and opportunity to love and provide attention to her husband and children; 3.
Gives more time for her family and own personal advancement; 4. When suffering from
an illness, gives enough time for treatment and recovery. For Children: 1. Healthy
mothers produce healthy children; 2.Will get all the attention, security, love, and care
they deserve. For the father: 1. Lightens the burden and responsibility in supporting his
family; 2. Enables him to give his children their basic needs (food, shelter, education, and
better future); 3. Gives him time for his family and own personal advancement; 4. When
suffering from an illness, gives enough time for treatment and recovery.
Family planning methods in the Philippines includes: 1. Vasectomy (Permanent);
2. Bilateral Tubal Ligation (Permanent); 3. Intra-Uterine Device/IUD (Long – Acting); 4.
Lactational Amenorrhea Method (LAM); 5. Basal Body Temperature (BBT); 6. Sympto-
Thermal Method (STM); 7. Standard Days Method (SDM); 8. Condom; 9. Injectables;
and 10. Pills.
Related Studies
24
Socio – Economic Profile and the Extent of the Implementation of Health

Care Services
Socioeconomic status is a contributing factor to disparities in health and
constitutes a barrier in accessing health services (Goddard and Smith, 1998, 2001;
Mooney, 2009; Schoen and Doty, 2004). Health disparity, a term used interchangeably
with health inequity, occurs when people‘s characteristics such as race, ethnicity, gender,
socioeconomic status, and geographic location constitute obstacles to health. Disparity to
access exists when people are hindered from accessing required health services due to
unavailability, costs, or lack of insurance (Braveman, 2006; Department of Health and
Human Services (US), 2010). Whitehead (1991) defined health inequity as the
differences in health which, are not only unnecessary and avoidable but, in addition, are
considered unfair and unjust (p. 220).
Furthermore, in the USA, a study on ethnic disparities in unmet needs for
alcoholism, drug abuse and mental health care revealed dissimilarities among Hispanics,
African Americans and whites. Hispanics and African Americans were found to have less
access to care, poor quality of care, and greater unmet need for alcoholism, drug abuse,
and mental health treatment when compared to whites (Wells et al., 2001, p. 2030).
Equally, a study on access to care for children with special needs found that disparate
access to and utilization of health services existed among racial and ethnic minority
children in comparison to white children. In addition to racial and ethnic disparity,
income and insurance coverage were also shown to contribute to poor access to health
services by children with special needs in the USA (Newacheck, Hung, and Wright,
2002).
25
Moreover, gender plays a role in creating disparities for access to health, in that
women are sometimes marginalized (Flores et al. 1998; Howden-Chapman and Cram,
1998; Nanda, 2002; Nandi et al., 2008; Phillips et al., 2000). Conversely, research has
shown that women utilizing GP services in Australia were more likely to receive a
prescription regardless of health or socioeconomic status (Scott et al., 1996) than their
male counterparts. Additionally, a study examining factors associated with gender
differences in having health insurance coverage and a usual source of medical care in
low-income communities in the USA found that employed women had more insurance
coverage than employed males. While there was no means by which to explain the
gender differential, the author concluded that private and public health insurance should
be more available to men in low income communities (Merzel, 2000).
Subsequently, another data gleaned from studies conducted in developed
countries suggested that the problem is not unique to developing countries (DeVoe et al.,
2007; Hussey et al., 2007; van Doorslaer, Masseria, & Koolman, 2006), despite
numerous interventions to improve access to health services. Hussey et al. examined
trends in socioeconomic disparities in general health care quality in various countries
including England, New Zealand, the USA and Canada, and found divergent
socioeconomic situations in regard to quality and health status. While the studies in these
countries identified disparity between social status and quality of health care, the
phenomenon requires further investigation to fully understand the problem. Given the
health systems that operate in these countries, it is of concern that distinct variations in
health among people exist. Large segments of these populations continue to receive
substandard health care and experience undesirable health status. It is also not uncommon
26
for these segments to be in the lower strata of society and without health insurance
(Hussey et al.).
Furthermore, individuals’ ability to pay out-of-pocket for health services hinges
greatly on their social status and determines whether they will seek or postpone care
when required (Kiwanuka et al., 2008). In the absence of an adequately financed health
system, cost becomes a disincentive to positive health-seeking behavior, as well as to the
provision of quality health services (Guilliford et al., 2001). This constitutes an obstacle
to accessing health care since consumers will avoid the financial hardship resulting from
seeking care. Moreover, indirect costs such as drugs, lost income and travel create
additional financial burdens for some persons. Of note is that access to health services is
also a problem in countries where even small fees were imposed for health care. In this
case, health-seeking behaviours of individuals were linked to their perception of the costs
that might be incurred in obtaining care. Furthermore, studies have corroborated the
notion that cost, among other factors, is an impediment to accessing health care among
the poorer segment of society in some countries (DeVoe et al., 2007; Kiwanuka et al.;
WHO, 2010b).
Moreover, people from low socioeconomic backgrounds were 10.0% less likely to
access preventive care at a general practitioner (GP) in the United Kingdom (Goddard
and Smith, 1998). Additionally, it was found that people living in deprived communities
who were diagnosed with angina had a 50.0% lower revascularisation rate than people
living in affluent communities. Equally, lack of health insurance coverage was found to
be an obstacle for consumers diagnosed with angina to access health care in the UK,
despite a universal health system (Goddard and Smith). In the absence of health
27
insurance, some individuals do not have equal access to health care. This is the reality for
people of low socioeconomic status, and a probable explanation for some individuals’
apathy in seeking health care, even though there is a need. This represents an important
barrier to access that may have eluded policymakers over time. This supports data from
other studies, which investigated barriers to access or disparities in access to health care,
and found that a lack of insurance coverage constituted a barrier to accessing health care
(Flores et al., 1998; Hussey et al., 2007; Phillips, Mayer, and Aday, 2000). The
inextricable link between health insurance coverage and access to health services is
unequivocal.
Additionally, health literacy among people of low socioeconomic status was
found to impact on their ability to access health services. The minimal degree of health
literacy was a concern among the community-dwelling elderly population in the USA.
According to Sudore et al. (2006), limited health literacy correlated with disparities in
health and access to health service, which, they claimed has the potential to produce
undesired health outcomes. Additionally, it is argued that limited health literacy is
common among some ethnic minority groups and predisposes the individuals to
unacceptable health status and increased risk of admission to hospital (Cooper, Hill, and
Powe, 2002).
Attitude as a Barrier in the Implementation of Health Care Services
Maternal health and health seeking behaviour of mothers have a huge impact not
only on the lives of women, but also on the lives of their children. Perhaps unsurprisingly
therefore there is a substantial body of health seeking behavior work directed specifically
at women. This typically highlights the difficulty women face in many developing
28
countries where they rely on the male head of household to secure access to medical
treatment, financially and practically. They may also require support from the wider
social network for childcare or household duties that must be undertaken while they
travel sometimes great distances for a medical consultation, often with long waiting times
at the other end (Bedri, 2001; Manhart et al, 2000; Rahman, 2000). Thus we have a body
of knowledge about the cultural, social and structural difficulties faced by women in a
variety of contexts in relation to their health seeking behaviours.
Another study by Yakong’s (2008) on rural Ghanaian women, posited that
economic ability to access health is a major factor affecting health care seeking
behaviours in general and reproductive health care of women in particular. For example,
in Ghana, the majority of women have limited control over family property and
household financial resources and limited access to credit from financial institutions. In
(Tawiah, 2011; Atuyambe et al., 2005; Kasolo et al., 2000; Obemeryer, 1993; Birungi et
al., 2006; Pearson et al., 2005), it is noted that women’s financial dependence on their
husbands affect their decision making because health care options must be supported by
husbands. Women lack the power to spend money on health care without their husbands’
permission. Collated findings exist elsewhere in Nigeria, Burkina Faso, Kenya, Ethiopia,
Philippines, India, and Pakistan (Abdool-Karim et al., 1994; Mekonnen, 2003; Wong et
al., 1987; Bhatia, 1995; Awusi et al., 2009; Negi et al., 2010; Babar et al., 2004).
Furthermore, Asiimwe, (2010), found out that in western Uganda, the ability of a
woman to afford antenatal care (ANC) services has a significant association to the
number of ANC visits she is likely to make. This resonates with studies elsewhere that
women having to take transport to ANC facility, high fees for necessary but costly
29
laboratory fees, drugs and consultation fees in case of private centres not serviced by
government hospitals are deterrence to the utilization of maternal services as highlighted
by Atuyambe et al., (2005). Although in their study, there was no significant relationship
between affordability and utilization of antenatal care, these associations indicates the
unwillingness by mothers to pay for ANC services.
Moreover, Bedri (2001) in her study of women’s health seeking behaviour around
abnormal vaginal discharge, highlighted the role of the husband and the availability of
knowledgeable social contacts as key factors in securing an early diagnosis and use of
health care services. She suggests women could be empowered by policy and health
system developments that encourage the creation of ‘expert social networks’ and ‘expert
husbands’ in order to ensure the necessary social infrastructure is in place to support
women through their health care seeking process. Ahmed et al (2000) also suggest that
efforts are needed to raise community awareness of the immediate and future benefits of
improving women’s health, and this also appeals more directly to existing social
structures and an opportunity to strengthen them for beneficial health outcomes, rather
than a further attempt to change behavior of individuals.
Culture and beliefs as a Barrier in the Implementation of Health Care
Services
Socio-cultural belief systems, values, and practices also shape an individual’s
knowledge and perception of health and illness/disease, and health care seeking practices
and behaviours (de- Graft Aikins, 2005; Caldwell and Caldwell, 1987; MoH, 2004;
UNICEF, 2005). These shared norms guide self-care practices, and the use of traditional
healers, both of which may support some healthy behaviours and contribute to unmet
30
health needs (Adongo et al., 1998; GMOH, 1999). In dominant patriarchal cultures such
as those found in Uganda and other parts of sub- Saharan Africa, men play an important
role in determining what counts as a health care need for women; men are in control of
almost all the resources in the family (Kasolo et al., 2000; Yakong, 2008; Bawah et al.,
1995; Assfaw, 2010).
Moreover, Men and women, young and old, who are often inclined to customary
beliefs, object to their wives going for antenatal care especially under skilled health
providers. In Kasolo et al, (2000), perception of men and women depict their agitation to
deny their wives or for that matter daughters in law from seeking antenatal care, “For us
men, we are not supposed to see. It is very shameful. How do you look at a woman’s
genitals?” Old man – Masindi. That “Private parts should only be looked at by your
husband when having sexual intercourse” Young women -Masaka. Most women prefer
Traditional Birth Attendants (TBAs) to doctors/nurses since TBAs do not see private
parts during attendance, except they just feel by a touch which is more common in the
rural parts of the country.
Furthermore, socio-cultural variables also affect access to health care services.
The educational level of a woman often affects her health care use. Attaining at least a
primary education contributes positively to the health of women by providing women
with skills training for employment and personal income thus enabling women to afford
health care services (Wickrama & Lorenz , 2002) Education level, employment, family
income and marital status shape women’s use of health care services. Furthermore,
income provides women with the ability to access improved nutrition and adequate
housing, both of which protect and advance their health status (Buor, 2004). Some studies
31
have found that there is positive association between maternal health care services use
and women’s formal employment suggesting that the capacity to earn could contribute to
maternal healthcare services utilization through empowerment. It has also been found that
in some regions of the world that non-working women are more likely to use some
maternal health care services than earning mothers (Skelenburg et al., 2004, Kamal,
2009). A woman’s marital status can also affect his health. Women may spend more time
caring for their husbands and families which impose a strain on his health.
Consequently, although the focus is often on social and cultural restrictions on
women, there are also other enabling and constraining factors. Wallman and Baker
(1996) provide a detailed list of ‘elements of livelihood’ that are likely to affect women’s
capacity to obtain treatment: actual money income, potential money income, social status,
social life, networks, autonomy and liability. These they argue will come into play after a
woman has assessed how good, kind, shameful, private, feasible and appropriate options
are, within the physical infrastructure of that area. The total resource base will vary in
absolute size between women, in relative proportions, geographic scope and according to
a particular illness episode. They use the model to study through a range of illness
episodes over time, and begin to “transform the respondent from a flat unit of enquiry
intoa person ‘in the round’, embedded, as real people are, in social relationships and
economic obligations which constrain all the decisions they make” (Wallman and Baker,
1996. 678). This allows a picture of the resources to build up as the actor experiences
them, and claim the authors, is a crucial step towards understanding why and how people
do what they do.
Family and Social dynamics as a Barrier in the Implementation of Health

Care Services
32
Barriers to health services experienced by some ethnic groups are largely
associated with unfamiliarity with the services, apprehension related to the negative
perception associated with some diagnoses and anxiety about entitlement to certain
services, as well as inequity in the services provided. Despite attempts to minimise the
disproportionate use of health services, some ethnic groups continue to experience
inequity (Guilliford et al., 2001). Goddard and Smith (1998), in an account on the
utilisation of mental health services among some ethnic groups in the UK, stated that
South Asian migrants from India, Pakistan, Bangladesh, [and] Hong Kong have relatively
low hospital admission rates for mental illness relative to people born in England
(average of 283 admissions per 100,000 population compared with 504) (p. 56). Of note
also is that socioeconomic status, negative perceptions and meanings attached to mental
illness may have contributed to the poor uptake of the services (Lipsedge, 1993).
Moreover, studies to investigate the high rates of schizophrenia and psychosis
among Caribbean people living in the UK found that recorded rates were potentially
affected by variations in patients’ presentation and doctors’ diagnostic and management
practices (Cochrane and Sashidharan, 1996).
Accessibility of health care services as a Factor that Affects the

Implementation of Health Care Services
Yamada et al. (2009), in a study on children‘s access to health services, concluded
that accessibility involved a number of variables such as ―paying cash for health care
services, family earnings, educational status of caregiver, the type of private and public
health insurances, ease of seeing a health personnel and the interface between service
provider and users (p. 448). In addition, distance from health facilities can be a deterrent
33
to consumers’ use of health facilities even though there is a need. This can be understood
in terms of the individual‘s location, nature of the roads to be used, and transportation
systems, as well as the communication systems in the areas. Studies have shown that
consumers either delay or forgo care if it requires significant loss of time or the travel
cost is astronomical. This results in increased mortality in some cases, especially
maternal mortality (Hardeman et al., 2004; Jacobs and Price, 2006; Klemick, Leonard,
and Masatu, 2009; McCaw-Binns, Standard-Goldson, Ashley, Walker, and MacGillivray,
2001; Peters et al., 2008).
Another study on the impact of geographic proximity to cardiac revascularisation
services in the USA, it was found that distance from the patient‘s home influenced the
utilisation of services at health facilities. According to the authors, ―geographic
proximity of patient‘s residence to cardiac revascularisation services and availability of
these services at the hospital nearest to the patient‘s residence was found to be strongly
associated with utilisation, even across a relatively small geographic area‖ (Gregory et al.,
2000, p. 54).
Moreover, a comparative study across developing countries in South East Asia
and Asia, unequal access much more for rich rather than poor is indicated in Indonesia
because of the growing role of private care provision. There is a less domination of
government in health care provision, particularly for poor. Although all of insurance
scheme has improved access to and utilization of health care services, the subsidy for
non-hospital, hospital outpatient and hospital inpatient is unequal between the rich and
the poor. Subsidy for poor is dominated for non-hospital care, whereas subsidy for
hospital inpatient and outpatient care is pro-rich. Some regulation indeed provide
34
coverage guarantee for the poor, but physical and economical constraints have
diminished factual accessibility.
Furthermore, system infrastructure affects access by accommodating or limiting
use through hours of operation, the appointment system, walk in facilities and telephone
services. Culture can influence access through inherent inequalities in the social system.
Gender also affects access, pushing women into gender specific roles that negatively
influence their health or force to seek permission to obtain health care. Other researchers
measure access via cultural beliefs, communication between patients and doctors, patient
waiting time and modes of transportation to and from the facilities (Wyss, 2003).
Moreover, health economists have posited that, to determine the availability of
health services, the costs for travel and difficulties encountered while obtaining or
forgoing care need to be estimated (Mooney, 1983). For example, when distance from
health facilities is considered the costs could be astronomical. Individuals who cannot
afford to travel sometimes delay accessing care or may be unable to obtain basic services
because of the distance from primary and secondary health care facilities available to
them in a particular geographic location.
On a study by Myriad in Uganda and elsewhere in sub-Saharan Africa (SSA)
have identified physical or geographical access to health care as a major barrier affecting
health care seeking behaviours of patients generally, and women’s reproductive health
care seeking specifically (Kasolo et al., 2000; MoH, 2004; GMOH, 1999). In developing
countries including Uganda, several factors impede accessibility, including cost of
services, distance to health services, lack of available transportation, high transportation
costs, poor road conditions and uneven distribution of health care facilities and lack of
35
independence by women to make decision on matters that directly affect their health
(Tawiah, 2011; Magadi et al., 2003; Anarfi and Ahideke, 2006). All of these factors
increase travel time and the difficulty in accessing health service facilities. In rural
Uganda, physical accessibility and acceptability remains a significant challenge to health
care service delivery.
Subsequently, as established earlier, cost may be a deterrent to patients utilising
the health services, even in settings where the services are free. Out-of-pocket payment is
often required for dental care, drugs, time lost from work, and travel. Financial incentives
to providers can impact on the availability, as well as type of services (Guilliford et al.,
2002), thereby improving access. It is important for health services to be affordable
generally, in order for individuals to access care in a timely manner. In the absence of
adequate financial resources, individuals have opted for self-treatment or engaged the
services of shopkeepers or traditional healers who may be more accessible in terms of
cheaper services (Hardeman et al., 2004; Jacobs and Price, 2006; Peters et al., 2008).
These actions are sometimes adopted on the premise that the condition is not serious
enough to travel far distances or pay exorbitant costs for health services. It is also thought
that traditional healers are more cost-effective, understanding, and familiar with the
socio-cultural positions of these individuals and their opening hours are convenient for
the users (Peters et al.; Rutebemberwa et al., 2009). While this practice of seeking
alternative treatment may achieve an immediate benefit, it is important to note the long-
term deleterious effects on the health of individuals and the burden on the health system.
This burden occurs because some health conditions may be in advanced stages by the
time an appropriate diagnosis is made. Additionally, disease conditions at an advanced

36
stage require more technologically-advanced therapy and also increase mortality rates
(Flores et al., 1998; Hardeman et al.; Peters et al.). Providers, therefore, need to mobilise
the necessary resources to ensure services are available and affordable. Although
accessibility is commonly suggested as a factor in health facility use, Bhatia and Cleland
(2001) support the findings of many others, that women are quite happy to travel further
to attend a private, more expensive service that is perceived to be of ‘good quality’.
Complex justifications are also seen for inappropriate use of treatment, over-dosage,
under-dosage, stopping a course halfway through or selecting particular drugs from a
lengthy prescription (Evans and Lambert, 1997; Manhart et al, 2000; Théra et al, 2000).
The type of health care provider that is sought, or the health seeking behaviour adopted,
also differs according to the type of disease.
Availability of health care providers as a Factor that Affects the

Another barrier in the rural areas is that travel time takes longer per kilometer
than in urban areas due to poor quality of roads and the burden of having to use several
modes of transportation. Climate is also a factor especially during the rainy season when
heavy rains and flooding create even worse road conditions. Advanced transportation is
often non-existent in developing nations and healthcare may be unattainable if the means
of transportation are in adequate or time consuming such as walking, bicycling or using
the bus (Perry and Gesler, 2000). These longer travel times deter individuals from
travelling particularly to access advanced technology that may only be available in large
health facility located in the cities. These sometimes overwhelming obstacles may also
encourage women in developing countries to turn to traditional medical practices.

37
Moreover, availability refers to the distance the patient lives from a health care
facility, transportation and total travel time, wait time and available services, (Hjortsberg
and Mwikisa, 2002, Perry and Gesler, 2000). In Andean, Bolivia where travel times are
greater than one hour by walking, (Perry and Gesler, 2000) found limited physical access
to care to be a major obstacle in improved health. Limited access is especially important
in rural areas where there are fewer healthcare facilities and villages may be physically
isolated.
Moreover, in Zambia, 56% of surveyed rural household perceived distance as an
obstacle (Hjortsberg and Mwikisa, 2002) In the same study, only 17% of individual
living more than 40 kilometers from a facility sought care when sick compared to 50% of
individuals living less than five kilometers away.
Provision of care and quality of services as a Factor that Affects the

According to World Health Assembly Resolution 58.33 (as cited in WHO,
2010b), everyone should have access to health services without incurring any financial
burden. The literature is, however, replete with research reports on the disparities in
access to health services by some groups of individuals. Policy documents such as the
WHO (1978) Alma Ata Declaration Health for All clearly addresses this issue. Despite
the challenges encountered, it is important to note that access to health care remains a
basic human right and is paramount to maintaining good health, gaining improved health
and remaining free of sickness (Gulliford, Figueroa-Munoz, and Morgan, 2003). The
interpretation of access, however, varies amongst countries; for example, in low income
countries access may be understood within the context of availability of basic health
services such as an individual‘s ability to obtain services from a physician or receive

38
maternal and child health care (Gulliford et al.; Oliver and Mossialos, 2004). In contrast,
in high-income countries, individuals have access to a wide range of health services and,
as such, the concept is interpreted through a different lens. For example, access is often
viewed in the context of how all-inclusive, timely, and equitable services are, as well as
the desirability of the health outcomes generated by having good access to care (Gulliford
et al.). Even where services are free, access can be compromised by high transport costs,
loss of income, unavailability of services, and long distances to health facilities (Asfaw et
al., 2004; WHO).
Moreover, the cost of health care services, prescription drugs and transportation
determine the affordability of health care. Hjorstborg and Mwikisa (2002) found cost to
be a critical determinant of health care access in Zambia. They argue that this is mostly a
rural concern where a large percentage of the population lives in poverty and have
difficulty paying for services. People residing in the rural areas pay a large proportion of
their income than their urban counterparts. Studies in Ghana, Swaziland, Zaire, and
Uganda showed a decline in use of health services as a result of introduction of user’s
fees. In Tanzania, there was a 53.4% decline in antenatal care while Nigeria reported a
56% rise in maternal mortality after the introduction of user’s fees (Bennett and Gilson,
2000). In Zambia, several studies found that low income people have higher incidences
of illnesses but use services less often (Hjorstborg and Mwikisa, 2002) showed that an
increase in the cost of health care especially affects the poorer patients who need to make
return visit to a health care facility and those who deem their illness not serious enough to
seek care. As women in many developing countries are expected to conform to social and
gender roles and remain at home to perform household work, they cannot develop
39
economic independence. As a result, they may be unable to afford services, especially
since essential goods such as food and education must be purchased before health care,
thus making their access to health care services limited.
Subsequently, in some countries, universal health coverage, whereby all people
have access to health services without incurring financial burden, is non-existent (WHO,
2010b); therefore, it is not uncommon for some individuals to pay out-of pocket for
health services. As a result, those who utilise the health services are often impoverished
because of catastrophic spending (Asfaw et al., 2004; Nimpagaritse and Bertone, 2011;
Ponsar et al., 2010; WHO, 2010a). For this reason, low-income earners may encounter
significant challenges in accessing quality health services, which have implications for
the achievement of equal access for equal need. In some countries, ―migrants, ethnic
minorities and indigenous people use services less than other population groups, even
though their need may be greater (WHO, p. 7). It was found that abolishing payment for
health care assists the underserved and vulnerable in obtaining care. Hence, poor access
to health care by some individuals has been one of the driving forces motivating policy
change regarding universal coverage and free health care by some policymakers
(Kiwanuka et al., 2008; PIOJ and STATIN, 2008; Ridde and Diarra, 2009). While access
may be viewed in relation to the availability of services, the timeliness of these services,
as well as their settings should also be given consideration (Rogers, Flowers, &
Pencheon, 1999).
Moreover, access is frequently used to determine the effectiveness of the services
being offered. A service that is accessible and utilised by the people who require it may
positively impact on the quality of service delivery. Furthermore, equity is achieved when
40
people with equal needs utilise equally accessible services. The equitability of the
services provided may result in unnecessary consequences, whereby there is uptake by
people with minimal capacity to benefit from the offerings. This ultimately compromises
the efficiency of the services provided. Similarly, the services provided should also match
with and respond to the need of the population if they are to be qualified as accessible
(Guilliford et al., 2001). The fact that the uptake of some, such as preventive services,
may be minimal among some segments of society should not be discounted. One of
problems in providing universal health coverage is the lack of quality of health care
facilities, goods, and services. Whereas the quality of those needed to acquire good health
status is required, the State has to ensure that health facilities, goods, and services are
scientifically and medically appropriate and of good quality. Universal health coverage
must include provision of skilled health care workers, scientifically approved drugs and
hospital equipment, and good building and facilities.
Another study by Ondimu (2000) disapproved this assumption by finding that
patients’ dissatisfaction in the Nana province in Kenya created a loss of community
confidence in the local public health facility. This negatively affected the health of
vulnerable groups such as the poor children and the pregnant women. Maternal health is
highly contingent on the quality of the local primary health care system, which is a
common entry point for antenatal care that helps identify problems in pregnancy early on.
Consistently poor performance in primary health facilities including lack of personnel,
lack of appropriate medicines, and indifferent or contemptuous treatment by facility staff
not only undermines the quality of care an expectant mother receives, but over time
erodes confidence in the health care system overall and deters women from seeking care
41
(Erim et al., 2012) in a study in Nigeria observed that women who experienced adverse
pregnancy outcomes in a facility may be less likely to seek facility-based obstetrical care
in the future.
42
Chapter 3
RESEARCH METHODOLOGY
This chapter presents the methodology of the study. Included are the discussion of
the research design, the locale of the study, the research participants, the research
instrument, validation of the research instrument, data gathering procedure and
processing method as well as the statistical tools which being utilized to analyze and
interpret the data.
Research Design
This study is an inferential-evaluative research design using both qualitative and
quantitative approach in the interpretation of data. Research wise, this identified and
described the barriers and factors that affect the implementation of health care services
among Sama Tribes in Sibutu, Tawi - Tawi. It also described the socio – economic
profile of the respondents (age, sex, civil status, religion, family type/size, educational
attainment, occupation and family income) and how these variables were correlated with
each other. The degree of relationships were expressed in terms of correlation
coefficients.
The study adopted descriptive survey approach in collecting data from the
respondents. The descriptive survey method was preferred because it ensures complete
description of the situation, making sure that there is minimum bias in the collection of
data and finding out the what, where and how of a phenomenon (Kothari, 2008).
Research Locale
Sibutu is a sixth class municipality and island in the province of Tawi - Tawi,
Philippines. According to the 2010 census, it has a population of 28,532 people. It lies
43
about 14 kilometres (8.7 mi) east of the coast of Sabah, Malaysia. The municipality
covers the main island of Sibutu as well as four small uninhabited islands 3.5 to 6
kilometres (2.2 to 3.7 mi) south of the main island, which are, from north to south:
Sicolan Calch Island, Sicolan Island, Sicolan Islet, and Saluag Island, the latter being the
southernmost island of the Philippines.
Sibutu Island has an area of 109 square kilometres (42 sq mi). It is an important
site for nature conservation. It was created out of Sitangkai, Tawi-Tawi, by virtue of
Muslim Mindanao Autonomy Act No. 197, which was subsequently ratified in a
plebiscite held on October 21, 2006. The Island is politically subdivided into
16 barangays. (1) Ambutong Sapal, (2) Datu Amilhamja Jaafar, (3) Hadji Imam Bidin, (4)
Hadji Mohtar Sulayman, (5) Hadji Taha, (6) Imam Hadji Mohammad, (7) Ligayan, (8)
Nunukan, (9) Sheik Makdum, (10) Sibutu (Poblacion), (11) Talisay, (12) Tandu Banak,
(13) Taungoh, (14) Tongehat, (15) Tongsibalo, and (16) Ungus-ungus.
In the island itself, there is one (1) District Hospital, one (1) Rural Health Unit,
and (2) Barangay Health Station.

44
(https://mobile.twitter.com/inquirerdotnet/status/696298638784352256)
(https://insights.looloo.com/tawi-tawi-top-places-to-visit/tawi-tawi-philippines-map)
FIGURE 2. MAP OF SIBUTU, TAWI - TAWI

45
Sampling Procedure
The participants were drawn through a probability sampling, specifically stratified
random and simple random sampling. In Stratified Random Sampling, there was a ready
and prepared list of the universe whose members were classified into certain categories.
In this case, it was by barangay. Using 0.10 as the actual percentage of the universe
considered as sample, an equal proportion of sample from each barangay was obtained.
The procedure arrived at a sample size of 473 household heads either the father or the
mother among Sama Tribe from the sixteen (16) barangays as seen in Figure 3.
After Stratified Random Sampling was done, the researcher employed Simple
Random Sampling based on the result on the number of household per barangay. In
Simple Random Sampling, specifically using the snowball/fishbowl technique, every
element of the population had an equal chance being selected as a source of data. In order
to obtain representative samples of household, a lottery – type selection where every
source of object was identified by means of a tag placed in a container, and the tags were
thoroughly mixed and drawn, with equal probability, after a random start.
46
Table 1
Stratified Sample of Research Respondents
POPULATION
(Census of
NAME OF Population and NUMBER OF
x .10 SAMPLE
BARANGAY Housing Tawi- HOUSEHOLDS
Tawi; 2010)
Ambutong Sapal 1,522 272 27.2 27
Datu Amilhamja 1,206 210 21 21
Jaafar
Hadji Imam 2,117 359 35.9 36
Bidin
Hadji Mohtar 1,601 274 27.4 27
Sulayman
Hadji Taha 1,254 184 18.4 18
Imam Hadji 1,478 225 22.5 23
Mohammad
Ligayan 1,873 314 31.4 31
Nunukan 1,869 353 35.3 35
Sheik Makdum 2,115 297 29.7 30
Sibutu 1,552 255 25.5 26
(Poblacion)
Talisay 1,517 315 31.5 32
Tandu Banak 2,326 352 35.2 35
Taungoh 2,610 401 40.1 40
Tongehat 1,433 286 28.6 29
Tongsibalo 2,016 292 29.2 29
Ungus-ungus 2,043 338 33.8 34
TOTAL 28,532 4,727 472.7 473
Respondents of the Study
The population under this study covered 473 household heads and limited only to
one (1) family member (either the father or the mother) from each of the randomly
selected households from the 16 Barangays of Sibutu, Tawi – Tawi. The inclusion criteria
47
in choosing the respondents were the following: 1. women who were either pregnant or
have been pregnant; 2. any male or female who have children under one year old; and 3.
any male or female who were either married or living together with a partner at the time
the study was conduct.
Research Instruments and its Validity
Self-constructed questionnaires were distributed to the identified respondents. The
questionnaire has four (4) parts. The first part seeks to gather the respondents’ socio-
demographic profile containing the personal information of the respondents such as age,
gender, civil status, religion, family size/type, educational attainment, occupation, and
family income. The second part contain statements related to the barriers in the
implementation of health care services as stated in the conceptual framework in the form
of checklist – Likert scale (4 – Always; 3 - Often; 2 – Sometimes; 1 - Never). The third
part covers list of statements related to the factors affecting the implementation of health
care services in the area, also in the form of checklist – Likert scale (4 – Always; 3 -
Often; 2 – Sometimes; 1 - Never). The fourth part encloses statements related to the
extent of the implementation of health care services such as EPI, antenatal care and
family planning in the area, also in the form of checklist – Likert scale (4 – Always; 3 -
Often; 2 – Sometimes; 1 - Never). Some statements/questions are intentionally repeated
for the purpose of ensuring consistency of answers.
The pretesting was implemented to at least ten (10) participants who were not
considered as respondents of the study. The ten (10) filled out survey tools were
48
subjected for Cronbach’s alpha analysis to check for the validity and reliability of the
research instrument.
Data Gathering Procedure
The needed primary data for this study were collected and analyzed through
Triangulation Method. Data were collected using three (3) main methods: First, the
interviewer administered survey questionnaires; Second, the observation of the
respondents and the current situation of health in the area is a must. And, third the Data
Analysis / Document Analysis were done using secondary data that were obtained from
the Hospital, Rural Health Unit, and Barangay Health Stations’ records to collect
information related to Expanded Program on Immunization, Antenatal Care and Family
Planning.
These data were checked and determined if they have reached their target (or if
the services under Expanded Program on Immunization, Antenatal Care and Family
Planning had been availed by the community residents, and the percentage of the
population who has availed of the services). The scaling of the data are: 1.) Highly
Implemented – 98 to 100% of the population; 2.) Moderately Implemented – 75 to 97%
of the population; 3.) Slightly Implemented – 50 to 74% of the population; and 4.) Not
Implemented – below 50% of the population.
Statistical Treatment
The Statistical Product and Service Solutions (SPSS) version 21 was used to
perform all the data computations in this study. The use of Software SPSS is the most
commonly used program for quantitative data analysis in the social sciences. For in-depth
treatment of data, the following statistical methods and techniques were employed:
49
Descriptive statistics. Frequencies and percentages were used to describe the
personal profile of the respondents.
1. Frequency. This is the total number of responses. Frequency of responses,
including the respondents’ personal profile was tallied for the computation of percentage
value.
2. Simple Percentage. This is a part of a whole expressed in hundredths and was
used to determine the frequencies and the percentages of the first variable. This includes
the manner on how the items were rated after the consolidation of data. The formula for
Simple Percentage is as follows:
P = (Fi/N) x 100%
where: Fi is the number of respondents and N is the total sample.
3. Measure of Central Tendencies by Mean. This was used in the study to
measure the average answers of the respondents particularly in the part of questionnaire
pertaining to the barriers and factors affecting the implementation of healthcare services
and the extent of its implementation.
The mean is the most commonly-used measure of central tendency. The mean is
simply the sum of the values divided by the total number of items in the set.
The notation used to express the mean depends on whether we are talking about
the population mean or the sample mean:
µ = population mean
x = sample mean
The mean is valid only for interval data or ratio data. Since it uses the values of all
of the data points in the population or sample, the mean is influenced by outliers that may
be at the extremes of the data set.

50
The formula for Weighted Mean is as follows:
Where: fi and xi are the frequencies and weights, respectively.
4. Standard deviation. The standard deviation represents the distribution of the
responses around the mean. It indicates the degree of consistency among the responses.
The standard deviation, in conjunction with the mean, provides a better understanding of
the data. For example, if the mean is 3.3 with a standard deviation (StD) of 0.4, then two-
thirds of the responses lie between 2.9 (3.3 –0.4) and 3.7 (3.3 + 0.4).
5. Pearson’s r Correlation. This was used for research problems 5 to find out the
possible correlation and significant relationship between the independent and dependent
variables that has nominal and ordinal data to serve as basis in rejecting or retaining the
null hypotheses.
The formula for Pearson’s r Correlation is as follows:
N  XY −  X  Y
r =
[ N  X 2 −( X ) 2 ][ N  Y 2 −( Y ) 2 ]
where: r = degree to which X and Y vary together

degree to which X and Y vary separately
51
r = covariance of X and Y
variance of X and Y
6. Spearman’s Rho Correlation. This was utilized for research problems 6 and 7
to find out the possible correlation and significant relationship between the independent
and dependent variables that has nominal and ordinal data to serve as basis in rejecting or
retaining the null hypotheses.
The level of significance is set at .05, which entails a .95% level of confidence
that there is a significant relation between the correlated variables. A negative (-)
correlation points to an inverse relationship direction between the independent and
dependent variables.
Based on the ordinal responses of the respondents, as the respondents’ response
direction for the independent variable goes down, there is the tendency that the
respondents’ response direction for the dependent variable will go up. A positive (+)
correlation points to a parallel relationship direction between the independent and
dependent variables.
Correlation coefficients whose magnitudes are between 0.9 and 1.0 indicate
variables which can be considered as very highly correlated.
variables which can be considered as highly correlated.
variables which can be considered as moderately correlated.
variables which can be considered as low correlation.

52
Correlation coefficients whose magnitudes are less than 0.3 have little if any
(linear) correlation.
It can readily see that 0.9 < [r] < 1.0 corresponds with 0.81 < r2 < 1.00; 0.7 < [r] <
0.9 corresponds with 0.49 < r2 < 0.81; 0.5 < [r] < 0.7 corresponds with 0.25 < r2 < 0.49;
0.3 < [r] < 0.5 corresponds with 0.09 < r2 < 0.25; and 0.0 < [r] < 0.3 corresponds with 0.0
< r2 < 0.09.

53
Chapter4
DATA PRESENTATION, ANALYSIS AND INTERPRETATION OF FINDINGS
This chapter presents the responses and the corresponding analysis and
interpretation of the data tabulated arrange according to how they were posted in the
statement of the problem. Part I of the survey questionnaire was descriptive in nature and
dealt with the demographic characteristics of the respondents such as age, sex, civil
status, religion, family type/size, highest educational attainment, occupation, and monthly
family income were tallied, analyzed, and interpreted using the frequency and percentage
distribution.
Moreover, Part II explained and interpreted the responses on the perception of the
sample respondent’s on the barriers in the implementation of healthcare services in terms
of attitude, culture and beliefs, and family and socio dynamics. It is presented through
mean, standard deviation, and descriptive rating.
Similarly, Part III of the survey questionnaire was about factors affecting the
implementation of health care services in terms of accessibility, availability of health care
providers, and provision of care and quality of services and Part IV about extent of the
implementation of the Health Care Services as to the selected DOH Programs in terms
EPI, Antenatal Care and Family Planning were presented through mean, standard
deviation, and descriptive rating to explain and interpret the responses of sample
respondents. Then followed by Part V, the correlation relationship between variables.

54
For an organized approach, the flow of the presentation, discussion and analysis
of data follows the pattern of the study’s statement of the problem.
Profile of the Respondents
The following table describes and discusses the profile of the respondents in terms
of age, sex, civil status, religion, family type/size, highest educational attainment,
occupation, and monthly family income.
Age
Below is a table that shows the frequency and percentage distribution of the
respondent’s by age.
Table 2
Frequency and Percentage Distribution of Respondents’ Age
Age (in yrs.) Frequency (f) Percentage (%)

Below 18 years old 73 15.4
19 to 29 years old 118 24.9
30 to 39 years old 161 34.0
40 to 49 years old 106 22.4
50 to 59 years old 13 2.7
Above 60 years old 2 0.4
TOTAL 473 100
Based on Table 2, the majority of the participants belong to the age group 30 to
39 years of old (34%), followed by 19 to 29 years of old (24.9%), and 40 to 49 years of
old (22.4%). Collectively, this means that most of the sample respondents were young
adult (20 to 40 years old) of which according to Roger Gould’s Seven Stages of Adult
Development have already established autonomy; growing and building for the future;
with a well-established marriage and careers; and is in the period of the surge of self-
esteem (Balita, 2008).

55
Moreover, there were less than 20 percent of the respondents from the age group
below 18 years of old, which constituted 73 or 15.4% out of the total. This youth (father
or mother) as the representative of the family household head indicates early parenthood
and early marriage practice (see Table 3, pg.58) among Sama Tribes, which permitted in
the perspective of Islam religion (see Table 4, pg. 60). Within this particular age bracket,
parents are expected as first-time mother and or father or inexperienced parents in terms
of child bearing and rearing. Consequently, may assume to have limited knowledge and
demand over healthcare services such as immunization, antenatal care, and family
planning.
Meanwhile, the least of the age group were 50 to 59 years of old, which
constituted 2.7%, and only 0.4% among 60 years of old above. They were the oldest
noted representative sample respondents of which R. Gould’s explained as the period of
transmission with a realization of mortality and concern for health. These set of
respondents could be the family’s grandparents in a household and may have extensive
knowledge and have had meticulous needs and services of healthcare for their children or
grandchildren.
Sex
Table 3 shows the frequency and percentage distribution of the respondents in
terms of Sex.
Table 3
Frequency and Percentage Distribution of Respondents’ Sex
Sex Frequency (f) Percentage (%)

Male 7 1.5
Female 466 98.5
TOTAL 473 100
56
Gender plays a role in creating disparities for access to health that are sometimes
being marginalized. Table 3 above presents the frequency and percentage distribution of
the respondent’s sex. It shows that majority of the respondents were female household
heads, with an overwhelming percentile figure of roughly ninety-nine (98.5%)
equivalently consisted 466 in number out of the total sample of 473. The dominating
figure of female as household heads is not surprising which could be due to their cultural
practice and beliefs and that they are majorly responsible in the direct care of their
children and in doing indoor task. Meanwhile, male household heads as representative
respondents were few due to some typical outdoor responsibilities as a provider such as
working or doing some business to support financial needs of the family.
Findings above accord to the study of Scott et al., (1996) in Australia that women
utilized health services were more likely to receive a prescription regardless of health or
socioeconomic status than their male counterparts. It is because women have numerous
health care needs or services especially during pregnancy due to possible life threatening
complications.
On the other hand, Wyss (2003) asserted that the gender specific roles of women
negatively influence their health or force to seek permission to obtain health care. Study
of Hjorstborg and Mwikisa (2002) emphasized that staying at home for women in a
developing country to perform a household work may not be able to develop economic
independence resulting to limited access to health care services which has been proven by
some studies (Flores et al. 1998; Howden-Chapman and Cram, 1998; Nanda, 2002;
Nandi et al., 2008; Phillips et al., 2000) that women are sometimes marginalized creating
disparities for access to health. However, in other countries like USA, it has been found
57
that among employees women had more insurance coverage than males (Scott et al.,
1996).
Civil Status
Table 4 presents the frequency and percentage distribution of the respondents’
civil status.
Table 4
Frequency and Percentage Distribution of Respondents’ Civil Status
Civil Status Frequency (f) Percentage (%)

Single 5 1.1
Married 447 94.5
Widowed 10 2.1
Separated 11 2.3
TOTAL 473 100
It showed that majority of the respondents were married with a frequency mark of
approximately ninety five percent (94.5%) consisting 447 samples in total. These
numbers of married respondents are expected to have more than 2 children as correlated
to their age shown in the Table 2 (pg. 54). It indicated that almost all of them had already
have experience on child rearing and thus have been consulting the needs of health care
provider to acquire services such as antenatal care and immunization for their children.
According to the DOH (2010), the presence of couple in counseling on the importance of
family planning is very important because it helps them to be informed on the right
choice of FP methods, proper spacing of birth, and addressing the right number of
children as well as in reinforcing pre-antenatal care and immunization.

58
On the other hand, a little more than two-percent (2.3%) of respondents involved
in the study whom were separated or presumably single-parents. That is only eleven (11)
samples from total population. Furthermore, it was closely followed by widowed merely
two-percent (2.1%) constituting ten (10) samples. Then, the remaining one percent
(1.1%) or a total of five (5) were identified as single. According to Yakong’s (2008)
study of rural Ghanaian, women living with no partner shown to have more difficulty in
accessing health services than with partner (e.g. couple living together).
Findings above imply that married respondents may have better access to health
care than being single, separated, or widowed because the couple could work together
hand-in-hand in addressing their health care needs and the likes.
Respondents’ Religion
Table 5 below presents the frequency and percentage distribution of the

respondents’ religion.
Table 5
Frequency and Percentage Distribution of Respondents’ Religion
Religion Frequency (f) Percentage (%)

Islam 473 100.0
TOTAL 473 100
It shows that all of the respondents practice the religion of Islam. It means that all
of them (Sama tribe) were Muslims observing Islamic laws. The Islamization of the
people in the southwestern Mindanao can be traced back through history that Moros
fought and resisted series of colonialization by Spaniards and Americans thereby
retaining their primary and former religion Islam. It accords to the data available in
Philippine Statistics Authority (PSA) [2014] that majority or more than 90 percent of the
religion in the people of Tawi-Tawi is Islam.

59
The data above may imply that the behavior, cultural practices, and views of
respondents were bounded by the doctrines from their religious affiliation. It means that
practices that may against their religious beliefs would somehow hinders the
implementation of healthcare services such as immunization, antenatal care, and family
planning. For instance, the use of condoms as part of the family planning method are
being disputatively opposed by Islamic scholars (Ulama) as unacceptable practice or non-
religious act.
Respondents’ Family Type
Table 6 below presents the frequency and percentage distribution of the
respondents’ family type.
Table 6
Frequency and Percentage Distribution of Respondents’ Family Type
Family Type Frequency (f) Percentage (%)

Nuclear 294 62.2
Extended 178 37.6
TOTAL 473 100
As shown, a majority of more than sixty two percent (62.2%) of the total
respondents have nuclear family type which constituted two-hundred ninety four (294) of
the studied population. Lastly, less than half or about 178 or 37.6 percent were in an
extended type of family.
A nuclear family type as described in Encyclopedia Britannica (2011) is also
called elementary family which is a family group consisting of a pair of man and woman
(adults) and their children (one or more), considering a time after the pair engagement,
different than Family-in-law. In contrast, extended family is a family that extends beyond
60
the nuclear family, consisting of parents, aunts, uncles, and cousins, all living nearby or
in the same household.
It implies that the respondents have strong family ties which could be helpful in
accessing health care services. However, it could be disadvantageous, on the other hand
as higher number of members were there in the family that limits the resources.
Respondents’ Family Size
family size.
Table 7
Frequency and Percentage Distribution of Respondents’ Family Size
Family Size Frequency (f) Percentage (%)

2 to 4 Family members 113 23.9
TOTAL 473 100
The table above exhibits that the majority of the family have five to seven (5-7)
family members, which accordingly, constituting of almost thirty-eight percent (37.8%)
or one hundred seventy nine (179) participants. According to Wagner and Schuber
(1985), larger families are more frequent with early marriage and rapid birth of the first
child. In larger families, child rearing becomes more rule ridden, less individualized, with
corporal punishment and less investment of resources. Smaller families tend to result in
higher IQ, academic achievement, occupational performance and more healthy.
Moreover, there were about one hundred sixteen (116) or almost twenty five
percent (24.5%) of the family with eight to ten (8-10) family members. It closely
followed by family with family members of one hundred thirteen (113) or approximately
61
twenty four percent (23.9%) of samples. It means that less than one fourth of the total
sample respondents were small families. Subsequently, there were then about sixty five
(65) or nearly fourteen percent (13.7%) of the sample respondents noted to have eleven to
thirteen (11-13) family members. This could represent the family group who were not
promoting the family planning due to religious beliefs, cultural practices, and personal
matters to mention few.
Highest Educational Attainment

highest educational attainment.
Table 8
Frequency and Percentage Distribution of Respondents’ Highest Educational
Attainment
Highest Educational Attainment Frequency (f) Percentage (%)

No formal education 1 .2
Vocational course 3 .6
Elementary level 22 4.7
Elementary graduate 5 1.1
High school level 69 14.6
High school graduate 178 37.6
College level 144 30.4
College graduate 48 10.1
With units in master’s program 3 .6
TOTAL 473 100
Education is a universal right for all and serves as a basis not only for qualifying
onto a job but also as a scale on ensuring quality outcome. Table 8 statistically inscribe
showing that majority of the respondents were high school graduates of about one
hundred seventy eight (178) or closely to thirty eight percent (37.6%) whereas college
level which constituted one hundred forty-four (144) respondents with a percentile mark
of thirty percent (30.4%) out from the total sample population. Many studies have
claimed that the quality of outcome is homogenous with respect to educational

62
attainment, which means that the higher the educational attainment, the higher the quality
outcome (Waller-Wise, 2013). Respondents who are highly educated may have different
view on the importance of health care services. It suggests that health concerns or issues
could be their priority concerns.
Moreover, there were only forty eight (48) respondent or a total percentile mark
of ten percent (10.1%) of the respondents who were college graduates and seemingly few
less respondents took units in masters’ program constituting only a number of three (3) or
less than one percent (0.6%) participated this study. According to Wickrama & Lorenz
(2002), education level shape women’s use of health care services. This means
respondents with low education level such as the 6.5 percent of the total respondents may
have less access to health care services.
Furthermore, one percent (1.1%) or five (5) or the respondents were elementary
graduates while twenty-two (22) nearly five percent (4.7%) reached the elementary level.
Also, there were three (3) of that was less than one percent (0.6%) proceeded to a
vocational course, and then only one participant (1) or 0.2% was without formal
education. In a study of The National Campaign to Prevent Teen Pregnancy (2002), it
shows that out of school youth most likely lead to early or teen age pregnancy. Early
pregnancy according to De Leon (2009) is highly associated with maternal mortality
because at their young age they are not educated and lack of skills and knowledge in
seeking available and accessible health services.
Similarly, one study in 2001 found that women who gave birth during their teens
completed secondary-level schooling 10–12% as often and pursued post-secondary

63
education 14–29% as often as women who waited until age 30 (Hofferth SL, Reid L,
Mott FL, 2001)
Occupation
Table 9 shows the frequency and percentage distribution of the respondents’
occupation.
Table 9
Frequency and Percentage Distribution of Respondents’ Occupation
Occupation Frequency (f) Percent (%)

Housewife 303 64.1
Land farmer 26 5.5
Seaweed farmer 91 19.2
Government Employee 45 9.5
Others 8 1.7
TOTAL 473 100
The findings reveal that majority of the respondents were housewife which
constituted three hundred three (303) or sixty four-percent (64.1%) out of the total
population of this study, validating the findings in Table 8 (pg. 61) that ninety percent
(90%) of them had no time and the opportunity to graduate in the college level. This lead
to the presumption that the husbands were the bread winners, an arrangement quite
typical in Muslim society.
On one hand, this may result into not so much aware of correct and truthful health
practices on a theoretical level. On the other hand, being housewives, the respondents
would probably be more attuned to the practical side of health and pregnancy.
64
Moreover, due to the geographical location of the area, some of the family
members’ occupations were into seaweed farming comprising ninety-one percent (91%)
or one hundred ninety two (192) respondents while and almost six percent (5.5%) or
twenty six (26) of samples involved were engaged in land farming. There were then forty
five (45) or nearly ten percent (9.5%) of the respondents whom were connected or
working in the government (government employee) whereas eight (8) of them or almost
two percent (1.7%) were identified as having other type of work (others) such as in
business, contracting, shipping and the like. The nature of their occupation has been
reflected to their monthly family income shown in Table 10.
Monthly Family Income
Table 10 shows the frequency and percentage distribution of the respondents’ area
of nursing service department.
Table 10
Frequency and Percentage Distribution of Respondents’ Monthly Family Income
Monthly Family Income Frequency (f) Percentage (%)

Below P2,500 / month 159 33.6
P2501 to P5,000 / month 189 40.0
P5,001 to P7,500 / month 55 11.6
P7,501 to P10,000 / month 7 1.5
P10,001 to P12,500 / month 14 3.0
P12,501 to P15,000 / month 3 .6
P15,001 to P17,000 / month 13 2.7
Above P17,001 / month 33 7.0
TOTAL 473 100
Findings above reveal that close to eighty-five percent (85) of the respondents
belonged to families earning less than 10,000 pesos a month, which means that they
belong to the D and E economic bracket.

65
The remaining fifteen percent (15) of the sample respondents have earnings of
more than 10,001 pesos per month. These could be the respondents who owned farming
or fishing and affiliated government as employees. This also evidently validates the
findings in the Table 9 (pg. 62) of the respondents’ occupation. According to Wallman
and Baker (1996) identified money income, potential money income, and social status as
a factors that can affect women’s capacity to obtain treatment or related maternal health
related services. According to Bennett and Gilson (2000), people residing in the rural
areas pay a large proportion of their income than their urban counterparts. This could be
due to the cost of living that group of people having in the locale as could be observed in
the area of Tawi-tawi. However, Hjorstborg and Mwikisa (2002) asserted that people
with low income have higher incidences of illnesses but use services less often that could
be due to financial constraint.
The findings shown in the table above imply that the respondents’ socio-
economic status (monthly income) encouraged them towards availing health care services
being implemented by the DOH particularly antenatal, immunization, and family
planning. For the family with higher number of family members yet with meager monthly
income may seek for free healthcare services.
Part 2 – Barriers in the Implementation of Health Care Services
The following table below discusses the barriers in the implementation of health
care services in terms of attitude, culture and beliefs, and family and social dynamics.
Attitude towards Expanded Program Immunization (EPI)

66
Table 11 shows the mean, standard deviation, and interpretation of the
respondents’ barriers in the implementation of healthcare services in terms of attitude
towards expanded program of immunization (EPI).
Table 11
Statement Indicators Mean Std. Interpretation
Deviation
1. I am afraid of vaccination due to the fear 2.15 1.071 Rarely

of multiple doses of
vaccination/procedures
2. I stopped my child from being immunized 1.43 .930 never
because of the side effects o immunization
3. I reject vaccination for no reason 1.36 .283 never
4. I have fears of subjecting my children for 1.36 .566 never

immunization because I pity them
5. I have no time to take my children for 1.92 1.046 rarely
immunization because I am busy on other
Average Weighted Mean 1.581 never
Scaling: 421-5.00=Always 2.61-3.40=Sometimes 1.00-1.80= never

3.41-4.20=often 1.81-2.60= rarely
The Expanded program on Immunization (EPI) was purposely made and design
as a response to the Universal Child Immunization goal. Table 11 shows statement about
respondents’ attitude towards EPI as barriers in the implementation of healthcare
services. The respondents asserted that they were “rarely” afraid of vaccination due to the
fear of multiple doses of vaccination or procedures (mean =2.15). It is the health center
and hospitals that provide monitoring card to the parents of the patients for the purposes
of monitoring, schedules, and follow-up visit for the next dose of vaccines. Ideally DPT,
Hepa-B, and OPV vaccines are given in 3 doses with three weeks of interval and single
dose of measles at the age of 9 months.

67
Similarly, respondents stated that they “rarely’ “ have no time to take their
children for immunization because of being busy on other things” with a ( mean=1.92). It
means that the parents of the children perceived immunization as important event for
their children in which their presence was highly valuable.
Moreover, respondents affirmed that they “never’ “stopped their children from
being immunized in spite of the side effects of immunization with a ( mean=1.43). They
also “never” “reject vaccination for no reason” with a ( mean=1.048) and “never”
“having fears of subjecting their children for immunization although it’s pity with (
mean= 1.36).
Based on the average weighted mean score of 1.581, it implies that respondents
regarded EPI as essential and beneficial to their children. It seems that the respondents
(parents) preferred to have their child experienced pain during injection(Immunization)
than acquiring immunizable diseases such as TB, meningitis, polio, hepatitis, liver
cirrhosis, and measles to name a few. The positive attitude of the respondents towards
EPI as one of the DOH programs has significant bearing to the extent of the
implementation of healthcare services in the locale of Tawi-Tawi.
Attitude Towards Antenatal Care
towards antenatal care.

68
Table 12
Barriers in the Implementation of Health Care Services in terms of Attitude

towards Antenatal Care
Indicator: Std.
Mean Interpretation
Antenatal Care Deviation
As pregnant woman, I do not go to health institutions
because:
o I am busy at home. 2.006 1.099 Rarely
o I have no reason to go or visit. 1.090 .493 Never
o My husband is not around. 2.203 1.150 Rarely
o No one will take care of our house. 2.093 1.173 Rarely
o I lack knowledge of how important it is on 1.114 .431 Never
health
Average Weighted Mean: 1.701 Never
Scaling: 4.21-5.00 – “Always” 2.61-3.40– “Sometimes” 1.00-1.80-“Never”
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
Pregnancy is a crucial process that puts life at stake due to possible complications
and thus necessary to have regular visit to the nearest facility for antenatal registration
and to avail prenatal care services. Table 12 shows statement about respondents’ attitude
towards antenatal care as barriers in the implementation of healthcare services. Based on
the findings in the table above, respondents stated that they were “rarely” consulting
health institutions because “their husband is not around” (mean=2.203), “none would
take care of their house” (mean=2.093), and “being busy at home” (mean=2.006). This
validates the outcome findings on the occupation shown on Table 9 (pg. 63) that being
housewife means the husband is away from home and the wife is taking the full
responsibilities of the household works that makes her busy. Pregnant mother may be
also afraid of going alone in the health institutions due to physiological struggles in
pregnancy especially during first and third trimester.

69
Moreover, respondents asserted that they have “never” consulted in health
institutions because of having “no reasons to go or visit” (mean=1.090) and “lacks
knowledge on its important to health” (mean=1.114). These findings could be related to
the educational attainment of the respondents as they might only have insufficient
knowledge of the importance of prenatal care or regularly vising health institutions for
regular maternal check-ups.
The data above imply that the respondents’ have negative attitude towards
antenatal care as evidenced by weighted mean score of 1.701 which denotes that
antenatal care is never a problem to them. This may decrease the acquisition of healthcare
services of pregnant women in some health institutions where prenatal care is accessible
and available.
In addition, the negative attitude of the respondents’ towards antenatal care could
be also associated to their socio-economic status. It accords to the explanation of
Asiimwe (2010) in his study at western Uganda that the ability of a woman to afford
antenatal care (ANC) services has a significant association to the number of ANC visits
she is likely to make. Similar findings also of Atuyambe et al., (2005) that mothers were
unwilling to pay for antenatal services.
Attitude towards Family Planning
towards family planning.

70
Table 13
Barriers in the Implementation of Health Care Services in terms of Attitude
towards Family Planning
Indicator: Std.
Mean Interpretation
Family Planning Deviation
As a mother, I do not go to health institutions because:
o I am busy at home. 2.002 1.097 Rarely
o I have no reason to go or visit. 1.082 .477 Never
o My husband is not around. 2.230 1.146 Rarely
o No one will take care of our house. 2.097 1.180 Rarely
o I lack knowledge of how important it is on 1.105 .423 Never
health
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
Family Planning and responsible parenthood assure greater opportunity for each
Filipino to reach his full potential and to attain his individual dignity. Table 13 shows
statement about respondents’ attitude towards family planning as barriers in the
implementation of healthcare services. Based on the findings in the table above,
respondents stated that they were “rarely” consulting health institutions to inquire about
family planning because “their husband is not around” (mean=2.230), “none would take
care of their house” (mean=2.002), and “being busy at home” (mean=2.097). Family
planning is an important decision to be decided amicably both by the couple, thus, the
husband and wife should be both present during consultation in health institutions
pertaining to FP.
Moreover, respondents asserted that they have “never” consulted health
institutions concerning to family planning because of having “no reasons to go or visit”
(mean=1.090) and “lacks knowledge on its important to health” (mean=1.114). It implies

71
that respondents have less attention about the importance of family planning which
means birth spacing was not their priority. This noticeably validates the findings in Table
7 (pg. 60) that more than seventy percent (70%) of the respondents have more than five
(5) family members.
Culture and Beliefs towards Expanded Program on Immunization (EPI)
respondents’ barriers in the implementation of healthcare services in terms of culture and
beliefs towards the expanded program on immunization.
Table 14
Barriers to the Implementation of Health Care Services in terms of Culture and
Beliefs towards Expanded Program Immunization (EPI)
Indicator: Std.
Mean Interpretation
Expanded Program Immunization (EPI) Deviation
1. Immunization is not acceptable because it is
1.171 .527 Rarely
against the culture and beliefs of others.
2. Immunization is forbidden or “Haram” to
1.177 .530 Never
some culture.
3. Fear on the immunization’s side effects. 2.158 .999 Rarely
4. Believe more on traditional treatments than
2.505 1.340 Rarely
medical treatments.
5. Fear on the newly manufactured vaccines (e.g.
1.811 .925 Rarely
Pneumonia Conjugate Vaccine).
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
Some cultures and beliefs define what healthcare services are needed for the
group. In Table 14 shows statement about respondents’ cultural beliefs and practices
towards expanded program on immunization as barriers in the implementation of
healthcare services. Based on the findings reflected on the table above, respondents stated
that they “rarely” “believe more on traditional treatments than medical treatments”
(mean=2.505), “fear on the immunization side effects” (mean=2.158), “fear on the newly
72
manufactured vaccines (e.g. pneumonia conjugate vaccine)” (mean=2.097), and
“immunization is not “rarely” acceptable because it is against the culture and beliefs of
others” (mean=1.171).
On the other hand, respondents claimed that “immunization is “never” forbidden
or “Haram to some culture” (1.177). Collectively, respondents (Sama tribe) have no
negative cultural belief and practices towards expanded program on immunization as
evidenced in the average weighted mean score of 1.764. Therefore, the culture and beliefs
of the respondents (Sama tribe) as regard to immunization has been perceived as “never”
a barrier in the implementation of healthcare services.
Culture and Beliefs towards Antenatal Care
beliefs towards antenatal care.
Table 15
Barriers in the Implementation of Health Care Services in terms of Culture and
Beliefs towards Antenatal Care
Indicator: Std.
Mean Interpretation
1. Tetanus Toxoid is not acceptable because it is
1.105 .340 Never
against the culture and beliefs.
2. Tetanus Toxoid is forbidden or “Haram” to some
1.126 .487 Never
culture.
3. Fear on Tetanus Toxoid vaccine’s side effects. 2.427 .788 Rarely
4. Fear on the side effects of taking Iron
2.530 .802 Rarely
supplements.
5. Believe more on the traditional birth
attendants (“Hilot”) than healthcare 3.255 1.193 Sometimes
professionals.
Average Weighted Mean: 2.088 Rarely
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
73
In Table 15, it presented statement regarding the respondents’ cultural beliefs and
practices towards antenatal care as barriers in the implementation of healthcare services.
Based on the findings in the table above, respondents stated that they “sometimes”
“believe more on traditional birth attendants (“Hilot”) than healthcare professionals”
(mean=3.255). According to Kasolo et al. (2000), most women prefer Traditional Birth
Attendants (TBAs) than doctors/nurses because they do not see private parts during
attendance, except they just feel by a touch which is more common in the rural parts of
the country. TBA could be also perceived by the respondents as inexpensive, available,
accessible and hassle free since TBA could make regular home visit or do home delivery
rather than endure burden of transportation for antenatal care or maternal consultation.
In addition, respondents further claimed that they “rarely” “fear on Tetanus
Toxoid vaccines side effects” (mean=2.427), and also they have “rarely” “fear on the side
effects of taking Iron supplements” (mean=2.530). It means that their perception on
Tetanus Toxoid (TT) and Iron Supplements could have a slight negative effects to their
health and the fetal development. It also imply that the respondents were not completely
knowledgeable nor fully aware of the benefits and advantages, which could be due to the
nature of their occupation (see Table 9, pg. 63).
Furthermore, respondents “never” claimed that “Tetanus Toxoid is forbidden or
“Haram” to some culture” (mean=1.126) and that the “Tetanus Toxoid is not acceptable
because it is against the culture and beliefs” (Mean=1.105). Collectively, respondents
believed that their cultural practices and beliefs “rarely” considered as a barrier in the
implementation of healthcare services in the locale of the study. It also implies that
74
antenatal care is wholeheartedly accepted and viewed as something beneficial to their
family.
Culture and Beliefs towards Family Planning
Table 16 presents the mean, standard deviation, and interpretation of the
beliefs towards family planning.
Table 16
Barriers in the Implementation of Health Care Services in terms of Culture and
Beliefs towards Family Planning
Indicator: Std.
Mean Interpretation
1. Family Planning is not acceptable due to culture
1.120 .508 Never
and beliefs.
2. Family Planning method is forbidden or
1.112 .489 Never
“Haram”.
3. Fear on the side effects of contraceptives such as
pills, DMPA (Depot Medroxyprogesterone 2.744 .838 Sometimes
Acetate) injections and IUD (Intrauterine Device).
4. Believe more on abstinence and withdrawal
methods than the modern family planning 3.065 1.007 Sometimes
methods
5. Believe that family planning methods are
1.611 .911 Never
abortifacient professionals.
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
In Table 16 displays statement concerning the respondents’ cultural beliefs and
practices towards family planning as barriers in the implementation of healthcare
services. Based on the outcome of the results in the table above, respondents revealed that
they “sometimes” “believe more on abstinence and withdrawal methods than the modern
family planning methods” (mean=3.065) and “sometimes” have “fear on the side effects
75
of contraceptives such as pills, DMPA (Depot Medroxyprogesterone Acetate) injections
and IUD (Intrauterine Device)” (mean=2.744). This could be due to the religious belief of
the respondents assert by the “Ulamas” or teaching of the Muslim scholars claiming that
contraceptives are not part of Islamic practices. It accords with ShodhGanga (2010) that
practices of FP is more on personal decision of the couple.
Moreover, respondents further claimed that they “never” “believe that the family
planning methods are abortifacient professionals” (mean=1.611), “Family Planning is not
acceptable due to culture and beliefs” (mean=1.120), and “Family Planning method is
forbidden or Haram” (mean=1.112). This implies that Family Planning is not being
prohibited in their cultural belief and practices as well as in their religious affiliation.
Collectively, respondents viewed family planning as a “rare” (weighted
mean=1.930) barrier in the extent of implementation of healthcare services. It implies that
Family Planning, as one of the program being implemented by the DOH, is not being
resisted or opposed through cultural practices and religious beliefs.
Family and Social Dynamics towards Expanded Program on Immunization

(EPI)
respondents’ barriers in the implementation of healthcare services in terms of family and
social dynamics towards EPI.

76
Table 17
Barriers in the Implementation of Health Care Services in terms of Family and
Social Dynamics towards Expanded Program Immunization (EPI)
Indicator: Std.
Mean Interpretation
Expanded Program Immunization (EPI) Deviation
1. Easily believed on hearsays being told by their
relatives and friends (e.g. misconceptions of 2.799 .861 Sometimes
immunization).
2. Mothers are noncompliant to follow-up schedules
2.334 .819 Rarely
of immunizations of their children.
3. No money to pay for the transportation in
1.118 .551 Never
going to the health facility.
4. No available family member to accompany the
2.577 .984 Rarely
children.
5. The family have strong ancestral beliefs. 1.389 .861 Never
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
In Table 17, it evidently shows the statement of respondents regarding the family
and social dynamics towards EPI as barriers in the implementation of healthcare services.
Based on the outcome findings, respondents stated that they “sometimes” “easily
believed on hearsays being told by their relatives and friends (e.g. misconceptions of
immunization)” (mean=2.799). This result relates to the type of family structure among
Sama tribe as most of them have extended type of family (See Table 6, pg. 59), which
means that they have a strong social networks and that simple hearsays could create
misconceptions.
Moreover, respondents claimed that they “rarely” have healthcare services on
immunization because there were “no available family member to accompany their
children” (mean=2.577), and also “mothers are noncompliant to follow-up the schedules
of immunizations of their children” (mean=2.334). It means that the head of the family
household have no legible buddy (adult) in acquiring healthcare services. It may also
77
imply that though they have extended family, some were small children or others were
too busy with their own responsibilities.
Furthermore, respondents “never” claimed that “their family have strong ancestral
beliefs” (mean=1.126) and that “financial constraint is not reasonable to pay for the
transportation in going to the health facility” (Mean=1.105). Collectively, respondents
“rarely” believed that family and social dynamics hinders or serve as barriers in the
implementation of healthcare services particularly in the context of EPI.
Family and Social Dynamics towards Antenatal Care
social dynamics towards antenatal care.
Table 18
Social Dynamics towards Antenatal Care
Indicator: Std.
Mean Interpretation
The mothers in the community:
o Seeks healthcare services at health 3.560 .781 Often
institutions.
o Do not visit health institutions without
2.932 .838 Sometimes
company.
o Believe on hearsays being told by their
relatives and friends (e.g. misconceptions of 2.737 .817 Sometimes
immunization and pills).
o Do not avail healthcare services due to
2.264 .882 Rarely
political reasons and issues.
o Do not have the time and fare to seek
healthcare services from healthcare 2.306 1.029 Rarely
institutions.
Average Weighted Mean: 2.759 Sometimes
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
78
In Table 18, it reflects statement of the respondents about the family and social
dynamics towards antenatal care as barriers in the implementation of healthcare services.
Based on the results, respondents expressed that they “often” “seeks the healthcare
services at health institutions” (mean= 3.560). It infers that mothers in the community
were concerned to their own state of health as well as their family members by visiting
health institution such as rural health units situated in every municipality.
Moreover, respondents affirmed that “sometimes” they “do not visit health
institutions without company” (mean=2.932), and “sometimes” they also “believe on
hearsays being told by their relatives and friends” (mean=2.737). It could suggest that
they have strong family ties and they considered the importance of presence of their
family members especially concerning health issues.
Furthermore, respondents confirmed that they “rarely” “do not avail healthcare
services due to political reasons and issues” (mean=2.264) and as well as they rarely do
not “do not have the time and fare to seek healthcare services from healthcare
institutions” (mean=2.306). Collectively, mothers in the community believed that family
and social dynamics towards antenatal care is “sometimes” (averaged weighted mean=
2.759) served as a barrier in the implementation of healthcare services.
Family and Social Dynamics towards Family Planning
social dynamics towards family planning.

79
Table 19
Social Dynamics towards Family Planning
Indicator: Std.
Mean Interpretation
1. The family do not agree on family planning. 2.911 1.371 Sometimes
2. The husbands disapprove the use of family
3.238 1.501 Sometimes
planning methods.
3. The relatives and friends discouraged the use of
family planning methods.
4. The wife is practicing family planning without
1.695 .695 Never
the approval or consent of the husband.
5. The couple volunteer to avail the family planning
2.023 1.251 Rarely
method.
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
Table 19 shows the statement indicating the responses of the respondents of this
study pertaining to the family and social dynamics towards family planning as barriers in
the implementation of healthcare services. Based on the outcomes, respondents expressed
that “sometimes” “the husbands disapproved the use of family planning methods”
(mean= 3.238) while the “relatives and friends discouraged the use of family planning
methods” (mean=3.198). Moreover, the “family do not agree on family planning”
(mean=2.911). It suggests that the family planning is an important issue that needs
discussion and approval within the family and its members. These responses could be a
collective reflection of the family household with less than three family members desiring
to have a bigger family size.
Meanwhile, respondents stated that the couple do “rarely” “volunteer to avail
family planning method” (mean=2.023). This could be the families who were curious
about the benefits of family planning to their lives. On the other hand, the wife expressed
80
that they “never” “practiced family planning without the approval or consent of the
husband” (mean=1.695). It particularly found that the decision about the practice of
family planning comes both from the couple. It also implies that the wife is respecting the
rights of husband in the decision of that matter.
Collectively, family planning in familial and social dynamics were “rarely”
(averaged weighted mean= 2.613) viewed as a barrier in the implementation of healthcare
services.
Part 3 – Factors Affecting the Implementation of Health Care Services
The following tables discuss the factors affecting the implementation of health
care services in terms accessibility of health care services, availability of health care
providers, and provision of care and quality of services.
Accessibility of Healthcare Services
Table 20 presents the mean, standard deviation, and interpretation of the factors
affecting the implementation of healthcare services in terms of accessibility.
Table 20
Factors Affecting the Implementation of Health Care Services in terms of
Accessibility
Accessibility of Health Care Services Std.

Mean Interpretation
Deviation
1. Vaccines are available and free of charge.. 4.382 .741 Always
2. Family planning supplies (condoms, pills, injectables,
4.188 .695 Sometimes
etc.) are available and free of charge.
3. Prenatal and postnatal services are available. 4.329 .740 Always
4. There is enough number of health institutions in the
4.900 .357 Always
municipality.
5. There is an available vehicle for transportation to
2.137 1.743 Rarely
health institutions.
6. The health institutions are BemONC or CemONC
4.881 .519 Always
certified.
Average Weighted Mean: 4.136 Often
81

3.41-4.20 – “Often” 1.81-2.60– “Rarely”
Table 20 shows the statement about the respondents’ accessibility of healthcare
services as a factor affecting its implementation. Based on the findings in the table above,
respondents stated that they were “always” “enough number of health institutions in the
municipality” (mean=3.255). Likewise, “prenatal and postnatal services were ‘always’
available” (mean=4.329). Also, they “always” (mean= 4.881) claimed that “the health
institutions were BemONC or CemONC certified”, and that the “vaccines were ‘always’
(mean=4.328) available and free of charge”.
Moreover, they further claimed that Family planning supplies (condoms, pills,
injectables, etc.) were “sometimes” (mean=4.188) available and free of charge. It could
be due to the fact that some health care units (or institutions) have regular schedule for
family planning concerns similar with the program of immunization that being regularly
scheduled every Wednesday.
On one hand, the respondents claimed that the “available vehicle for
transportation to health institutions is rarely” operating (mean=2.137). It is because the
standard for every rural health units, there should be one vehicle intended for
transportation of patients and related matters concerning health issues.
Collectively, respondents stated that health care services were “often” (averaged
weighted mean=4.136) accessible. It goes to show that the accessibility of health care
services could be considered as moderate factor that can affect the implementation of
health care services.

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Availability of Health Care Providers
Table 21 shows the mean, standard deviation, and interpretation of the factors
affecting the implementation of healthcare services in terms of availability of health care
providers.
Table 21
Factors Affecting the Implementation of Health Care Services in terms of
Availability of Health Care Providers
Availability of Health Care Providers Std.

Mean Interpretation
Deviation
1. There is enough number of healthcare
4.420 .636 Always
professionals in the nearest health institution.
2. The healthcare professionals are equipped with
different trainings (e.g. BLS, ACLS, BemONC, 4.661 .516 Always
CemONC).
3. The healthcare providers are effective and
4.317 .611 Always
efficient.
4. The healthcare providers are productive. 4.331 .612 Always
5. The providers choose to whom the health
1.636 1.241 Never
services will be given.
6. The healthcare providers are equipped with
4.794 .414 Always
skills, knowledge and attitude.
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
Table 21 draws statement about respondents’ perception towards availability of
healthcare providers as a factor affecting the implementation healthcare services. Based
on this particular conclusive result above, it reveals that the “healthcare providers are
‘always’ (mean=3.255) equipped with skills, knowledge and attitude, and that “the
healthcare professionals also are always (mean=4.611) equipped with different trainings
(e.g. BLS, ACLS, BemONC, CemONC). The respondents asserted that healthcare
providers are “always” (mean=4.331) productive, effective, and “always” (mean=4.317)

83
efficient; and that their numbers (healthcare professionals in the nearest health institution)
is “always” (mean=4.420) enough.
It implies that the health care providers working in the health institutions were
committed as evidenced by their attendance and dedication because their patients (or
respondents) had have trust on their performance. It was also evident from the statement
that the providers “never” (mean= 1.636) choose to whom shall the health services be
given”
Collectively, respondents stated that health care providers were “often” (averaged
weighted mean=4.136) available and accessible. It essentially implies to the effect that
the availability of health care providers could be considered as moderate factor that can
affect the implementation of health care services.
Provision of Care and Quality of Services
Table 22 shows the mean, standard deviation, and interpretation of the factors
affecting the implementation of healthcare services in terms of Provision of Care and
Quality of Services.
Table 22 shows statement about respondents’ perception towards provision of
care and quality of services as a factor affecting the implementation healthcare services.
Based on the findings of the study in the table above, respondents perceived that
“healthcare providers were “always” well-trained with the different health-related
trainings (mean=4.894) while, “the healthcare providers were “always’ providing health
teachings to their patients/clients (mean=4.858). It implies that the health care providers
84
in the health institution in the locale of the study were competent and truly implementing
their work professionally.
Table 22
Factors Affecting the Implementation of Health Care Services in terms of Provision
of Care and Quality of Services
Provision of Care and Quality of Services Std.

Mean Interpretation
Deviation
1. The health institutions are equipped with
3.968 .671 Often
advanced technology.
2. The health institutions are practicing infection
4.803 .413 Always
control procedures.
3. There are available equipment and supplies
3.820 .643 Often
when needed.
4. The healthcare providers are practicing sterile and
aseptic techniques in handling equipment and 4.849 .396 Always
supplies during and after procedures.
5. The healthcare providers are well trained with
4.894 .381 Always
the different health-related trainings.
6. The healthcare providers are providing health
4.858 .383 Always
teachings to their patients/clients.
Average Weighted Mean: 4.532 Always
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
Similarly, the respondents also claimed that the “healthcare providers are ‘always’
practicing sterile and aseptic techniques in handling equipment and supplies during and
after procedures” (mean=4.849). Furthermore, the “health institutions has been claimed
as ‘always’ practicing infection control procedures” (mean=4.803). It connotes that the
healthcare providers were careful enough in not spreading microorganisms, which could
be the caused for acquiring communicable diseases.
Moreover, respondents asserted that “there are often available equipment and
supplies when needed” (mean=3.820) and “the institutions are ‘always’ often equipped
with advanced technology” (mean=3.9689).

85
Generally, based on the average weighted mean score of 4.532, respondents
perceived that there was always a provision of care and quality of services in the
implementation of healthcare services. It denotes that the provision of care and quality of
services were weak or negligible factor that affects the implementation of healthcare
services in the context of EPI, antenatal care, and family planning.
Part 4 – Extent of the Implementation of Health Care Services
The following tables discuss the extent of the implementation of health care
services as to selected Department of Health (DOH) programs in terms of EPI, Antenatal
care, and Family Planning. Below is a table that shows the mean, standard deviation, and
interpretation of the extent of the implementation of healthcare services in terms of EPI.
Expanded Program on Immunization
Table 23 presents the mean, standard deviation and interpretation of the extent of
the implementation of health care services in terms of expanded program on
immunization.
The Expanded Program on Immunization (EPI) is made and designed as a
response to the Universal Child Immunization goal. Table 23 shows the statement
regarding the respondents’ perception towards implementation of EPI as part of the
healthcare services being implemented nationwide under the program DOH. Based on the
result in the abover table, respondents illustrated and answered “always” on the following
statements: “The recommended sequence of the co – administration of vaccines was
followed by the health institution” (mean=4.864); “Health teaching on the importance of
immunization was done” (mean=4.896); “Supplies needed for immunization were

86
available in the health institution” (mean=4.754); “Vaccine recipients or their
parents/guardians were being informed on the side effects or adverse reactions of the
vaccine” (mean=4.902); “Contraindications to immunization were being explained”
(mean=4.917); ‘”EPI recording and reporting was being accomplished” (mean=4.911);
and, “Preparation and calculation of vaccine requirement were correctly followed”
(mean=4.911).
Table 23
Extent of the Implementation of Health Care Services in terms of Expanded
Program on Immunization
Expanded Program of Immunization Std.

Mean Interpretation
Deviation
Vaccines against preventable diseases such as:
o Pentavalent Vaccines 3.9831 .878 Often
o Pneumonia Conjugate Vaccines 3.9831 .878 Often
o Oral Polio Vaccines 3.9831 .878 Often
3.9831 .878 Often
o Measles Vaccine 3.9831 .878 Often
o Hepa B Vaccine was available
The cold chain system for ensuring the potency of
4.071 .838 Often
vaccine is maintained.
The recommended sequence of the co – administration
4.864 .577 Always
of vaccines is followed by the health institution.
Health teaching on the importance of immunization
4.896 .478 Always
was done.
Supplies needed for immunization are available in the
4.754 .694 Always
health institution.
Giving of Hepatitis B vaccine right after delivery
was done.
Vaccine recipients or their parents/guardians are being
informed on the side effects or adverse reactions of the 4.902 .503 Always
vaccine.
Contraindications to immunization are being
4.917 .482 Always
explained.
EPI recording and reporting is being accomplished. 4.911 .487 Always
Preparation and calculation of vaccine requirement are
4.911 .487 Always
correctly followed.
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
87
Moreover, respondents affirmed that vaccines against preventable diseases
namely: Pentavalent, Pneumonia Conjugate, Oral Polio, Measles, and Hepa B were
“often” implemented (mean=3.9831). On the other hand, the giving of Hepatitis B
vaccine right after delivery was “sometimes” done (mean=2.854). The giving of Hepa B
vaccines could be attributed to the preference of the mothers in giving birth assisted by a
traditional birth attendants in which vaccines may not be always available to them at
hand.
Collectively, with an average weighted mean score of 4.506 suggests that the
expanded program on immunization (EPI) was always implemented as part of the
healthcare services under the DOH programs.
Antenatal Care
Table 24 presents the mean, standard deviation, and interpretation of the extent of
the implementation of healthcare services in terms of antenatal care.
Table 24
Extent of the Implementation of Health Care Services in terms of Antenatal Care
Antenatal Care Std.

Mean Interpretation
Deviation
Nutritional counselling during prenatal visit was done. 4.338 .853 Always
Promotion of healthy lifestyle including advice
relative to smoking cessation, healthy diet, regular 4.232 .823 Always
exercise.
Prenatal assessment such as:
4.934 .476 Always
o Weight and blood pressure monitoring is being
practiced. 4.828 .790 Always
o Measurement of fundic height against the age of
gestation is being observed. 4.835 .779 Always
o Fetal heart beat and movement was monitored.
o Leopold’s maneuver was done. 4.936 .474 Always
Tetanus toxoid is available every prenatal. 4.315 .770 Always
Skilled birth attendant/ Skilled health professional –
assisted delivery and facility based deliveries 4.890 .586 Always
including the use of partograph is being promoted in
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the health institution.

There is a proper management of pregnancy and
1.887 1.094 Rarely
delivery complications.
EINC (Essential Intrapartum and Newborn
Care)/Unang Yakap practices are being practiced for 4.682 .923 Always
safe and quality care of the woman during childbirth.
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
Every woman has to visit the nearest facility for antenatal registration and to avail
prenatal care services to avoid possible maternal and child complications especially
during pregnancy. Table 24 above shows the statement about respondents’ perception
towards antenatal care as part of the healthcare services being implemented nationwide
under the program DOH. Based on the outcome result, the respondents likely answered
“always” in terms of the following statements: “Nutritional counseling during prenatal
visit was done” (mean=4.338); “Promotion of healthy lifestyle including advice relative
to smoking cessation, healthy diet, regular exercise” (mean=4.232); “Prenatal assessment
such as: Weight and blood pressure monitoring were being practiced (mean=4.4.934)”,
Measurement of fundic height against the age of gestation was being observed
(mean=4.828), “Fetal heart beat and movement was monitored” (mean=4.835), and
Leopold’s maneuver was done (mean=4.936)
Similarly, the respondents also responded “always” in terms of the following
statement: “tetanus toxoid is available every prenatal” (mean=4.315); “skilled birth
attendant/ Skilled health professional – assisted delivery and facility based deliveries
including the use of partograph is being promoted in the health institution”
(mean=4.890); and, “EINC (Essential Intrapartum and Newborn Care)/Unang Yakap
practices are being practiced for safe and quality care of the woman during childbirth”
(mean=4.682).
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However, a notable and interesting stand of the respondents’ statement that there
was a “rare” proper management of pregnancy and delivery complications (mean=1.887).
It could be due to the fact that there were limited services in rural health stations
compared to hospitals. It imply that compliance to antenatal care is very important to
detect possible early complications and, thus, early referral of patients to hospitals could
be done.
Collectively, with an average weighted mean score of 4.387, it claims that the
antenatal care is “always” being implemented as part of the healthcare services under the
DOH programs. However, it has shown to have scope and the limitations particularly
proper management of pregnancy and delivery complications.
Family Planning
Table 25 shows the mean, standard deviation, and interpretation of the extent of
the implementation of healthcare services in terms of family planning.
Table 25
Extent of the Implementation of Health Care Services in terms of Family Planning
Family Planning Std.

Mean Interpretation
Deviation
There is a family planning counseling in our health
4.570 .802 Always
institution.
Advantages and disadvantages of family planning are
4.534 .830 Always
being explained by the health providers.
Possible side effects, complications and signs that
require an immediate visit to health institution is being 4.572 .838 Always
discussed.
Benefits of family planning for both on the mother,
4.568 .843 Always
father and children are being explained.
Discussion on the different types of natural family
2.321 1.197 Rarely
planning was provided in our health institution.
Instruction for the use of SDM (Standard Days
1.708 1.192 Never
Method) beads is accurate.
Combined oral contraceptive family planning
4.613 .843 Always
method is available in our health institution.
There is a trained health provider for the insertion 1.556 .864 Never
90
of IUD (Intrauterine Device).

Barrier methods such as condoms and cervical caps
4.247 1.280 Always
are available in the health institution.
There are available supplies and equipments for
permanent family planning methods such as 1.672 .660 Never
vasectomy and BTL (bilateral tubal ligation).
3.41-4.20 – “Often” 1.81-2.60– “Rarely”
According to UNFPA Southern Philippines Office (2009), Family planning is one
of the 10 elements of reproductive health. It refers to a program which enables couples
and individuals to decide freely and responsibly the number and spacing of their children
and to have the information and means to carry out their decisions, and to have informed
choice and access to a full range of safe, legal and effective family planning methods,
techniques and devices. In Table 25, it shows statement about the respondents’ perception
towards family planning as part of the healthcare services being implemented nationwide
under DOH program.
Based on the findings, respondents markedly responded “always” on the
following statements: “There is a family planning counseling in our health institution”
(mean=4.570); “Advantages and disadvantages of family planning are being explained by
the health providers” (mean=4.534); “Possible side effects, complications and signs that
require an immediate visit to health institution is being discussed (mean=4.4.572)”,
“Benefits of family planning for both on the mother, father and children are being
explained” (mean=4.568), Combined oral contraceptive family planning method is
available in our health institution (mean=4.613), and “Barrier methods such as condoms
and cervical caps are available in the health institution” (mean=4.247).
Moreover, respondents claimed that the “discussion on the different types of
natural family planning is rarely provided in our health institution” (mean=2.321). On

91
one hand, respondents attested that the “instruction for the use of SDM (Standard Days
Method) beads is never accurate” (mean=1.708) and “there are never available trained
health provider for the insertion of IUD (Intrauterine Device) (mean=1.556). This could
be related to the perception of the respondents that the procedure was being executed by
the trained health care professional like doctors or physicians.
Collectively, with an average weighted mean score of 3.436, it implies that family
planning is “often” implemented as part of the healthcare services under the DOH
programs. In the Islamic point of view, Family Planning is a systematic and consistent
planning of the family wherein members are happy because they worship Allah of good
health, better education and stable income and they have contributions to the optimum
development of the society. According to Sheikh Mustfa Mashour, a measure of a
responsible and happy family does not include material elements such as physical health,
beautiful house, good food, clothes, social status and position in the government, but the
essential requisites of a strong Muslim family are constant care for the members of the
family to become true obedient of Islam because of their faith and worship to Allah, of
pleasant attitudes and dealing others (Mashour, 1998).s
Part V - Significant Relationship between Variables
Relationship between Independent Variables and Dependent Variable
The following tables discuss the significant relationship between independent

variables and dependent variable. The independent variables are the socio economic
profile of the respondents, barriers in the implementation of health care services, and
factors affecting the implementation of health care services as correlated to the dependent
92
variable which is the extent of the implementation of health care services as to selected
DOH programs in terms of EPI, antenatal care, and family planning.
Correlation between Respondents’ Personal Profile and Extent of the

Implementation of Healthcare Services
Table 26 shows the significant relationship between respondent profile (age, sex,
civil status, religion, family type, family size, educational attainment, occupation, and
family income) and the extent of the implementation of health care services using
Pearson’s r Correlation Coefficient.
Table 26
Relationship between Respondents Socio-economic Profile and the Extent of the
Pearson’s r
Independent Dependent Computed p
Correlation Results
Variable Variable Value
Value
Age .187* .000 Significant
Sex .038 .415 Not Significant
Civil Status -.025 .595 Not Significant
Extent Not Significant or
Religion .a .a
of the Error
Family Type Implementation .082 .073 Not Significant
Family Size of Health Care -.019 .678 Not Significant
Educational Services
.086 .063 Not Significant
Attainment
Occupation .095* .039 Significant
Family Income .311* .000 Significant
*Correlation is significant at the 0.05 level (2-tailed).
a. Cannot be computed because at least one of the variables is constant
With the use of the Pearson’s r Correlation, the independent variable appertaining
the personal profile of the respondents’ in terms of age, sex, civil status, religion, family
type, family size, highest educational attainment, occupation, and family income were
substantially and evidently correlated to the extent of implementation of health care
services as the dependent variable to determine if there is significant relationship between
the two variables.

93
Table 26 evidently exhibits that the respondents’ personal profile in terms of sex,
civil status, religion, family type, family size, and highest educational attainment has “No
Significant” relationship to the extent of implementation of health care services. Based
on the table presentation above detailing its statistical results, the value of the Pearson’s r
Correlation are 0.038, 0.025, a, 0.082, -0.019, and 0.086 with a computed p-value of
0.415, 0.595, a, 0.073, 0. 678 and 0.063 respectively which were greater than 0.05 alpha
level of significance.
The variable of the personal profile of the respondents that confirms ‘significant’
relationship were the age, occupation, and monthly family income with a Pearson’s r
Correlation value of 0.187, 0.095, and 0.311 with computed p-value of 0.000, 0.039 and
0.000 which lesser than 0.05 alpha level of significance. The positive correlation between
these two variables entails a proportional relationship. This suggests that there could be a
possibility that as the independent variable increases (or decreases), the dependent
variable increases (or decreases).
Practically, as the age of the head of the family household increases (gets older),
view of the health needs of the family member broaden and thus recognizes the
importance of the availability or implementation of health care services. This is true with
R. Gould’s theory (Balita, 2008) that middle and late adult have more realization of
mortality and concern for health.
It further shown that there was a slight positive yet noteworthy correlation
(Pearson r value = 0.095) between the respondents occupation and the extent of
implementation of health care services. Since most of the respondents were mother, they
could essentially focus to the health needs of their children as part of their needs, which
94
was significant in the implementation of health care services by DOH such as the
immunization for their children, family planning, and antenatal or prenatal consultation.
According to the Department of Health, mothers in every household that have been
reached by the DOH house-to-house programs increases the statistics of maternal
consultation in some health care units.
Similarly, family income was significant (p value=0.00) and has low positive
correlation to the extent of health care services. Since it has proportional relationship, it
means that as the income of the respondents increases, the extent of health care services
increases as well. It is because a family with higher income has the financial means to
avail health care needs or services. This finding accord to the study of Gulliford et al.;
Oliver and Mossialos (2004) that families with high income have access to a wide range
of health services. Similar justification by Asfaw et al. (2004) and WHO (2010) that
family with fewer income do clings more on free health services and thus unavailability
may compromised their accessibility and health status.
Therefore, the research null hypothesis (Ho1) fundamentally prove that there is no
significant relationship between the respondents’ socio-economic profile in terms of sex,
civil status, religion, family type, family size, and highest educational attainment were
“not rejected” but “rejected” in terms of age, occupation, and monthly family income.
Correlation between Barriers in the Implementation of Healthcare Services

and Extent of the Implementation of Healthcare Services
Table 27 shows the significant relationship between the barriers in the

implementation of healthcare services and the extent of its implementation using
Spearman’s Rho Correlation Coefficient.
95
Table 27
Relationship between Barriers in the Implementation of Health Care Services and
the Extent of its Implementation
Spearman’s
Independent Dependent Rho Computed
Results
Variable Variable Correlation p Value
Value
Attitude Extent .223* .000 Significant
Culture and Beliefs of the .280* .000 Significant
Implementation
Family and Social
of Health Care .295* .000 Significant
Dynamics
Services
With the use of the Spearman’s Rho Correlation, the independent variable which
is the barriers in the implementation of healthcare services in terms of attitude, culture
and beliefs, and family and social dynamics were correlated to the extent of the
implementation of health care services as the dependent variable to determine if there is
significant relationship between the two variables.
As clearly shown in Table 27, it profoundly confirmed that the respondents’
barriers in the implementation of healthcare services in terms of attitude, culture and
beliefs, and family and social dynamics has “significant” relationship to the extent of the
implementation of health care services. Based on the calculated results, the value of the
Spearman’s Rho Correlation are .223, 0.280, and 0.295 with a computed p-value of
0.000, 0.000, and 0.000 respectively. Both the independent and dependent variable have
positive correlation or has proportional relationship. This vitally denotes that there is a
probable chance that as the independent variable increases (or decreases), the dependent
variable increases (or decreases).
Based on the finding, it implies that a positive attitude towards the
implementation of healthcare services among Sama tribes in the different sector of Tawi-
96
tawi helps improved the later. It agrees with the findings of Kasolo et al., (2000), MoH,
(2004), and GMOH (1999) that negative health seeking behavior was identified as major
barrier in the implementation of available health services particularly in concerning
women’s reproductive health. It also supports the stand of Adongo et al. (1998) and
GMOH (1999) that healthy behaviors contributes in the building of social network and
empowered mobilization of health services.
Moreover, some studies (de- Graft Aikins, 2005; Caldwell and Caldwell, 1987;
MoH, 2004; UNICEF, 2005) asserted that socio-cultural belief systems, values, and
practices also shape an individual’s knowledge and perception of health and
illness/disease, and health care seeking practices and behaviors. Since the respondents
(Sama tribe) were all Muslims and construed the belief that women shall ideally stay at
home for child rearing and bearing has a positive reinforcement towards health services
(as shown in Table 23, 24, and 25). Collectively, Sama tribe culture and beliefs could
empower health system development.
Furthermore, in terms of family and social dynamics, Sama tribe has been realized
having reliable social networks. Better ties between head of the family household may
promote an opportunity to strengthen them for beneficial health outcomes. According to
Wallman and Baker (1999), wider network in a family or community setting helps to
empower social dynamics development and access of healthcare services.
Therefore conclude that the research null hypothesis (Ho2) proven to have “no
significant” relationship between the barriers in the implementation of healthcare services
in terms of attitude, culture and beliefs, and family and social dynamics to the extent of
the implementation of healthcare services were “rejected”.

97
Correlation between Factors Affecting in the Implementation of Healthcare

Services and Extent of the Implementation of Healthcare Services
Table 28 shows the significant relationship between the factors affecting the
implementation of healthcare services in terms of accessibility of health care, availability
of health care providers, and provision of care and quality of services to the extent of the
implementation of healthcare services using Spearman’s Rho Correlation Coefficient.
Table 28
Relationship between Factors Affecting the Implementation of Health Care
Services and the Extent of its Implementation
Independent Dependent Spearman Rho Computed

Results
Variable Variable Correlation Value p Value
Accessibility of
-.165* .000 Significant
Health Care Services Extent
Availability of of the
Health Care Implementation -.194* .000 Significant
Providers of Health Care
Provision of Care and Services
.015 .214 Not Significant
Quality of Services
With the use of the Spearman Rho Correlation, the independent variable the
covering the factors affecting the implementation of health care services in terms of
accessibility of healthcare services, availability of healthcare providers, and provision of
care and quality of care services were correlated to the extent of the implementation of
healthcare services to determine if there is significant relationship between the two
variables.
As presented in Table 28, it showed that the “provision of care and quality of
services” has “No Significant” relationship to the extent of the implementation of
healthcare services. Based on the result of table presentation, the value of the Spearman
98
Rho Correlation was 0.015 and p-value of 0.214. On the other hand, the factors affecting
the implementation of healthcare services in terms of accessibility of health care and
availability of health care providers has “Significant” relationship to the extent of the
implementation of healthcare services with a corresponding Spearman Rho Correlation of
-0.165 and -0.194 with a p-value of 0.000 and 0.000 respectively.
The negative correlation value indicates that the independent and dependent
variable were inversely proportional to each other. It means that as the independent
variable increases (or decreases), the dependent variables decreases (or increases). In this
study, availability refers to the distance the patient lives from a health care facility,
transportation and total travel time, wait time and available services. It suggests that if the
distance to a health care facility and decrease hour of transportation, it could improve and
increase the extent of the implementation of health care services. In a study of Perry and
Gesler (2000) in Bolivia found that limited physical access to health care can be a major
obstacle in improved health care. In Zambia, 56% of surveyed rural household
perceived distance as an obstacle (Hjortsberg and Mwikisa, 2002). Similarly, only 17%
of individual living more than 40 kilometers from a facility sought care when sick
compared to 50% of individuals living less than five kilometers away.
Therefore, the null hypothesis (Ho3) established a proof that there is no
significant relationship between the factors affecting the implementation of health care
services in terms of “provision of care and quality of services”, which is “not rejected”
but “rejected” in terms of the “accessibility of health care services” and the
“availability of healthcare provider”.

99
Chapter 5
SUMMARY, FINDINGS, CONCLUSION AND RECOMMENDATIONS
This chapter presents the summary, major findings, conclusion, implications, and
recommendations. The findings of the data served as basis for drawing out the
implications and important recommendations of the study.
Summary
The overriding purpose of this study was to determine the extent of the
implementation of health care services and identify barriers and factors that may affect
the implementation of health care services among Sama tribes of Sibutu, Tawi-Tawi. The
study was conducted in the municipality of Sibutu, province of Tawi-Tawi. It was
purposely and intentionally chosen since the researcher is native to the place and believed
that there has been an existing problem in the implementation of health care services
especially the DOH Programs such as the Expanded Program on Immunization (EPI),
antenatal care, and family planning (FP). Specifically, it answered the following
questions:What are the Socio – economic Profile of the Sama Tribe in terms of age, sex,
civil status, religion, family type or size, educational attainment, occupation and family
income?;What are the barriers in the implementation of health care services in terms of
attitude; culture and beliefs and family and social dynamics?;What are the factors
affecting the implementation of health care services in terms of accessibility of health
care services; availability of health care providers and provision of care and quality of
services?; What is the extent of the implementation of the Health Care Services as to the
selected DOH Programs in terms of EPI, antenatal care and family planning?; Is there a
significant relationship between the socio – economic profile of the respondents and the
100
extent of the implementation of health care services?; Is there a significant relationship
between the barriers in the implementation of the health care services and the extent of its
implementation? And Is there a significant relationship between the factors affecting the
implementation of the health care services and the extent of its implementation?
The research design used in the study was inferential evaluative that utilized the
mix methods of qualitative and quantitative descriptive approach in the interpretation of
data. The responses were gathered from 473 respondents. The SPSS (Software Package
for Social Sciences) was used to derive the statistically reliable results. The tests and
statistical methods applied were Frequency, Simple Percentage, and Measure of Central
Tendencies by Mean, Standard Deviation, Pearson’s r correlation, and Spearman’s Rho
correlation. The Statistical Findings were detailed in Chapter 4, which tabulates the
results of the hypotheses and form the main findings of this research work.
Major Findings
Based upon the analysis of the study, the following findings are attained. The
profile of the respondents revealed that the majority of them or 34.0 percent belongs to
the age group 30 to 39 years of old, while 24.9 percent belongs to the age bracket 19 to
29 years of old, and 22.4 percent belongs to the age group 40 to 49 years of old. There
were less than 20 percent of the respondents from the age group below 18 years of old,
which constituted 15.4 percent out of the total. Majority of them or 98.5 percent were
female outnumbering 1.5 percent male in which most of them or 94.5 percent were
married, 2.3 percent were separated, 2.1 percent were widowed, and 1.1 percent as single.
Moreover, all of the respondents’ religion is Islam. It firmly concludes that all of
them (Sama tribe) or 100.0 percent were Muslims. Majority of them or 62.2 percent had
101
nuclear family type while 37.6 percent were in an extended type of family. Majority of
the family or 37.8 percent have 5 to 7 family members, 24.5 percent of the family with 8
to 10 family members, closely followed by 23.9 percent of the family with 2 to 4 family
members, and 13.7 percent of the sample respondents noted to have 11 to 13 family
members.
In addition, most of them or 37.6 percent were high school graduate, 30.4 percent
reached college level, 14.6 percent reached high school level, 10.1 percent were college
graduate, 4.7 percent who reached elementary level, 1.1 percent were elementary
graduate, very few or 0.6 percent with units in masters’ program, 0.6 percent proceeded
to a vocational course, and 0.2 percent without formal education. Majority of them or
64.1 percent were housewife, 19.2 percent were seaweed farmers, 9.5 percent who are
connected or working in the government, 5.5 percent were land farmers, and 1.7 percent
identified as having other type of work (others) such as business, contracting, shipping
and the like. Their monthly income varies amongst them as shown that 40.0 percent
having monthly income of 2,501 to 5,000 pesos and 33.6 percent has below 2,500 pesos,
then 11.6 percent having monthly income ranging 5,001 to 7,500 pesos, 7.0 percent has
above 17,001 pesos, 3.0 percent for 10,001 to 12,500 pesos, 2.7 percent for 15,001 to
17,000 pesos, 1.5 percent for 7,501 to 10,000 pesos, and 0.6 percent having monthly
income of 12,501 to 15,000 pesos.
In the same vein as, the respondents showed positive attitude towards Expanded
Program on Immunization (EPI) and regarded it as essential and beneficial to their
children, while having negative attitude towards antenatal care. The respondents had less
attention about the importance of the Family Planning, which connote that birth spacing
102
was not their priority. The culture and beliefs of the respondents as regard to
immunization had been perceived as “never” a barrier in its implementation. The
respondents believed that their cultural practices and beliefs towards antenatal care
“rarely” considered as a barrier in its implementation, and viewed Family Planning as a
“rare” barrier in the extent of implementation of health care services.
Furthermore, respondents’ “rarely” believed that family and social dynamics
hindered or served as barriers in the implementation of health care services particularly in
the context of EPI. Mothers in the community believed that family and social dynamics
towards antenatal care “sometimes” served as a barrier in the implementation of health
care services, while Family Planning in family and social dynamics were “rarely” viewed
as a barrier in the implementation.
The respondents also revealed that the health care services were “often”
accessible, which implies that the accessibility of health care services could be
considered as moderate factor that can affect the implementation of health care services.
The availability of health care providers could also be considered as a moderate factor
that can affect the implementation of health care services. The respondents perceived that
there should always a provision of care and quality of services in the implementation of
health care services which was a weak or a negligible factor that affects the
implementation of health care services.
On the other hand, the Expanded Program on Immunization (EPI) had been
always implemented as part of the health care services under the Department of Health
Program. Antenatal care had been always implemented too as part of the health care
services under the Department of Health programs. However, it had shown to have scope
103
and limitation particularly proper management of pregnancy and delivery complications,
while Family Planning had often implemented as part of the health care services under
the Department of Health programs.
The respondents’ personal profile in terms of sex, civil status, religion, family
type, family size, and highest educational attainment showed to have no significant
relationship to the extent of implementation of health care services. Nevertheless, the
personal profile of the respondents that shown significant relationship were age,
occupation, and monthly family income.
The respondents’ barriers in the implementation of health care services in terms of
attitude, culture and beliefs, and family and social dynamics had significant relationship
to the extent of the implementation of health care services.
The factors affecting the implementation of health care services in terms of
provision of care and quality of services had no significant relationship to the extent of
the implementation of health care services. While in terms of accessibility of healthcare
and availability of healthcare providers, it had significant relationship to the extent of the
implementation of health care services.
Conclusion
In the light of the findings, the following conclusions are forwarded. The Sama
tribes of Sibutu, Tawi-Tawi are continuously facing many challenges in terms of health
care needs. Health care services such as the Expanded Program on Immunization (EPI),
antenatal care, and family planning was the primary focus of this study to measure the
extent of its implementation in the said locale.

104
As inferred from the findings, it shows that the respondents’ personal profile in
terms of sex, civil status, religion, family type, family size, and highest educational
attainment has no significant relationship to the extent of implementation of health care
services. However, personal attributes such as age, occupation, and monthly family
income has significant relationship to the extent of implementation of health care
services. Thus, the null hypothesis number 1 (H01) stated as “there is no significant
relationship between the respondents’ socio-economic profile and the extent of
implementation of health care services in terms of sex, civil status, religion, family type,
family size, and highest educational attainment is accepted”, but rejected in terms of
age, occupation, and monthly family income. Then the null hypothesis number 2 (H02)
stated as “there is no significant relationship between the barriers in the implementation
of health care services in terms of attitude, culture and beliefs, and family and social
dynamics to the extent of its implementation of health care services is rejected”. Lastly,
then the null hypothesis number 3 (H03) stated as “there is no significant relationship
between factors affecting the implementation of health care services and the extent of its
implementation in terms of provision of care and quality of services is not rejected,
however rejected in terms of accessibility of health care services and availability of
health care providers”.
The researcher concluded that health care services such as the Expanded Program
on Immunization (EPI) and antenatal care is, therefore, always implemented in the said
locale. However, a notable and interesting stand of the respondents was on the statement
that there is a rare proper management of pregnancy and delivery complications. It could
be due to the fact that there were limited services in rural health stations compared to
105
hospitals. It means that compliance to antenatal care is very important to detect possible
early complications. Thus early referral of patients to hospitals could be done while
family planning is often implemented as part of health care services under the
Department of Health programs.
The personal characteristics of the respondents such as age imply that as the age
of the head of the family household increases (gets older), view of the health needs of the
family member broaden. Hence, recognizes the importance of the availability or
implementation of health care services. Since most of the respondents were mothers
(housewife), they could focus to the health needs of their children as part of their needs,
which is significant in the implementation of health care services. Then, the family
income as found to be significant means that family with higher income has financial
means to avail health care needs or services. Based on the findings, it implies that a
positive attitude towards implementation of health care services helps improve the later.
Since the respondents were all Muslims and construed to the belief that women shall
ideally stay at home for child rearing and bearing has positive reinforcement towards
health services. Then in terms of attitude and culture and beliefs, it was found out that the
Sama tribes have a problem especially in health seeking behavior.
Furthermore, it also implies that other theories related to the implementation of
health care services must be also examined. In this sense in general, contributes to the
body of growing knowledge that can holistically improve the implementation of health
care services.
Recommendations
106
Based on the findings of this study, the following recommendations are
formulated.
Since culture and attitude found to be the factors that affect the implementation of
health care services. Henceforth, to improve its implementation among Sama tribes of
Sibutu, Tawi-Tawi, the researcher recommends the following:
There should be a Multi – sectoral approach of addressing the problems based on
the findings of the study:
It is strongly suggested that there should be a Population Education to the locale
of the study by DOH, considering the family size of most family in the area were getting
bigger while the family income is getting smaller which is not proportionate to raising a
big family. Thus, it is strongly recommended that Sama tribe should think at reducing
their number of children depending on their income.
It also likewise recommended that there should be adequate dispensing of the
medicines or supplies intended for the Sama people in Sibutu, Tawi-Tawi. There should
be a conduct of Behavioral Change Program that should influence the attitude of the
respondents especially in availing for the health services.
In order to improve the attitude of the health care team in the provision of health
care, there must be strategies to educate people in term of the need for health services.
Like, strategies to further improve health outcomes most especially with the birthing
facilities which should include the attendance of skilled health professionals at all
deliveries in health facilities capable of providing basic or comprehensive emergency
obstetric and neonatal care (BEmOC or CEmOC). Steps to implement this approach
107
should include the upgrading of facilities (RHUs and hospital) to become BEmOC or
CEmOC and the organization of BEmOC teams.
In addition, the researcher would like to recommend the school especially to the
nursing department to continue their efforts in imparting the skills and the knowledge to
all their students about the importance of health during community exposures.
Lastly, it is suggested also that there is a need to conduct a qualitative
research/study for the in-depth interview of the Sama tribes to support the findings of the
study and for further validation.

108
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Appendix A

Graduate School
COLLEGE OF HEALTH SCIENCES
Marawi City
September 2016
Dear Respondents,
Greetings of Peace!
The undersigned is conducting a study entitled "EXTENT OF THE
IMPLEMENTATION OF HEALTH CARE SERVICES AMONG SAMA TRIBES
OF SIBUTU, TAWI – TAWI", in partial fulfilment of the requirement for the degree,
Master of Arts in Nursing (Major in Nursing Administration).
In connection with this, I am requesting you to be one of the respondents of this

study. I would like to give you a short interview in the form of questionnaire and
checklist. Rest assured that all of the information provided will be kept with utmost
confidentiality. Your cooperation will mean a lot.
Thank you and God bless!
Sincerely yours,
JONABER T. MOHAMMAD-SABIL, RN
Noted by:
DR. NAIMA D. MALA, RN, MN, MAN

Thesis Adviser
Approved by:
MINOMBAO RAMOS – MAYO, PhD
Dean, MSU-Graduate School
Appendix B
116

Graduate School
COLLEGE OF HEALTH SCIENCES
Marawi City
CONSENT TO PARTICIPATE IN A RESEARCH STUDY

THESIS TITLE: EXTENT OF THE IMPLEMENTATION OF HEALTH CARE
SERVICES AMONG SAMA TRIBES OF SIBUTU, TAWI – TAWI
Purpose of the Study: This research will identify the factors that affects the
implementation of health care services and as to what extent the DOH programs
specifically the Expanded Program on Immunization, Antenatal Care and Family
Planning are being implemented among Sama Tribes.
Please check ( ) the box

1. I confirm that I have read and understand the information
sheet for the above study and have had the opportunity to [ ]
ask questions.
2. I understand that my participation is voluntary and that I am
free to withdraw at any time, without giving reason. [ ]
3. I agree to take part in the above study. [ ]
4. I agree to the interview. [ ]
5. I agree to the use of anonymity of quotes in publications. [ ]
Your signature below indicates that you have decided to participate in this study,
and that you have read and understood the information provided above.
______________________________________
Name & Signature of Participant
Date Accomplished: ____________________
Request by:
JONABER T. MOHAMMAD-SABIL, RN
Researcher/MAN Student
MSU-Main, Marawi City
09977143724/09657288208
jonabertiannok@yahoo.com
Appendix C
117
SURVEY QUESTIONNAIRE
Research Title: "EXTENT OF THE IMPLEMENTATION OF HEALTH

CARE SERVICES AMONG SAMA TRIBES OF SIBUTU,
TAWI – TAWI”
DIRECTION: Accomplish the following questionnaire with necessary
information. Kindly put a check ( ) on the space provided.
PART 1. RESPONDENTS’ SOCIO – ECONOMIC PROFILE
Age ( ) 18 years old & below ( ) 50 – 59 years old

( ) 19 – 29 years old ( ) 60 years old & above
( ) 30 – 39 years old
( ) 40 – 49 years old
Sex ( ) Male ( ) Female
Civil Status ( ) Single ( ) Separated

( ) Married ( ) Others, please specify:
( ) Widowed ____________________
Religion ( ) Islam ( ) Others, please specify:

( ) Christianity ____________________
Family Type ( ) Nuclear ( ) Others, please specify:

( ) Extended ____________________
Family Size ( ) 2 – 4 members ( ) 11 – 13 members

( ) 5 – 7 members ( ) Others, please specify:
( ) 8 – 10 members ____________________
Educational Attainment ( ) No formal education ( ) Vocational Course

( ) Elementary level ( ) Elementary graduate
( ) High School level ( ) High School graduate
( ) College level ( ) College graduate
( ) with Units in the Masters’ ( ) with Units in the Doctoral
Program Program
( ) with Masters’ Degree ( ) with Doctoral Degree
Occupation ( ) Housewife ( ) Govt. Employee

( ) Land Farmer ( ) Others, please specify:
( ) Seaweed Farmer ___________________
Family Income ( ) 2,500 & below/month ( ) 10,001 – 12,500/month

118
( ) 2,501 – 5,000/month ( ) 12,501 – 15,000/month

( ) 5,001 – 7,500/month ( ) 15,001 – 17,000/month
( ) 7,501 – 10,000/month ( ) 17,001 & above/month
DIRECTION : Please put a check on the space provided that corresponds your
answer to the statements by using the following scaling.
5 - Always = at all times

4 - Often = many times or frequently
3 - Sometimes = at times or occasionally
2 - Rarely = not often or seldom
1 - Never = at no time or not in any degree or not under any condition
PART 2. BARRIERS TO THE IMPLEMENTATION OF SERVICES
A. ATTITUDE
SCALE
No. INDICATORS (EPI) 5 4 3 2 1
ALWAYS OFTEN SOMETIMES RARELY NEVER
A.1 I am afraid of vaccination due to the fear of
multiple doses of vaccination/procedures.
(Talow ma tugsuk)
A.2 I stopped my child from being immunized
because of the side effects of immunizations.
(Paharok magpatugsuk anak pasal efek tambal)
A.3 I reject vaccinations for no reason. (Mba
hungun magpatugsuk)
A.4 I have fears of subjecting my children for
immunization because I pity them. (Talow
magpatugsuk anak pasal maaseh)
A.5 I have no time to take my children for
immunization because I am busy on other
things. (Mba niyah time para mowa anak
magpatugsuk)
SCALE
No. INDICATORS (ANTENATAL CARE) 5 4 3 2 1
As pregnant woman, I do not go to health

institutions because (Bilang bottong, mba aku
A.6 ni clinic pasal):
o I am busy at home. (Sagow ma lumah)
A.7 o I have no reason to go or visit. (mba
niyah ni hadjat ni clinic)
A.8 o My husband is not around. (Mba luun
halla)
A.9 o No one will take care of our house.
(Mba niyah musiyah lumah)
119
A.10 o I lack knowledge of how important it is

on health. (Mba niyah pangadjih pasal
health)
SCALE
No. INDICATORS (FAMILY PLANNING) 5 4 3 2 1
As a mother, I do not go to health institutions

A.11 because (Bilang inah, mba aku ni health center
pasal):
o I am busy at home. (Sagow ma lumah)
A.12 o I have no reason to go or visit. (mba
niyah ni hadjat ni clinic)
A.13 o My husband is not around. (Mba luun
halla)
A.14 o No one will take care of the house.
(Mba niyah musiyah lumah)
A.15 o I lack knowledge of how important it is
on health. (Mba niyah pangadjih pasal
health)
B. CULTURE AND BELIEFS

SCALE
B.1 Immunization is not acceptable because it is
against the culture and beliefs of others. (Mba
jari magpa-immunize ma pagkahagad kami)
B.2 Immunization is forbidden or “Haram” to some
culture. (Haram ma bahasa iya immunization)
B.3 Fear on the immunization’s side effects. (Talow
ma efek immunization)
B.4 Believe more on traditional treatments than
medical treatments. (Mas magkahagad ma
tambal kabiyasahan – “tambal – lahat”)
B.5 Fear on the newly manufactured vaccines (e.g.
Pneumonia Conjugate Vaccine). (Talow ma
tugsuk bahau beteh na Pneumonia Conjugate
Vaccine)
SCALE
B.6 Tetanus Toxoid is not acceptable because it is
against the culture and beliefs. (Mba ni talimah
tetanus toxoid ma agama)
B.7 Tetanus Toxoid is forbidden or “Haram” to
some culture. (Haram tetanus toxoid ma agama
kasean)
120
B.8 Fear on Tetanus Toxoid vaccine’s side effects.

(Talow ma efek tetanus toxoid vaccine)
B.9 Fear on the side effects of taking Iron
supplements. (Talow ma efek pag-inum tambal
iron)
B.10 Believe more on the traditional birth attendants
(“Hilot”) than healthcare professionals. (Mas
mahagad ma pandey min aa iskulan ma
healthcare)
SCALE
B.11 Family Planning is not acceptable due to
culture and beliefs. (Mba jari mag family
planning ma agama)
B.12 Family Planning method is forbidden or
“Haram”. (Haram iya family planning)
B.13 Fear on the side effects of contraceptives such
as pills, DMPA (Depot Medroxyprogesterone
Acetate) injections and IUD (Intrauterine
Device). (Talow ma sayd efeks banan tambal
nipakey beteh pils, DMPA maka IUD)
B.14 Believe more on abstinence and withdrawal
methods than the modern family planning
methods. (Mas mahagad ma withdrawal
method min bahau family planning methods)
B.15 Believe that family planning methods are
abortifacient. (Magkahagad iya family planning
tu makapulak)
C. FAMILY AND SOCIAL DYNAMICS

SCALE
C.1 Easily believed on hearsays being told by their
relatives and friends (e.g. misconceptions of
immunization). (Mahagad ma haka-haka
banan bagey maka kampong)
C.2 Mothers are noncompliant to follow-up
schedules of immunizations of their children.
(Mba niparuli eh mga inah bang sumilan ni
bowa beleng anak nipa-immunize)
C.3 No money to pay for the transportation in going
to the health facility. (Mba niyah sin panukey
hasupaya takka ni health center)
C.4 No available family member to accompany the
121
children. (Mba niyah ngahuwangan banan

anak)
C.5 The family have strong ancestral beliefs.
(Kalandu mahagad ma kaombo’-omboan)
SCALE
The mothers in the community (Banan inah ma

C.6 kowman) :
o Seeks healthcare services at health
institutions. (Maku tabang ma health
center)
C.7 o Do not visit health institutions without
company. (Mba misita ni health center
bang maniyah seheh)
C.8 o Believe on hearsays being told by their
relatives and friends (e.g.
misconceptions of immunization and
pills). (Mahagad ma haka-haka banan
kampung maka bagey pasal
immunization maka pils)
C.9 o Do not avail healthcare services due to
political reasons and issues. (Mba
tabuwanan healthcare services pasal
political reasons)
C.10 o Do not have the time and fare to seek
healthcare services from healthcare
institutions. (Mba niyah time maka
panukey hasupaya takka ni health
center)
SCALE
C.11 The family do not agree on family planning.
(Mba magkahagad ma family planning)
C.12 The husbands disapprove the use of family
planning methods. (Mba hungun halla ngusal
family planning methods)
C.13 The relatives and friends discouraged the use of
family planning methods. (Mba hungun banan
kampung maka bagey ngusal family planning
methods)
C.14 The wife is practicing family planning without
the approval or consent of the husband. (Ngusal
family planning danda mba tasayu halla na)
C.15 The couple volunteer to avail the family
planning method. (Maghanda-maghalla ngusal
122
family planning method)
DIRECTION : Kindly use the following scaling for Part 3 statements.

1 - Never = at no time or not in any degree or not
under any condition
PART 3. FACTORS AFFECTING THE IMPLEMENTATION OF HEALTH

CARE SERVICES
D. ACCESSIBILITY OF HEALTH CARE SERVICES

SCALE
No. INDICATORS 5 4 3 2 1
D.1 Vaccines are available and free of charge.
(Niyah banan tugsuk maka mba nibayaran)
D.2 Family planning supplies (condoms, pills,
injectables, etc.) are available and free of
charge. (Banan supplies ma family planning
mba nibayaran)
D.3 Prenatal and postnatal services are available.
(Niyah prenatal maka postnatal services)
D.4 There is enough number of health institutions in
the municipality. (Sarang heka health center
ma paglahat)
D.5 There is an available vehicle for transportation
to health institutions. (Niyah asal
sasakatan/pameyaan ni health center)
D.6 The health institutions are BemONC or
CemONC certified. (Certified ma BemONC or
CemONC banan health center)
E. AVAILABILITY OF HEALTH CARE PROVIDERS

SCALE
E.1 There is enough number of healthcare
professionals in the nearest health institution.
(Harang heka banan aa maghinang ma health
centers)
E.2 The healthcare professionals are equipped with
different trainings (e.g. BLS, ACLS, BemONC,
CemONC). (Niyah katau sigiya banan aa
123
maghinang ma health centers)

E.3 The healthcare providers are effective and
efficient. (efectib pagbuwan sigiya health
services)
E.4 The healthcare providers are productive.
(Productive banan aa sigiya)
E.5 The providers choose to whom the health
services will be given. (Tasayu eh sigiya bang
siyan nibuwanan health services)
E.6 The healthcare providers are equipped with
skills, knowledge and attitude. (Hap maka
niyah katau banan aa sigiya)
F. PROVISION OF CARE AND QUALITY OF SERVICES

SCALE
F.1 The health institutions are equipped with
advanced technology. (Makey sigiya advanced
technology)
F.2 The health institutions are practicing infection
control procedures. (Nipakey eh health centers
iya pangontrol banan sakki/infections)
F.3 There are available equipments and supplies
when needed. (Heka maka niyah banan
panyap/supplies bang kalagihan)
F.4 The healthcare providers are practicing sterile
and aseptic techniques in handling equipments
and supplies during and after procedures. (Ni
lanuan eh sigiya pahap banan mga panyap
song maka katis nipakey)
F.5 The healthcare providers are well trained with
the different health-related trainings. (Biyasa
na banan healthcare providers ma hinang
sigiya)
F.6 The healthcare providers are providing health
teachings to their patients/clients.
(Nipamanduh eh sigiya ma manusiyah
kahapan ma baran)
DIRECTION : Kindly use the following scaling for Part 3 statements.

124
1 - Never = at no time or not in any degree or not

under any condition
PART 4. EXTENT OF IMPLEMENTATION OF HEALTH CARE SERVICES
G. EXPANDED PROGRAM ON IMMUNIZATION

SCALE
G.1 Vaccines against preventable diseases such as
(Kahapan tugsuk hasupaya ta illagan sakki):
G.1.A. Pentavalent Vaccines
G.1.B. Pneumonia Conjugate Vaccines
G.1.C. Oral Polio Vaccines
G.1.D. Measles Vaccine
G.1.E. Hepa B Vaccine was available
(Niyah)
G.2 The cold chain system for ensuring the
potency of vaccine is maintained. (Ni mentain
cold chain system hasupaya tapakey banan
tugsuk)
G.3 The recommended sequence of the co –
administration of vaccines is followed by the
health institution. (Ni beyah banan sarah bang
teinnga eh makey tugsuk)
G.4 Health teaching on the importance of
immunization was done. (Eh masaplag iya
kahapan immunization)
G.5 Supplies needed for immunization are
available in the health institution. (Niyah
banan supplies kalagihan ma immunization)
G.6 Giving of Hepatitis B vaccine right after
delivery was done. (Nibuwanan tugsuk HepaB
pag nganak)
G.7 Vaccine recipients or their parents/guardians
are being informed on the side effects or
adverse reactions of the vaccine. (Nihakaan
seheh pasyente ma pasal efek tugsuk ma
baran)
G.8 Contraindications to immunization are being
explained. (Nipahati sukang ma immunization)
G.9 EPI recording and reporting is being
accomplished. (Ni record iyan bey
tapamuwan)
G.10 Preparation and calculation of vaccine
requirement are correctly followed. (Nibeyah
toongan teingga eh muwan tugsuk)
125
H. ANTENATAL CARE
SCALE
H.1 Nutritional counselling during prenatal visit
was done. (Nibuwanan pangadji aa bottong ma
bang iyan hap ni kakan eh na)
H.2 Promotion of healthy lifestyle including advice
relative to smoking cessation, healthy diet,
regular exercise. (Nipahati iya healthly lifestyle
beteh ngillagan siga, mangan kinakan hap ma
baran, maka mag-exercise)
Prenatal assessment such as (Aa bottong
niandaan):
H.3 - weight and blood pressure monitoring is being
practiced. (Timbang maka lahah na)
H.4 - measurement of fundic height against the age of
gestation is being observed. (Heya anak ma
bulan na)
H.5 - fetal heart beat and movement was monitored.
(Kubbuk jantung maka usik anak na ma jalom
bottong)
H.6 - Leopold’s maneuver was done.
(Lai ni hilut bottong na)
H.7 Tetanus toxoid is available every prenatal.
(Niyah tetanus toxoid bang magpa-prenatal)
H.8 Skilled birth attendant/ Skilled health
professional – assisted delivery and facility
based deliveries including the use of partograph
is being promoted in the health institution.
(Nabang maanak banana a niyah pangadjih na
magpaanak ma health centers)
H.9 There is a proper management of pregnancy
and delivery complications. (Tagaga hap
pagbottong maka pag-anak)
H.10 EINC (Essential Intrapartum and Newborn
Care)/Unang Yakap practices are being
practiced for safe and quality care of the
woman during childbirth. (pag-nganak ni apply
EINC)
I. FAMILY PLANNING
SCALE
I.1 There is a family planning counselling in our
126
health institution. (Muwan pangadjih

makahalan family planning banan health
centers)
I.2 Advantages and disadvantages of family
planning are being explained by the health
providers. (Pamahati kahapan family planning
maka mba kahapan na)
I.3 Possible side effects, complications and signs
that require an immediate visit to health
institution is being discussed. (Pamahati banan
side efeks family planning hasupaya tapaandah
ni clinic)
I.4 Benefits of family planning for both on the
mother, father and children are being explained.
(Eh mahati kahapan na ma inah, mmah, maka
banan anak)
I.5 Discussion on the different types of natural
family planning was provided in our health
institution. (Pamahati ginisan family planning
tapakey)
I.6 Instruction for the use of SDM (Standard Days
Method) beads is accurate. (Pamuwan bang
teingga eh makey SDM)
I.7 Combined oral contraceptive family planning
method is available in our health institution.
(Niyah pils ma health centers)
I.8 There is a trained health provider for the
insertion of IUD (Intrauterine Device). (Niyah
aa biyasa matuk IUD)
I.9 Barrier methods such as condoms and cervical
caps are available in the health institution.
(Niyah du sab condoms maka cervical caps ma
health centers)
I.10 There are available supplies and equipments for
permanent family planning methods such as
vasectomy and BTL (bilateral tubal ligation).
(Niyah panyap tapakey para ma vasectomy
maka BTL)
Thank you for your cooperation and for your time.

127
APPENDIX D
PROOF OF EDITING
CERTIFICATION
This certifies that the Master of Arts in Nursing Thesis of Mr. Jonaber Tianok
Mohammad-Sabil, RN, MAN entitled, “EXTENT OF THE IMPLEMENTATION OF
HEALTHCARE SERVICES AMONG SAMA TRIBES OF SIBUTU, TAWI-
TAWI”, was edited by Prof. Corazon S. Olpoc.
This is certified for whatever legal purpose it may serve.
PROF. CORAZON S. OLPOC

Editor
128
APPENDIX E
PROOF OF STATISTICAL ANALYSIS
CERTIFICATION
This is to certify that Mr. Jonaber Tianok Mohammad-Sabil, RN, MAN a

graduate student from MSU Graduate School - College of Health Sciences, Marawi
City has requested the undersigned to check the statistical analysis used for his thesis
entitled:
“EXTENT OF THE IMPLEMENTATION OF HEALTHCARE SERVICES

AMONG SAMA TRIBES OF SIBUTU, TAWI-TAWI”
The following statistical tools were used in the analysis:

1. Frequency Distribution (Frequency, Percentage)
2. Mean, Standard Deviation, Ranking
3. Weighted Mean
4. Pearson-r Correlation
5. Spearman Rho Correlation
This certification is issued on November 25, 2016 upon the request of Mr.
Mohammad Sabil for whatever legal purpose it may serve him best.
Prof. Hamdoni K. Pangandaman, RN, RPT, MAN

Data Processor/ Statistician
129
APPENDIX F
CURRICULUM VITAE
PERSONAL INFORMATION
Name : Jonaber Tianok Mohammad -Sabil, RN, MAN
Date of Birth : November 5, 1989
Place of Birth : Sibutu, Tawi – Tawi
Home Address : Brgy. Nunukan, Sibutu, Tawi – Tawi
Civil Status : Single
Mother’s Name : Sittie Sara Idji Tianok
Father’s Name : Mohammad -Sabil G. Sammah (Ret. PNP)
EDUCATIONAL ATTAINMENT
Elementary : Nunukan Elementary School
Sibutu, Tawi – Tawi
March 2002
Secondary : Notre Dame of Sibutu

Sibutu, Tawi – Tawi
March 25, 2006
College : SMD Foundation Academ y, Marawi City

Bachelor of Science in Nursing
March 25, 2012
Advanced : Mindanao State Universit y, Marawi Cit y

Studies Master of Arts in Nursing
October 2018
PROFESSIONAL EXPERIENCE
Integrated Provincial Health Office - LDS : Contractual/ Govt.

Feb. 2013 – Dec. 31, 2013 : RN Heals
Integrated Provincial Health Office - LDS : Contractual/ Govt.

Feb. 2014 – June 30, 2017 : NDP Nurse

MAN Thesis JonaberTM PDF

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EXTENT OF THE IMPLEMENTATION OF HEALTHCARE SERVICES

AMONG SAMA TRIBES OF SIBUTU, TAWI-TAWI

JONABER TIANOK MOHAMMAD–SABIL, RN

The Faculty of the Graduate School of the Mindanao State University

EXTENT OF THE IMPLEMENTATION OF HEALTH CARE SERVICES

Conducted and submitted by JONABER

NAIMA D. MALA, RN, MN, MAN, PhD

RANDY IAN GALLEGO, RN, MAN HAMDONIE K. PANGANDAMAN, RN, MAN

RANDY IAN GALLEGO, RN, MAN

In the Name of Allah, the Most Gracious, the Most Merciful.

This work is dedicated to my family, my advisors, and my friends. I thank and

lending me you laptop whenever I needed it.

me and giving me strength in my everyday life.

“No success gained without pain and effort”.

Thesis Adviser: Dr. Naima D. Mala, RN, MN, MAN

The researcher recommends a Multi-sectoral approach of addressing the problems

Key words: Expanded Program on Immunization, Antenatal Care, Family Planning,

1 THE PROBLEM AND ITS SCOPE

2 REVIEW OF RELATED LITERATURE AND STUDIES

Review of Related Literature

4 DATA PRESENTATION, ANALYSIS, AND INTERPRETATION

5 SUMMARY, FINDINGS, CONCLUSION, AND

A Sample Letter to the Respondents 115

1 Stratified Sample of Research Respondents 46

2 Frequency and Percentage Distribution of Respondent’s Age 54

3 Frequency and Percentage Distribution of Respondent’s Sex 55

4 Frequency and Percentage Distribution of Respondent’s Civil Status 57

5 Frequency and Percentage Distribution of Respondent’s Religion 58

6 Frequency and Percentage Distribution of Respondent’s Family Type 59

7 Frequency and Percentage Distribution of Respondent’s Family Size 60

8 Frequency and Percentage Distribution of Respondent’s Highest 61

9 Frequency and Percentage Distribution of Respondent’s Occupation 63

10 Frequency and Percentage Distribution of Respondent’s Monthly 64

11 Barriers in the Implementation of Health Care Services in terms of 66

12 Barriers in the Implementation of Health Care Services in terms of 68

13 Barriers in the Implementation of Health Care Services in terms of 70

14 Barriers in the Implementation of Health Care Services in terms of 71

15 Barriers in the Implementation of Health Care Services in terms of 72

16 Barriers in the Implementation of Health Care Services in terms of 74

17 Barriers in the Implementation of Health Care Services in terms of 76

18 Barriers in the Implementation of Health Care Services in terms of 77

19 Barriers in the Implementation of Health Care Services in terms of 79

20 Factors Affecting the Implementation of Health Care Services 80

21 Factors Affecting the Implementation of Health Care Services 82

22 Factors Affecting the Implementation of Health Care Services 84

23 Extent of the Implementation of Health Care Services in terms of 86

24 Extent of the Implementation of Health Care Services in terms of 87

25 Extent of the Implementation of Health Care Services in terms of 89

26 Relationship Between Respondents Socio-Economic Profile and 92

27 Relationship Between Barriers in the Implementation of Health Care 95

28 Relationship Between Factors Affecting the Implementation of Health 97

1 A Schematic Diagram Showing the Interplay Between the 7

2 Map of Sibutu, Tawi-Tawi Highlighted 44

THE PROBLEM AND ITS SCOPE

underlying determinants of health. Globally, reducing maternal mortality is the health-

increase coverage and reduce barriers to the use of various services.

middle-income countries in the region, such as Vietnam. The Government of the

(Philippines National Demographic and Health Survey, 2008)

in reduction from 18 to 14 per 1,000 live births from 1993 to 2011.

institutions are encouraged to participate and cooperate.

identified problems that the researcher personally encountered, which subsequently

served as a motivation to look for solutions.