After reading this chapter, the nurse will be able to:
Describe the problems encountered regarding communication when giving culturally appropriate nursing care to Filipino-American clients.
Explain the Filipino-American orientation to time and space and the relevance to culturally appropriate nursing care.
Describe how health care beliefs, values, behaviors, medical and folk practices, and attitudes affect health-seeking behaviors of Filipino-American clients.
Identify how beliefs of Filipino Americans affect the internal locus of control and subsequently the environmental control variable.
Describe biological variations that may be found in the Filipino-American client.
Overview of the Philippines
The Philippine Islands constitute an independent nation located in the Pacific Ocean approximately 450 miles off the southeastern coast of China. Taiwan is the nearest neighbor, approximately 65 miles to the north; Indonesia is 150 miles to the south.
More than 7000 islands compose the Philippine Archipelago; however, the largest islands, Luzon (40,420 square miles) and Mindanao (36,537 square miles), account for 94% of the country’s total land area. All the remaining islands are less than 6000 square miles in area. Most of the Philippine Islands are hilly and mountainous, with very little level land. The principal island, Luzon, has several mountains that run from the north to the south of the island. The range, known as the Sierra Madre, runs parallel with the northeastern coast combined with the central Cordillera to form the spine of the Philippines. The highest mountain is Mount Apo (6690 feet) on Mindanao. The islands are of volcanic origin ( ).
The Philippine Islands enjoy warm, even temperatures throughout the year. The average monthly temperature in the Philippines ranges from 76° to 84° F. Cooler temperatures are found at higher altitudes; however, temperatures below 60° F are a rare occurrence. Typhoons usually strike the Philippines at least once a year. The average rainfall for most of the islands is at least 60 inches of rain per year, with some areas receiving up to 125 inches of rain.
The population of the Philippines in 2014 was estimated at 107,668,231 people, with a birth rate of 24.24 live births per 1000 persons and an infant mortality rate of 17.64 per 1000, down from 35.2 per 1000 in 1997. Similarly in 2014, the life expectancy at birth was 72.48 years for the total population: 69.52 years for men and 75.59 for women ( ). The population density is 935.2 per square mile, with the Philippines ranking the thirteenth most populous country ( ). The median age of the population is 23.5 years in the aggregate. Likewise, the median age is 23.0 for males and 24.0 years for females ( ). Of the population, 35% is under age 15 and 4.1% is 65 or older. The life expectancy is 69.52 years for males and 75.59 years for females. Most of the people in the Philippines are of Malaysian (that is, Austronesian) descent, with the two major ethnic groups being Christian Malay (91.5%) and Muslim Malay (4%) ( ). More specifically, 28.1% are Tagalog, 13.1% are Cebuano, and 9.0% are Ilocano ( ). However, people of Chinese, American, and Spanish origin are also native to the Philippines. The population is unevenly distributed, with Luzon, Cebu, Negros, Bohol, Leyte, and Panay being the most heavily populated islands. Education on the islands is free and compulsory for ages 7 to 12, resulting in a literacy rate of 92.6% ( ; ).
The economy of the Philippines is based on agriculture. One of the principal crops is rice, which occupies about half the farmed land in the Philippines. Corn and coconuts are also very important crops, and other significant crops include root crops, fruits, nuts, sugarcane, abaca, tobacco, ramie, kapok, and rubber. Although agriculture is the principal industry, the yields per crop per acre are among the lowest in Asia ( ). Causes of low productivity of agriculture in the Philippines include poor farm management, inadequate use of fertilizers, poor seeds, and lack of incentive on the part of the farmers because many are tenant farmers ( ). The lack of agricultural productivity has resulted in a variety of dietary deficiencies among the people, including insufficient iron and vitamins ( ; ). The living environment also results in the prevalence of Ascaris lumbricoides worm populations in Filipino children in both urban and rural areas ( ). Fishing is also a major industry in the Philippines, with the number of persons engaged in fishing being second only to those in agriculture, and it provides one of the primary dietary mainstays, second only to rice. Major industries include textiles, pharmaceuticals, chemicals, food processing, and electronics assembly. Natural resources include forests, crude oil, and metallic and nonmetallic minerals. Approximately 36% of the labor force is agricultural. The rest of the work force is divided between industry (16%) and services (48%) ( ). The gross domestic product (2014) was $453.2 billion, which was $4700 per capita, up from $2530 in 1997 ( ). The unemployment rate was 7.0% in 2010 ( ; ).
More than 40% of the country is covered by forest. Resources found in the forest include Philippine mahogany and pine. Minerals mined in the Philippines include gold, copper ore, and chromite. The country continues to lack adequate supplies of mineral fuels, although coal is mined on the islands of Cebu and Mindanao.
The ancestors of the Malay people probably migrated from Southeast Asia and were undoubtedly hunters, fishers, and unsettled cultivators ( ). Magellan first visited the archipelago in 1521. Twenty-one years later, the islands were named in honor of King Philip II of Spain, and Spain retained possession of the islands for 350 years. Following the Spanish-American War in 1898, Spain ceded the islands to the United States for $20 million. However, the Filipinos declared their independence and initiated guerrilla warfare against the troops from the United States until peace was established in 1902 and a civilian governor-general from the United States assumed control. Throughout the early 1900s, a Philippine legislature was established and steps set in motion to establish a commonwealth ( ).
When Japan attacked the Philippines in 1941 and occupied the islands in World War II, enormous destruction occurred ( ). During the war, the United States extended economic aid to the Philippines as compensation for the large military bases established on the island, and following the war, the Philippines were granted independence. The Republic of the Philippines was established in 1946. From 1946 to 1965, the Philippines pursued an American-style, two-party government. However, in 1965 President Ferdinand Marcos subverted the constitution and ruled as a lifetime dictator. Marcos abolished martial law in 1981 but retained most of his own power. From 1981 to 1986 there was a growing resistance to Marcos’s rule. In 1986, Corazón Aquino, whose politically involved husband had been assassinated, possibly by Marcos’ supporters, won a spectacular electoral victory over Marcos and forced him to flee the country ( ). In the year that followed, the Aquino government survived coup attempts by Marcos’s supporters. Negotiations on renewal of leases for U.S. military bases threatened to sour relations between the two countries. However, when volcanic eruptions from Mount Pinatubo severely damaged Clark Air Base in July 1991, the United States simply abandoned the base. In 1992, General Fidel Ramos, who had the support of outgoing President Corazón Aquino, won the presidency, and the opposition gained control of Congress. In 1992, the U.S. Navy officially ended a long U.S. military presence and turned over Subic Bay Naval Base to the Philippines. A cease-fire agreement was signed between the government and Muslim separatist guerrillas in 1994, but the rebels did not abide by the accord. A new treaty providing for the development of an autonomous Muslim region on Mindanao was signed in 1996. This treaty formally ended the 24-year rebellion, which had claimed more than 120,000 lives.
Joseph Estrada won the presidential election in 1998 but was impeached in 2000 for bribery. In 2000, the government repeatedly clashed with the Moro Islamic Liberation Front, which abducted several groups of hostages, including tourists, while demanding money for their release ( ). In the spring of 2001, Vice President Gloria Macapagal-Arroyo became president ( ). After battles with an Islamic guerrilla group and assistance from the United States, the insurgents were suppressed and President Arroyo won reelection in 2004. Tropical storms and flooding in 2004 displaced 880,000 and left 1060 dead and 560 missing ( ; ).
Immigration to the United States
Three different waves of Filipino immigrants have come to the United States: the first-wave, or pioneer, group; the second-wave group; and the third-wave, or new immigrant, group ( ). Although “Philipino American” is the correct spelling because there is no F in the Philipino alphabet, “Filipino American” is the accepted English spelling ( ). The feminine form, “Filipina,” is acceptable usage, although it does not appear often. Today, Filipinos are the second largest Asian-American subpopulation in the United States and represent 4.4% of all foreign-born U.S. residents.
The first-wave, or pioneer, group is diverse, particularly because of the different times of arrival of its members in the United States and their reasons for immigrating. The first-wave Filipino immigrants were originally drafted to work on trade ships that were traveling from China to the United States ( ). From 1565 to 1815, hundreds of Filipinos escaped from the trading ships and went first to Mexico and finally to Louisiana and other regions throughout the United States. In 1907, with the passage of the gentleman’s agreement that restricted Japanese immigration, Filipinos were recruited to work in Hawaii on sugar plantations ( ). Many of the first-wave Filipino immigrants worked on California farms or in Alaskan canneries, and still others worked as cooks or domestic helpers. From 1907 to 1930, Filipinos provided inexpensive and unskilled labor, such as housekeepers, janitors, farmhands, and cooks. In 1934, the United States passed what was known as the Tydings-McDuffie Act, which held Filipino immigration to an annual quota of no more than 50 persons. This act established a Philippine commonwealth and changed the legal status of Filipinos from “nationals” to “aliens” in the United States. When Filipinos were labeled “nationals,” they had the rights of citizenship except the rights to vote, own property, or marry. However, with the new alien status, the technical rights of limited citizenship were abolished ( ).
The second wave of immigration began after the Philippine Islands won independence from the United States in 1946, when the annual quota was raised to 100 persons. Many Filipinos who served in the U.S. Armed Forces immigrated to the United States with their families after World War II. noted that during this period many of the Filipino men were physically separated from their immediate kin and denied full participation in the larger American society. Therefore, many of the second-wave group, particularly the men, relied on communal arrangements as their social group.
The new immigration group, or the third wave of immigrants, is composed of those Filipinos who have immigrated to the United States since 1965 as a result of the liberalization of the immigration quota. In 1974, Urban Associates reported that in the 10-year period from 1960 to 1970, the Filipino population residing in the United States doubled, from 343,000 to 774,652. From 1965 to 2009, the population of Filipino Americans almost doubled again, to 2,475,754 ( ). In 2010, a total of 2,628,168 Filipinos called the United States home ( ). Today, Filipinos represent approximately 0.7% of the total U.S. population. This number represents a 30.3% increase in the Filipino population since the 1990 census ( ). Currently, Filipino Americans are the largest Asian group in California, where more than half of the Filipinos in the United States reside. By geographical location, 52.4% of Filipino Americans reside in the West, 27.0% reside in the Northeast, 8.1% in the Midwest, and 12.4% in the South ( ). In 2010, Filipino Americans again constituted the third largest group of Asians in the United States, outnumbered in terms of population only by Chinese Americans ( ).
Of the number of Filipino Americans residing in the United States before 1975, 21.7% were foreign born. Of the number residing in this country between 1975 and 1979, 11.1% were foreign born; between 1980 and 1990, 31.6% were foreign born; and between 2000 and the present, of the number of adults 18 years of age and older, 73.5% were foreign-born ( ). The median age of Filipino-American people residing in the United States is 38.3 years, compared with 33.0 years for other Asian Americans and 36.7 years for the general U.S. population. In addition, only 6% of all Asian Americans are 65 years of age or older, compared with 13% of the general U.S. population ( ).
Among Filipino Americans, third-wave immigrants appear to be better educated than members of the first and second waves; however, some of these people still experienced discrimination. In general, Filipino Americans are noted for high educational standards, with parents placing high value on education ( ). In 2010, 91.8% of Filipino-American males and 93.5% of Filipino-American females 25 years of age or older held a high school diploma, and 43.4% of males and 50.7% of females held a bachelor’s degree ( ).
The median family earnings in 2009 for Filipino Americans ranges from slightly lower to higher than that for the general U.S. population, depending on whether it is the median per capita individual income or median family income being analyzed. The median family income for Filipino Americans was $75,000 compared with $49,800 for the general U.S. population ( ). The median per capita income for Filipino-American males was $44,416 compared with $45,320 for the U.S. population. For Filipino-American women it was $42,258 as compared with $35,549 for women in the general U.S. population ( ). It is interesting to note that the opposite is true for the poverty rate among Filipino Americans, which is slightly lower than that among their White counterparts (7% vs. 8%) ( ).
reports in Strangers from a Different Shore that for many Filipinos, although they toil in America, they still experience an “unfinished dream,” with a society unwilling to embrace its own diversity. On the other hand, many Filipino Americans are being recognized across the United States for excellence, including achievement in academia ( ), in theater ( ), in higher education ( ), in medicine ( ), in politics ( ), and in poetry ( ). Unlike other Asian Americans, recent Filipino immigrants tend not to stand out as much; they speak English fluently, are highly educated, have economic well-being, and are Christians ( ). The label of “invisible minority” also extends to the relative lack of political power and representation of, by, and for Filipino Americans. Congress has established 2 months in celebration of Filipino-American culture in the United States. “Asian Pacific American Heritage Month” is celebrated in May. Upon Filipinos’ becoming the largest Asian-American group, “Filipino American History Month” was established for October, commemorating the first landing of Filipinos on October 18, 1587, in Morro Bay, California.
Since the 1960s, there has been an exodus of nurses from the Philippines to the United States ( ). Nurses educated in the Philippines have been attracted to the United States because of job opportunities, which have become especially attractive in the present nursing shortage. Although most nurses coming from the Philippines have a bachelor of science in nursing and graduate education offers additional opportunities to advance, many continue to work in staff positions, often with a second job, in order to maintain a steady financial support for family members still living in the Philippines ( ). Filipino nurses have had to make many adjustments to deliver nursing care in the United States, including learning new technologies and the American work ethic and value system. noted that cultural attributes common in the Philippines that may be retained by the Filipino nurse working in the United States can be negative but may also be positive—for example, showing deference to elders and persons who outrank them, thus appearing timid, and working very hard and not complaining. Although Filipino-American nurses have their own unique ethnic identity and rich cultural heritage, Filipino nurses are often lumped into the general category of “Asian nurses.” Because they are not given a separate ethnic grouping in statistics collected by the Health Resources and Services Administration’s National Sample Survey of Registered Nurses, noted that Filipino nurses are, for the most part, a “hidden minority.” noted that a significant number of nurses who have emigrated from the Philippines and have enjoyed full-time employment and high job satisfaction are now at retirement age, which will negatively affect the registered nurse population in the United States.
Dialect and Language
One of the greatest difficulties that faced Filipinos during the 1960s was the task of forming a more integrated national community. This task was made even more difficult because of sociological diversity and because more than 93 dialects were spoken in the Philippines at the time ( ). The boundary between “language” and “dialect” in the Philippines is blurred. The most common languages are Tagalog, Ilocano, Cebuano, Bicolano, Pampangan, and Chabacano ( ). Although 86% of Filipinos speak one of eight major languages as their mother tongue, the fact remains that many diverse languages and dialects are spoken across the country. Filipinos have long recognized the problem with dialect and language, and in 1930 the government adopted a policy to develop a national language based on Tagalog. In addition to Tagalog, English and Spanish were also adopted as official languages of the Philippines. However, adoption of a national language by the people was slow, and by 1960 only 44.5% of Filipinos spoke Tagalog, 39.5% spoke English, and 2% spoke Spanish ( ). At that time more than 93 Filipino languages were being spoken in the country ( ). Today most Filipinos speak the national language, Tagalog (also known as Filipino) but use English for business, legal transactions, and school instruction beyond the third grade. A hybrid of Tagalog and English (Taglish) is used commonly in business and social interactions as well as in health interactions ( ).
In the United States, Filipino immigrants have been willing to undergo discomfort and cultural alienation with the hope that their children might improve the economic status of the people through education. However, one tragic flaw in this scheme is the language barrier encountered by the children in the public school systems in the United States ( ). Even today, the public schools are not able to cope with the problem of bilingual education in languages other than Spanish and English. In 2009, 61% of Filipino Americans spoke a language other than English at home. Even today, Filipino Americans continue to have the fourth largest percentage (22.1%) of linguistically isolated people among all of the Asian groups residing in the United States. Some 20% of Filipino Americans live in linguistically isolated households ( ; ). A great number of Filipinos speak Tagalog, Visayan, Taglish, and Ilokano at home. Tagalog is the sixth most spoken language in the United States ( ; ).
noted that the elderly Filipino man is generally concrete in thinking and pragmatic in problem solving. Shimamoto also noted that when a Filipino man acknowledges emotions in a verbal manner, this may be interpreted as a sign of unmanliness or weakness. Cultural values emphasize group harmony and smooth interpersonal relationships; decision making may be shared among family members according to a patient’s needs. A clinician could develop a family decision tree or algorithm. Decisions may be referred to family members living outside the United States, or birth order may be used to designate decisions ( ; ).
Filipino Americans tend to use tone of voice to emote or to romanticize the language ( ). An individual may get loud in the presence of a group of family members or may become agitated or emotional when nervous or frightened. Typically, however, Filipinos are soft spoken and will say nothing rather than disagree.
Filipino Americans are “laid-back, easy-going, serene people” ( ). Thus, there is a tendency for Filipinos to avoid direct expression of disagreement. This protects them from losing face or respect. For example, it was noted in a Midwestern psychiatric hospital that a Filipino male physician, who was a family practitioner, would not disagree directly with a female psychiatrist. In areas of disagreement, the physician would communicate information to the psychiatrist by telling the nursing staff to relay the message (Davidhizar, personal communication, 1997). In this scenario, the difficulties were encountered because Filipinos are a polite people who do not like to disagree, particularly with people in authority, and because some Filipino men experience discomfort with women as authority figures.
Some Filipino people experience difficulties when discussing topics that are considered personal, including sex, tuberculosis, and socioeconomic status. The issues of sex and sex education are considered so sensitive that Filipino parents generally do not openly or deliberately discuss them with their children ( ). Because tuberculosis is a dreaded and feared disease among Filipino people—in the Philippines the morbidity and mortality for this disease remains high as a result of unsanitary living conditions—some Filipino people may also avoid discussion about tuberculosis ( ; ; ).
Some Filipinos have an expressed need for modesty, privacy, and confidentiality. Therefore, it is often difficult for the nurse to begin interventions immediately without a period of small talk on topics considered safe conversation, such as the weather, the condition of family members, or sports events. It is also important for the nurse to remember that Filipino-American clients may be hesitant to express feelings and emotions in a group setting. Filipinos are sensitive to the concept of shame or saving face. It may be only out of strong respect for the health care professional that they will disclose personal information that is needed to plan adequately for health care ( ).
Nonverbal language is important for Filipino persons. For example, direct eye contact in the Filipino culture between an older man and a younger woman may be indicative of either seduction or anger. Little eye contact is likely to be used with superiors and authority figures. Another situation in which a nurse may encounter nonverbal communication on the part of a Filipino-American client is in a group setting. Because some Filipino people fear losing face in public situations, the Filipino-American client may be hesitant to express personal feelings in a group setting and may resort to remaining silent. It is important to assess the meaning of silence and to determine if it means approval or not.
Filipinos tend to be very polite and therefore tend to behave agreeably even to the extent of personal inconvenience ( ). The term for this form of agreement is pakikisama, which means “getting along with others at all costs.” Some Filipino nurses have difficulty giving commands to staff but rather prefer to request politely that they do an assignment. Another trait for which some Filipinos are known is amor propio, which is actually a Spanish term adapted to the Filipino language, meaning “self-esteem.” Therefore, when a Filipino’s amor propio is wounded, there is a tendency to preserve personal dignity by silence or aloofness to demonstrate self-pride. Filipinos will tend to agree even when they mistrust the physician or nurse because they do not want to risk hurting the other person’s feelings. Therefore, for some Filipinos a hesitant “yes” could be indicative of a positive “no” because they wish to avoid a direct, blunt “no.” In the Filipino language, there are hierarchical terms for “yes” and “no.” The term used depends on whether one is speaking to a person of lower, equal, or superior status. When uncertain as to the status of the person with whom they are conversing, some Filipino Americans will use a silent nod to avoid giving possible offense. Also, a Filipino-American client will commonly address a physician or nurse as “Doctor” or “Mrs.”; however, if the name is unknown, this same individual may only nod ( ).
Touching is not uncommon, although handshakes are not commonly practiced by Filipino Americans. Elderly people are shown respect by being kissed on the hand, forehead, or cheeks ( ).
Implications for Nursing Care
It is important for the nurse to remember that a large majority of first-wave Filipino immigrants came to this country with little or no education and may have extreme difficulty comprehending English, especially English spoken in medical jargon ( ). Therefore, the nurse should use interpretive aids such as pictures and interpreters. It is also important for the nurse to remember that if an interpreter is used, the interpreter should speak the same language and same dialect as the client. The nurse should be aware that many Filipinos use a nonverbal response, such as a smile or a raised eyebrow, as an acknowledgment to what has been said, rather than giving a verbal response ( ). It is important for the nurse to watch the Filipino client when speaking rather than waiting for a verbal response.
Regardless of immigration-wave status, the Filipino-American client may view the nurse as an authority figure and therefore relate to the nurse with formality and modesty. Because gender and age differences also have particular significance in the Filipino culture, it would be wise for the nurse to consider both gender and age when communicating with the client. For example, because an elderly person is highly revered in the Filipino culture, it would be inappropriate as well as disrespectful for the nurse to address the elderly Filipino-American client by a first name. The nurse might try using such Tagalog designations as opo or oho, which are used to show respect and honor to the person being addressed ( ). The Tagalog designation po should be inserted when an elderly Filipino American is addressed because it conveys respect and is similar to designations in the English language such as “madam” or “sir” ( ).
It is important for the nurse to remember that direct eye contact for Filipinos has various connotations. A young female nurse who is assigned to an elderly Filipino-American male client may encounter difficulties when communicating with this client, who may remain aloof and reserved and avoid eye contact altogether ( ).
Because Filipino men, regardless of age, have great difficulty acknowledging emotions verbally, recommended that the nurse assume an authority-figure role during the development of the nurse–client relationship. Because of the Filipino trait of deference toward authority figures, Filipino-American men, regardless of age, are likely to respect the nurse’s position and to listen and adhere to the nurse’s suggestions because of the position. It is important for the nurse to appear knowledgeable and competent when communicating with a Filipino-American client and to avoid talking down to the client. It is also important for the nurse to remember that because some Filipino men experience discomfort with women as authority figures, difficulties may arise even in nurse–physician relationships. For example, when a female nurse is communicating with a Filipino-American male doctor, the nurse should use sensitivity in offering suggestions or criticism. Some Filipino Americans encounter difficulties in group settings, particularly in situations where both men and women are present. Therefore, one-on-one encounters may be best, so that the client or professional with whom the nurse is talking feels free to express true feelings and emotions ( ).
Because Filipino-American clients tend to be modest, it is important to offer female clients not only a gown but also a robe. Male clients should be offered pants as well as a gown ( ).
Because Filipinos have arrived in the United States in different groups and have adapted to the culture at different levels, it is important for the nurse to recognize that different acculturation patterns will be present and to assess for level of acculturation. have adapted for use with Filipino Americans an acculturation tool first developed for Hispanics. The 12-item instrument, Acculturation Scale for Filipino Americans (ASASFA), has been validated with experts and psychometric testing and is available in two versions, English and Tagalog. Use of the ASASFA can provide a measure for comparing the acculturation patterns of individuals and lead to broader cross-cultural knowledge and understanding.
Some Filipino Americans tend to collapse their space inward and limit the amount of personal space available. This is caused in part by the Filipinos’ strong feeling for family ( ). On immigration to the United States, the personal space of Filipino Americans also collapsed inward because some of the people lived in urban ghettos, or “little Manilas,” that were vastly overpopulated ( ).
Implications for Nursing Care
Filipino Americans are perceived as a family-oriented cultural group. Therefore, it is not uncommon for a Filipino client to have the entire family, which includes nuclear and extended family members, hovering at the bedside. Even an adult who is unmarried with no relatives in the vicinity is likely to have a number of Filipino-American visitors because they are sensitive to the loneliness that illness can provoke. The astute nurse will use family members to the advantage of the client. Rather than viewing their presence as an overcrowding of space in the hospital for both the health care professionals and the client, the nurse should capitalize on these customs and traditions by involving family members in educational training programs that will assist the client in returning to an optimal level of functioning. In addition, it is important to solicit family and client input to develop shared goals.
It is also important for the nurse to remember that Filipino Americans are familiar with a limited personal space because it is always shared with other family members. Therefore, the space provided in a hospital setting may appear to be overextended, thus leading the client to collapse personal space inward even more. While hospitalized, Filipino Americans may be reluctant to venture out of the personal space that is allocated or leave their room for any reason ( ).
In response to illness, Filipino elders may often follow a pathway to seeking professional health care that begins with self-monitoring of symptoms to ascertain possible cause, severity, threat to one’s functional capacity, and economic and emotional inconvenience to the family. The extended trajectory from symptom onset to medical treatment may also be affected by sociopolitical and historical experiences of injustice, by racial or gender discrimination felt by the elders themselves, or by attitudes passed on to them by family members who had difficult experiences ( ).
Most of the first-wave immigrants who came to the United States were not allowed to immigrate with their wives. This immigration pattern was responsible for a disproportionate ratio of males to females. The male-to-female ratio in 1930 for Filipinos residing in the United States was 14 to 1, compared with 1.1 to 1 for the rest of the population ( ). noted that because Filipino men were separated from their families, they tended to rely on communal arrangements with other Filipino immigrants, who often came from the same island in the Philippines. Most of the first-wave immigrants had little or no education and, because of discriminatory practices that existed throughout the United States, did not receive more education or a better job.
After World War II, when the immigration policies became more relaxed in the United States, more Filipino women began to enter the country, and a more normal family pattern followed. Despite the fact that more women were able to immigrate during the second and third waves, it has been noted that the age of Filipino-American husbands continues to exceed that of their wives. Because of their disproportionate ages, many young Filipino-American women have been widowed early, thus leading to the establishment of the Filipino matriarchal system. In 1974, 69% of Filipino-American families were matriarchal with young children, and at least 23% of all Filipino-American families were extended ( ). noted that the ratio of extended families to nuclear families was at least twice that of the rest of the U.S. population. Today, however, married couples represent approximately 59.7% of all Filipino-American households, whereas female-headed households (matriarchal) make up only 13.6% of Filipino-American families ( ).
In 1974, 38% of all Filipino-American families had five or more members ( ). In 2009, this number decreased somewhat, and the average Filipino-American family now has 4.0 persons, compared with the national average of 3.2 ( ). studied ethnic groups in relation to twinning rates in California. Numbers of Filipino twins were similar to those of Chinese and Japanese but higher than those of Koreans, Thai, and Vietnamese, an indication that twinning rates are modified by both migration and interethnic mixing.
Although the number of matrifocal families has decreased, the matriarchal system remains an integral part of Filipino cultural values. The matriarchal system may be the reason that the family has taken on paramount importance for Filipino Americans. This is evidenced even during times of illness. When a member of a Filipino-American family becomes ill, family members often keep a bedside vigil and participate in client care. noted that Filipino-born women who are less acculturated are more likely than women from some other ethnic groups to move in with others who are more acculturated.
Family Systems and the Relationship to Culture
The Filipino culture is a blend of various heritages, although there are some basic traits that most Filipino people manifest. Individualization is a key to understanding the Filipino culture and an individual of Filipino descent. As a result of the Chinese influence on family solidarity, Filipinos on the Philippine Islands tend to socialize with people from the same region. This same clannishness is evident in the United States among the many organizations in the Filipino communities. Persons in the younger generations may have values that are in direct opposition to the traditional values held by older persons. In the Philippine Islands, many youths resemble their Western counterparts, particularly in areas of social values, dress, and music ( ). Although these same similarities exist among adolescents in the mainstream United States and Filipino-American adolescents, many Filipino-American youths still observe such traditional values as respect for elders, love of family, and preservation of self-esteem.
In the Filipino culture there is a strong feeling for family, which is a result of the Chinese influence. Today, these strong feelings for family continue and may be manifested by old-fashioned patterns imposed by the family patriarch or the equally authoritarian matriarch. noted Filipino-American men traditionally have positions of power, dominance, and privilege and are concerned about challenges to their family leadership and to “losing face.” The Filipino child is taught always to give deference to an elder and never to question the decision of an elder. In return for such obedience, the Filipino child receives solicitous protection from elders. In the absence of both parents, the eldest Filipino child becomes the ruling authority and must be obeyed. conducted qualitative research with Filipino-American grandparents and noted that, rather than viewing grandparenting as a burden, it is viewed as an integral part of the role and part of the “give and take” of family responsibility.
Parent–adolescent communication about sex has been found to be sometimes limited, resulting in limited sex education ( ). On the other hand, a study by noted that social support for pregnant women was extensive and included a network size of 5.74. For the most part, in the Filipinos studied, immediate family members provided the support. Filipinos also reported that sisters were most likely to be the first to receive information about the pregnancy, with husbands listed third. This was in contrast to the Mexican Americans studied, who reported discussing the pregnancy first with their husbands.
Filipinos are predominantly Roman Catholic, which has been attributed to the influence of the Spanish missionaries in the Philippines as early as 1520. In 2006, chief religions included Roman Catholic, 81%, and Muslim, 5% ( ). The remaining religious groups include Evangelical, Aglipayan, Iglesia ni Kristo, other Christian, and other ( ).
Filipino mothers are encouraged to eat well and to get plenty of sleep at night. In the last few months of pregnancy, they are discouraged from staying in a dependent position, such as sitting or sleeping during the day, for fear of water retention. Sexual intercourse during the last 2 months of pregnancy is considered taboo. Eating prunes, sweet foods, or squid is also considered taboo for a pregnant woman ( ; ). It is believed that such foods will, respectively, make the baby wrinkled, lead to a large baby and difficult delivery, and tangle the baby’s cord inside the mother. If a physician is not available, a midwife may be called on to assist in the delivery. Fathers are usually not present but rather are with male friends for support while their wives deliver. A pregnant Filipino woman may walk around the room to promote dilatation. Most Filipino women will moan or grunt during labor. Others may become loud and almost hysterical ( ). A symbolic unlocking ritual may be performed during labor. Traditionally, showers and bathing were prohibited for 10 days postpartum ( ).
Traditionally, it was an expectation of all Filipino mothers to breastfeed. This tradition is changing. In a study by , Filipino women who ceased breastfeeding early or did not breastfeed were studied. It was found that a low birth weight reduced the likelihood of breastfeeding. This is significant because there are already high risks related to low birth weight and proved benefits of breastfeeding. Thus, these researchers noted that nurses should give special emphasis to promoting breastfeeding. For example, a working mother may have the baby fed formula while she is at work or may have breast milk left for the baby.
Traditionally, male circumcision was not done at birth. Today it is more common for a male baby to be circumcised before discharge from the hospital.
Rituals Related to Death and Dying
If a client has a diagnosis of terminal disease, the client should not be told before the family is consulted. The family will usually want to disclose the prognosis to the client and in some cases will prefer to protect the client from knowing the diagnosis ( ). The health care professional should generally continue to communicate with the head of the family outside of the patient’s presence regarding the health status. If the family is Catholic, the family will usually want the Catholic priest to give the sacrament of the sick, in which the client is anointed with holy oil. A Filipino client given a terminal diagnosis will probably prefer to die at home with dignity. A decision to not resuscitate is usually very difficult and will be determined by the entire family. Death is given very high regard by Filipino Americans. Death is a spiritual event, and the client and family may ask for religious medallions, rosary beads, and other objects of spiritual significance to be near the client. The family may pray at the bedside of a dying family member. If a client dies in a hospital room, the family members will usually want to say goodbye before having the body taken out of the room and may want to wash the body. Muslims will want Muslim rites performed ( ). investigated attitudes of critically ill Filipino-American patients and their families toward advance directives and noted that the overall attitude was positive. However, the completion rate and knowledge of advance directives were low, which suggested to the researchers that participants may have wished to avoid disagreement. Terminally ill Filipino-American patients usually prefer to die at home, and noted that in a study of 78 Filipino Americans contemplating death, many expressed a desire to die in their homelands. Becker noted that the preoccupation of respondents with where to die apparently reflects the desire to reconcile issues of continuity, as well as cultural meanings surrounding memory, ritual, and family.
Funerals in the Philippines can be simple or elaborate, with a band accompaniment, several priests officiating, and a large group of mourners. Rituals generally include a wake, novenas, and establishing a burial site acceptable to all the members of the family. A first-year anniversary of the death event in which the family unites draws closure to the mourning. For the traditional Filipino, women related to the deceased may wear white during this period, and weddings and other celebrations may be delayed as a show of respect. Most Filipinos believe in life after death and believe that caring for the spiritual needs of the dying is necessary for peaceful transition of the soul to the afterlife ( ).
Implications for Nursing Care
In the Philippine Islands, the family unit is the basic unit of social organization. Several generations of Filipinos are linked by descent and marriage. For some Filipinos, family relationships are so important that many of the kinfolk live under the same roof or as close to each other as possible. Furthermore, membership in a family union is perceived by some Filipinos as being more important than membership in a trade union ( ). Therefore, many nursing implications are based on family structure and organization. Because Filipino-American clients are very family oriented, the nurse must remember that these clients may always have their families hovering about them. The sick Filipino child may feel lost without the mother constantly at the bedside, and when grandparents are ill, the entire family may keep vigil at the bedside out of respect for the elderly. Whenever it is possible, the nurse should arrange for family members to stay at the client’s bedside during a hospital stay. Family members will want to bring food from home that is soothing for the body, such as rice soup, and in most cases clients will expect that this will occur.
It is important for the nurse to remember that the family structure of first- and second-wave immigrants may be significantly different from that of third-wave immigrants in that more matriarchal family structures may be found in the earlier generations. Thus the varying family structures may present the need for unique and varying approaches to health care needs. Another implication for nursing care is associated with the fact that some first- and second-wave immigrants have a limited education compared with third-wave immigrants, who were better educated when they came to the United States. When a Filipino-American client from the first- or second-wave group is hospitalized, it is important that the nurse not only involve families but also recognize the need to modify educational approaches to the family’s and client’s level of understanding.
It is helpful for the nurse to be aware that throughout the United States and particularly in California, Filipino-American centers are being established ( ). Filipino student organizations are available at some universities ( ), and the location of Filipino organizations, including the Web site of the Philippine Nurses Association ( pna-ph.org ), are available online.
Filipino Americans appear to have both a past- and a present-time orientation. According to , human nature has a postulated range of variations, including evil, good and evil, and good. People react to these value orientations by virtue of a time frame of reference. For example, past-time–oriented people view human nature as being basically evil, and so control and discipline of the self are continuously required if any real good is to be achieved. On the other hand, present-time–oriented people view human nature as a mixture of good and evil, and so although control and effort are needed, lapses in control and effort can be understood and need not always be severely condemned. For some Filipino Americans there is a prevailing attitude that one should unquestionably accept what life and death bring because, regardless of human effort, supernatural forces are mitigating and control the world. It is this attitude that influences some Filipino-Americans’ time orientation.
Because Filipino Americans are both past- and present-time oriented, they distinguish between social and business time. They tend not to become too aggravated when social functions do not start on time, and so they operate on “Filipino time.” This trait results in part from their past-time orientation, which values human relationships and human nature over current events. However, Filipino Americans do equate success in business in Western society with a prompt observation of business time, which is perceived as being both present- and future-time oriented ( ). Nevertheless, for some Filipino Americans there is a prevailing attitude that time and providence will solve all ( ).
Implications for Nursing Care
Because Filipino Americans are both past- and present-time oriented, it is important for the nurse to remember that often a Filipino-American client may ignore health-related issues, preferring to leave these things in the hands of God ( bahala na ). Some Filipino Americans may use the term talaga, which means “destined” or “inevitable.” When some Filipino Americans are ill, past-time orientation becomes obvious because of a tendency to attribute conditions to the will of God and to cope with illness by praying and hoping that whatever God’s will is, it is best for the individual.
Because of their past-time orientation, there is a tendency among some Filipino Americans toward noncompliance regarding medical regimens. In addition, these same individuals may not adhere to appointments or scheduled deadlines for health-related matters. Filipino immigrants are considered at risk for hypertension, coronary heart disease, and diabetes at midlife and at old age, along with other metabolic conditions.