The social and cultural context of the mental health of Filipinas in Queensland

Samantha Thompson, Lenore Manderson, Nicole Woelz-Stirling, Amanda Cahill,

Margaret Kelaher

Objective:

To describe the social and cultural context of risk surrounding the mental healthof Filipino women living in Queensland, Australia and elicit the meaning and experience ofmental health and illness for these women.

Methods:

One hundred and thirty-nine in-depth interviews and 7 focus group discussions(FGDs) were nested within the baseline survey of the Filipina cohort of the AustralianLongitudinal Study on Women’s Health. Seventy-four in-depth interviews and 8 FGDs wereconducted at follow-up. A semi-structured interview guide that included sections on emotionalhealth, social support and changes guided these. A subset of responses was fully transcribedand analysed for ethnographic content and themes.

Results:

‘Mental’ problems are highly stigmatized, in comparison to ‘emotional’ problemsthat are believed to result largely from the absence of close family ties. The loss of these tiesand the transition from a collectivist to individualist society are key themes related toemotional distress in Filipinas.

Conclusions:

This understanding of meaning and context of mental health and its riskfactors in migrants is important for informing public health and clinical practice and for theimprovement of quantitative research instruments.

Key words:

Australian and New Zealand Journal of Psychiatry 2002; 36:681–687

Filipinos, mental health, migration, qualitative research.

While epidemiological research is important in defin-ing mental health as a problem, identifying risk factorsand providing a point of comparison between popula-tions, qualitative research provides insights into themeanings and experiences of mental health and illness,and the social and cultural context of risk [1,2]. In this

paper we draw on the findings of qualitative researchnested within the baseline and follow-up surveys of theFilipina (we use the term Filipina to refer to women fromthe Philippines now living in Australia) cohort of theAustralian Longitudinal Study on Women’s Health, toprovide context and understanding to the quantitativefindings on mental health described in the accompanyingpaper in this issue [3].

Culture influences the experience and manifestationsof mental health and illness [4]. Symptoms of mentalillness cannot be properly identified by measurementinstruments, which conventionally do not take intoaccount differences in conceptualization and expressionin non-Western populations [4–6]. An understanding ofthe mental illness behaviours within specific culturalcontexts has implications for epidemiological sampling,measurement and clinical care.

We have shown elsewhere that Filipinas, who aresingle, dissatisfied with life in Australia, or report a

Samantha Thompson, Research Fellow (Correspondence); Nicole Woelz-Stirling, Research Assistant; Amanda Cahill, Research Assistant

Women’s Health Australia, Australian Centre for International andTropical Health and Nutrition, School of Population Health, Universityof Queensland, Australia. Email: SamT@acithn.uq.edu.au

Lenore Manderson, Director

The Key Centre for Women’s Health in Society, The University ofMelbourne, Melbourne, Australia

Margaret Kelaher, Research Fellow

Joseph L Mailman School of Public Health, Columbia University, US

Received 6 December 2000; 2nd revision 9 April 2002; accepted 16 April2002.

682 CONTEXT OF FILIPINA MENTAL HEALTH

major change in their financial situation, relationship orhealth, are at greater risk of mental distress [3]. The socialand cultural context within which these risk factors areexperienced and affect mental health is important forunderstanding the variation between Filipinas and otherethnic groups in order to develop culturally appropriatepublic health interventions [6].

Several models have been proposed to explain theeffects of social and cultural change and health [7,8]Many of these are limited because they place a largeemphasis on acculturation (change in immigrants’ valuesand beliefs towards that of the host country) and assumethat individuals move along a continuum from the ‘origi-nal’ culture to the ‘dominant’ culture, losing their originalculture as they adopt the new culture along the way.Anthropological studies have shown that culture is notstatic or linear but is a complex concept that is fluid andis something people constantly redefine [8,9]. Modelsfocused on acculturation also tend to place less impor-tance on significant changes to the individual’s social andeconomic contexts.

Rogler [10] proposes a more holistic framework forunderstanding the experience and consequences ofmigration. He describes migration and resettlement asinvolving three broad transitions that are mediated by ageand gender: (i) changes in bonding and the reconstructionof social networks, (ii) extraction from one socioeco-nomic system and insertion into another, and (iii) thetransition from one cultural system to another.

Rogler’s first transition describes the separation of anindividual from her primary networks of family, friendsand neighbours, and the development of new social net-works in the host society [10]. Success in re-establishingsocial networks in the host society reduces the negativeeffects of uprooting and associated psychological distress[11]. The types of networks can be categorized accordingto homogeneity, density and amount of social supportavailable, with low-density heterogeneous networks par-ticularly protective of the mental health of immigrants[11]. There is some evidence that although like-ethniccommunity support is beneficial for migrant groups,high-density networks within an ethnic group can bedetrimental because they restrict the development of tiesoutside of the group [11].

The second transition, which involves extraction fromone socioeconomic system and insertion into another, hasa major effect on the individual’s role relationships.Migrants who have to start over again in an occupation oflower prestige than they occupied in the society of originexperience role inconsistencies [12]. Structural limita-tions that occur as a result of discrimination can limitfulfilment of their role as a spouse or parent and may limittheir access to valued social roles outside the household

[12]. Although the research on the consequences of thistype of role strain is limited, it has been hypothesized toresult in behavioural responses with negative conse-quences for individual mental health [12].

The transition from one culture to another is the thirdcomponent of the migration experience. Moving to asociety with different cultural values and the acquisitionof elements of the host culture is a major feature of themigration experience [10]. For Filipino-Australians, likemany other Asian migrants, this involves a transitionfrom a collectivist society – where the goals of the grouptake precedence to the goals of an individual – to anindividualist one [13]. In the case of Filipinas, cross-cultural marriage to Australian men is likely to make thistransition more difficult as cultural values are challengedat the most intimate level.

Finally, gender needs to be considered as a moderatorof these transitions [2,10]. The World Mental HealthReport highlights disempowerment and violence as beingat the root of the mental health problems of womenworldwide [14]. These factors may be more pronouncedfor women who migrate for reasons of marriage and as aresult are in position of less control over their life events[11] and experience a decrease in socioeconomic status.

This paper will describe how risk factors particular tothe Filipina migration experience (and identified in theprevious quantitative study [3]) interfere with Rogler’stransitions, limiting Filipinas ability to adapt to life inAustralia and contributing to poor mental health. It willalso explore Filipinas’ experience and conceptualizationof poor mental health as a result of this process anddescribe the implications for quantitative research instru-ments and health service delivery.

Background

Filipinas have migrated to Australia since the early1900s, but the rate increased from the mid 1960s aswomen migrated to marry Australian men. In the mid1980s, Filipinas constituted 80% of all wives who enteredAustralia from Asian countries, resulting in a ratio ofFilipino women to men of more than 3–1 in Queensland[15]. More than 80% of women participating in the Fili-pina cohort of the ALSWH were married to Australiansor men of nationalities other than Filipino [3]. Althoughthis trend slowed thereafter, immigration from the Philip-pines has continued at a constant rate [15–18].

Economic difficulties and declining eligibility to marryin the Philippines are the major reasons women marryAustralian men [18]. Migration from the Philippines,particularly of women, is a family strategy for economicgain; it is actively promoted by the Philippines Govern-ment and remittance from overseas earnings is a major

S. THOMPSON, L. MANDERSON, N. WOELZ-STIRLING, A. CAHILL, M. KELAHER 683

source of national revenue [19,20]. The average age atmarriage of women in the Philippines in the 1980s was22 years [18]. Unmarried women approaching 30 andunwed mothers experience pressure to marry but are seenas less eligible than other women [18]. Most Filipinasmarrying Australian men are older than 25 and the meanage is around 30 [18]. The average age at migration forwomen married to Australian men in our study was 31[21]. The Australian-born and Australian migrant menwho marry Filipina women also have reduced eligibilityto marry. A substantial proportion are greater than 45,divorced and share the desire to have wives who wouldfit the traditional role as housewife [18]. Consistent withthe overall population distribution in Queensland, abouttwo-thirds of the men who marry Filipinas live in Bris-bane or another city. The remainder living in rural,remote or lesser urban areas [18].

The majority of women come from outside Manila[18]. Many are professional or clerical women; bar andhospitality girls are a minority [18]. Their educationlevels are high, with nearly one-third coming to Australiahaving completed a university degree [22]

.

Methods

The design has been described elsewhere [3]. The qualitative com-ponent consisted of in-depth interviews and focus group discussions(FGD) with a subset of the sample at baseline and follow-up. Womenwere invited to take part in an in-depth interview immediately followingthe questionnaire or in a FGD or later. Five interviewers were trained toconduct the interviews. The focus group discussions were run by atrained facilitator.

Participants were selected at baseline and follow-up based on geo-graphical region, age and employment status [22]. At baseline, 139interviews were conducted and an additional 90 women participated in7 FGDs. One year later, 74 members agreed to participate in a secondinterview and 82 participated in 8 FGDs.

The interviews and FGDs were guided by a semistructured interview/discussion guide and took one to one and a half hours. The baselineinterview included six sections: immigration, jobs, social support, rela-tionships, health services and health. The follow-up included threesections: changes, social support and emotional health. Following theadvice of the reference group, the word ‘mental’ was not used becauseof stigma; rather, discussion around mental health was encouragedusing the terms ‘emotional health’ and ‘emotional problems’. Eachinterview and FGD was conducted in English and taped with thepermission of the participants.

A selected subset of 22 baseline and 20 follow-up interviews weretranscribed. A further 60 baseline interviews and 54 follow-up inter-views and 6 follow-up FGDs were selectively transcribed. Interviewsrich in qualitative information and those including discussion of mentalhealth experience were chosen for full or part transcription. A targetedselection process ensured that each of the varying characteristics of thecohort (age, marital status, employment status, geographical region,length of time living in Australia and mental health status as measuredin the GHQ-28 survey) was represented.

The qualitative data were entered and coded for major themes using

NUD

*

IST

. Further coding was conducted by two of the authors sepa-rately and compared for consistency and reliability. Any differences incoding were reconciled. Data were analysed using thematic and ethno-graphic content analysis [23–25].

Results

In this section we examine the risk factors for poor mental health iden-tified in our previous article [3] in terms of Rogler’s transitions: (i) socialnetwork separation and reconstruction, (ii) change in socioeconomicstatus, and (iii) transition from one culture to another [10].

Separation and reconstruction of social networks

Filipina women say that the family is the main confiding unit andsource of emotional and instrumental support in the Philippines,whereas in Australia, in the absence of family, it is the individual. Sep-aration from family is often exacerbated by the unmet expectation thatthe husband will be the main confidant and source of emotional supportin Australia. It is this absence of support, rather than the presence ofadditional stressors, that nearly all of the Filipinas interviewed see as themain cause for depression and emotional problems. For example, prob-lems in raising children are not seen as a contributor to stress, instead itis the lack of support in the absence of extended family in assisting withthe task. Women say that depression and emotional problems areuncommon in the Philippines because an individual always has a familymember to whom they can talk and who will support them:

Depression is not common in the Philippines. It is non-existent.They can always relate to someone else. They can always havesomeone to talk to and support them. There is no such thing asdepression.

Depression in Australia is therefore seen as the result of an absenceof family:

We’re more depressed here because I don’t think I am happybecause my family’s not around here. I have to go on with mylife with only my husband and my daughter. If I’m living in thePhilippines I have my sister there and I can say my problem.

Women say that if there is no one they can fully trust, regardless ofhow severe the problems or feelings, then it is necessary to keep theirproblems ‘inside’, to pray, or to make themselves busy rather thandiscuss them with someone.

When a woman migrates to Australia, financial support is expectedin the direction from the individual in Australia to her parents andsiblings in the Philippines. The obligation to remit to the family in thePhilippines is not only a source of stress for women (many of whomexperience financial difficulty in Australia) but can result in difficultyin maintaining family ties and eventual disconnection from the inher-ently supportive ties. For example, one woman spoke of having littlecontact with her family in the Philippines because of their constantrequests for money that she could not supply. When she divorced andremarried, she did not inform her family. Being unable to meet herobligations resulted in her severing her networks of emotional support.Some women are torn between wanting to remit and being in a positionof little financial control in the marriage. Also, in many cases, womenare in a poor financial position.

684 CONTEXT OF FILIPINA MENTAL HEALTH

The financial pressure of travelling to the Philippines and contribut-ing to funeral expenses often compounds stress resulting from a deathof a family member in the Philippines (which was identified as a riskfactor in the quantitative survey). Women also talk about the high costof phone calls to the Philippines to keep in touch with family, particu-larly in the first years following migration. In the context of thesefinancial pressures, it is not surprising that changes in financial statuswas identified in the quantitative survey as associated with poorermental health.

Marriage problems and the absence of support from their husband areseen by the women interviewed as major contributors to depression.Women expect marriage to offer them emotional support and trust.However, marriage may be highly stressful due to drinking, gamblingand domestic violence, and more commonly, miscommunication andcultural misunderstanding. In one woman’s words:

In the Philippines, the most emotional problem is the husbandhaving a girlfriend. In Australia, it is having a fight with herhusband.

Another woman said:

In a normal relationship, the husband would be the primaryconsultant in the case of stress. However, in real life, thehusband is the primary reason for the emotional distress.

These problems are reflected in the results of the quantitative surveythat indicated that women who are married or in de facto relationshipssuffer more mental health problems than women who are widowed,separated or divorced.

Despite these problems, the Australian partner’s family is often onesource of new social networks in Australia. Previous findings suggestthat women married to Australian men have better access to housingand social services than Filipinas married to Filipinos [26]. This mightpartly explain why married women or those in de facto relationshipswere measured to have better overall mental health than single women.However, although these networks appear to be important in adaptingto life in Australia, women feared the lack of permanence in theserelationships, for example, if the husband were to die. A prime concernwas the loss of financial security and apocryphal tales circulate ofFilipina widows being left penniless when all inheritance flowed to ahusband’s Australian children and other relatives.

Community ties are important to Filipinas in Australia for culturalidentity, sharing language, religion and interests, assisting with infor-mation, and in some cases, providing financial assistance. However,these networks are seen as very separate from the tight and supportivefamily unit. One woman describes the family as sacred, like a castle thathas to be protected from everyone with information never leaking fromits walls. So a woman may have several friends and community affilia-tions, but she is still likely to miss the key emotional and instrumentalsupport provided only within the walls of the ‘family castle’.

From one socioeconomic system to another

In moving from the Philippines to Australia, women experience majorchanges in social status at work, home and in the community. Lack ofrecognition of qualifications and underemployment is a major problemin adjusting to life in Australia. This is reflected in the quantitativeresults that showed an unexpected trend of women who were employed

or studying being more likely to have poor mental health compared towomen who were unemployed.

Even women who have been living in Australia for more than 10years vividly recall the experience of looking for employment as one ofthe most difficult times in their experience of migration. Women talkabout having no one to look after the children in order to go out andlook for work, and believe that their American-English accent anddiscriminatory attitudes prevent them finding work. Furthermore, addi-tional study is often required to have their qualifications recognized inAustralia, which is also a financial burden. The combined cost of studyand need to generate an income encouraged women to work in afactory, restaurant or shop, even though they may have been a teacher,accountant or nurse in the Philippines. Women identify these unmetexpectations about life in Australia as a source of emotional healthproblems such as depression. This woman, who was diagnosed withclinical depression said:

The reason why I’m depressed (is) because I couldn’t practicemy career (in Australia).

The type of work women accept is physically and psychologicallydemanding. Women have little control over working conditions, includ-ing the hours they work. They often have to balance this work with theirrole in looking after the home and children and supporting their hus-band. Many women opt to study part-time to achieve a qualificationwhile earning an income. For example, one woman attends college part-time for a business degree, works as an insurance agent full time, doesthe accounting for her husband’s business, does the housework and is awife and mother.

In addition to the role inconsistency in employment, women explainthat the woman’s role in marriage is different to that in the Philippineswhere they are granted control of household finances. In many Filipina-Australian marriages, the husband sees his role as controlling thehousehold finances and this can become a major source of tension. Asalready noted, the woman’s obligation to remit also adds to the stressassociated with this role change.

Furthermore, women’s relative social status compared to other Fili-pinas in Australia is often inconsistent with what it was in the Philip-pines, and this can be a cause of tension within the Filipino-Australiancommunity. A woman of a lower social status in the Philippines maygain access to greater financial resources in Australia through marriagethan a Filipina with considerably higher education and social standingin the Philippines. The tension between social status in the Philippinesand economic status in Australia often becomes a source of conflictwithin Filipino-Australian organizations.

From one culture to another

Three aspects of the cultural transition stand out as important forFilipinas: (i) the shift from collectivist to individualist society, (ii) barri-ers to practicing core aspects of Filipina culture in the home throughfood and language, and (iii) unexpected language difficulties. These aremost marked for Filipinas in cross-cultural marriages.

In the Philippines, decisions are made at the level of families. Thetransition from sharing problems and making decisions as a family unitor collective to dealing with issues as an individual is a difficulttransition for Filipinas, and as we have already discussed, it is seen as amajor cause of poor emotional health in Filipina-Australians. While

S. THOMPSON, L. MANDERSON, N. WOELZ-STIRLING, A. CAHILL, M. KELAHER 685

Australian husbands may argue, ‘I married you, not your family’, incollectivist societies marriage to an individual is marriage to the family.This results in marital tensions because of the woman’s conflictingobligations to her Australian husband and to family in the Philippines.

Culture is reinforced in everyday life through food practices andlanguage [24]. Filipino-Australian community organizations arefocused around Filipina food, language and other cultural activities thatreaffirm cultural identity. At the household level, many Filipinasmarried to Australian men or non-Filipino migrants have little controlover everyday food and language practices. Many women say that afterarriving in Australia, they were strongly discouraged to cook Filipinofood, in preference to ‘Australian’ food, and some husbands mayprohibit Tagalog (or Visayon) to be spoken in the home, thus prevent-ing the everyday practice of Filipina culture. The adjustment fromAmerican- to Australian-English to successfully communicate is dif-ficult for Filipinas and an often unexpected barrier upon arrival inAustralia.

Filipinas’ experience of mental illness

Filipinas talk about mental distress as two distinct types – emotionalproblems and mental problems. The perceived causes and experiencesof these differ. Filipinas described emotional problems as being causedby ‘everyday problems’, that is, the types of risk factors described in theprevious sections and a lack of support to deal with these problems.

In contrast to the causes of emotional problems, isolation of theindividual and ‘softness’ of character are the perceived causes of mentalproblems. Some women talk about traditional beliefs such as taking abath during menstruation as a cause, but they also acknowledge these asbeing ‘traditional beliefs’ superseded by ‘science’. The major distinc-tion between the causes of emotional and mental problems is that whilethe former are linked to specific situations, an individual’s attributesand actions are major themes of the latter.

Filipina’s talk about emotional problems as if they are trapped insidethe body, needing to be let out through tears, prayer or physical exertion(such as cleaning the house). Some women talk about such ways ofeliminating these problems as ‘natural’ in contrast to the ‘unnatural’method of seeking professional support from a psychologist, psychia-trist or social worker. In the Philippines, an older relative or neighbourwould be consulted for counsel, and Filipinas married to a Filipino inAustralia are able to consult an older Filipino to assist with the problemsof the couple.

Talking to family and friends is seen as the best method for dealingwith emotional problems but in Australia, away from tight family andcommunity networks of trust, this is difficult. Discussing problems withfriends is seen as having the potential to make problems worse becauseof gossip within the Filipino-Australian community, and therefore, highvalue is placed on the strength of the individual in handling her ownproblems. As this woman says:

Filipino women are strong enough to deal with their problemsthemselves, and should avoid talking about them with theirfriends, because friends have an evil eye which could deterioratethe situation even further.

In the absence of close family, particularly parents, other older familymembers and trusted community members, emotional problems areseen as the individual’s responsibility.

Consulting mental health services

The word ‘mental’ is highly stigmatized for Filipinas. Women talkedof the fear associated with consulting psychiatric services, being labelledas ‘crazy’, and spoiling their family’s reputation. As one womanexplains:

In the Philippines, once you go to a psychiatrist the peoplearound you will think that something is wrong, they will thinkyou are crazy, something wrong with your mind. We don’t likeneighbours or somebody will say she went to a psychiatrist,she’s already crazy, then they spread the rumours, they spread itaround and it hurts your reputation.

Women say that the problem needs to be severe to justify the use ofmental health services; in most cases it was not felt necessary. Emo-tional problems are perceived as temporary, connected to specificrelationship or financial difficulties, which do not require externalintervention. Intervention is only seen as necessary in the case ofbiological problems, independent of events or a person’s situation. Asone woman says:

Psychiatrists are not a way for Filipino women to deal withemotional problems, but should be resorted to only when thereare serious brain problems. Psychologists are not helpful either,because a friend could fulfil the same role.

Psychiatric services are also perceived as expensive. Women say thatin the Philippines, only the rich use such services, although, they alsofelt that less educated women are in greater need of these services. Thedifferent structure of health services in Australia appears to be a furtherbarrier to their use. For example, women were critical about the needfor referral, and lacked familiarity with psychologists compared topsychiatrists. Women also addressed language issues and the value ofbeing able to express themselves in Tagalog when discussing theiremotional problems.

Discussion

Our results show that the context of life events needs tobe considered in interpreting the association between lifeevents experienced and mental distress. Three featuresstand out: (i) problems with finance, relationships andhealth are experienced as chronic daily hassles as muchas they are experienced as discrete life events, (ii) stres-sors often ‘snowball’ or occur in clusters, and (iii) stres-sors cannot easily be separated from Filipinas’ networksof social support.

Kuo and Tsai [11] showed that although stressful lifeevents were associated with mental distress in Asian-American immigrants, daily hassles were the strongestpredictor of psychological symptoms. Financial stresshas been identified as a major source of social stress [27].In the current study, financial stressors included loss ofincome associated with return to full time study toachieve recognition of overseas qualifications, financialpressure of remittances, financial conflict within the mar-riage, and underemployment. Measurement of daily

686 CONTEXT OF FILIPINA MENTAL HEALTH

hassles in addition to life events is recommended forfuture epidemiological mental health research in the Fili-pino and other immigrant populations.

The second feature of Filipinas’ experience of stressorselicited in the qualitative research is the ‘snowballing’ ofproblems. The experience of one life event often resultsin the experience of additional stressful events, mostoften a change in financial situation. For example, thedeath of a family member often results in a major finan-cial change because of the obligation to contribute to thefuneral costs and costs associated with travelling back tothe Philippines. Similarly, in the event of illness in anelderly husband the woman may be expected to leavepaid employment to care for him, resulting again in amajor financial change.

The third characteristic of stressors, that they cannoteasily be separated from Filipinas’ networks of support,highlights the limitations of the buffering hypothesis, thatis, social support works by cushioning the effects ofstressors on an individual. Stress and support are oftennot separable and an understanding of the broader contextof an individual’s experience of stress and support iscrucial [2]. For Filipinas, the three major networks ofsupport – spouse, family and Filipina community – arealso major sources of stress, particularly financial. Fur-thermore, common to these networks are barriers to com-munication and receiving counsel. Sharing problems andemotions has been shown to be important for Filipinamigrants [28,29]. For example, thousands of Filipinadomestic workers gather in the central area of HongKong on Sundays, spending the day in groups, usuallycomposed of women from particular regions who obtaingroup counselling for their concerns and problems [29].Kuo and Tsai [11] showed that the number of friendswith whom one could talk to ‘frankly’ stood out as themost important social support component for Asiangroups related to decreased depression. The ability ofFilipinas living in Queensland to talk frankly to otherFilipinas appears to be restricted by their geographicaldispersal and mix of socioeconomic and regional back-grounds. Social support has been shown to be an impor-tant factor in promoting mental health and is an importantinclusion for future epidemiological studies, although, aswe have shown, separating social support from stress is aconceptual and methodological challenge.

The effects of current marital and employment status ofFilipinas can be understood in the context of the socioe-conomic transition from the Philippines to Australia. Fil-ipinas viewed employment and marriage in Australia asrepresenting discontinuity of a woman’s role, both pro-fessionally and in terms of expected role in marriage.Underemployment is the more important measure ofemployment status as it incorporates this transition. In

addition to role discontinuity in employment and mar-riage, financial strain means that women are often alsounable to fulfil their financial obligations to relatives, oneof the major benefits expected from migration. For Fili-pina-Australians, the socioeconomic transition representsa disruption of family and work roles that shape identityand give meaning to life.

Implications for quantitative research and health service delivery

Consistent with findings in other Asian populations,among Filipinas ‘mental’ illness is highly stigmatizedand associated with weakness in personality [30]. This islikely to have affected how women responded to com-ponents of the GHQ-28. For example, several questionswithin the severe depression component pertain to sui-cidal thoughts and tendencies that are seen by Filipinasas the behaviour of someone who is ‘mentally’ ill, andthey may be reluctant to admit to such behaviour. Simi-larly, the component of the GHQ-28 measuring socialdysfunction may fail to capture the experience of mentaldistress in Filipinas because the qualitative analysisshows that they respond to emotional problems bymaking themselves busy and are careful not to disclosetheir problems socially, outside of the close family unit.The qualitative results are indicative of the inability ofthese components to capture the experience of mentaldistress in Filipinas. This highlights the importance ofvalidation of mental health instruments for specific cul-tural groups – a common limitation of epidemiologicalstudies on migrant mental health in Australia [3,31,32].

Filipinas’ experience of mental distress also has impor-tant implications for health service delivery. The causesand solutions for acceptable ‘emotional’ problems areseen as very separate from highly stigmatized ‘mental’problems. Emotional problems are seen as a consequenceof separation from family and consultation with theirspouse or older family members is seen as an appropriatecourse of action when such problems are experienced. Ina study of Korean-Americans’ perceptions of informaland formal support for psychological problems and atti-tudes towards professional help [33], the counsellor andminister of religion were rated as the most helpful profes-sionals. The spouse was seen as the most helpful sourceof informal support even when the psychological prob-lems involved marital conflict and this support wasviewed as more helpful than a psychologist, psychiatristor social worker. The authors concluded that telling aKorean immigrant that a counsellor was available tosupport family life would be more acceptable thanaddressing the psychological and family problems of anindividual directly. The qualitative results of the current

S. THOMPSON, L. MANDERSON, N. WOELZ-STIRLING, A. CAHILL, M. KELAHER 687

study support a similar approach, but additional consider-ation is required regarding the cross-cultural nature ofmany Filipina marriages, domestic violence and the rela-tive powerlessness of Filipinas to involve husbands infamily counselling. Nevertheless, informing women thata counsellor is available to the individual or family ismore likely to result in a positive response than referral toa psychologist, psychiatrist or social worker.

Acknowledgements

This research was funded by the CommonwealthDepartment of Health and Aged Care. We would like tothank the Filipino Community Co-ordinating Council ofQueensland, affiliated organizations and our referencegroup. We also thank Jenny Phillips, Alla Ryboy andAnne Marie Benedicto.

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