Abstract
While epidemiological research is important in defining mental health as a problem, identifying risk factors and providing a point of comparison between populations, qualitative research provides insights into the meanings 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 research nested within the baseline and follow-up surveys of the Filipina (we use the term Filipina to refer to women from the Philippines now living in Australia) cohort of the Australian Longitudinal Study on Women's Health, to provide context and understanding to the quantitative findings on mental health described in the accompanying paper in this issue [3].
Culture influences the experience and manifestations of mental health and illness [4]. Symptoms of mental illness cannot be properly identified by measurement instruments, which conventionally do not take into account differences in conceptualization and expression in non-Western populations [4–6]. An understanding of the mental illness behaviours within specific cultural contexts has implications for epidemiological sampling, measurement and clinical care.
We have shown elsewhere that Filipinas, who are single, dissatisfied with life in Australia, or report a major change in their financial situation, relationship or health, are at greater risk of mental distress [3]. The social and cultural context within which these risk factors are experienced and affect mental health is important for understanding the variation between Filipinas and other ethnic groups in order to develop culturally appropriate public health interventions [6].
Several models have been proposed to explain the effects of social and cultural rchange and health [7, 8] Many of these are limited because they place a large emphasis on acculturation (change in immigrants' values and beliefs towards that of the host country) and assume that individuals move along a continuum from the ‘original’ culture to the ‘dominant’ culture, losing their original culture as they adopt the new culture along the way. Anthropological studies have shown that culture is not static or linear but is a complex concept that is fluid and is something people constantly redefine [8, 9]. Models focused on acculturation also tend to place less importance on significant changes to the individual's social and economic contexts.
Rogler [10] proposes a more holistic framework for understanding the experience and consequences of migration. He describes migration and resettlement as involving three broad transitions that are mediated by age and gender: (i) changes in bonding and the reconstruction of social networks, (ii) extraction from one socioeconomic system and insertion into another, and (iii) the transition from one cultural system to another.
Rogler's first transition describes the separation of an individual from her primary networks of family, friends and neighbours, and the development of new social networks in the host society [10]. Success in re-establishing social networks in the host society reduces the negative effects of uprooting and associated psychological distress [11]. The types of networks can be categorized according to homogeneity, density and amount of social support available, with low-density heterogeneous networks particularly protective of the mental health of immigrants [11]. There is some evidence that although like-ethnic community support is beneficial for migrant groups, high-density networks within an ethnic group can be detrimental because they restrict the development of ties outside of the group [11].
The second transition, which involves extraction from one socioeconomic system and insertion into another, has a major effect on the individual's role relationships. Migrants who have to start over again in an occupation of lower prestige than they occupied in the society of origin experience role inconsistencies [12]. Structural limitations that occur as a result of discrimination can limit fulfilment of their role as a spouse or parent and may limit their access to valued social roles outside the household [12]. Although the research on the consequences of this type of role strain is limited, it has been hypothesized to result in behavioural responses with negative consequences for individual mental health [12].
The transition from one culture to another is the third component of the migration experience. Moving to a society with different cultural values and the acquisition of elements of the host culture is a major feature of the migration experience [10]. For Filipino-Australians, like many other Asian migrants, this involves a transition from a collectivist society – where the goals of the group take precedence to the goals of an individual – to an individualist one [13]. In the case of Filipinas, crosscultural marriage to Australian men is likely to make this transition more difficult as cultural values are challenged at the most intimate level.
Finally, gender needs to be considered as a moderator of these transitions [2, 10]. The World Mental Health Report highlights disempowerment and violence as being at the root of the mental health problems of women worldwide [14]. These factors may be more pronounced for women who migrate for reasons of marriage and as a result 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 to the Filipina migration experience (and identified in the previous quantitative study [3]) interfere with Rogler's transitions, limiting Filipinas ability to adapt to life in Australia and contributing to poor mental health. It will also explore Filipinas' experience and conceptualization of poor mental health as a result of this process and describe the implications for quantitative research instruments and health service delivery.
Background
Filipinas have migrated to Australia since the early 1900s, but the rate increased from the mid 1960s as women migrated to marry Australian men. In the mid 1980s, Filipinas constituted 80% of all wives who entered Australia from Asian countries, resulting in a ratio of Filipino women to men of more than 3–1 in Queensland [15]. More than 80% of women participating in the Filipina cohort of the ALSWH were married to Australians or men of nationalities other than Filipino [3]. Although this trend slowed thereafter, immigration from the Philippines has continued at a constant rate [15–18].
Economic difficulties and declining eligibility to marry in the Philippines are the major reasons women marry Australian men [18]. Migration from the Philippines, particularly of women, is a family strategy for economic gain; it is actively promoted by the Philippines Government and remittance from overseas earnings is a major source of national revenue [19, 20]. The average age at marriage of women in the Philippines in the 1980s was 22 years [18]. Unmarried women approaching 30 and unwed mothers experience pressure to marry but are seen as less eligible than other women [18]. Most Filipinas marrying Australian men are older than 25 and the mean age is around 30 [18]. The average age at migration for women married to Australian men in our study was 31 [21]. The Australian-born and Australian migrant men who marry Filipina women also have reduced eligibility to marry. A substantial proportion are greater than 45, divorced and share the desire to have wives who would fit the traditional role as housewife [18]. Consistent with the overall population distribution in Queensland, about two-thirds of the men who marry Filipinas live in Brisbane 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 and hospitality girls are a minority [18]. Their education levels are high, with nearly one-third coming to Australia having completed a university degree [22].
Methods
The design has been described elsewhere [3]. The qualitative component consisted of in-depth interviews and focus group discussions (FGD) with a subset of the sample at baseline and follow-up. Women were invited to take part in an in-depth interview immediately following the questionnaire or in a FGD or later. Five interviewers were trained to conduct the interviews. The focus group discussions were run by a trained facilitator.
Participants were selected at baseline and follow-up based on geographical region, age and employment status [22]. At baseline, 139 interviews were conducted and an additional 90 women participated in 7 FGDs. One year later, 74 members agreed to participate in a second interview 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 baseline interview included six sections: immigration, jobs, social support, relationships, health services and health. The follow-up included three sections: changes, social support and emotional health. Following the advice of the reference group, the word ‘mental’ was not used because of stigma; rather, discussion around mental health was encouraged using the terms ‘emotional health’ and ‘emotional problems’. Each interview and FGD was conducted in English and taped with the permission of the participants.
A selected subset of 22 baseline and 20 follow-up interviews were transcribed. A further 60 baseline interviews and 54 follow-up interviews and 6 follow-up FGDs were selectively transcribed. Interviews rich in qualitative information and those including discussion of mental health experience were chosen for full or part transcription. A targeted selection process ensured that each of the varying characteristics of the cohort (age, marital status, employment status, geographical region, length of time living in Australia and mental health status as measured in 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 separately and compared for consistency and reliability. Any differences in coding were reconciled. Data were analysed using thematic and ethnographic content analysis [23–25].
Results
In this section we examine the risk factors for poor mental health identified in our previous article [3] in terms of Rogler's transitions: (i) social network separation and reconstruction, (ii) change in socioeconomic status, 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 and source of emotional and instrumental support in the Philippines, whereas in Australia, in the absence of family, it is the individual. Separation from family is often exacerbated by the unmet expectation that the husband will be the main confidant and source of emotional support in Australia. It is this absence of support, rather than the presence of additional stressors, that nearly all of the Filipinas interviewed see as the main cause for depression and emotional problems. For example, problems in raising children are not seen as a contributor to stress, instead it is the lack of support in the absence of extended family in assisting with the task. Women say that depression and emotional problems are uncommon in the Philippines because an individual always has a family member 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 have someone to talk to and support them. There is no such thing as depression.
Depression in Australia is therefore seen as the result of an absence of family:
We're more depressed here because I don't think I am happy because my family's not around here. I have to go on with my life with only my husband and my daughter. If I'm living in the Philippines I have my sister there and I can say my problem.
Women say that if there is no one they can fully trust, regardless of how severe the problems or feelings, then it is necessary to keep their problems ‘inside’, to pray, or to make themselves busy rather than discuss them with someone.
When a woman migrates to Australia, financial support is expected in the direction from the individual in Australia to her parents and siblings in the Philippines. The obligation to remit to the family in the Philippines is not only a source of stress for women (many of whom experience financial difficulty in Australia) but can result in difficulty in maintaining family ties and eventual disconnection from the inherently supportive ties. For example, one woman spoke of having little contact with her family in the Philippines because of their constant requests for money that she could not supply. When she divorced and remarried, she did not inform her family. Being unable to meet her obligations resulted in her severing her networks of emotional support. Some women are torn between wanting to remit and being in a position of little financial control in the marriage. Also, in many cases, women are in a poor financial position.
The financial pressure of travelling to the Philippines and contributing to funeral expenses often compounds stress resulting from a death of a family member in the Philippines (which was identified as a risk factor in the quantitative survey). Women also talk about the high cost of phone calls to the Philippines to keep in touch with family, particularly in the first years following migration. In the context of these financial pressures, it is not surprising that changes in financial status was identified in the quantitative survey as associated with poorer mental health.
Marriage problems and the absence of support from their husband are seen 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, gambling and domestic violence, and more commonly, miscommunication and cultural misunderstanding. In one woman's words:
In the Philippines, the most emotional problem is the husband having a girlfriend. In Australia, it is having a fight with her husband.
Another woman said:
In a normal relationship, the husband would be the primary consultant in the case of stress. However, in real life, the husband is the primary reason for the emotional distress.
These problems are reflected in the results of the quantitative survey that indicated that women who are married or in de facto relationships suffer more mental health problems than women who are widowed, separated or divorced.
Despite these problems, the Australian partner's family is often one source of new social networks in Australia. Previous findings suggest that women married to Australian men have better access to housing and social services than Filipinas married to Filipinos [26]. This might partly explain why married women or those in de facto relationships were measured to have better overall mental health than single women. However, although these networks appear to be important in adapting to life in Australia, women feared the lack of permanence in these relationships, for example, if the husband were to die. A prime concern was the loss of financial security and apocryphal tales circulate of Filipina widows being left penniless when all inheritance flowed to a husband's Australian children and other relatives.
Community ties are important to Filipinas in Australia for cultural identity, sharing language, religion and interests, assisting with information, and in some cases, providing financial assistance. However, these networks are seen as very separate from the tight and supportive family unit. One woman describes the family as sacred, like a castle that has to be protected from everyone with information never leaking from its walls. So a woman may have several friends and community affiliations, but she is still likely to miss the key emotional and instrumental support provided only within the walls of the ‘family castle’.
From one socioeconomic system to another
In moving from the Philippines to Australia, women experience major changes in social status at work, home and in the community. Lack of recognition of qualifications and underemployment is a major problem in adjusting to life in Australia. This is reflected in the quantitative results that showed an unexpected trend of women who were employed or studying being more likely to have poor mental health compared to women who were unemployed.
Even women who have been living in Australia for more than 10 years vividly recall the experience of looking for employment as one of the most difficult times in their experience of migration. Women talk about having no one to look after the children in order to go out and look for work, and believe that their American-English accent and discriminatory attitudes prevent them finding work. Furthermore, additional study is often required to have their qualifications recognized in Australia, which is also a financial burden. The combined cost of study and need to generate an income encouraged women to work in a factory, restaurant or shop, even though they may have been a teacher, accountant or nurse in the Philippines. Women identify these unmet expectations about life in Australia as a source of emotional health problems such as depression. This woman, who was diagnosed with clinical depression said:
The reason why I'm depressed (is) because I couldn't practice my career (in Australia).
The type of work women accept is physically and psychologically demanding. Women have little control over working conditions, including the hours they work. They often have to balance this work with their role in looking after the home and children and supporting their husband. Many women opt to study part-time to achieve a qualification while earning an income. For example, one woman attends college parttime for a business degree, works as an insurance agent full time, does the accounting for her husband's business, does the housework and is a wife and mother.
In addition to the role inconsistency in employment, women explain that the woman's role in marriage is different to that in the Philippines where they are granted control of household finances. In many Filipina-Australian marriages, the husband sees his role as controlling the household finances and this can become a major source of tension. As already noted, the woman's obligation to remit also adds to the stress associated with this role change.
Furthermore, women's relative social status compared to other Filipinas in Australia is often inconsistent with what it was in the Philippines, and this can be a cause of tension within the Filipino-Australian community. A woman of a lower social status in the Philippines may gain access to greater financial resources in Australia through marriage than a Filipina with considerably higher education and social standing in the Philippines. The tension between social status in the Philippines and economic status in Australia often becomes a source of conflict within Filipino-Australian organizations.
From one culture to another
Three aspects of the cultural transition stand out as important for Filipinas: (i) the shift from collectivist to individualist society, (ii) barriers to practicing core aspects of Filipina culture in the home through food and language, and (iii) unexpected language difficulties. These are most marked for Filipinas in cross-cultural marriages.
In the Philippines, decisions are made at the level of families. The transition from sharing problems and making decisions as a family unit or collective to dealing with issues as an individual is a difficult transition for Filipinas, and as we have already discussed, it is seen as a major cause of poor emotional health in Filipina-Australians. While Australian husbands may argue, ‘I married you, not your family’, in collectivist societies marriage to an individual is marriage to the family. This results in marital tensions because of the woman's conflicting obligations to her Australian husband and to family in the Philippines.
Culture is reinforced in everyday life through food practices and language [24]. Filipino-Australian community organizations are focused around Filipina food, language and other cultural activities that reaffirm cultural identity. At the household level, many Filipinas married to Australian men or non-Filipino migrants have little control over everyday food and language practices. Many women say that after arriving in Australia, they were strongly discouraged to cook Filipino food, in preference to ‘Australian’ food, and some husbands may prohibit Tagalog (or Visayon) to be spoken in the home, thus preventing the everyday practice of Filipina culture. The adjustment from American- to Australian-English to successfully communicate is difficult for Filipinas and an often unexpected barrier upon arrival in Australia.
Filipinas' experience of mental illness
Filipinas talk about mental distress as two distinct types – emotional problems and mental problems. The perceived causes and experiences of these differ. Filipinas described emotional problems as being caused by ‘everyday problems’, that is, the types of risk factors described in the previous sections and a lack of support to deal with these problems.
In contrast to the causes of emotional problems, isolation of the individual and ‘softness’ of character are the perceived causes of mental problems. Some women talk about traditional beliefs such as taking a bath during menstruation as a cause, but they also acknowledge these as being ‘traditional beliefs’ superseded by ‘science’. The major distinction between the causes of emotional and mental problems is that while the former are linked to specific situations, an individual's attributes and actions are major themes of the latter.
Filipina's talk about emotional problems as if they are trapped inside the body, needing to be let out through tears, prayer or physical exertion (such as cleaning the house). Some women talk about such ways of eliminating these problems as ‘natural’ in contrast to the ‘unnatural’ method of seeking professional support from a psychologist, psychiatrist or social worker. In the Philippines, an older relative or neighbour would be consulted for counsel, and Filipinas married to a Filipino in Australia are able to consult an older Filipino to assist with the problems of the couple.
Talking to family and friends is seen as the best method for dealing with emotional problems but in Australia, away from tight family and community networks of trust, this is difficult. Discussing problems with friends is seen as having the potential to make problems worse because of gossip within the Filipino-Australian community, and therefore, high value is placed on the strength of the individual in handling her own problems. As this woman says:
Filipino women are strong enough to deal with their problems themselves, and should avoid talking about them with their friends, because friends have an evil eye which could deteriorate the situation even further.
In the absence of close family, particularly parents, other older family members and trusted community members, emotional problems are seen as the individual's responsibility.
Consulting mental health services
The word ‘mental’ is highly stigmatized for Filipinas. Women talked of the fear associated with consulting psychiatric services, being labelled as ‘crazy’, and spoiling their family's reputation. As one woman explains:
In the Philippines, once you go to a psychiatrist the people around you will think that something is wrong, they will think you are crazy, something wrong with your mind. We don't like neighbours or somebody will say she went to a psychiatrist, she's already crazy, then they spread the rumours, they spread it around and it hurts your reputation.
Women say that the problem needs to be severe to justify the use of mental health services; in most cases it was not felt necessary. Emotional problems are perceived as temporary, connected to specific relationship or financial difficulties, which do not require external intervention. Intervention is only seen as necessary in the case of biological problems, independent of events or a person's situation. As one woman says:
Psychiatrists are not a way for Filipino women to deal with emotional problems, but should be resorted to only when there are 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 that in the Philippines, only the rich use such services, although, they also felt that less educated women are in greater need of these services. The different structure of health services in Australia appears to be a further barrier to their use. For example, women were critical about the need for referral, and lacked familiarity with psychologists compared to psychiatrists. Women also addressed language issues and the value of being able to express themselves in Tagalog when discussing their emotional problems.
Discussion
Our results show that the context of life events needs to be considered in interpreting the association between life events experienced and mental distress. Three features stand out: (i) problems with finance, relationships and health are experienced as chronic daily hassles as much as they are experienced as discrete life events, (ii) stressors often ‘snowball’ or occur in clusters, and (iii) stressors cannot easily be separated from Filipinas' networks of social support.
Kuo and Tsai [11] showed that although stressful life events were associated with mental distress in Asian-American immigrants, daily hassles were the strongest predictor of psychological symptoms. Financial stress has been identified as a major source of social stress [27]. In the current study, financial stressors included loss of income associated with return to full time study to achieve recognition of overseas qualifications, financial pressure of remittances, financial conflict within the marriage, and underemployment. Measurement of daily hassles in addition to life events is recommended for future epidemiological mental health research in the Filipino and other immigrant populations.
The second feature of Filipinas' experience of stressors elicited in the qualitative research is the ‘snowballing’ of problems. The experience of one life event often results in the experience of additional stressful events, most often a change in financial situation. For example, the death of a family member often results in a major financial change because of the obligation to contribute to the funeral costs and costs associated with travelling back to the Philippines. Similarly, in the event of illness in an elderly husband the woman may be expected to leave paid employment to care for him, resulting again in a major financial change.
The third characteristic of stressors, that they cannot easily be separated from Filipinas' networks of support, highlights the limitations of the buffering hypothesis, that is, social support works by cushioning the effects of stressors on an individual. Stress and support are often not separable and an understanding of the broader context of an individual's experience of stress and support is crucial [2]. For Filipinas, the three major networks of support – spouse, family and Filipina community – are also major sources of stress, particularly financial. Furthermore, common to these networks are barriers to communication and receiving counsel. Sharing problems and emotions has been shown to be important for Filipina migrants [28, 29]. For example, thousands of Filipina domestic workers gather in the central area of Hong Kong on Sundays, spending the day in groups, usually composed of women from particular regions who obtain group counselling for their concerns and problems [29]. Kuo and Tsai [11] showed that the number of friends with whom one could talk to ‘frankly’ stood out as the most important social support component for Asian groups related to decreased depression. The ability of Filipinas living in Queensland to talk frankly to other Filipinas appears to be restricted by their geographical dispersal and mix of socioeconomic and regional backgrounds. Social support has been shown to be an important factor in promoting mental health and is an important inclusion for future epidemiological studies, although, as we have shown, separating social support from stress is a conceptual and methodological challenge.
The effects of current marital and employment status of Filipinas can be understood in the context of the socioeconomic transition from the Philippines to Australia. Filipinas viewed employment and marriage in Australia as representing discontinuity of a woman's role, both professionally and in terms of expected role in marriage. Underemployment is the more important measure of employment status as it incorporates this transition. In addition to role discontinuity in employment and marriage, financial strain means that women are often also unable to fulfil their financial obligations to relatives, one of the major benefits expected from migration. For Filipina-Australians, the socioeconomic transition represents a disruption of family and work roles that shape identity and 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 stigmatized and associated with weakness in personality [30]. This is likely to have affected how women responded to components of the GHQ-28. For example, several questions within the severe depression component pertain to suicidal thoughts and tendencies that are seen by Filipinas as the behaviour of someone who is ‘mentally’ ill, and they may be reluctant to admit to such behaviour. Similarly, the component of the GHQ-28 measuring social dysfunction may fail to capture the experience of mental distress in Filipinas because the qualitative analysis shows that they respond to emotional problems by making themselves busy and are careful not to disclose their problems socially, outside of the close family unit. The qualitative results are indicative of the inability of these components to capture the experience of mental distress in Filipinas. This highlights the importance of validation of mental health instruments for specific cultural groups – a common limitation of epidemiological studies on migrant mental health in Australia [3, 31, 32].
Filipinas' experience of mental distress also has important implications for health service delivery. The causes and solutions for acceptable ‘emotional’ problems are seen as very separate from highly stigmatized ‘mental’ problems. Emotional problems are seen as a consequence of separation from family and consultation with their spouse or older family members is seen as an appropriate course of action when such problems are experienced. In a study of Korean-Americans' perceptions of informal and formal support for psychological problems and attitudes towards professional help [33], the counsellor and minister of religion were rated as the most helpful professionals. The spouse was seen as the most helpful source of informal support even when the psychological problems involved marital conflict and this support was viewed as more helpful than a psychologist, psychiatrist or social worker. The authors concluded that telling a Korean immigrant that a counsellor was available to support family life would be more acceptable than addressing the psychological and family problems of an individual directly. The qualitative results of the current study support a similar approach, but additional consideration is required regarding the cross-cultural nature of many Filipina marriages, domestic violence and the relative powerlessness of Filipinas to involve husbands in family counselling. Nevertheless, informing women that a counsellor is available to the individual or family is more likely to result in a positive response than referral to a psychologist, psychiatrist or social worker.
Footnotes
Acknowledgements
This research was funded by the Commonwealth Department of Health and Aged Care. We would like to thank the Filipino Community Co-ordinating Council of Queensland, affiliated organizations and our reference group. We also thank Jenny Phillips, Alla Ryboy and Anne Marie Benedicto.