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Filipino Cultural Characteristics and Health Care Beliefs and Practices in Health Education

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13_FILIPINO CULTURAL CHARACTERISTICS AND HEALTH CARE BELIEFS AND PRACTICES IN

HEALTH EDUCATION.

CULTURE
q is defined as the “totality of socially transmitted pattern of thoughts, values, meanings,
and beliefs”
q is inscribed in our bodies and in our minds” (Tan 2008). As such, the relationship of
culture and health is important to understand as it impacts an individual’s worldview
and decision-making process

FILIPINO CULTURE
q is the summation of indigenous forces and foreign influences that had come to bear
upon the people in varying degrees during the last centuries.

Malay

American Chinese

CONTRIBUTORY
FACTORS TO
FILIPINO CULTURE

Spanish Indian

Hindu

THE FILIPINO CULTURAL PERSPECTIVES

q The Traditional Concept
 hold that Filipino culture was developed due to the conglomeration of the physical,
intellectual, moral and spiritual aspects.
 q The Nationalistic View
 regards culture as the summation of the needs of people, the description of their
past and present condition, an expression of their values, thoughts and emotions,
and the depiction of their historic struggles too liberate themselves.
q Cultural Dualism
 the Philippines is a transitional society dominated on one side by the traditional
culture and on the other side by the modern culture.

THE FILIPINO CULTURE

A. Belief System
 Filipinos are believers of religion.
 They believe so much on supernatural powers and viewed themselves as only a
speck in this wide universe.
 Success is considered a blessing from above, as a result of good luck and faith.
 Good is considered relative.
 Happiness and success differ from one person to another.
 Hospitality is practice.

B. Value System
 Cultural values are shared assumptions of what is right, good or important.
 Guide man's behaviour and action as he relates himself in most situations in life.
 Can best be seen from the aspects of personal and social relationships.
 Majority of Filipinos value more their honor rather than wealth.
 In decision-making, the Filipinos usually consult and take into consideration the
consensus of the family members as the feelings of those who are to be affected.
 Filipinos love to mingle with other people particularly with friends and relatives.
 They engaged themselves in mutual cooperation (bayanihan).
 Filipinos are friendly. They smile at people, even with strangers.
 They are warm and simple.
 Filipino women are regard and respected.

THE FILIPINO VALUES

1. Utang-na-loob
 it is a technique of reciprocity of debt of gratitude to others within the family
circle or primary group, sometimes unlimited in nature, emotional rather
than financial or rational.
 it is sign of marginal economy where no place is available in bargaining,
formal agreements, written contracts, specific rights and responsibilities.
2. Pakikisama
 closely to utang-na-loob
 it is the value of belongingness and loyalty to the small in-group with
sensitivity to the feelings of others on the principle of “give and take.”
  is a folk concept of good public relations and avoidance of conflict with the
leader or majority of the groups.
3. Hiya
 controls a large extent the behaviour of the individual.
 dependent on others will think, say and do.
 because of hiya, a Filipino cannot say “NO” even it is against his will to do
what is being requested.
4. Bahala na
 common expression among Filipinos and this rest on the fatalistic outlook
and strong dependence on the “spirits” who will take care of everything if
they are really meant for a person.
5. Authoritarianism
 it is the dependence of the Filipinos in a paternalistic rather than in a stern
way upon the elders of the family, upon their boss, if employed, and upon
people in authority as their father figure.
 commonly practice in the Filipino family which basically patriarchal in nature.
 the father is seen as the head that makes major decisions affecting the
family.
6. Individualism
 pattern of behaviour which characterizes the Filipino as self-centered.
 the desire to make the name for himself becomes the primary motivation for
success.
7. Amor-propio
 individual's highly emotional reaction to protect his honor and dignity when
they are threaten or questioned and to retaliate.
 common forms of this are “hele hele bago quiere” or pakipot which shows at
a person initially refusing an offer even if he wants very much to accept it.

CULTURAL CHARACTERISTICS: Filipinos

q Communication styles
 Eye contact is avoided
 Sex & financial status are too personal to discuss
 Engage in small talk before discussing serious matters
 Values personal dignity and preserving self-esteem
q Family, social, work relationships
 Strong family ties
 Multigenerational
 Family interests stronger than individual needs
 Defer to elderly for guidance
 Individual behaviour reflects on family
q Health values and beliefs
  Illness related to
o Natural forces
o Supernatural forces
o Metaphysical forces
 Fatalistic view
q Health customs and practices
 Uses folk and scientific medicine
 Stoic expression; pain is God’s will

Studies of health practices among Filipino Americans suggest that people originally from rural
areas in the Philippines are more knowledgeable regarding home remedies, traditional healing
techniques, and supernatural ailments, whereas those coming from the urban areas rely more
on Western medical interventions and over-the-counter medications. However, healing
practices in both groups are utilized simultaneously as well (Montepio, 1986/1987; Vance,
1999). Filipinos, especially those who migrated late in life, have the tendency to self-diagnose,
self-medicate, and seek alternative therapies. This practice causes great concern to most health
care providers, since these older adults only seek medical care when their illness is already very
serious or in an advanced stage, leading to missed opportunities for optimal treatment.
Community-based efforts to promote equitable access to health care for Filipino American
older adults through outreach using the support of Filipino American socie

ties ( e.g. Knights of Columbus) will likely lead to earlier diagnosis and treatment.

Health Beliefs and Behaviors: Indigenous Health Beliefs

Concept of Balance (Timbang)
This concept is central to Filipino self-care practices and is applied to all social relationships and
encounters. According to this principle, health is thought to be a result of balance, while illness
due to humoral pathology and stress is usually the result of some imbalance. Rapid shifts from
“hot” to “cold” cause illness and disorder. Illustrated below are a range of humoral balances
that influence Filipino health perceptions:
 Rapid shifts from “hot” to “cold” lead to illness
 “Warm” environment is essential for maintaining optimal health
 Cold drinks or cooling foods should be avoided in the morning
 An overheated body is vulnerable to disease; a heated body can get “shocked”
 When cooled quickly, it can cause illness
 A layer of fat maintains warmth, protecting the body’s vital energy
 Imbalance from worry and overwork create stress and illness
 Emotional restraint is a key element in restoring balance
 A sense of balance imparts increased body awareness (Adapted from Becker, 2003).

Health Beliefs and Behaviors: Theories of Illness

Physical and mental health and illness are viewed holistically as an equilibrium model. In
contrast, other explanatory models may include mystical, personalistic and naturalistic causes
of illness or disease (Anderson, 1983; Tan, 1987; Tompar-Tiu & Sustento-Seneriches, 1995).
Mystical Causes
Mystical causes are often attributed to experiences or behaviors such as ancestral retribution
for unfinished tasks or obligations. Some believe that the soul goes out from the body and
wanders, a phenomenon known asBangungot, or that having nightmares after a heavy meal
may result in death.
Personalistic Causes
Personalistic causes are associated with social punishment or retribution from supernatural
forces such as evil spirit, witch (Manga ga mud) or sorcerer (mangkukulam). The forces cast
these spells on people if they are jealous or feel disliked. Witch doctors (Herbularyo) or priests
are asked to counteract and cast out these evil forces through the use of prayers, incantations,
medicinal herbs and plants. For protection the healer may recommend using holy oils, or
wearing religious objects, amulets or talismans (anting anting).
Naturalistic Causes
Naturalistic causes include a host of factors ranging from natural forces (thunder, lightning,
drafts, etc.) to excessive stress, food and drug incompatibility, infection, or familial
susceptibility.

Health Beliefs and Behaviors: Basic Logic of Health and Ilness

The basic logic of health and illness consists of prevention (avoiding inappropriate behavior that
leads to imbalance) and curing (restoring balance); it is a system oriented to moderation.
Parallel to this holistic belief system is the understanding of modern medicine with its own
basic logic and principles for treating certain types of diseases. These two systems co-exist, and
Filipino older adults use a dual system of health care (Anderson, 1983; Mc Bride, 2006;
Miranda, Mc Bride & Spangler, 1999).

Health Beliefs and Behaviors: Health Promotion/Treatment Concepts

Health beliefs and practices are oriented towards protection of the body.
Flushing
The body is thought to be a vessel or container that collects and eliminates impurities through
physiological processes such as sweating, vomiting, expelling gas, or having an appropriate
volume of menstrual bleeding.
Heating
Adapts the concept of balanced between “hot” and “cold” to prevent occurrence of illness and
disorders.
Protection
Safeguards the body’s boundaries from outside influences such as supernatural and natural
forces.

Health Beliefs and Behaviors: Health Behaviors

Response to Illness

Filipino older adults tend to cope with illness with the help of family and friends, and by faith in
God. Complete cure or even the slightest improvement in a malady or illness is viewed as a
miracle. Filipino families greatly influence patients’ decisions about health care. Patients
subjugate personal needs and tend to go along with the demands of a more authoritative
family figure in order to maintain group harmony. Before seeking professional help, Filipino
older adults tend to manage their illnesses by self-monitoring of symptoms, ascertaining
possible causes, determining the severity and threat to functional capacity, and considering the
financial and emotional burden to the family.

They may even resort to utilizing traditional home remedies such as alternative or
complimentary means of treatment. They may discuss their concern with a trusted family
member, friend, spiritual counselor or healer (Yeo, 1998). Seeking medical advice from family
members or friends who are health professionals is also a common practice among Filipino
older adults and their family members, especially if severe somatic symptoms arise (Anderson,
1983).
Coping Styles
Coping styles common among elderly Filipino Americans in times of illness or crisis include:
 • Patience and Endurance (Tiyaga): the ability to tolerate uncertain situations
 • Flexibility (Lakas ng Loob): being respectful and honest with oneself
 • Humor (Tatawanan ang problema): the capacity to laugh at oneself in times of
adversity
 • Fatalistic Resignation (Bahala Na): the view that illness and suffering are the
unavoidable and predestined will of God, in which the patient, family members and
even the physician should not interfere
 • Conceding to the wishes of the collective (Pakikisama) to maintain group harmony
Responses to Mental Ilness
Indigenous traits common among elderly Filipino Americans when faced with illness related to
mental conditions:
 • Devastating shame (Hiya)
 • Sensitivity to criticism (Amor Propio)
Common Perceptions of Filipinos about Mental Illness
 • Unwillingness to accept having mental illness, which leads to the avoidance of needed
mental health services due to fear of being ridiculed
 • Involvement of other coping resources such as reliance on family and friends or
indigenous healers, and dependence on religion which can diminish the need for mental
health services
 • Prioritizing of financial and environmental needs which preclude the need for mental
health services
 • Limited awareness of mental health services resulting in limiting access
 • Difficulty in utilizing mental health services during usual hours because of the
unavailability of working adult family members
 • Mental illness connotes a weak spirit, and may be attributed to divine retribution as a
consequence of personal and ancestral transgression
 • Lack of culturally oriented mental health services
Though such coping mechanisms, perceptions and traits may help elderly Filipino Americans
adjust initially to their illnesses, these tactics also pose barriers and impede implementation of
necessary treatment intervention in a timely fashion.
Cultural Values
Interpersonal Relationships
Smooth Interpersonal Relationships are a core value for every Filipino community; they involve
a shared identity, engagement on an equal basis with others, and giving importance to the
individual versus agencies or institutions. This cultural characteristic is also known as
“Personalism.” The high value placed on sensitivity and regard for others, respect and concern,
understanding, helping out, and consideration for others’ limitations, often creates discord with
American tendencies toward openness and frankness (Agoncillo & Guerrero, 1987; Enriquez,
1994).
Perceptions regarding physician preferences dictate who will provide care and how much trust
is given.
Two main concepts determine the interaction between a Filipino and a health care provider:
 1. “One of Us” (Hindi ibang Tao) versus
 2. “Not one of Us” (Ibang Tao)
Health providers who are respectful, amenable and willing to accommodate the patient’s needs
are considered to be Hindi ibang Tao.
If the provider is considered Ibang Tao, Filipino Americans will be reluctant to express their
feelings and emotions. They will designate a family member to mediate or advocate on their
behalf while responding politely to the provider at a formal and superficial level.
The concept “Not one of Us” involves:
 • civility (Pakikitungo)
 • mixing (Pakikisalamuha)
 • joining/participating (Pakikilahok)
 • adjusting (Pakikisama)
The concept “One of Us” includes:
 • mutual trust/rapport (Pakikipagpalagayan ng loob)
 • getting involved (Pakikisangkot)
 • oneness/full trust (Pakiisa)
(Pasco, 2004; Enriquez, 1994; Pe Pua, 1990).
Family and Filial Responsibility
Children are taught to show affection for older family members and respect for older adults and
authority. They are expected to seek the advice of and accept the decisions of their older
adults. They are obligated to care for older adults and aging parents, and maintain group
harmony, loyalty, and emotional ties with parents and other family members across the life
span (Chao & Tseng, 2002; Mc Bride, 2006; Miranda, Mc Bride & Anderson, 2000; Superio,
1993). In a study of Asian American older adults in New York City, Filipino older adults (N=52)
were the least likely to consider care giving responsibility a burden and dependency on other
people a serious problem (Asian American Federation of New York, 2003).
Spiritual Life and Religiosity
Religion is deeply embedded in and intertwined with Filipino culture. It is central to people’s
lives and enables them to face life’s challenges and adversities with strength and optimism
(Tompar-Tiu & Sustento- Seneriches, 1995). Filipino Americans use spirituality and religion as
part of their coping practice, especially when dealing with illness.
Religious practices include:
  • attending mass
 • praying the rosary and novena
 • expressing devotion to saints and the Virgin Mother
 • receiving the sacraments and holy communion
 • reconciliation
 • anointing the sick
 • observing religious holidays and rituals
 • going on pilgrimages
In a small qualitative research study of elderly female Filipino immigrants in Vallejo, CA, most of
the participants believed that certain illnesses that cannot be treated by modern medicine can
be treated through divine intercession (Verder-Aliga, 2007). Prayers, church affiliation, spiritual
fellowship and counseling play a crucial part in the healing process and in the promotion of
wellness and good health.
In a study on culture and health among Filipino Americans in central Los Angeles, the majority
of elderly Filipino subjects exhibited deep levels of religiosity, and had a strong view of God’s
role in human health and wellbeing (Historic Filipinotown Health Network, 2007).

Preparatory Considerations
Demonstrating Respect
Use Miss, Mrs., or Mr. when addressing an elderly Filipino American. Avoid addressing the elder
by first name during the first encounter since this familiarity might be perceived as a sign of
disrespect.
Greeting
A firm handshake with a smile and eye contact is appropriate. If the older patient is
accompanied by other family members, greet the older patient first. The social greeting “How
are you?” translates into Tagalog as “Kumusta po kayo“. The word po, which conveys respect, is
automatically added at the end of every sentence or phrase when communicating with an older
or elderly person.
Informal Conversation
Having a conversation about grandchildren or other non-medical life events or interests
(hobbies) puts the Filipino elder at ease. A clinician who shares briefly a personal anecdote,
particularly about children in her/his family, is recognized more as human being to whom the
older adult can relate rather than as an authority figure.

Verbal Communication
1. English Proficiency

Many Filipinos take pride in their ability to read, write, and speak English. They may feel
offended if asked about the need for an interpreter.
2. Culture-Based Communication Guide

Though many elderly Filipino Americans can communicate in English, there may be challenges
when they are confronted with high-stress situations.

tips iconFor clinicians working with older Filipino individuals, the following guidelines may be
useful:

• When the cadence and inflections in spoken English make it difficult to understand the
patient, ask permission to seek the services of an interpreter. To avoid offending the patient,
explain that the purpose of having the interpreter is to reassure the clinician that the medical
terms are accurately described to the patient.
• It is important not to use family members/friends as interpreters for health care related
issues.
• When introducing the need for an interpreter, do so in a respectful manner as in the following
model presentation:
“Mrs. Kabayan, I want to discuss some important issues related to your health. I know that you
speak English. However, with your permission, I would like to request the presence of an
interpreter today. An interpreter will help both of us communicate clearly with each other, I do
not mean any disrespect. I just want to make sure that we give you the best possible care and
using an interpreter will help ensure this.”
• Questions such as “Do you understand?” or “Do you follow?” may be considered
disrespectful. Instead, ask the patient to repeat the instructions with the explanation that the
feedback process is for the clinician’s benefit to ascertain whether he/ she has done a thorough
job.
• For elderly Filipino Americans who are less educated and have minimal acculturation
experience, never make the assumption that a “Yes” answer means that she or he understood
the discussion or agrees with the decision or opinion of the health care provider.
In most cases, “Yes” merely means “I heard you.” Filipino older adults who are used to high-
context communication may feel puzzled and offended by the preferred precision and
exactness of the American communication process.
• Many older adults, particularly those from intergenerational households, look to a trusted
adult family member as their “surrogate decision maker” and would expect the clinician to keep
this individual informed of issues related to their health. Such a preference may not be
expressed or openly discussed by the elder or the family member.
• It is considered disrespectful to challenge, question, or express disagreement with an
authority figure such as a health care provider. To encourage open communication, providers
need to reassure a reticent or passive elder that asking questions or expressing opinions would
not offend them.
• Use phrases that connote relationships such as “Our aim is,” “This is your problem” and “We
are working on this.“
• Clinicians should explore and listen to older adults’ beliefs about health and illness. Be
respectful of their behaviors. Patiently explain from your perspective what has to be done and
why.
• When an older adult is accompanied by other family members, seek the elder’s consent
before disclosing sensitive and private issues in order to maintain the patient’s privacy and
autonomy and avoid embarrassing the patient.

Respectful Nonverbal Communication

1. Pace of Conversation

Allow brief periods of silence or pauses in the conversation to enable the patient to process
information that may be occurring in the native language (Tagalog), especially for those with
limited English proficiency.

2. Physical Distance

Maintain a reasonable personal space of 1 to 2 feet. Take height into consideration. A seated
position for interaction is highly recommended.

3. Eye Contact

Sit at eye level with the patient for the interview; make brief and frequent eye contact, even
though the patient’s eye contact is of shorter duration than the clinician’s. Older patients may
look down or look away most of the time as a sign of respect to an authority figure, a
professional, or someone who is of a higher social class. Prolonged eye contact between an
older Filipino male patient and a younger female clinician may be flirtatious.

4. Emotional Responsiveness

Filipino Americans’ emotional responsiveness and affect may be misleading. Look for changes in
facial expression—older adults may smile or chuckle inappropriately, which could be a sign of
nervousness or embarrassment or may be simply a personal mannerism. Explore the meaning
of flat affect and downcast eyes during the interview.

5. Body Movement

Frequent hand gestures may be used by Filipino Americans for emphasis:

• They may cover their mouths with one hand when making conversation or smiling as an
expression of shyness or embarrassment.
• The common American gesture for “come here”, i.e., moving the pointed upward index finger
forward and back, is an insulting gesture to less acculturated Filipino Americans. An acceptable
gesture is to extend one hand towards the person with palm facing down and then flex and
extend the four fingers (with no thumb) several times.
• Head wagging or nodding (unconscious movement of one’s head) has many meanings and
should not be confused with shaking one’s head in agreement.
• Head movement can also mean “Yes I’ll cooperate” or “I hear you” even though the person
does not understand you. This is mostly the case among Filipino immigrants who are less
educated and have minimal acculturation experience.
6. Touch

Young female service providers should practice discretion when touching older Filipino male
patients in situations such as laying a hand on the patient’s hand or shoulder to give comfort in
moments of distress. Elderly Filipino women have a heightened sense of modesty, and show
reservation in subjecting themselves to physical examinations involving female body parts.
Health care providers should ask permission before performing this kind of examination and
should avoid rushing through the procedure.

A male provider should always be accompanied by a female staff member when examining an
elderly female’s private areas. Elderly Filipino women may spontaneously touch a hand or arm
or hug a service provider to express appreciation for services rendered.

Use of Standardized Assessment Instruments

Except for A Short Acculturation Scale for Filipino Americans (ASASFA), to date there are no
known geriatric assessment instruments that have been validated and standardized for Filipino
Americans. The ASASFA was designed for bilingual Filipino immigrants receiving healthcare at
Southern California health maintenance organizations, the majority (77%) of whom had college
and/or advanced education (de la Cruz, Padilla, & Butts, 1998).

Ethnogeriatric Assessment
Ethnic Affiliation and Acculturation
Community Involvement
Assess participation in social, cultural, and educational activities in the Filipino community.
Active membership in local Filipino organizations may indicate the extent of the support
network in the community. One might want to:
 • Assess for indigenous tribal ancestry—e.g., Muslim, Negrito, Malayan, Mestizo, or
 • Assess for multi-racial background— Filipino Americans have the second largest
number of interracial marriages among Asian immigrant groups (Le, 2010).
Language Assessment
Determine language preferences for interviews and written health information. Two of the
items in the five-point Likert Scale have proven to be significant predictors of acculturation:
 1. Language preference
  2. Self-identification of cultural identity (e.g., selfidentification of cultural identity as very
Filipino, somewhat Filipino, partly Filipino, partly American, mostly American, very
American).
Religion
Assess how the elder practiced his or her religion prior to immigrating to the US as well as the
current religious practice. Determine the importance of religious affiliations, activities, rituals,
and other support from the church that help promote and maintain the patient’s spiritual
growth and stability.

Patterns of Decision-Making
Filipino culture fosters values that enhance group harmony and smooth interpersonal
relationships. Family cohesiveness serves as a driving force for shared decision making among
family members in accordance with the patient’s needs. Clinicians could develop a family
decision-making tree or algorithm.
A primary decision maker may not be designated prior to a health crisis. Decisions may be
delegated to family members living outside the US, or birth order may be used to designate the
decision maker (McBride, 2006; Tompar – Tiu & Sustento – Seneriches, 1995).
The clinician should ask questions such as: “Who should we talk to?” or “Who can help in
making decisions about your treatment in the future?” Family members are often expected to
make decisions or speak for older adults; those without any close relatives may rely on friends,
clergy, or a trusted service provider.
In complicated situations, a “go-between,” such as a trusted friend (compadre/comadre), cleric
or member of a faith organization, who is usually not a family member, may facilitate the
interaction or dialogue.

Clinical Assessment Domains: Health and Social History

Mental Health
Risk factors for depression among elderly Asian American women, including Filipino
immigrants, include:
 • poor general health with increased impairment of activities of daily living (ADLs)
 • social isolation
 • stressful life changes
 • requiring a higher level of assistance from children
 • being less religious
 • experiencing a greater cultural gap between themselves and their children. (Asian
American Federation of New York, 2003)
The care giving or surrogate-parenting role can also place a burden on elderly individuals, which
could result in situational depression (McBride 2006; Tompar – Tiu & Sustento – Seneriches,
1995).
Clinicians should be cognizant about common indigenous traits and perceptions among elderly
Filipino Americans suffering from mental illnesses such as depression.
Several validated screening tests can be utilized to facilitate the detection of depression in
elderly adults, including:
  • Center for Epidemiologic Study Depression Scale
 • Geriatric Depression Scale
 • General Health Questionnaire
 • Beck Depression Inventory
Recommendations:
 • Pay attention to the level of education and acculturation and English language
proficiency. Always ask for professional interpreters when administering such screening
tests.
 • Assess for social support and availability of other community resources.
Risk of Elder Abuse
Risk factors for abuse may include:
 • lower levels of acculturation,
 • living with non-family members or in an intergenerational household,
 • dependence on other adults to move about,
 • lack of ability to use simple technology (e.g. telephone),
 • lack of English proficiency,
 • degraded physical appearance (i.e., self neglect) (Lewis, Sullivan & McBride, 2000).
Also assess for other suspicious physical signs of abuse, and for other types of abuse (emotional
abuse, sexual abuse, neglect by caregivers, self-neglect, financial exploitation, and health care
fraud and abuse).
Use of Community-Based Healers and Spiritual Counselors
Traditional treatment (herbals, nutritional supplements, prayers, etc.) often are used
concurrently along with Western medical treatment (Grudzen & McBride, 2001; McBride,
2006). Thus, we stress the importance of eliciting the usage of indigenous healing practices in a
gentle and non-judgmental manner and take time to educate patients and families about the
potential for adverse interactions between the different systems of healing.
Other Sources of Health Care
Older adults who frequently travel to the Philippines or visit other family members in the US
may be receiving medical care from a physician in the Philippines or in other locations.
Dietary History
The Filipino American diet is relatively high in fat and cholesterol compared to the diets of other
Asian Americans. Organ meats such as tripe, pork blood, pork and chicken intestines, and
poultry liver are well-liked. The typical diet uses high-sodium condiments such as fish sauce
(Patis), shrimp paste (Bagoong), soy sauce (Toyo), anchovies and anchovy paste. Pastries and
rice cakes high in concentrated sugar are often eaten for dessert. Due to these dietary
practices, Filipino Americans are at high risk for developing cardiovascular-related conditions
(coronary artery disease, hypertension, hyperlipidemia, obesity, diabetes, hyperuricemia and
gout). Filipino Americans exhibit significantly higher levels of hypertension than other Asian
Americans. These levels are similar to those in African Americans who live in the US (Nguyen,
2006).

Clinical Assessment Domains: Physical Examination and Screening Test

Respiratory Diseases
COPD and respiratory infections such as influenza and pneumonia rank 4th and 6th as the
leading cause of death respectively among elderly Filipino Americans. Increased incidence of
smoking among Filipino men compared to other Asian ethnic groups put them at higher risk for
developing COPD. Increasing age, presence of other chronic co-morbidities like diabetes
mellitus, cardiovascular disease such as CHF, and COPD put them at higher risk for developing
pneumonia and influenza. Identify personal risk factors, medical history, social habits, and
immunization history.
Cognitive and Affective Status
Stigma and shame may delay access to diagnostic and treatment resources for Alzheimer’s
disease and mental health problems. It is common for less-educated elderly Filipino immigrants
with minimal acculturation experience to perceive such cognitive problems as part of the
normal aging process. Highly acculturated families may be hesitant to seek resources. The
public image of the family is the prime concern, and there is a tendency to be crisis-oriented.
Psychiatry is perceived to be a resource for the affluent. Somatic symptoms such as headache,
loss of appetite, sleeplessness, fatigue and low energy level are common presentations of
depression. Medication for treating mental illness is much preferred to psychotherapy. Trusted
members in the community such as clergy, lay ministers or healers may be preferred. Family
therapy or group therapy may be too threatening to less acculturated older adults.
In evaluating elderly Filipino patients for cognitive dysfunction and mental illness, one should
be cognizant of common indigenous traits, perceptions, and coping mechanisms. Simple
validated screening tests such as the Geriatric Depression Scale (GDS) for depression, the Mini
Cog and the Clock Drawing Test to determine cognitive dysfunction are easy to administer,
especially among less educated and less acculturated elderly individuals. For highly educated
individuals, more sensitive (98%) and specific (97%) tests such as the Mini Mental State Exam,
the Clock Drawing Test and the Mattis Dementia Rating Scale are preferable.
Osteoporosis Screening
Despite limited research concerning the risk and incidence of osteoporosis among elderly
Filipino Americans, this group is not immune and is at increased risk with advancing age. Initial
screening using the Dexa Scan should begin at age 65 for women with a low risk of developing
osteoporosis or fracture. Initial screening using the Dexa Scan should begin between the ages of
60 – 64 for women with a high risk of developing osteoporosis or fracture. Repeat screening
every 2 years using the Dexa Scan. In addition to physicians, nurses in the ambulatory care
setting play an important role in educating patients and families about this issue.
Cardiac and Vascular Diseases
Cardiovascular disease, stroke, diabetes mellitus, aortic aneurysm and dissection and
hypertension rank respectively as numbers 1, 3, 5, 9 and 10 among the leading causes of death
for elderly Filipino Americans. These risks are amplified by increasing age, unhealthy social
habits (smoking) and dietary practices and physical inactivity.
Cancer
Malignancy ranks second as the leading cause of death for elderly Filipino Americans. Decisions
to screen patients should be individualized and be based on the following factors such as
expected life expectancy, preferences, plan for what the patient may or may not want to do
further if screening had positive findings, as well as degree of burden to the patient (Hall KT,
2010).
Functional Status
Assess patient activities in the community, the presence or absence of activities of daily living
(ADL) impairments, and environmental home safety measures. Because of the cultural value of
interdependent/ dependent relationships, determining the presence or absence of
instrumental activities of daily living (IADL) impairments (driving skills, using and balancing
check books, use of modern household appliances) may not be critical for less acculturated and
low income elderly individuals who depend heavily on other family members.

Family and Community Assessment

Older adults could be living in a group setting with unrelated adults, in an extended family, with
a spouse, or alone. The Filipino community monitors this subgroup through organizations.
Highly acculturated older adults (who age in place) may be isolated from the Filipino
community. An extended Filipino family may include non-biological members. Integration into
the family system occurs slowly as individuals become known and trusted.
Within the Filipino community, children are taught filial responsibility and respect for older
adults. A lack of support may be perceived when adult children have two or more jobs. A sense
of social isolation may be interpreted by older adults as rejection by the family, lack of respect,
lack of love and being unwanted. These assumptions evoke feelings of psychological neglect.
Depending on resources, older adults may take periodic trips to the Philippines or visit adult
children in various parts of the US. Older adults also make telephone calls and exchange
videotapes in order to communicate with relatives and friends living outside the US.
Important Characteristics of Neighborhoods
Characteristics of urban or suburban neighborhoods that might be important to Filipino
American older adults include:
 • availability of public transportation
 • presence of Asian businesses
 • Asian or Filipino food products in the grocery stores
 • proximity to a senior center
 • nearby church and recreational facilities
 • degree of integration of the neighborhood
 • size of the Filipino American population
 • crime rate
 • air quality
 • recreational facilities that offer activities and services popular with Filipino seniors
such as dancing, picnics/barbeques, popularity contests followed by award and
dinner/dances
 • support from the neighborhood and community in the form of programs such as
neighborhood watch.
Suburban living without these features, or living in an inter-racial household, may produce a
sense of social and cultural isolation.

End-of Life Preferences

Few studies have systematically examined the cultural needs of Asian ethnic minorities
regarding end-of-life care. Filipino families may struggle with or avoid talking about advance
directives and life support decisions when family members are seriously ill or dying. Culture and
beliefs also dictate the rules for disclosure or truth-telling regarding terminal health diagnoses
and prognoses. Filial obligation is imperative in the Filipino culture and is practiced to protect
the patient, maintain hope, and ensure a good death. Discussions regarding end-of-life issues
and advance directives should be approached cautiously, because discussing such sensitive
issues may raise the fear that the discussion itself could lead to or invoke unwanted outcomes
(Cantos, 1996).
Many Filipinos have fatalistic perceptions known as “Bahala Na” (what is destined or inevitable;
illness is always “the will of God”) when confronted with serious or life-threatening illness (Mc
Laughlin, 1998; Bigby, 2003; Vance, 1995). A descriptive, correlational, crosssectional study of
22 critically-ill Filipino Americans, aged 55 and older, and their family members regarding
attitudes towards advance directives showed that overall attitudes towards advance directives
were positive, especially among acculturated and highly educated families. Completion rates
among the patients were low (10%), most probably due to their fatalistic belief that illness is
destined or inevitable, thus rendering advance directives pointless (Mc Adam, 2005).
A large retrospective study was conducted of the last year of life of Asian-American Pacific
Islander (AAPI) and white Medicare beneficiaries registered in the Surveillance, Epidemiology,
and End Results Program. White (n=175,467) and AAPI (n=8,614) patients aged 65 and older
who were dying with lung, colorectal, breast, prostate, gastric, or liver cancer were studied
(Ngo- Metzger, Phillips & McCarthy, 2008).
The data showed that all Asian Americans including Filipino American older adults were less
likely to enroll in hospice care. In a Filipino American and Cambodian American comparative
study which involved three in-depth interviews over a 1-year period with 48 Cambodian
Americans and 78 Filipino Americans, the subjects stated that they wanted to go back to their
country of origin and die in their homelands (Becker, 2002).

Problem-Specific Data
Different models can be applied in providing culturally responsive care to Filipino Americans.
Panos and Panos (2000) developed a culturally sensitive assessment process that focuses on
several domains:
 • Physician awareness of his or her own cultural identity
 • Identification of patient’s cultural orientation, belief system, level of acculturation and
language preference
 • Assessing patient’s stress and adaptive coping and functioning
 • Determining patient’s family relationships and support system
 • Assessing patient’s views on and concepts of health and illness