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Acculturative stress in Filipino migrants

with functional English: implications for
health promotion
ab c c
Della Maneze , Yenna Salamonson , Nathan Attwood & Patricia
b
Mary Davidson
a
Sydney South West Area Health Service, Multicultural Health
Service, Ingleburn, Australia
b
Faculty of Nursing and Midwifery, University of Technology
Sydney, Broadway, Australia
c
School of Nursing and Midwifery, University of Western Sydney,
Penrith, Australia
Published online: 12 Jul 2013.

To cite this article: International Journal of Culture and Mental Health (2013): Acculturative
stress in Filipino migrants with functional English: implications for health promotion, International
Journal of Culture and Mental Health, DOI: 10.1080/17542863.2013.812131

To link to this article: http://dx.doi.org/10.1080/17542863.2013.812131

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 International Journal of Culture and Mental Health, 2013
http://dx.doi.org/10.1080/17542863.2013.812131

Acculturative stress in Filipino migrants with functional English:

implications for health promotion
Della Manezea,b*, Yenna Salamonsonc, Nathan Attwoodc and Patricia Mary
Davidsonb
a
Sydney South West Area Health Service, Multicultural Health Service, Ingleburn, Australia;
b
Faculty of Nursing and Midwifery, University of Technology Sydney, Broadway, Australia;
c
School of Nursing and Midwifery, University of Western Sydney, Penrith, Australia
(Received 29 November 2012; final version received 2 June 2013)
Downloaded by [Della Maneze] at 20:06 15 July 2013

The lack of host language proficiency is an important source of acculturative

stress among new immigrants and is known to negatively impact on both physical
and mental health. However, the acculturative stress and stressors of migrants
from culturally and linguistically diverse (CALD) backgrounds with functional
English language skills in Australia are less well-explored. Using the Filipino
migrants as examplar, this paper reviews acculturative stress in three sub-
population groups in this community: family migrants, Filipino spouses of
Australian men and skilled, professional migrants. Despite English language
ability, socioeconomic difficulties upon migration are a common source of
acculturative stress. Intergenerational and cultural gaps within the family are
conflict points that may cause depression and suicidal ideation. Changes in
lifestyle and diet, incongruence of Western health practices with cultural beliefs
may unfavourably affect health. Skilled and professional migrants experience
stress due to underemployment, non-utilisation or non-recognition of qualifica-
tions obtained overseas. The health issues of CALD communities with functional
English language skills are often overlooked in comparison with migrants lacking
host population language skills. Taking sociocultural issues into consideration is
pivotal when designing health promotion initiatives to meet the needs of
Australian migrants with functional English language skills.
Keywords: acculturative stress; acculturation; migrants; Filipino; health; English
language

Introduction
Migrants experience multiple simultaneous changes when they settle in a new
country, which can be challenging to their health and family relationships. This often
requires new settlers to harness both internal and external resources as they adapt to
a new cultural milieu. The adjustment that migrants experience, and the ongoing
interactions with the dominant paradigm of their host country, is termed accultura-
tion (Berry, 1997). In the process of this adjustment, conflicts may arise within the
person, resulting in a negative psychological and emotional state known as
acculturative stress (Belizaire & Fuertes, 2011; Berry, 1997). Immigrants with higher
levels of adaptive coping experience less acculturative stress and report higher

*Corresponding author. Email: della.maneze@sswahs.nsw.gov.au

# 2013 Taylor & Francis

 2 D. Maneze et al.

health-related quality of life (Berry, 1997). Published studies have also shown that
acculturative stress has a negative impact on both physical (Hubert, Snider, &
Winkleby, 2005; Jasso, Massey, Rosenzweig, & Smith, 2004) and mental health
(Hovey, 2000a; Wrobel, Farrag, & Hymes, 2009) and has been linked with the
development of chronic diseases (Finch, Hummer, Kol, & Vega, 2001), lower self-
rated health (Finch & Vega, 2003), depressive symptoms and suicide ideation
(Hovey, 2000a; Wrobel et al., 2009).
Although the lack of language skills of the host country is a significant
contributing factor in mediating the experience of acculturative stress (Spoonley,
Peace, Butcher, & O’Neill, 2005), it is not the only determinant. Other contributing
factors include the motivation to migrate, culture-related issues, social support
systems, economic stress, perceived discrimination and racism (Berry, 1997). In a
recent study among Filipinos in Australia, Hannah and Lê, (2012) found that in
addition to language and communication barriers, area of origin in the Philippines,
the length of residency and mismatched expectations of healthcare hinder their
ability to access health services. Very few studies in Australia explore acculturative
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stress among migrants, despite the increasing pluralistic population.

The aim of this paper is to examine factors other than a lack of host language
skills that may contribute to acculturative stress in immigrants. Filipino migrants to
Australia have high levels of self-rated English language skills (Australian Bureau of
Statistics, 2007), which can sometimes be mistaken for an absence of a cultural chasm
between this group and the greater populace of the host country. This paper also
aims to provide justification of the need to tailor health promotion strategies to meet
the needs of this migrant group with functional host-language abilities but which is,
nevertheless, culturally distinct.

Filipino migrants in Australia

In the last 20 years, the annual permanent arrivals of Filipino migrants to Australia
have quadrupled. Data from the Australian Bureau of Statistics (2008) indicate that
Filipinos are now one of the top five immigrant populations from non-English
speaking countries to Australia. Since the 1960s, there has been a steady increase in
the Filipino diaspora to Australia, brought on by the quest for a better alternative to
the socioeconomic uncertainty and perceived lack of opportunities in the home
country (Rafael, 2000; Siar, 2011; Tupas, 2004).
The Philippine migration to Australia is uniquely characterised by a preponder-
ance of women, which has been attributed to a high rate of intermarriage between
Filipino women and Australian men (Woelz-Stirling, Manderson, Kelaher, &
Gordon, 2000) and underscores the importance of placing a gendered lens on the
interpretation of the Filipino migrant experience. While this unique characteristic
sparked interest and made Filipino migrants visible to feminist researches (Creatore
et al., 2010; Fu et al., 2003; Hannah & Lê, 2012; Kelaher, Williams, & Manderson,
2001; Woelz-Stirling et al., 2000), this limited the focus. This attribute could also
explain the higher self-rated English proficiency among Filipino women (96.4%)
compared with men (88.6%), although equal percentage of men and women (2.3%)
indicated that they speak English ‘not well or not at all’ (Australian Bureau of
Statistics, 2007). The curious mix among Filipinos of upholding traditional Asian
values while actively embracing Western ideas and language (Mendoza, 2001), adds
to the uniqueness of the Filipinos and yet disadvantages the community by becoming
 International Journal of Culture and Mental Health 3

‘blended’ with the Western host culture to be almost invisible, being neither fully
Asian nor Western (Sanchez & Gaw, 2007). Hence, it is not surprising that there is
limited health research data on the Filipino population in Australia, despite the trend
of increasing migration. This is highlighted by a database search on migrant groups
to Australia described below.
In a Medline search using the three highest non-English migrant source countries
in Australia as keywords
‘Chinese’, ‘Vietnamese’ and ‘Filipino’ (truncated into
different spelling variations) plus ‘health’ and ‘Australia’ from 2000 to 2010 found
73 studies on the Chinese, 62 studies on the Vietnamese and 9 studies on the Filipinos,
which are summarized in Table 1. A key omission in the Australian literature is the
absence of focus beyond gender-based discrete issues, while the studies on the Chinese
and Vietnamese populations covered a broader range of physical and mental health
issues across different age groups. Given the trend of migration from the Philippines, a
wider focus on the health needs should be undertaken to reflect the current population
profile as demonstrated by the ABS data. The limited research provides opportunities
for more extensive studies, especially in an increasing migrant population group.
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Push and pull factors and acculturative stress

The motivations behind migration are often described in terms of push-pull factors.
‘Push’ factors are those circumstances in the home country that compel people to
look for better opportunities elsewhere, in contrast, ‘pull’ factors are those that draw
people to another country that is perceived to have the ‘better opportunities’ (Dorigo
& Tobler, 2005). It has been stated that acculturative stress is highest among migrants
who are thrust into involuntary acculturation, for example among refugees, and is
purported to be the least among those who migrated primarily as a consequence of
pull factors (Saroca, 2007). Nevertheless, groups such as the Filipino migrants to
Australia, who may have the language skills of the adoptive country but are distinctly
of different culture, have their own unique challenges and sources of acculturative
stress. Added to this, the Filipino migrants consist of three disparate sub-population
groups with their own unique sources of acculturative stress. These are those
who migrated as: (1) family migrants, (2) spouse or partner of Australian men or
(3) professionals or with ‘in-demand’ skills for the Australian workforce.

Acculturative stress and Filipino family migrants

Although circumstances may vary, the primary motivation for migration is common,
that is, to find better opportunities for economic and personal growth (Ronquillo,
Boschma, Wong, & Quiney, 2011; San Juan, 2000; Woelz-Stirling et al., 2000).
However, the cost of migration upon arrival, which is often financed by personal
loans from relatives and friends, can be in itself a source of acculturative stress. In
addition to the relocation costs, new migrants are often expected to offer financial
help to their extended families in the Philippines. The fact that US$10.7 billion in
gross remittance is sent to the Philippines annually by Filipinos living abroad
(Baggio, 2008) is evidence of this phenomenon. This puts further stress on Filipino
family migrants.
Women, especially, are burdened, not only with employment responsibilities but
also with the care and upkeep of home and family (Woelz-Stirling et al., 2000). This
responsibility and workload are likely to have a negative impact on their health,
 4
Table 1. Studies on migrant Filipino health in Australia.

D. Maneze et al.
Study Type of study Health focus Findings and conclusion

1 Carolan, M., Steele, C., & Margetts, H. Cross-sectional survey: 143 women with Knowledge about Filipino and Vietnamese women were
(2010). Knowledge of gestational gestational diabetes from Vietnamese, gestational diabetes found to have the least knowledge about
diabetes among a multi-ethnic cohort in Indian, Filipino and Caucasian (GDM) and food GDM and food values. English language
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Australia. Midwifery, 26(6), 579
588. backgrounds. values. skills alone was not associated with
greater understanding of GDM.
2 Carolan, M., Steele, C., & Margetts, H. Cross-sectional survey. Same sample as Attitudes towards Filipino and Vietnamese were found to
(2010). Attitudes towards gestational Reference 1, administered with the gestational diabetes. value tight glucose control the least
diabetes among a multiethnic cohort in ‘Diabetes Attitude Scale’. because of lower education level
Australia. Journal of Clinical Nursing, suggesting lower understanding of
19(17
18), 2446
2453. glycaemic control. English fluency was
not associated with higher valuing of
tight glucose control.
3 Small, R., Lumley, J., & Yelland, J. Interview-based study of 318 women Depression measured Less depression in Filipino women
(2003). Cross-cultural experiences of (107 Filipino) 6
9 months after birth to by the Edinburgh compared with the other two groups.
maternal depression: Associations and explore socio-demographic, obstetric Postnatal Depression Positive association between depression
contributing factors for Vietnamese, and postnatal health and support Scale. and migrating for marriage. Contributing
Turkish and Filipino immigrant women variables associated with maternal factors for depression among Filipinos
in Victoria, Australia. Ethnicity & depression. include isolation (homesickness) and
Health, 8(3), 189
206. marital problems.
4 Small, R., Lumley, J., & Yelland, J. Interview-based study. Same sample as Depression and Vietnamese and Filipino women were
(2003). How useful is the concept of Reference 3, assessed for their physical somatisation of found to have low prevalence of
somatization in cross-cultural studies of and mental health using SF-36 and depression symptoms. depression and somatic symptoms.
maternal depression? A contribution depression scores (using Edinburgh
from the mothers in a New Country Postnatal Depression Scale).
(MINC) study. Journal of Psychosomatic
Obstetrics & Gynecology, 24(1), 45
52.
5 Small, R., Yelland, J., Lumley, J., Brown, Interview-based study of 318 mothers Satisfaction with Lower satisfaction with the maternity
S., & Liamputtong, P. (2002). Immigrant six months after giving birth, about maternity care services. care services among Filipino women but
women’s views about care during labor maternity care experiences. were given the opportunity to visit ward
and birth: An Australian study of before operation and discuss options with
Vietnamese, Turkish and Filipino caregivers which was attributed to
women. Birth, 29(4), 266
277. English language skills.
 Table 1 (Continued )

Study Type of study Health focus Findings and conclusion

6 Thompson, S., Manderson, L., Woelz-
Stirling, N., Cahill, A., & Kelaher, M.
(2002). The social and cultural context of
the mental health of Filipinas in
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A blend of surveys, interview-based and
focus-group discussions of 139 Filipino
women living in Queensland, Australia
and their experiences related to their
For Filipinos, having ‘mental’ problems is
To elicit meaning and
highly stigmatise compared with
experiences related to
mental health and ‘emotional’ problems. Problems were
illness. largely attributed to an absence of close

Queensland. Australian and New Zealand
Journal of Psychiatry, 36(5), 681
687.
7 Thompson, S., Hartel, G., Manderson,
L., Woelz-Stirling, N., & Kelaher, M.
(2002). The mental health status of
mental health and illness. family ties and transition issues from a
collectivist to individualist society.
Prospective follow-up survey of 346 Mental distress as Higher prevalence of mental distress
Filipino women for potential predictors measured by the GHQ- among the study sample compared to
of psychological distress and changes 28. national survey data, but lower than

International Journal of Culture and Mental Health

Filipinas in Queensland. Australian and
New Zealand Journal of Psychiatry,
36(5), 674
680.
8 Kelaher, M., Potts, H., & Manderson, L.
(2001). Health issues among Filipino
women in remote Queensland.
Australian Journal of Rural Health, 9(4),
150
157.
9 Kwon, S., Bower, C., & English, D.
(2003). Birth defects in the offspring of
non-Caucasian, non-Indigenous women
in Western Australia. Birth Defects
Research Part A: Clinical and Molecular
Teratology, 67(7), 515
521.
over 12 months.
Survey of 338 women married to Settlement-related life
Filipino men or Australian men, their events and health
settlement experience, health status and status.
health service utilisation.
Retrospective data analysis of the Prevalence of birth
Western Australian Maternal and Child defects.
Health Research database. Identifcation
of birth defects among non-Caucasian
and non-indigenous women.
other migrant groups.
Women married to Australian men
experienced fewer settlement-related
issues and mental health problems,
suggesting intercultural relationships may
be important in facilitating acculturation.
Low risk of birth defect among babies of
Vietnamese and Filipino women, partly
explained by the healthy-immigrant effect
and the low levels of health-damaging
lifestyle practices, e.g. alcohol and
tobacco use during pregnancy.

5
 6 D. Maneze et al.

exacerbated by the cultural value of ‘hiya’, or saving face, which compels migrants to
keep the stresses within themselves and avoid airing their ‘dirty laundry’ in public
(Wolf, 1997). In addition, traditional health customs that may be observed in the
home country, especially during significant life events, such as childbirth, may not be
congruent with Western practices and may be a barrier to health seeking behaviour
(Small, Rice, Yelland, & Lumley, 1999; Stewart, Das, & Seibold, 1998). Furthermore,
as a consequence of migration, lifestyle acculturative adjustments such as dietary
changes are found to exacerbate the risk of chronic diseases like diabetes and
hypertension (Dela Cruz & Galang, 2008; Popkin, 1993).
There are reports in the literature that some of the Filipino ‘1.5 generation’
migrant children (those who were born in the host country or migrated at a very early
age) struggle with cultural identity (David & Okazaki, 2006) and experience familial
conflicts due to cultural differences between generations and intercultural values
changes (Portes & Rumbaut, 2001; Wolf, 1997). Migrant adolescents have difficulties
shuffling between cultures, leading to confusion and identity crisis (Kim, Brenner,
Liang, & Asay, 2003), which may have an adverse impact on their mental health and
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peer relationships. A qualitative study on Filipino adolescents in California found

high incidence of suicide and suicide ideation attributable to family conflicts, despite
the external appearance of a high level of assimilation with the Western culture
(Leong, Leach, Yeh, & Chou, 2007; Wolf, 1997).
Elderly Filipino migrants also face their own sources of acculturative stress.
According to the 2006 Australian Bureau of Statistics census data, 16% of the
Filipino population are 55 years and older and of these, more than 70% are females
(Australian Bureau of Statistics, 2008). A number of Filipino elderly women,
petitioned by their children to take care of grandchildren while they work, face more
difficult cultural adaptations because of language issues and social isolation. In a
study of Filipino elderly in the USA and in Australia (Cichello, Thomas, & Xenos,
2006), lack of income, lower English language skills and education, and social
isolation were reported to be important factors causing acculturative stress and
depression among the elderly (Mui & Kang, 2006; Wrobel et al., 2009).

Acculturative stress and the Filipino spouse

Women dominate the sex profile of the Filipino community in Australia in a ratio
of 54.8 males for every 100 females (Australian Bureau of Statistics, 2007). The
disproportionate number of Filipino women is in part a consequence of the high
number of females who migrated as marriage partners of Australian men in the 1980s
(Kelaher, et al., 2001). This trend is seen to continue to the present times with the
Australian Department of Immigration and Citizenship data highlighting that in
2010
2011, 84% of family visas granted to Philippine-born migrants were to partners
of Australian citizens (Economic Analysis Unit, 2012). Many of the women who
married Australian men through the mediation of a commercial marriage bureau
often come from a disadvantaged socioeconomic background and in more peripheral
regions in the Philippines (Cabigon, 2010; Jackson, 1989). The age difference
between the Australian husbands and their Filipino wives can be as much as 20 to
30 years (Jackson, 1989; Stewart et al., 1998). The age and culture gap and, more
importantly, the imbalance of power in the intercultural marital relationship,
complicate cross-cultural adjustment of Filipino women, particularly when partners
have blended families, live in geographically isolated areas with limited opportunities
 International Journal of Culture and Mental Health 7

for social networking and possess very traditional views of marriage and family and
a distorted view of Filipino women as portrayed by media (Kelaher et al., 2001).
This image of Filipino women as ‘mail-order brides’ has created a negative
perception in this country and has stereotyped and stigmatised Filipino women in
Australia (Saroca, 2007). The pejorative image alienates and marginalises these
women and encompasses all Filipino women in Australia, regardless of how they
migrated, whether they have Australian or Filipino husbands or even how long they
have been married. This perceived stigma makes them feel judged even by their own
community, ashamed, isolated and unable to seek help (Saroca, 2007), which could
limit their visibility. The lack of social support among newly arrived migrants,
particularly those who arrived on spouse visas, is a contributing factor to
acculturative stress. In a study of postpartum depression among new immigrant
Filipino mothers in Australia, depression was found to be primarily brought about
by having marital problems and feeling unsupported (Small, Lumley, & Yelland,
2003). Access to professional counselling services was limited by cultural stigma,
strong reliance on religious coping and lack of knowledge of available services
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(Sanchez & Gaw, 2007). Stewart et al., in 1998, explored the postpartum experience
of 30 Filipino women in Brisbane, Australia, reporting that in addition to language
and communication problems, cultural differences in perinatal care were major issues
in the unsatisfactory childbirth experience. Similarly, a study by Small, Yelland,
Lumley, Brown and Liamputtong (2002) found that 61% of Filipino women rated
their maternity experience as less satisfactory and less positive because of the
caregivers’ attitude, which was perceived to be unhelpful, unfriendly and unkind.
They found that immigrant women were less likely to experience the maternity care
they wanted.
Self-rated English language proficiency may not be associated with an adequate
level of understanding of health issues. This is evidenced by the study of Carolan,
Steele and Margetts (2010) comparing a cohort of multiethnic women in Melbourne
regarding their knowledge of gestational diabetes mellitus (GDM) and food values.
They found that the small sample of Filipino women (n 13), despite having high
self-rated English skills, had the least knowledge and scored the lowest in attitude
toward seriousness of GDM, concluding that English language proficiency alone
does not equate to better comprehension of gestational diabetes.
In addition to many sources of acculturative stress in the new country, Filipino
women who married Australian men are also expected by their Filipino families
overseas to provide financial help. This cultural obligation can contribute to marital
conflicts and marriage breakdowns (Woelz-Stirling et al., 2000). The inability to
provide financial help to their family in the Philippines may cause feelings of anxiety
and inadequacy, leading to depression.

Acculturative stress and the professional Filipino migrants

The Philippines is one of the largest exporters of skilled professionals (Alburo &
Abella, 2002). In 2008, there were an estimated 8,187,710 Philippine-born migrants
worldwide with 34
48% classified as permanent migrants between 1999 and 2008. Of
this population, a total of 265,844 were migrants to Australia, 233,943 permanent
residents, 23,926 temporary migrants and 7975 without valid residence or work
permits (Siar, 2011). One reason for the high migration rate is the high level of
unemployment in the Philippines, even in those with tertiary education (Alburo &
 8 D. Maneze et al.

Abella, 2002). Pull factors for developed countries such as Australia include higher
income with overtime and penalty rates, better work conditions, technological
advancements and opportunity for family migration to counties with more stable
socio-politico-economic environments (Lorenzo, Galvez-Tan, Icamina, & Javier,
2007).
In a study of 32 Filipino migrants in Australia and New Zealand, the majority of
participants claimed they did not experience employment difficulties, yet 46%
commenced studies for a certificate, diploma or degree when reaching the host country
(Siar, 2011). This was attributed to the difficulties migrants experienced of being
gainfully employed in an occupation related to their previous education or training
upon arrival. Foreign credentials may not be recognised, resulting in a partial or
absolute failure of recognition of prior learning (Dean & Wilson, 2009). In Australia,
only 6.5% of skilled migrant professionals from the Philippines use their qualification
in their current employment (Hawthorne, 2003). The pressure to find employment
almost immediately is increased by changes to immigration policy, where social benefits
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are withheld in the first two years of settlement (Junankar & Mahuteau, 2005).
In general, migrants are not well informed about the local labour market or the
norms in obtaining a job, such as resume structure and interview techniques. This lackof
local knowledge may narrow their employment opportunities and limit them to less
favourable jobs, which may be high-pressured work with irregular hours, low salary or
limited job mobility, thus decreasing their job satisfaction (Junankar & Mahuteau,
2005). De Castro, Gee and Takeuchi (2008a) found in a study among Filipino
Americans that job-related stress and frustration had an adverse impact on the health
of new arrivals, lowering self-rated physical and mental health and leading to anxiety,
depression and suicidal ideation (De Castro, Rue, & Takeuchi, 2010). This finding is
consistent with the findings reported in an Australian study showing that those
immigrants who are underemployed, job mismatched or whose qualifications are not
needed for the job, have more mental health issues (Reid, 2012). In addition, experience
of discrimination within the workplace based on being Filipino is found to be associated
with occupation-related injury, illness and poorer health (De Castro et al., 2008b).

Implications for health promotion

Health promotion among multicultural communities faces the dilemma of finding
the delicate balance in resource allocation, while maintaining equity across different
cultural groups. Because the lack of language skills has been proven to be an
important factor in inducing acculturative stress and to adversely affect health, it is
not surprising that many health promotion interventions for cultural minorities are
geared towards those with low levels of English language skills. However, there is a
danger of oversimplifying health promotion interventions for multicultural commu-
nities and limiting strategies to just addressing language skills inadequacy as the
primary criterion for prioritising health interventions. Translation of information
and providing interpreters are used as easy options to address multicultural health
issues. But, as described above, this is a complex and diverse issue. Having English
language skills may not necessarily equate to adequate health literacy (Andrus &
Roth, 2002; Sentell, Baker, Onaka, & Braun, 2011) and therefore a more targeted
health promotion program design may be needed. Since culture plays a pivotal role in
health behavior and practices, it is a concern that the needs of those in communities
 International Journal of Culture and Mental Health 9

with functional English language are often unnoticed, thus overlooking the influence
of culture and its impact on health issues.
Acculturative stress is an established factor in the development of chronic illness
in immigrants. Among Filipinos, this is aggravated by socioeconomic pressures,
which influence prioritisation of economic and environmental needs over health
issues. Lifestyle changes such as the adoption of a Western diet exacerbate the
development of lifestyle diseases (Antecol & Bedard, 2006; Kandula, Kersey, &
Lurie, 2004), which necessitates a culturally relevant strategy that is acceptable to the
target population.
Immigration is in itself stressful and difficulty in acculturation has been included
in the Diagnostic and statistical manual of mental health IV
TR, Axis IV, as an
example of a social environment stress factor (American Psychiatric Association,
2000) Chronic stress leads to depression and was a common finding in all three
Filipino population subgroups, independent of the host country (Finch & Vega, 2003;
Hovey, 2000b). The loss of social network upon migration intensifies isolation. Access
to social support from the community is found to enhance migrants’ well-being and
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adjustment and mitigates the effects of discrimination (Noh & Kaspar, 2003) but
often takes time to establish. Furthermore it has been observed that Filipinos
culturally tend to deny, ignore, somatize or tolerate emotional issues and rely on
spiritual healing because of strong religiosity (Sanchez & Gaw, 2007). Consequently,
there is low utilization of mental health services. Therefore, despite English language
skills in this population, culturally appropriate healthcare strategies are needed to
address cultural issues, reduce disparities and promote healthcare utilization.
Culturally competent health service policies and staff training have been used with
some success to reduce health inequities in and achieve better health outcomes for
migrant populations (Bischoff, 2006). In addition to philosophical strategies to
promote tolerance and cultural competence, there should be a focus on providing
migrants clear instructions on how to navigate the healthcare system and specify a
rationale for screening programs. Visual presentations among Filipinos may increase
the accessibility of key health information as well as looking towards cultural strategies
such as faith-based interventions to access vulnerable populations. Providing the use of
interpreters and translations in ethnic populations with host language facility may be
beneficial provided that these are offered without being patronizing or condescending.
Health promotion strategies will benefit from a focus on respect and tolerance from
health practitioners and flexibility in accommodating cultural practices.
It is also important that health promotion initiatives acknowledge both the
positive and negative aspects of migration and provide support for making cultural
transition, particularly when it affects health.
Increasingly it is recognised that to promote accessibility, acceptability and
appropriate healthcare interventions, these need to be tailored and targeted to the
local community. An example of a health promotion program that implemented
extensive cultural tailoring to increase breast and cervical cancer screenings among
Filipino women in Hawaii was designed by Fu et al. (2003). Several cultural-based
strategies were used, including taking the time to establish rapport by ‘obeying’ the
norms and protocols of social interactions of the Filipino culture, creating a ‘party’
atmosphere rather than an ‘education session’ to cater to the highly social nature of
the community and employing story-telling in the ‘lectures’ given by an educator
from the same culture and gender, who used a combination of dialects spoken by the
group. They also addressed logistics issues, such as providing transportation and
 10 D. Maneze et al.

childcare. Proponents of the program attributed their success to the strategies used to
make the program culturally appropriate and sensitive to the target community. They
were able to educate and reach women who previously were not accessing services.
This can be successfully translated in the Australian setting given that the same
cultural issues are faced by Filipinas in this country.

Conclusion
The lack of host language skills is an important factor in inducing acculturative
stress among migrants. Nevertheless, it is not the only factor that brings about
acculturative stress. Other factors, such as motivation to migrate, economic issues,
social support, unemployment and underemployment, cultural differences, gender
stereotypes, perceived discrimination and racism, also contribute to acculturative
stress, which can affect mental and physical health.
Important in health promotion interventions for a multicultural community is
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understanding the characteristics of the community and identifying the cultural

issues that contribute to health problems. This is vital in designing culturally tailored
health interventions that allow communities to feel able to respond to and that meet
their specific needs.
In multicultural groups with functional English language skills, such as Filipinos,
cultural beliefs and traditional practices play an important role in health seeking
behavior. Because of skills in the host language, detection of health disparities is a
challenge and needs deeper investigation and research as it can be trivialised as
cultural eccentricities or be lost in the issues of the more prevalent dominant culture.
The ability to speak the language does not necessarily equate to health literacy or
absence of acculturative stress in culturally and linguistically diverse communities,
but may disadvantage the community by rendering them ‘invisible’ to the health
promotion radar. Understanding the complex and multifaceted dimensions con-
tributing to acculturative stress is critical for effective healthcare interventions.

Notes on contributors
Professor Patricia Mary Davidson is the Director of the Centre for Cardiovascular and
Chronic Care at the University of Technology, Sydney, and Professor of Cardiovascular
Research at St Vincent’s Hospital, Sydney. She is a Fellow of the Royal College of Nursing,
Australia, co-chair of the NSW Health Clinical Expert Reference Group for Cardiovascular
Disease, Immediate Past President of the Australasian Cardiovascular Nursing College,
Chairperson of the Cardiac Nursing Council of Cardiac Society of Australia and New
Zealand, Immediate Past Secretary of the International Nursing Doctoral Education, Counsel
General of the International Council on Women’s Health Issues (ICOWHI), and a Board
member of the National Heart Foundation (NSW).

Associate Professor Yenna Salamonson is the Director of Academic Workforce and Senior
Lecturer at the University of Western Sydney. She is a Clinical Nurse Specialist in Intensive
Care, High Dependency and Coronary Care units. Yenna’s research focuses on nursing
education, cardiovascular nursing and disease management, pharmacology and quantitative
research methods.

Dr Della Maneze, obtained her Doctorate of Medicine in the Philippines. She is currently a
PhD candidate at the University of Technology, Sydney and the Multicultural Health
Promotion Officer SWSLHD.
 International Journal of Culture and Mental Health 11

Nathan Attwood is a 2011 University of Western Sydney BN Graduate. He completed his BN

(Hons) early 2013 and is currently a Research Assistant at UWS and studying Nutritional
Medicine at the Australian Institute of Applied Sciences.

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