FILIPINO CULTURAL ATTITUDES AND HELP-SEEKING

BEHAVIORS FOR SUBSTANCE USE

A Project

Presented to the faculty of the Division of Social Work

California State University, Sacramento

Submitted in partial satisfaction of

the requirements for the degree of

MASTER OF SOCIAL WORK

by

Jehn Rielle Caoile

SPRING
2015
 FILIPINO CULTURAL ATTITUDES AND HELP-SEEKING

BEHAVIORS FOR SUBSTANCE USE

A Project

by

Jehn Rielle Caoile

Approved by:

_______________________, Committee Chair

Francis Yuen, DSW, ACSW

_______________________
Date

ii
Student: Jehn Rielle Caoile

I certify that this student has met the requirements for format contained in the University

format manual, and that this project is suitable for shelving in the Library and credit is to

be awarded for the project.

_________________________, Graduate Program Director __________________

S. Torres, Jr. Date

Division of Social Work

iii
 Abstract

of

FILIPINO CULTURAL ATTITUDES AND HELP-SEEKING

BEHAVIORS FOR SUBSTANCE USE

by

Jehn Rielle Caoile

This research study attempts to identify cultural attitudes that impact the help-seeking

behavior of Filipinos in the U.S. with a substance use disorder (SUD). Data was

collected from self-identified service providers, family members, and former users who

all reported to be knowledgeable about this issue. The findings show that the cultural

attitude “bahala na” (come what may) likely removes a user’s sense of responsibility to

seek help, and likely hinders the ability of support persons to provide the help that a user

may need. These findings indicate that repurposing “bahala na” as a cultural concept

may be a critical step to facilitate the help-seeking behavior of Filipino substance users.

The data also implicates a potential role for social work in developing a culture-specific

and multi-systemic approach to promote such repurposing in the Filipino community.

_______________________, Committee Chair

Francis Yuen, DSW, ACSW

_______________________
Date

iv
 ACKNOWLEDGEMENTS

The author would like to express sincere gratitude to the following individuals for

their involvement in the completion of this project:

Dr. Francis Yuen, the project advisor, for his incredible support and guidance

throughout this entire research process;

Dr. Ford Kuramoto, the president of Magna Systems, for helping make the

connections with different agencies to initiate participant recruitment;

The representatives of these agencies, Glenn Andres (outpatient director of the

Asian American Drug Abuse Program), Cecile Ascalon (family support and case

manager at the West Bay Pilipino Multi-Service Center), and Dr. Leonardo Pandac

(program director of the Pacific Asian Alcohol and Drug Program), for all their efforts in

recruiting eligible participants for this study;

The educators at Pilipino/a Educational Partnerships (PEP) for their interest in the

research topic and for providing additional help in recruitment;

Above all, the author would also like to extend her sincerest appreciation to her

family, friends, and mentors, for their love and unwavering support throughout this

academic endeavor.

v
 TABLE OF CONTENTS
Page

Acknowledgements ....................................................................................................... v

List of Tables ............................................................................................................. viii

Chapter

1. INTRODUCTION .................................................................................................. 1

Background of the Problem .............................................................................. 1

Statement of the Research Problem ...................................................... 2

Assumptions ...................................................................................................... 5

Justification ....................................................................................................... 5

2. REVIEW OF THE LITERATURE ........................................................................ 6

Sociocultural Factors ........................................................................................ 7

Perceived Social Inequality............................................................................. 13

Theoretical Perspectives ................................................................................. 16

Substance Use and Mental Health .................................................................. 19

Cultural Competence in Healthcare ................................................................ 23

3. METHODOLOGY ............................................................................................... 27

Study Design ................................................................................................... 27

Sampling and Data Collection Procedures ..................................................... 27

Data Collection Instruments ........................................................................... 29

Data Analysis Plan .......................................................................................... 30

Protection of Human Subjects ........................................................................ 31

vi
4. STUDY FINDINGS AND DISCUSSIONS ......................................................... 32

Overall Findings.............................................................................................. 32

Specific Findings and Discussion ................................................................... 34

Quantitative Data ................................................................................ 34

Qualitative Data .................................................................................. 38

Summary of Findings ...................................................................................... 41

5. SUMMARY AND RECOMMENDATIONS ..................................................... 43

Implications for Social Work .......................................................................... 43

Limitations ...................................................................................................... 45

Recommendations ........................................................................................... 45

Conclusion ...................................................................................................... 47

Appendix. Online Survey Questionnaire .................................................................... 48

References ................................................................................................................... 53

vii
 LIST OF TABLES
Tables Page

1. Correlations Between Help-Seeking Behavior (HSB) & Cultural Attitudes....... 35

2. Correlations Between Help-Seeking Behavior (HSB) & Cultural Perceptions... 36

3. Correlations Between Supportive Intervention (SI) & Cultural Perceptions ...... 37

4. Correlations Between Community Efforts & Positive Outcomes ....................... 38

viii
 1

Chapter 1

Introduction

This study examines the relationship between cultural attitudes and help-seeking

behaviors among Filipinos living in the U.S. with a substance use disorder (SUD).

Additionally, this study looks at the underutilization of treatment services in the Filipino

community as it relates to cultural attitudes and help-seeking behaviors. The significance

of family intervention and community awareness is further explored. There is also a

strong focus on the cultural attitudes that perpetuate passivity in the Filipino community.

Specifically, “bahala na” (come what may), is utilized as the fundamental cultural

attitude that encompasses other values specific to the Filipino culture. This study looks at

how this attitude relates to “hiya” (shame), “pakikisama” (social acceptance), and

“pakialam” (meddling/caring). To do so, the general effects of “bahala na” is defined and

measured to determine if this attitude is a risk or protective factor for substance users.

The established effects of this cultural attitude provide insight into the forces that drive

help-seeking behavior, such as indignity, stigma, and fears of social rejection.

Background of the Problem

National data shows that Asian American and Pacific Islanders (AAPI), as a

single group, have low rates of alcohol and drug use disorders (Fong & Tsuang, 2007).

However, such generalized data does not reflect the prevalence of drug use in specific

AAPI subgroups. Therefore, it does not account for the clinical significance or impact on

specific communities. Among Asian subcultures, Filipinos and Pacific Islanders rank

highest in substance use yet they are underrepresented in treatment services (Nagasawa,
 2

Qian, & Wong, 2000). This implicates a need to foster community awareness and

increase access to services that are specific to the Filipino culture. More importantly, the

problem demonstrates a greater need to strengthen the help-seeking behavior of Filipino

substance users to utilize such services through the support and understanding of their

support system.

Statement of the Research Problem

Filipinos rank as a prevailing community in substance use. This gives grounds to

explore the influence of their cultural attitudes on help-seeking behavior, and how it

relates to the underutilization of treatment services. This study particularly looks at the

cultural attitudes that convey passivity and relinquishment of control. These attitudes

may delay or prevent treatment entirely for Filipino substance users. In addition, it is

also important to consider the cultural values that discourage family involvement as this

places Filipino substance users at a greater disadvantage to reach out for support.

Study purpose. This study aims to identify contributing factors that could

encourage help-seeking behavior among Filipinos living in the U.S. with a substance use

disorder (SUD). In doing so, the data collected in this study may better inform

practitioners to further improve efficacy of services, reduce cultural barriers to substance

use treatment, and increase rates of treatment admissions. By carrying out this study’s

purpose, it also aims to bring awareness to the Filipino community and facilitate open

lines of discussion regarding the issue of substance use.

Definition of terms. This study explores the help-seeking behavior of Filipinos

living in the U.S. with a SUD. Although they are essentially “Filipino-Americans,” the
 3

term for self-reference is still “Filipino” because members of this ethnic group may not

all identify as American. As the flagship of Filipino cultural attitudes and values for this

study, “bahala na” is defined as “come what may.” This way of life typically gives

Filipinos the opportunity to leave their worries up to a higher being. In relation to this

prominent attitude, other cultural values are further explored. Particularly, this study

looks at “hiya” (shame), pakikisama (social acceptance), and pakialam (meddling/caring)

to fully examine the cultural influence on the help-seeking behavior of Filipinos with

substance use disorders.

For the purpose of this study, help-seeking behavior is defined as either actively

seeking help or responding positively to the support system’s efforts in helping the

substance user achieve sobriety or maintain abstinence from all substances. In this case,

a substance user refers to a person who either has a formal diagnosis, or considers oneself

as such. The substances in use can be either alcohol, tobacco, and/or illicit and

prescription drugs. To have a formal diagnosis of a substance use disorder (SUD), the

individual must meet two of the following in the same 12-month period according to the

Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical

Manual of Mental Disorders:

1. The individual may take the substance in larger amounts or over a longer

period than was originally intended

2. The individual may express a persistent desire to cut down or regulate

substance use and may report multiple unsuccessful efforts to decrease or

discontinue use
 4

3. The individual may spend a great deal of time obtaining the substance, using

the substance, or recovering from its effects

4. Craving is manifested by an intense desire or urge for the drug that may occur

at any time but is more likely when in an environment where the drug

previously was obtained or used

5. Recurrent substance use may result in a failure to fulfill major role obligations

at work, school, or home

6. The individual may continue substance use despite having persistent or

recurrent social or interpersonal problems caused by exacerbated by the

effects of the substance

7. Important social, occupations, or recreational activities may be given up or

reduced because of substance use

8. This may take the form of recurrent substance in situations in which it is

physically hazardous

9. The individual may continue substance use despite knowledge of having a

persistent or recurrent physical or psychological problem that is likely to have

been caused or exacerbated by the substance

10. Tolerance is signaled by requiring a markedly increased dose of the substance

to achieve the desired effect or a markedly reduced effect when the usual dose

is consumed
 5

11. Withdrawal is a syndrome that occurs when blood or tissue concentrations of

a substance decline in an individual who had maintained prolonged heavy use

of the substance. (pp. 483-484)

Assumptions

This study assumes that the participants have provided honest and truthful

responses on the online survey questionnaire. This requires the study to accept that the

respondents have professional and/or personal knowledge about substance use among

Filipinos living in the U.S. Apart from being familiar with substance use in this

community, the study also presumes that the respondents have a high level of knowledge

about the Filipino culture and its common attitudes and traits.

Justification

This study intends to promote awareness about substance use in the Filipino

community and to enhance cultural competency in the delivery of treatment services.

Meeting these aims may then increase the help-seeking behavior of Filipinos and

encourage the involvement of their support system. For this reason, it is evident that the

objectives of this study are consistent with the values of social work. Similar to social

work, this study takes into account the value of service, social justice, dignity and worth

of the person, importance of human relationships, integrity, and competence. For one,

encouraging family involvement signifies the importance of human relationships.

Furthermore, the call for culture-specific SUD treatment implicates the need for health

systems to provide culturally competent services with integrity. Though these services,

the individual may certainly maintain their dignity and self-worth.

 6

Chapter 2

Review of the Literature

To understand substance use in the Filipino community, it is important to consider

the core values of the culture itself. Nadal (2000) states that Filipino Americans have a

unique experience with alcohol and tobacco use. He believes that their cultural values

define their experience, which makes it distinct from that of other Asian Americans. In

particular, Nadal discusses three specific values that make up the Filipino identity: (a)

pakikisama (social acceptance); (b) kapwa (the unity of self and others); and (c) hiya

(loss of face or shame). These core values are absolutely pertinent to the Filipino

substance user and his or her social connections.

According to Nadal (2000), Filipinos thrive on social acceptance as they aspire to

be members of a collective group or community. That being said, Filipinos can be easily

susceptible to group peer pressure. For example, Filipinos can be pressured into using

substances, such as tobacco and alcohol, to feel a sense of acceptance and belongingness.

Over time, Filipinos may then identify with collective groups of other substance users.

By being part of these groups, Filipinos are given the opportunity to foster their sense of

self as they unite their identity with that of others. In these groups, Filipinos not only feel

socially accepted but they also develop a positive sense of self as well. For some

Filipinos, it can be incredibly challenging to maintain their social ties when such

connections put their family name at risk. Therefore, Filipino substance users may not

easily recognize mental problems, including substance use, because doing so may only

damage their dignity and invoke shame (Tabbada, 2005).

 7

Sociocultural Factors

For Asians, stigma from substance use disorders is a significant barrier that can

come in several different forms (Fong & Tsuang, 2007). Like any other member of any

ethnicity, there is the general stigma of seeking help for a substance use disorder. At the

same time, Asian American and Pacific Islanders (AAPI) also have to face the stigma of

seeking help for psychiatric and behavioral problems. Filipino substance users may then

act on the cultural attitude “bahala na” (come what may) to avoid taking responsibility

altogether (Gripaldo, 2005). By turning to this attitude, users can take advantage of the

opportunity to let go of their problems and leave them up to a higher power.

According to Fong and Tsuang (2007), the level of awareness and understanding

for substance use disorders can be quite low in AAPI communities. This lack of

recognition of a substance use problem serves as another important barrier to accessing

care, especially for Filipinos. It may very well prevent users from ever seeking help.

Given the number of cultural barriers that stand against Filipinos, Nadal (2000) argues

the need for ethnocentric therapeutic practice to treat Filipino substance users.

To better understand the Filipino experience in substance use, Laus (2013)

explored the way social connections were associated with the methamphetamine use of

Filipinos. He interviewed 14 Filipino Americans from Northern California and examined

how these networks of Filipino American methamphetamine users were influenced by

class and generational status. For first generation users, methamphetamine was

considered a coping mechanism for social class disadvantages. On the contrary, second

generation users turned to methamphetamine specifically because it was the social drug at
 8

that time. For both generations, family dysfunction emerged as a common theme in each

interview. According to the interviewees, ineffective family communication worsened

their living situation and provoked their level of drug dependency.

For these Filipino methamphetamine users, lack of communication resulted in a

culture of silence, as their problems were considered too inappropriate to discuss (Laus,

2013). In some cases, it was necessary for families to turn a blind eye in order to prevent

discord and salvage the social status of the family. This belief appears to be supported by

the cultural trait “pakialam,” which is interchangeable for meddling or caring (Manauat,

2005). To avoid potential conflict and overstepping boundaries, family members may

often choose to not confront a user about their substance use even if they cared very

much for the user’s well-being. Through these interviews, Laus ultimately found that it

was important for users to realize the impact of their networks on their drug use. This

served as a pivotal moment in their ability to break away from the social ties that

reinforce their continued usage. For a few of the interviewees, the involvement of their

family and friends could have encouraged an earlier inception of this realization.

Unfortunately, the impact of substance use disorders on AAPI populations are

typically unseen by family members and friends (Fong & Tsuang, 2007). Only until

forced interventions such as arrest, hospitalization, or homelessness, do family and

friends choose to become involved. Traditionally, AAPI respond to crises through denial

or attempting to handle the situation on their own. Therefore, familial insulation can be

another barrier to treatment, as AAPI prefer to solve the problem without asking for help

outside the family. Given these significant dynamics, families may also benefit from
 9

services that can help them reduce their negative emotions and increase their

understanding for the user.

Through these services, AAPI families may be better able to identify and

minimize their enabling and codependency behaviors (Fong & Tsuang, 2007). For

Filipinos especially, reducing these behaviors can be very difficult given the importance

they place on family harmony. Research suggests that there is an evident need for such

family services in the AAPI community. According to non-pharmacological studies

(Fong & Tsuang, 2007), about 40% of the Asian callers to the tobacco helpline in

California were friends or family members , while only 6% of the non-AAPI callers were

as such. Therefore, the treatment of AAPI substance users may be more effective with

the involvement of family members, as opposed to Western themes of self-reliance and

personal responsibility. With their involvement in treatment, Filipino families may

ultimately help a user meet his or her need for acceptance and belongingness.

It is evident that Filipinos highly value social acceptance. This can be especially

true for Filipino adolescents. In a study that examined the influence of ethnic identity on

drug use, a positive correlation was found between both variables (James, Kim, &

Armijo, 2000). For the purpose of their study, the researchers measured ethnic identity

using these characteristics: (a) affirmation and belongingness, (b) ethnic identity

achievement, (c) ethnic behavior, and (d) other group orientation. Drug use, on the other

hand, was measured based on: (a) misuse, (b) abuse, and (c) chemical dependency

diagnoses. Their sample consisted of 127 adolescents from ethnically diverse schools in

a large urban school district. Each adolescent was interviewed to compare ethnic identity
 10

and drug use among adolescents from different ethnic groups. Based on their findings,

White adolescents scored lower than members of the four ethnic minority groups and

mixed racial group. They also found a positive correlation between high levels of ethnic

identity and heavy drug use, with ethnic minority adolescents ranking higher in drug use

than White adolescents. These results show that social influences may in fact have a

significant impact on the development of heavy drug use.

Focusing on the Asian American identity, in particular, data suggest that there are

strong cultural and environmental influences to drinking and illicit drugs (Fong &

Tsuang, 2007). Although current trends show that AAPI have higher rates of alcohol and

drug abstinence, the subgroup of non-abstainers demonstrated equal rates of substance

dependence as compared to Caucasians. To better understand these trends in drug use,

the personal perspectives of Asian Americans should be considered.

In their analysis of substance use and ethnic identity, Moloney, Hunt, and Evans

(2008) interviewed 206 young Asian Americans to gain a greater insight on their

identities as substance users. In these interviews, Moloney et al. (2008) obtained three

common narratives:

1. One group noted difficulties arising from their Asian American identities, the

experiences of culture clash, and stresses associated with acculturation and

Americanization and saw their substance user as an outgrowth of this;

2. A second group viewed their drug use as unusual among Asian Americans and

saw their drug use as indicative of the degree to which they have grown apart

from Asian culture and toward White/American culture;

 11

3. A third group did not see their identities as Asian Americans, drug users, or

Asian American drug users as problematic. (p. 397)

In the development and application of culture-specific therapeutic practice, it would be

essential to consider these perspectives to better serve underrepresented ethnic groups in

treatment services.

Considering the strong influence of culture on drug use, it is important to integrate

cultural sensitivity in substance use prevention interventions. In an effort to do so,

Resnicow, Soler, Braithwaite, Ahluwalia, and Butler (2000) developed a model for

understanding cultural sensitivity in the field of substance use prevention. The authors

defined cultural sensitivity in two dimensions: surface structure and deep structure.

According to Resnicow et al. (2000), surface structure “involves matching intervention

materials and messages to observable, ‘superficial’ characteristics of a target population.

This may involve using people, places, language, product brands, music, food, locations,

and clothing familiar to, and preferred by, the target audience” (p. 271). Essentially, it

refers to how suitable interventions are for a specific culture. On the other hand,

Resnicow et al. (2000) define deep structure as:

Incorporating the cultural, social, historical, environmental, and psychologic

forces that influence the target health behavior in the proposed target population.

For example, peer influences may exert a greater influence on substance use

initiation among White and Hispanic than among African American youth, while

parental influences may be stronger among African Americans. (pp. 271-272)

 12

Based on this model, the authors found that the utilization of a surface structure increased

acceptance of messages, while deep structure conveyed the importance of such messages.

Given the significance of a deep structure model, it is important to pay attention

to the different forces that make up this model. In their study, Allen and Lo (2010) used

data from the 2004 General Social Survey to examine the effects of religiosity and

spirituality on substance use. They found that the likelihood of substance use decreased

with increasing levels of religiosity. Social bonding variables, however, did somewhat

modify this negative relationship and increased the likelihood of substance use. Similar

to the effects of social bonding, spirituality was positively associated with substance use

when controlling for religiosity. These results serve as evidence for the influence of

social bonding and spirituality as risk factors for substance use, and the role of religiosity

as a protective factor.

Congruent with the purpose of this study, further studies have taken a step further

to account for racial differences in protective factors. Lo, Tenorio, and Cheng (2012)

analyzed the 2007 National Survey on Drug Use and Health to examine how marriage

and religiosity can protect members of certain racial/ethnic groups against co-occurring

substance use and serious psychological distress. They found that religiosity elevated the

mental health of racial/ethnic minority individuals more than that of Whites. In contrast,

Whites’ mental health benefitted more from wealth and education than that of minorities.

Although poverty and heavy substance use are not necessarily related, poverty can often

increase the risk for a given level of use (Room, 2005). Based on these findings, it is
 13

evident that race and ethnicity may modify effects of education and poverty on substance

use and psychological distress.

Perceived Social Inequality

For Filipinos, perceived social inequality can serve as a driving force for

substance use. To demonstrate this, Gee, Delva, and Takeuchi (2007) examined

associations between self-reported unfair treatment and substance use defined by:

prescription medication use, illicit drug use, and alcohol dependence. They analyzed data

from the 1998-1999 Filipino American Community Epidemiological Survey to assess the

relationship between the two stated variables. Their findings suggest that unfair

treatment may contribute to illness and subsequent use of prescription medicine. As for

illicit drugs and alcohol, they found that some individuals might use these substances to

cope with stress associated with treatment they perceived to be unfair.

In most cases, unfair treatment can be described as perceived discrimination. To

explore the role of discrimination in substance use disorders (SUD) among minority

groups, Lo and Cheng (2012) looked at whether the presence or absence of a current

SUD can be explained by social status and discrimination. They analyzed data from the

2001-2002 Collaborative Psychiatric Epidemiology Surveys to examine interaction

effects between discrimination and social status. In doing so, they explored whether

social status factors are conveyed by discrimination, and if this would foster a SUD.

They found that the presence of a SUD is likely to be associated with perceived

discrimination. Most significantly, discrimination’s strongest association with SUD was

 14

observed for Asian respondents with lower incomes and for Hispanic respondents with

little education.

With these findings, it is also important to consider the role of immigration status

of Filipinos and how it relates to their perceived discrimination and substance use. Kim

and Spencer (2011) also used data from the 1998-1999 Filipino American Community

Epidemiological Survey to examine the association between perceived discrimination and

heavy drinking behavior by immigration status. For US-born Filipinos, they found three

risk factors that increased the probability for heavy drinking: (a) living in San Francisco,

(b) lower religious participation, and (c) higher perceived discrimination. This was not

the case, however, for foreign-born Filipinos as their only risk factor was being male.

Therefore, US-born Filipinos had a greater level of risk for alcohol use as compared to

their immigrant counterparts.

To further understand the Filipino experience in substance use, it is important to

take into account their risk and protective factors. Kim, Kim, and Nochajski (2010)

argue that the location of residence makes a significant difference when assessing for

such factors. They also used the same data from the Filipino American Community

Epidemiological Survey to compare the 12-month prevalence of alcohol use disorder

(AUD) between Filipino Americans who currently drink alcohol and live in San

Francisco or Honolulu. Their evidence supported the importance of residential location.

It was evident that Filipino American drinkers living in San Francisco and Honolulu had

different risk and protective factors for AUD. For current drinkers in San Francisco,

higher psychological distress, US-born, and lower religiosity placed them at greater risk
 15

for AUD. In contrast, Honolulu drinkers were more at risk if they had more years of

education and lower emotional support.

Apart from risk and protective factors, Filipinos in San Francisco and Honolulu

also show differences in perceived unfair treatment depending on their level of social

support (Gee et al., 2006). Gee et al. (2006) examined “whether unfair treatment is

associated with health conditions, whether social support moderates this association, and

whether such relationships differ by location” (p. 677). Data was also derived from the

1998-1999 Filipino American Community Epidemiological Survey to look for potential

interactions between support, unfair treatment, and location of residence. The researchers

found evidence to support the association between reports of unfair treatment and

increased illness. In addition, several interactions were found between: (a) instrumental

support and city, (b) emotional support and city, and (c) unfair treatment and city. A

single interaction was also evident between instrumental support, unfair treatment, and

city. Their findings suggest that local contexts may influence the types of treatment and

resources that members of ethnic minority groups receive.

There is a great deal of evidence to support that perceived social inequality

increases the risk of substance use among Filipinos. With social inequality as a driving

force, potential stigmatization only drives Filipinos further away from seeking treatment.

According to Room (2005), there are two different literatures on stigma: (a) the first

literature centers on mental illness and considers “the negative effects of stigma on the

stigmatized or on the professional-patient interaction” (p. 150); and (b) the second

literature focuses on crime and views “stigmatization as a form of social control” (p.
 16

150). For this reason, it is apparent that both perspectives of stigma relate to drug and

alcohol use.

Theoretical Perspectives

From a theoretical standpoint, substance use among Filipino can be better

understood using three theories: (a) social control theory (Hirschi, as cited in Nagasawa,

Qian, & Wong, 2000), (b) peer cluster theory (Oetting & Beauvais, as cited in Nagasawa

et al., 2000), and (c) theory of segmented assimilation (Portes & Zhou, as cited in

Nagasawa, Qian, & Wong, 2001). According to social control theory, people may violate

the rules of society when social bonds are weak or absent (Laus, 2013). Therefore,

Filipinos who lack the presence of positive role models in their households may have a

higher risk of alcohol and drug use.

Consistent with this theory, Nagasawa, Qian, and Wong (2000) found that

commitment to school and to high moral standards protects youth from drug and alcohol

use. They used data from the 1995-1996 Asian Student Drug Survey, by the National

Institute of Drug Abuse, to examine the extent to which social control and peer cluster

theories explain drug and alcohol use among students of various Asian American

subgroups. It is known that drug and alcohol use differs significantly across subgroups.

For instance, Pacific Islander and Filipino American youths are shown to have the highest

rates of substance use, while Chinese American youths have the lowest rates of use. In

support of social control theory, their findings suggest that families play a preventative

role in helping Chinese and Asian Indians abstain from substances. For Southeast

Asians, teachers had a greater impact than families in promoting substance abstinence.
 17

At the same time, they also gathered evidence to support peer cluster theory

(Nagasawa et al., 2000). They found that the use of substances by peers also plays a

significant role in encouraging the same behavior. Their findings indicate that youths of

all ethnic groups tend to use drugs and alcohol when their peers have engaged in the

following deviant behaviors: (a) used marijuana, (b) become intoxicated, and (c)

affiliated with gangs, or (d) encouraged marijuana use. For the most part, however, the

collected data was more consistent with social control theory in explaining the substance

use of Asian Americans.

In networks of Filipino substance users, peer cluster theory explains “the

willingness of Filipinos to use drugs and alcohol in the presence of one another” (Laus,

2013, p. 1103). Peer clusters of Filipino drug users, for example, work to introduce

members to other drugs and perpetuate substance use. To test this theory for cross-

cultural validity, Kim, Zane, and Hong (2002) examined the effects of Asian American

youths’ immigration experience on the relationship among protective factors. Their

results provided partial support for the validity of the peer cluster model. Consistent with

earlier research, the peer domain variable was significantly related to substance use. The

family domain variable, on the other hand, served as a protective factor against substance

use, which supports the validity of social control theory. Unlike both variables, the

school domain variable did not have any effects on substance use.

Aside from peer and family influences, it is also important to look at the process

of assimilation for Filipino substance users. According to Nagasawa, Qian, and Wong

(2001), segmented assimilation theory “considers the immigrant culture and social capital
 18

as critical factors in the assimilation process” (p. 351). They used data from the 1995-

1996 Asian Student Drug Survey to analyze patterns of marijuana use and delinquent

behavior. They examined the adoption of teen drug and delinquent subcultures among

Asian Pacific youth within the context of segmented assimilation. Their findings suggest

that immigrant youth and US-born Asian youth have several different types of adaptation.

They found that the each ethnic group (i.e., Japanese, Chinese, Filipino, Korean,

Southeast Asian, Asian Indian, and Pacific Islander youth) differed significantly in their

marijuana use. Most notably, Pacific Islander and Filipino youth were more likely than

Japanese youth to use marijuana. Korean, Southeast Asian, and Asian Indian youth,

however, did not differ significantly from the Japanese youth in marijuana use. As for

delinquent behavior, Chinese youth were the least likely to engage in such behavior,

while Filipino and Pacific Islander youth were the most likely to do so.

In support of this, Johnson VanGeest, and Cho (2002) used data from the 1991

U.S. National Health Interview Survey to compare the substance use patterns of

immigrants to those of native-born populations. They found that U.S. immigrants were

less likely to use alcohol and other drugs than native-born citizens. Further research also

implicates a significant relationship between immigrant status and risky behavior among

Asian adolescents. Hussey et al. (2007) used data from the 1994-1995 National

Longitudinal Study of Adolescent Health to examine drug use among Asian adolescents

in the U.S. They compared the drug use behaviors of US-born Asian adolescents to that

of foreign-born Asian youth. They found that Asian adolescents born in the U.S. were

more likely to engage in drug risk behaviors. In general, their findings show that the
 19

assimilation to U.S. norms is such a rapid process that deviant behaviors often manifest

by the second generation of Asian adolescents.

Substance Use and Mental Health

The stigma of mental illness in the API community may contribute to the

prevalent substance use of Filipinos as they view self-medication as more acceptable than

seeking professional help. To further explore this, Harris and Edlund (2005) used data

from two national surveys in 2001 and 2002 to evaluate the association between past 30-

day substance use and past year unmet need for and use of mental health care. Subjects

of the 2001 National Household Survey on Drug Abuse and the 2002 National Survey on

Drug Use and Health were between the ages of 18 and 65, and had at least one past year

mental disorder symptom and no past year substance use. Over 18,800 participants

responded to both national surveys combined. Among these participants, Harris and

Edlund found that the use of illicit drugs, with the exception of marijuana, increased with

an unmet need for mental health care.

At the same time, however, the use of illicit drugs did not decrease with the

utilization of mental health care (Harris & Edlund, 2005). Although heavy alcohol use

was not associated with unmet need for mental health care, it was significantly higher

among individuals who did not utilize mental health care. Marijuana, on the other hand,

was not associated with either unmet need or mental health care use. With these apparent

correlations, Harris and Edlund argue that screening and treatment is critical for those

with mental health problems. These measures may ultimately prevent the development

of substance use disorders among such individuals.

 20

Consistent with the research of Harris and Edlund (2005), Encrenaz and Messiah

(2006) found that the use of healthcare decreases the probability of psychiatric

comorbidity with substance use disorders (SUD). According to Encrenaz and Messiah,

individuals with a non-substance related psychiatric disorder (NSRPD) are more

vulnerable to problematic drug use. This explains the frequent psychiatric comorbidity

among individuals with a SUD. Encrenaz and Messiah believed that treating the NSRPD

reduces the likelihood of a secondary SUD. To demonstrate this, they looked at the

mental disorders and healthcare use of 224 students and examined how the use of

healthcare influences the association between SUD and NSRPD. Comparison to subjects

without a NSRPD, those with at least two NSRPDs who did not utilize healthcare for

treatment were more likely to have had a lifetime SUD. Those with only one NSRPD,

however, were as likely as those with no NSRPD to have had a SUD. Based on these

results, it is apparent that access to and utilization of healthcare may protect individuals

with NSRPD from developing a secondary SUD.

Similarly, research also shows that the utilization of mental health services

reduces the risk of alcohol use (Encrenaz, Kovess-Masféty, Sapinho, Chee, & Messiah,

2007). In this study, the authors examined the influence of mental health service

utilization on anxiety or depressive disorders (ADD) and risk of 12-month problematic

alcohol use. To do so, they randomly selected members of a mutual health insurance

company and evaluated each individual for lifetime ADD (DSM-IV), mental health

service utilization for ADD, and risk of 12-month problematic alcohol use. Their results

indicated that the individuals with several ADDs who used mental health services
 21

reduced their risk of alcohol use. This, however, was not the case for individuals with

only one ADD who also utilized mental health services. These results clearly

demonstrate the importance of considering mental health service use as an influential

variable for psychiatric comorbidity.

Evidently, mental health services can play a significant role in reducing an

individual’s risk of developing a SUD if he or she has a preexisting psychiatric disorder.

With this in mind, it is also important to look at how likely these individuals will utilize

mental health services in the first place. In a study by Abe-Kim et al. (2007), results from

the 2002-2003 National Latino and Asian American Study were used to evaluate the rates

of mental health-related service utilization and subjective satisfaction between immigrant

and US-born Asian Americans. Compared to the general population, Asian Americans

demonstrated lower rates of any type of mental health-related service use regardless of

immigration status. When compared to their immigrant counterparts, however, US-born

Asian Americans demonstrated higher rates of service use. Given this lack of service

use, Asian American immigrants with psychiatric disorders may be in an even more

vulnerable position in developing a secondary SUD.

Derived from the same national sample, further research also illustrated low rates

of healthcare use among Asian American women despite reported physical, behavioral,

and mental health problems (Appel, Huang, Ai, & Lin, 2011). In physical, behavioral,

and mental health, Appel et al. (2011) found:

1. Chinese American women reported the highest rates of headache, other pain,

hypertension, heart diseases, heart attacks, chronic lung diseases, and asthma.
 22

2. Vietnamese American women reported the highest rates of ulcer, stroke, and

diabetes.

3. Filipino American women had the highest rates of cancers and epilepsy.

4. Filipino women ranked highest on all types of drug use and cigarette smoking,

compared with their counterparts.

5. Filipino American women reported significantly better mental health self-

rating compared with their Chinese and Vietnamese American counterparts.

(p. 1703)

Regardless of their health concerns, all three groups of Asian American women

demonstrated minimal helpseeking behavior as supported by their low rates of seeking

healthcare services.

Given this cultural norm, it is essential to assess the different forces that urge

Filipinos to avoid seeking help when needed. In their cultural analysis of helpseeking

behavior, Gong, Gage, and Tacata (2003) explored existing research on Filipino

Americans and the cultural variables of face and language. Compared to other systems,

such as professional (mental health specialty and general practitioner) and folk, they

found that the lay system (family, friends, local community) is the most frequently used

source of care for Filipino Americans. This finding serves as evidence to support that

face and language are important cultural factors that contribute to their helpseeking

behavior. Therefore, these areas should be considered when developing and

implementing interventions for cultural competence in treatment services.

 23

Cultural Competence in Healthcare

Limited access to and poor perceived helpfulness with healthcare may explain the

low number of Asian Americans utilizing mental health services. To address racial and

ethnic disparities in health and healthcare, it is important to look at cultural competence

on all levels of the system according to Betancourt, Green, Carrillo, and Ananeh-

Firempong (2003). In their attempt to develop a framework of cultural competence

interventions, these researchers conducted a literature review that examined: (a)

sociocultural barriers to care, (b) the level of the healthcare system at which a given

barrier occurs, and (c) cultural competence efforts that address these barriers. From what

Betancourt et al. (2003) gathered, “sociocultural barriers to care were identified at the

organization (leadership/workforce), structural (process of care), and clinical (provider-

patient encounter) levels” (p. 293). To overcome these barriers, they argue to put these

interventions into practice: (a) recruiting minorities into health professions, (b) expanding

interpreter services, and (c) educating providers on cross-cultural issues.

To widen the scope of this research on cultural competence and healthcare

disparities, experts in cultural competence from distinct areas (i.e., managed care,

government, and academe) were interviewed to identify their perspectives (Betancourt,

Green, Carrillo, & Park, 2005). Based on their responses, it was apparent that many

healthcare stakeholders were developing initiatives in cultural competence. Nonetheless,

each expert varied in their reasons for advancing cultural competence as their respective

area had a different mission, set of goals, and influence. Unfortunately, this may limit the
 24

sense of urgency in implementing cultural competence interventions that are aimed to

reduce barriers to treatment for Filipinos with substance use disorders.

In line with cultural competence on a clinical level, research shows apparent

disparities in physician care (Blendon et al., 2008). In the 2007 Harvard School of Public

Health/Robert Wood Johnson Foundation survey, adults living in the U.S. were randomly

selected to compare the perceptions of the quality of physician care between Whites and

people of color. In the sample of 4,334 subjects, 14 racial and ethic subgroups were

formed. According to the results, at least 5 and as many as 11 subgroups perceived their

care to be significantly worse than care for Whites on each measure examined. On most

of the measures, Chinese Americans and Korean Americans were at least 15 percentage

points more negative than Whites. Even after controlling for socioeconomic

characteristics and language skills, many of the differences in perceived quality of

physician care still remained the same across all groups. This implicates a greater need to

reduce barriers to treatment through the development implementation of cultural

competence interventions.

Barriers to treatment not only lead to an underutilization of substance use and

mental health treatment for AAPI, but also result in an underestimation of substance use

in the AAPI community (Fong & Tsuang, 2007). In support of this, reports indicate that

AAPI are greatly underrepresented in substance use treatment across different settings,

from residential to outpatient to hospital-based admissions. Additionally, studies have

shown that AAPI with substance use disorders are less likely to enter treatment as
 25

compared to non-AAPI. On the surface, this low number of AAPI in treatment suggests

that there is a lower overall rate of AAPI with substance use disorders.

However, according to the Treatment Episode Data Set (TEDS), less than 1% of

all patients who are admitted to national treatment surveys report themselves as AAPI

(Fong & Tsuang, 2007). Among those who identify as AAPI, their primary reason for

admission was alcohol, marijuana, stimulants, opiates, and cocaine. Nonetheless, data

also shows that more AAPI are presenting to treatment for first time, which has increased

the number of AAPI that enter treatment. For this reason, the low number of AAPI

presenting to treatment may be reflective of “the larger healthcare disparity that exists

between those that need treatment and those that actually present to treatment” (Fong &

Tsuang, 2007, p. 53).

Although the stereotype is that AAPI do not present or come to treatment, the

reality is that there are several significant and unique barriers to accessing care (Fong &

Tsuang, 2007). For one, reports have indicated that AAPI have poor access to care for

medical care and mental healthcare, which makes it more likely that access to substance

use care is also lacking. This limited access may partly be due to “cost, awareness that

care exists, or lack of actual services that can be accessed” (Fong & Tsuang, 2007, p. 56).

Not only is there a lack in services, but there is also a deficit in quality services as well.

More specifically, there is a lack of evidence-based programs that are effective in the

treatment of substance use in the AAPI community. This serves as another critical

system issue as it reflects a lack of culturally competent services suited for a specific

AAPI language, cultural beliefs, and values.

 26

For AAPI substance users, this creates a double barrier, as those with substance

use disorders regardless of ethnicity often do not access or seek treatment (Fong &

Tsuang, 2007). In most cases, the most recognized barrier is the issue of shame in asking

for help for a SUD. As stated previously, this is especially true for Filipinos. Without

the proper services to appropriately address these issues, Filipinos and other Asian

ethnicities will continue to underutilize treatment services and will remain

underrepresented as a group with significant levels of substance use disorders.

 27

Chapter 3

Methodology

This research study used non-randomized purposive sampling to collect a

combination of quantitative and qualitative data. Both sets of data were then examined

through statistical and content analysis. The following sections present a comprehensive

overview of this study’s methods.

Study Design

This description survey study aims to examine the relationship between two

variables without manipulating their external environment. For this study, the two

variables are: (a) cultural attitudes and (b) help-seeking behavior. Therefore, the study

describes the cultural attitudes that may hinder or facilitate the help-seeking behavior of

Filipinos with substance use disorders.

Sampling and Data Collection Procedures

This research study utilized purposive sampling to recruit participants for this

study. Purposive sampling was specifically used because respondents were required to

meet a specific criteria based on their knowledge of the research problem. Participants

were recruited by representatives from the following agencies and organizations: (a)

Asian American Drug Abuse Program in Los Angeles, CA; (b) West Bay Pilipino Multi-

Service Center in San Francisco, CA; (c) Pacific Asian Alcohol and Drug Program in Los

Angeles, CA; and (d) Pinoy-Pinay Educational Partnerships in San Francisco, CA. This

study’s author was referred to the three primary agencies by Dr. Ford Kuramoto, a

longtime director of the National Asian Pacific American Families Against Substance
 28

Abuse (NAPAFASA). Dr. Kuramoto was able to assist the author in connecting with the

service providers involved in this study. Each agency was receptive and agreed to assist

in the study’s recruitment process. Since potential respondents did not respond

immediately, bi-weekly reminders were sent out to facilitate data collection. To further

the data collection process, this study’s author connected with a colleague from the fourth

organization listed above. In doing so, the study was able to achieve a relatively

moderate response rate.

In order to be eligible, individuals needed to be 18 years of age or older and have

personal and/or professional knowledge about Filipino cultural attitudes and help-seeking

behaviors for substance use. The pool of subjects were limited to service providers,

family members, and former users who were familiar with substance use among

Filipinos. More specifically, participants needed to identity with one or more of the

following: (a) a service provider working with Filipino clients in a substance use

treatment facility or a culture specific organization; (b) a family member of a Filipino

who is a current or former user; and (c) a Filipino who is a former user. This study’s

author attempted to recruit 30 participants. In total, the study achieved an 83% response

rate with a total of 25 participants.

To collect data for this study, this study’s author used Google Forms to create an

online survey questionnaire that is completely anonymous. The stated organizations and

agencies recruited subjects based on the criteria provided. Designated representatives

sent out the recruitment invitation on behalf of this study’s author. The recruitment

invitation sent to participants included a link to the online survey in order for them to
 29

access the informed consent form and questionnaire. In their invitation, subjects were

notified that participation would take no more than 20 minutes. Given the accessibility of

the data collection tool, the study was conducted in the location that each participant

chose to access and complete the online survey. In terms of the data collected, only this

study’s author had full access to this information. It is confidentially maintained in a

password protected and encrypted file in the principal investigator’s personal computer

using Google Drive.

Data Collection Instruments

This research study utilized an online survey questionnaire (see Appendix)

consisting of Likert scales to measure the correlation between Filipino cultural attitudes

and help-seeking behavior for substance use. Predominantly, the research question and

hypotheses guided the development of this questionnaire as the current literature

informed its major content. In the beginning of the survey, participants were asked to

rank alcohol and other drugs by prevalence of use in the Filipino community.

Participants were then instructed to select a percentage range of Filipinos in which they

believe used substances to self-medicate and cope with an unmet need for mental health

care. To define a substance user’s support system, participants were directed to choose

two individuals that a Filipino substance user would seek help from. Based on their

selection, participants were asked to rank the likelihood of the following: that a substance

user would seek from these individuals, that these individuals would recognize the

problem and intervene without being prompted by the user, and that their involvement

would encourage the user to go into treatment.

 30

To gain a better understanding of a user’s relationship with his or her support

system, participants were instructed to state what would necessitate involvement from the

support system and to describe how they would typically respond. Afterwards,

participants were directed to either agree or disagree with a number of statements that

drew upon the cultural attitudes and values that may have an impact on the help-seeking

behavior of Filipino substance users. Participants were then given different approaches

to raising awareness about substance use in the Filipino community and were told to rank

each one by perceived effectiveness. At the end of the survey, participants were asked to

complete an open-ended question regarding the possibility of repurposing cultural

concepts to facilitate the help-seeking behavior of Filipino substance users.

Data Analysis Plan

This research study used descriptive statistics to evaluate the frequencies of

responses for each question. This provided the mean, median, and mode of the nominal

variables explored in this study, which showed the averages of the selected responses.

Additionally, a bivariate correlation analysis was performed using a two-tailed test of

significance. In particular, Spearman’s rho was applied to examine the association

between the variables on an ordinal scale: (a) help-seeking behavior and cultural

attitudes; (b) help-seeking behavior and cultural perceptions; (c) supportive intervention

and cultural perceptions; and (d) community efforts and positive outcomes.

For the qualitative data obtained, a content analysis was conducted to extract

pertinent themes from the responses to the open-ended question that explored the

possibility of repurposing the cultural concept “bahala na” to facilitate help-seeking

 31

behavior. To do so, key ideas were identified in each response. Each key idea was

counted for recurrence. Prevalent key ideas were then used to develop a categorical

theme and to differentiate one from another. Therefore, the categories made up and

described the prevailing themes derived from this content analysis.

Protection of Human Subjects

The Protocol for the Protection of Human Subjects was submitted and approved

by the University Human Subjects Review Committee, Division of Social Work

subcommittee as exempt research. This study poses no risk to participants. In this

study’s approved protocol, the following areas of risks were considered: (a)

psychological, (b) sociological and economic, (c) confidentiality, and (d) privacy. This

study posed no psychological risk as the information that the respondents provided in the

survey were not that different from those of any regular conversations with companions.

As for sociological and economic risk, the service providers who responded to the survey

were not terminated from their agencies for their participation in this study.

To address confidentiality and privacy, participants were informed about these

key ethical considerations in their provided consent form. Participants were notified that

any information obtained in connection with this study remains confidential. They were

also informed that responses are completely anonymous as an assigned research code

identifies each participant response. In addition, they were assured that their participation

is entirely voluntary and are free to discontinue participation at any time. Essentially, the

study utilized an implied consent procedure to acquire informed consent from subjects

where a completed questionnaire indicated their consent to participate.

 32

Chapter 4

Study Findings and Discussions

As a prevailing ethnic community in substance use, Filipinos have unique cultural

attitudes that may hinder their help-seeking behavior and discourage supportive

intervention by their family and friends. In all, these significant influences may delay or

even prevent methods of treatment entirely for Filipinos with substance use disorders

(SUD). For this reason, the study explored the influence of Filipino cultural attitudes that

particularly convey passivity and relinquishment of control. In doing so, this study aimed

to identify ways to facilitate help-seeking behavior of Filipino substance users.

Overall Findings

The study collected 25 total responses from individuals that identify as the

following: service provider (n=3); family member (n=18); former user and family

member (n=1); former user, family member, and service provider (n=1); and unknown

(n=2). The composite figure, designated as Steven, is provided below to present the

frequencies of the collected data and to better illustrate the study’s overall findings. For

this purpose, Steven is referred to as a Filipino living in the U.S. with a SUD.

To begin, among all possible substances, Steven is most likely using alcohol,

tobacco and illicit drugs. He is also somewhat likely using prescription drugs. There is a

low to moderate chance (25%-50%) that he uses substances to self-medicate to cope with

an unmet need for mental health care. For example, Steven could be turning to alcohol

and other drugs to treat his depression or anxiety.

 33

If Steven were to seek help from his support system, the first person he would

seek help from would be a family member and an alternate person would be a friend.

However, it is not likely that Steven would actually seek help from a family member or a

friend. It is also not as likely that these individuals would choose to be involved and

provide Steven with supportive interventions. If these individuals were to be involved in

this way, Steven would be somewhat likely to seek treatment. Unfortunately, in most

cases, only during forced interventions upon the user do these individuals choose to

become involved. In this case, Steven’s family and friends would most likely help him

seek treatment after he has been either arrested, hospitalized, or become homeless.

Steven is most likely using the Filipino cultural attitude, “bahala na,” as an excuse

to not seek for help as it helps him be more passive about his situation. For Steven, a

passive attitude can also help him feel less shameful about using, which hinders his

ability to ask for help. Not asking for help protects him from facing the stigma of having

a substance use disorder. By protecting himself from such stigma, he is able to maintain

his perception of social acceptance by his community of other substance users who may

or may not also identify as Filipino. Overall, acting on this attitude is a way for Steven to

minimize his feelings of shame, stigma, and fears of social rejection. This cultural

attitude ultimately removes personal responsibility from Steven, which deters him from

ever considering seeking help.

Given the hindering effects of “bahala na,” this attitude most likely interferes with

Steven’s help-seeking behavior. Acting on this attitude masks his urgency for help, as he

may not want to be a burden to others. In comparison, “bahala na” most likely decreases
 34

the likelihood that Steven’s family and friends will provide supportive interventions.

Similar to Steven’s perceptions, using “bahala na” masks his friends and family’s

urgency to intervene, as they may not want to meddle or overstep their boundaries. More

likely than not, Steven’s ethnic community is aware of substance use as an issue among

Filipinos but choose to not address it as such. For Steven, the following community

efforts may reduce the hindering effects of “bahala na” and encourage him to seek

treatment: (a) utilizing multimedia sources, (b) training key community leaders, and (c)

partnering with health organizations.

Specific Findings and Discussions

The study’s specific findings supported the hypothesis that Filipino cultural

attitudes of passivity and relinquishment of control likely prevent or delay methods of

treatment for a substance use disorder (SUD). Spearman’s rank correlation coefficient

(rho) was used to examine the relationships between the following pairs of variables: (a)

help-seeking behavior and cultural attitudes; (b) help-seeking behavior and cultural

perceptions; (c) supportive intervention and cultural perceptions; and (d) community

efforts and positive outcomes. Tables 1, 2, 3, and 4 show the correlation coefficient (rs)

and significance levels (p-values) for each correlated variables. Among these variables,

there is a strong positive correlation the closer rs is to 1, and there is a strong negative

correlation the closer rs is to -1.

Quantitative Data

As evidenced by Table 1, seeking help was negatively correlated with the

following variables: (a) avoiding stigma (rs=-.593), (b) maintaining social acceptance
 35

(rs=-.638), and (c) minimizing negative feelings of shame, stigma, and fears of social

rejection (rs=-.445). Therefore, a Filipino substance user like Steven would be less likely

to seek help the more that he believes that this would increase the likelihood of stigma

avoidance, social acceptance, and minimized internal negativity. Similarly, the

likelihood of “bahala na” encouraging help-seeking behavior decreases when users

associate passivity with this cultural attitude (rs=-.446), and when they believe that not

seeking help increases the likelihood of the aforementioned events (avoiding stigma rs=-

.470; maintaining social acceptance rs=-.495; and minimizing negative feelings rs=-.628).

On the other hand, the likelihood of “bahala na” decreasing help-seeking behavior

increases only when users believe that they can avoid stigma (rs=.581) and maintain their

social acceptance (rs=.544).

Table 1

Correlations Between Help-Seeking Behavior (HSB) & Cultural Attitudes

Measure 1 2 3 4 5 6 7 8
1. HSB – – – – – -.593 -.638**
**
-.445*
2. Increase HSB – – -.597** -.446* – -.470* -.495* -.628**
**
3. Decrease HSB – -.597 – – – .581** .544** –
4. Passivity – -.446* – – .805** .470* .663** .776**
5. Shame – – – .805** – .431* .567** .568**
6. Stigma -.593** -.470* .581** .470* .431* – .930** .707**
7. Acceptance -.638** -.495* .544** .663** .567** .930** – .826**
* ** ** ** **
8. Minimization -.445 -.628 – .776 .568 .707 .826** –
Note. *p < 0.05, two-tailed. **p < 0.01, two-tailed.

Furthermore, Filipino substance users are more likely to associate “bahala na”

with passivity if they believe that this will help them feel less shameful (rs=.805), avoid

stigma (rs=.470), maintain social acceptance (rs=.663), and minimize potential internal
 36

negativity (rs=.776). Users are also more likely to feel less shameful when they can avoid

stigma (rs=.431), maintain social acceptance (rs=.567), and minimize internal negativity

(rs=.568). They are also more likely to avoid stigma when they can maintain social

acceptance (rs=.930) and minimize internal negativity (rs=.707). In addition, Filipino

substance users are more likely to maintain their level of social acceptance when they can

minimize their feelings of shame, stigma, and fears of social rejection (rs=.826).

As evidenced by Table 2, the likelihood of “bahala na” fostering help-seeking

behavior decreases as Filipino substance users perceive this cultural attitude as a way for

them to avoid being a burden to their support persons (rs=-.461). In addition, the

likelihood of “bahala na” limiting help-seeking behavior increases as users act on this

cultural attitude to mask their urgency for help (rs=.689) to perhaps help them avoid

being a burden (rs=.524).

Table 2

Correlations Between Help-Seeking Behavior (HSB) & Cultural Perceptions

Measure 1 2 3 4
**
1. Increase HSB – -.597 – -.461*
2. Decrease HSB -.597** – .689** .524**
3. Masks Urgency for Help – .689** – .493*
4. Avoids Burden to Others -.461* .524** .493* –
* **
Note. p < 0.05, two-tailed. p < 0.01, two-tailed.

Particularly, “bahala na” masking a user’s urgency for needing help was found to

be positively correlated with “bahala na” being utilized as a way for the user to avoid

being a burden on his or her support system (rs=.493). Therefore, it can be inferred that
 37

users may feel a lesser urge to ask for help if they believe that this would help them be

less of a burden.

As evidenced by Table 3, the likelihood of “bahala na” encouraging supportive

intervention decreases as support persons use this cultural attitude to mask their urgency

to intervene (rs=-.592) and if they believe that using this attitude may help them avoid the

need to meddle (rs=-.512). In the same way, the likelihood of “bahala na” discouraging

supportive intervention increases as support persons use this attitude for the reasons

stated above (masking urgency to intervene rs=.567; avoiding need to meddle rs=.494).

Table 3

Correlations Between Supportive Intervention (SI) & Cultural Perceptions

Measure 1 2 3 4
** **
1. Increase SI – -.640 -.592 -.512*
2. Decrease SI -.640** – .567** .494*
** **
3. Masks Urgency to Intervene -.592 .567 – .906**
4. Avoids Need to Meddle -.512* .494* .906** –
Note. *p < 0.05, two-tailed. **p < 0.01, two-tailed.

It is also worth noting that a positive correlative was found between “bahala na”

masking a support person’s urgency to intervene and “bahala na” being used as a way for

the support person to avoid the need to meddle (rs=.906). This connection implicates that

support persons may feel a lesser urge to intervene if they believe that this would keep

them from overstepping their boundaries.

As evidenced by Table 4, positive correlations were found between a number of

community efforts and positive outcomes. For one, the effectiveness of using multimedia
 38

sources increases as key leaders are trained (rs=.733), which also increases the likelihood

of reducing the hindering effects of “bahala na” as a cultural concept (rs=.510).

Table 4

Correlations Between Community Efforts & Positive Outcomes

Measure 1 2 3 4 5
**
1. Multimedia Utilization – .733 – .510** –
**
2. Trained Key Leaders .733 – .510** – –
**
3. Healthcare Partnerships – .510 – – –
**
4. Reduces Passive Attitudes .510 – – – .707**
5. Increases Treatment Rates – – – .707** –
Note. **p < 0.01, two-tailed.

Likewise, the effectiveness of key leaders rises as partnerships with health

organizations are developed (rs=.510). Significantly, it was also found that reducing the

hindering effects of “bahala na” would likely increase treatment admission rates among

Filipino substance users (rs=.707).

Qualitative Data

In the content analysis of the responses, key ideas were identified in each

response and counted for recurrence. A prevalent idea served as a categorical theme to

differentiate one from another. Each category was then used to describe a prevailing

theme to the one open-ended question used in the study. A number of themes were found

in response to the possibility of repurposing the cultural concept “bahala na” to facilitate

the help-seeking behavior of Filipino substance users. The study collected 17 total

responses from individuals that identify as the following: service provider (n=2); family

member (n=13); former user and family member (n=1); and former user, family member,
 39

and service provider (n=1). Altogether, four themes were extracted from the content

analysis based on the number of responses that formed each theme.

In support of each summary of the extracted themes, a direct quote from a

respondent is included to represent the findings of the content analysis. Each participant

responded to the following open-ended question: is it possible to repurpose “bahala na”

to facilitate the help-seeking behavior of Filipino substance users; if so, how? Among the

17 respondents, two family members stated that they were unsure of how to repurpose

this cultural concept in such a way and did not provide a further explanation. Therefore,

the following themes are based on the remaining 15 responses.

Impracticality. Among the remaining 15 respondents, four of which (consisting

of 2 family members; 1 family member and former user; and 1 service provider, family

member, and former user) reported that it is not possible to repurpose “bahala na” due to

its pervasive use in the Filipino culture. For this reason, removing this concept from the

culture’s worldview would be the only way to facilitate the help-seeking behavior of

Filipino substance users. In particular, one respondent made the following suggestion:

eliminate “bahala na” as a cultural concept and address critical issues such as substance

use in the community.

We have to eliminate this way of stinking thinking. It's similar to avoiding or

ignoring the elephant in the room. We have to address critical issues, such as drug

abuse, immediately. (service provider, family member, and former user)

Reconceptualization. As opposed to eliminating the cultural concept entirely,

two family members were in agreement with one another as they made the following
 40

suggestions: redefine interconnected cultural concepts, and reconceptualize “bahala na”

in a way that empowers substance users to utilize their inner strength as a holistic

approach to healing and recovery.

I think ‘bahala na’ is heavily connected (as are many Pilipino cultural concepts) to

‘hiya.’ Not just in ‘shame’ or ‘embarrassment,’ but most importantly on creating

DOUBT in individuals of our communities – this largely has to do with

understanding what is socially appropriate for our communities as well. I think

that ‘bahala na’ allows for Pilipino users AND support systems to perpetuate

‘hiya.’ Additionally, it's also heavily connected to ‘sino ka ba?’ You know, ‘who

are you (to tell me what I am doing wrong / how to live my life / how to fix it)?’

When people feel hiya, they ask sino ka ba? And when others are asked sino ka

ba? they feel hiya, and resort to ‘bahala na.’ In order to repurpose ‘bahala na’

there has to be a lot more work done with other cultural concepts that also hinder

the (lack of) help-seeking behavior of Filipino substance users. (family member)

Religiosity. On the other hand, three respondents (2 family members and 1

service provider) made the following recommendation: reclaim “bahala na” to have a

stronger religious message that discourages passivity.

‘Bahala na’ has a religious connotation since Bahala is derived from Bathala

meaning God. Because a large part of the community is very religious, we can

reclaim this statement by having our community/religious leaders explain that

God would want the best for our well being – that the life He gave us is a gift and
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being passive about our health is not what He intended. I believe reclaiming this

statement would resonate with a lot of Filipinos. (service provider)

Awareness. In contrast, six respondents (5 family members and 1 service

provider) called for a particular course of action to counter the hindering effects of the

cultural concept: educate the Filipino community about the negative effects of substance

use and raise awareness about “bahala na” as a significant barrier for the user to seek help

and for their support persons to provide help.

We need to spread awareness about its hindering effects, so that we no longer

have to use it as a crutch. Whether we are the user, or a user's support person, we

need to become active participants in our own care and the care of others. If we

continue to act on this cultural concept, we may miss important opportunities to

be involved in such a meaningful way. (family member)

Summary of Findings

The study findings show that Filipino substance users most likely use the cultural

attitude “bahala na” to remove their sense of personal responsibility. Using this passive

attitude may help Filipino substance users minimize their feelings of shame, stigma, and

fears of social rejection. This attitude may also mask the urgency for substance users to

seek help as they may not want to be a burden on others. In the same way, “bahala na”

masks the urgency for support persons to intervene as they also may not want to overstep

their perceived boundaries.

For these reasons, the findings show that substance users are not likely to seek

help from their family and friends who are also not as likely to provide supportive
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interventions. However, the involvement of these support persons would somewhat

likely increase the likelihood of users seeking treatment. To reduce these hindering

effects and encourage treatment, the community may benefit from utilizing multimedia

sources, training key community leaders, and partnering with health organizations. In

addition to implementing these community efforts, repurposing “bahala na” as a cultural

concept may also facilitate the help-seeking behavior of Filipino substance users.
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Chapter 5

Summary and Recommendations

This research study met its key objectives and identified factors that could

repurpose hindering cultural attitudes such as “bahala na” to encourage the help-seeking

behavior of Filipino substance users. In particular, the findings suggest that supportive

interventions may increase a user to seek treatment. This shows that the involvement of

family and friends may prevent the occurrence of forced interventions upon the user such

as arrest, hospitalization, or homelessness. However, support persons are only likely to

intervene after these events have occurred, and this may partly be due to the adoption of

“bahala na” as an influential cultural attitude for many Filipinos. Consistent with the

literature, the results suggest that a variety of substances are prevalent in the Filipino

community. This makes Filipinos highly susceptible to substance use and in need of

more support services and programs.

Implications for Social Work

The results of this study provide social work practice approaches for those

working with Filipino substance users. As evidenced by the gathered data, practice may

be most effective when it aims to strengthen, and not change, the substance user’s sense

of self. If the desire for change comes from users themselves, they are better able to

develop their own course of action to do so. In the process, service providers can

recognize the ways in which cultural attitudes, such as “bahala na,” are associated with

shame, stigma, and social rejection.

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To enrich the personal growth of users, service providers can then reframe such

concepts in a way that fosters the ability of users to enhance their sense of self. As

supported by the findings of this study, it is also important to keep in mind that Filipino

users may prefer not to be a burden on their family and friends, which may then hinder

their ability to reach out for support. This serves as a valuable opportunity to facilitate

communication between the user and his or her support persons.

The results of this study also provide social work practice approaches for those

working with the families of Filipino substance users. Based on the data collected,

practice may be most effective when it aims to relieve the family’s emotional tensions

and to identify their enabling behaviors toward the user. Again, it is important to

facilitate communication between the user and his or her support persons, as the findings

suggest that Filipino family members may prefer not to meddle and overstep their

boundaries. Therefore, reframing the family’s ideas and developing ways for them to

provide supportive intervention are key objectives.

The findings of this study reveal that there is a desire in the Filipino community to

raise critical awareness about the effects substance use, and the cultural attitudes that

discourage the need for help and the need to provide support. The data shows that

community members are interested in using multimedia sources, training key leaders, and

partnering with health organizations to raise such awareness. As the findings suggest,

these efforts may all be effective ways in reducing the use of passive cultural attitudes

and increasing the utilization of treatment services by Filipino substance users.

 45

As the qualitative data suggests, it may also be beneficial to promote cultural

values that encourage the act of supporting others in their time of need. However, it is

essential to recognize the negative cultural concepts associated with substance use prior

to promoting these values. According to the respondents, this may require demystifying

substance use through education and facilitating open lines of communication between

users and their support persons.

Limitations

There are significant limitations in this study that make the results not

generalizable. The sample is not only very limited in size, but it is also comprised of a

large number of participants with indirect perspectives on substance use in the Filipino

community. For example, a low number of respondents were actually former users and

had first hand experience on being a substance user as a Filipino. The majority of

respondents were instead family members followed by service providers. Therefore, the

results provided greater insight on the experiences of family members of substance users.

This also made it very difficult to extract meaningful data when differentiating the

perspectives of different knowledge bases.

Recommendations

Consider surveying only former users to gain a direct perspective of the Filipino

experience in seeking help for substance use. Though this approach requires more

networking with agencies and organizations for support in the recruitment process, it

removes biases from indirect perspectives (e.g., family members and service providers).

However, it may be worth noting the differences in perspectives between former users
 46

who identify as service providers and/or family members of other substance users as well.

In this case, eligible participants must be a former user and may also identify as a service

provider and/or a family member.

Network with culture specific organizations and agencies as early as possible to

develop a professional working relationship with each representative that will assist with

the recruitment process. If possible, meet with the agencies and organizations in person

and prepare a presentation defending the importance of researching substance use in the

Filipino community. Given the sensitivity of the topic, connect with a large number of

organizations and agencies to ensure a high response rate. For example, consider Filipino

specific student organizations in local college campuses. It is also important to be direct

with each organization and agency, and work out a definitive number of eligible

participants in their list of contacts that will be able to respond.

It is critical to start data collection as early as possible to leave room for common

research barriers such as a low response rate. To prompt immediate participation, it is

important to set a definitive deadline for participants to respond. Throughout the period

of data collection, it is beneficial to send consistent reminders to encourage more

participation from eligible respondents. These reminders may include a reiteration of the

research study’s benefits and an expression of gratitude for those who have already

participated. Most importantly, collaborating with representatives from each

organization and agency is essential as this will provide an opportunity to work out a plan

of action to increase response rate and decrease common research barriers.

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Conclusion

The author of this study is a graduate student researcher and a fellow member of

the Filipino community. Given the author’s cultural and ethnic background, the research

findings were expected by this author. The results of this study affirm the author’s

personal observations about the community and how it particularly responds to the needs

of Filipino substance users. This research study, in in its entirety, serves as a step closer

to enacting change in the Filipino community as it brings awareness to the cultural

attitudes that negatively impact the behavior of Filipino substance users and their support

persons. With such awareness, practitioners are better informed and equipped to improve

the efficacy of treatment services which may then reduce cultural barriers and encourage

Filipinos to utilize these services. Ultimately, the findings of this study call for the

development of culture specific programs that aim to reduce the health disparities of

Filipino substance users and improve their health outcomes. The availability of these

programs may further improve the quality and delivery of care for Filipinos overall.
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Appendix

Online Survey Questionnaire

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