Filipino Child Health in the United States Filipino Child Health in the United States
Centers for Disease Contol
Filipinos are the second largest Asian subgroup in the United States, but few studies have examined health and health care disparities in Filipino children. The objectives of this review are 1) to appraise current knowledge of Filipino children’s health and health care and 2) to present the implications of these findings for research, clinical care, and policy.
We identified articles for review primarily via a Medline search emphasizing the terms Filipino and United States crossed with specific topics in child and adolescent health that fall under one of Healthy People 2010’s 28 focus areas.
Filipino children are underrepresented in medical research. Studies that compare Filipino children and adolescents with white children or children of other Asian Pacific Islander subgroups suggest disparities with regard to gestational diabetes, rates of neonatal mortality and low birth weight, malnutrition in young children, overweight, physical inactivity and fitness, tuberculosis, dental caries, and substance abuse. Studies that compare Filipino adults with white adults describe adult Filipino health problems similar to those of Filipino children, including higher rates of diabetes, hypertension, and metabolic syndrome. Health care disparities remain to be determined.
Health and health care disparities appear to exist for Filipino children, but more research is needed to confirm these findings. Practitioners serving this population need to consider social and cultural factors that can increase or diminish risk for health problems. There are priorities in research and policy that, if pursued, may improve the health care and health outcomes of Filipino children.
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The population of Asian Pacific Islander (API) children in the United States is expected to more than double by 2025 (1). Yet, we have only a limited understanding of the health and health care issues that characterize these children. Many studies that include API children report aggregated results, which mask key variations in health status among API subgroups. Moreover, many recent national surveys of children and adolescents do not collect data on API subgroups (2,3).
Filipinos are the second largest API subpopulation in the United States (4). On average, one in five Asians in the United States is Filipino (5). Most Filipinos live in California or Hawaii; however, Filipino populations in other states have more than doubled in the past decade (e.g., Texas, Florida). California is home to the largest Filipino population with more than 1 million, and Hawaii ranks second. Between 1990 and 2000 the U.S. Filipino population grew by 68.1% (6). Figures 1 and 2 display the distributions of the U.S. child population by ethnicity and by Asian population subgroup (7), respectively.
Figure 1. Percentage of U.S. children (Aged 0–18) by racial or ethnic group, 2000. All categories include those of mixed race or mixed ethnicity (7). Calculated by Joyce R. Javier from U.S. Census Bureau, Census 2000 Summary File 2 (SF 2) 100-Percent Data files. [A tabular version of this chart is also available.]
Figure 2. U.S. Asian children (Aged 0–18) by subgroup, 2000. All categories include those of mixed race or mixed ethnicity (7). Calculated by Joyce R. Javier from U.S. Census Bureau, Census 2000 Summary File 2 (SF 2) 100-Percent Data files. [A tabular version of this chart is also available.]
Studies that compare Filipino adults with other API or white adults have found disparities in areas such as cancer, cardiovascular health, and mental health (8,9). Little has been published about the health of Filipino children and adolescents. In this descriptive review of the literature, we compare the health of Filipino and white children to determine whether Filipino children are among those children in the United States that experience health and health care disparities. When data are available, we highlight differences between Filipino and other Asian subgroups. We also present important health and health care issues for which data are available on Asians but not on Filipinos specifically.
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We identified articles for review primarily via a Medline search of the terms Filipino and United States crossed with specific topics in child and adolescent health that fall under one of Healthy People 2010’s 28 focus areas. Studies selected for review were for the most part limited to those that were published between 1985 and 2005, were written in English, had subjects in the United States, compared Filipinos or Asians with other racial or ethnic groups, and addressed specific topics in child and adolescent health. Topics addressed were access to quality health services, maternal and infant health, nutrition, oral health, overweight, physical activity and fitness, respiratory diseases, infectious diseases and immunizations, sexually transmitted diseases, substance abuse, tobacco use, injury and violence prevention, mental health, and conditions highly prevalent among adults on which there are no studies with Filipino children as subjects (e.g., diabetes, heart disease). These topics were selected because they fall under one of Healthy People 2010’s 28 focus areas (10). We further examined the references listed in the identified articles and, where available, followed electronic links to related articles through the PubMed search engine.
In this article the term Filipino denotes any U.S. resident originating from any of the original peoples of the Philippine Islands. We do not use the terms API and Asian interchangeably. API refers to Asians and Pacific Islanders together as one group. When we refer to these two groups separately, the term Asian does not include Pacific Islanders. An Asian is a person whose origins are in any of the original people of the Far East, Southeast Asia, or the Indian subcontinent, including the Philippine Islands. A Pacific Islander is a person whose origins are in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Pacific Islanders are a separate category from Asians, although they are sometimes included with Asians or relegated to an other category.
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Health disparities can manifest in two major areas: health and health care. In this review, we first address health care, specifically examining access to quality health care. We then focus on the health of Filipino youth in three categories: infant and young child health, school-age youth and adolescent health, and relevant adult health problems. We present the identified health studies with specific data on Filipino infants and young children (Table 1), school-age youth and adolescents (Table 2), and relevant adult diseases (Table 3).
Access to quality health services
Research is lacking on the quality of medical care among Filipino children. With respect to health care access, national data show that Filipino children in the United States are more likely than white children to have health insurance. Filipino youths also have more favorable health status than white youths as indicated by less frequent school absence, less learning disability, less use of prescription medications, and fewer chronic conditions. However, Filipino children are more likely than white children to be without a usual place for receiving health care and not to have had contact with a health professional within the previous 12 months (11). Also, compared with Filipino adolescents living in the United States for short periods, Filipino adolescents living in the United States for long periods tended to report more physical health problems (12). These studies suggest that Filipino children face barriers to health care access and use that extend beyond health insurance issues, highlighting the need to consider generational status (i.e., whether the child is a first, second, or third generation immigrant) and time spent in the United States when considering risk for health problems.
Infants’ and young children’s health (aged 0–5 years)
Maternal and infant health
Studies have documented mixed perinatal outcomes for Filipinos, and when these outcomes are worse compared to whites, familiar risk factors (e.g., lack of prenatal care, smoking status) do not completely explain this variation. Compared with white mothers, Filipino mothers have similar infant, neonatal, and postneonatal mortality rates (13). However, Filipino women are at increased risk for delivering infants who are of moderately low (defined as 1,500–2,499g) and very low birth weight (defined as 500–1,499g) (14), preterm (15), or stillborn (16).
For Filipino women, the association between maternal place of birth and child health has been mixed. National data demonstrate a pattern consistent with the epidemiological paradox in that, compared with the offspring of U.S.-born mothers, the offspring of Philippine-born mothers have more favorable birth weights as well as lower infant mortality rates (13,17,18). Philippine-born mothers are also less likely to use alcohol and tobacco and have inadequate prenatal care during their pregnancies but are more likely to have inadequate weight gain (less than 22 pounds) (18). A study in Hawaii found that, compared with U.S.-born Filipinos, foreign-born Filipinos had a higher risk of preterm delivery and low birth weight (19).
According to the National Vital Statistics Report (17), in 2002 Filipino mothers (data not available by place of birth) had the highest rate of gestational diabetes among all measured subgroups at 59.8 per 1,000. Another study using national data reported that Philippine-born Filipino mothers are significantly more likely to have diabetes during pregnancy than U.S.-born Filipino mothers (20). The impact of the mother’s place of birth on diabetes prevalence may be partially explained by the older childbearing age of Filipino immigrant mothers, but differences in diabetes prevalence remain even after adjusting for differences in maternal age and other sociodemographic characteristics.
Weitz et al examined teen pregnancy among API subgroups and reported that when data on APIs are disaggregated, Filipinos have the highest percentage of births to teens (6%) among California’s six largest API groups (Chinese, Filipino, Vietnamese, Korean, Indian, and Japanese) (21). Compared with white teens, Filipino teens are more likely to request a pregnancy test and no other services from a provider, suggesting that they are sexually active but not looking for birth control. According to national data, U.S.-born Filipino mothers are more likely to be under age 20 than foreign-born Filipino mothers (11.0% vs 2.7%) (17). These studies reveal the importance of considering moderating variables (e.g., maternal place of birth, regional variations, maternal age, and genetic predisposition) when examining maternal and infant health outcomes in Filipinos.
There have been a limited number of nutrition studies on Filipino children because they are not sampled as a group in national or large regional studies. A longitudinal study of immigrant school-aged children in San Francisco revealed that all immigrant children, including those from the Philippines, showed catch-up growth in weight and height. This finding suggests that they arrived in this country with a deficiency in either height or weight and that they were malnourished before arriving in the United States (22). Another study of children participating in Hawaii’s Women, Infants, and Children program found that, among 1-year-olds, Filipinos had the highest percentage of underweight (30.2%); among children aged 2 to 4 years, Filipinos had the highest percentage of short stature (19.0%) (23). These two studies suggest that Filipino immigrant children may be affected by a statistically significant degree of relative malnutrition.
There are no national data on the prevalence of dental caries among Filipino children. In Hawaii, Filipino children stand out as having one of the highest rates of dental caries (defined as decayed and filled teeth), a rate nearly three times the national average. The proportion of Filipino children with baby bottle tooth decay and unmet dental treatment needs is higher than the proportion of white children (24). A study using community focus groups in the Northern Mariana Islands, a commonwealth of the United States, found that the low value of baby teeth and the negative treatment experiences parents had with painful dental care were major determinants of health beliefs surrounding oral health care for their children (25). Qualitative research allows for cultural tailoring of interventions, which may make dental treatment more acceptable to the targeted group. For example, our literature review revealed that advertising claiming that preventive visits are pain- and fear-free, in contrast to the experiences of parents when they were young, could be an important strategy to promote dental visits earlier in childhood.
School-age youth and adolescent health (aged 6–18 years)
Overweight, physical activity, and fitness
A study of fifth, seventh, and ninth graders in California demonstrated that Filipino males were more likely to be obese (defined as Body Mass Index [BMI] >85th percentile) than white males, and Filipino females were more likely to be obese than white females (26). In a study that did not separate males from females, Filipino adolescents had a lower prevalence of obesity than white adolescents. However, Filipino adolescents born in the United States were more than twice as likely to be obese as were those born outside the United States (27).
Research on perceptions of obesity and body- or self-dissatisfaction reported varied results based on age and sex. A study of college students found that Filipino males had the highest BMI and were the most body- or self-dissatisfied of all male comparison groups (28). A study of third grade children in 13 Northern California public elementary schools revealed that Filipino girls were as likely to have overweight concerns and body-dissatisfaction as white girls (29).
Filipino adolescents were significantly less likely to be physically active than white adolescents (30). Filipino females (aged 10–15 years) and Filipino males (aged 10–11 years) also exhibited slower mile run or walk times than white boys and girls (26). The foregoing studies suggest that estimates of the prevalence of obesity, physical activity, and body dissatisfaction among Filipino children vary according to age and immigration status.
There are no national prevalence data available on Filipino children for asthma, a highly prevalent chronic condition. According to a California survey of 7th, 9th, and 11th grade students conducted from 2001 to 2003, Filipinos have the highest lifetime asthma prevalence rates (23.3%) among API subgroups (31). This prevalence rate is lower than the rate for African Americans, higher than the rate for whites and Asians overall, and comparable with the rate for Puerto Ricans, an already recognized high-risk population.
Infectious diseases and immunizations
Immigrant children from the Philippines are the second largest immigrant group in the United States with tuberculosis (32). A study of targeted school-based tuberculosis screening among high-risk adolescent populations in San Diego revealed that Filipinos are more likely to have positive tuberculin skin test (TST) results than whites. Although the Bacille Calmett-Guerin (BCG) vaccine was mentioned as a potential source of false-positive TST results, researchers were unable to correlate BCG vaccination with size of skin test induration because of lack of reliable data on past BCG vaccinations (33).
We were unable to find any studies reporting national or state immunization rates for Filipino children. Perinatal transmission is the most common mode of hepatitis B transmission, and the remainder of hepatitis B carriers are usually infected during early childhood. Among pregnant Asian American women, the prevalence of hepatitis B surface antigen positivity is higher among women born in the Philippines (5.1%) than among Asian American women born in the United States (2.0%) (34). A study in Los Angeles County found that about one third of Filipino fourth-grade students had their full series of hepatitis B vaccine (35). Both studies reveal the need to raise awareness that hepatitis B virus plays a role in the etiology of liver carcinoma and that infection is largely preventable through hepatitis B vaccination.
Sexually transmitted diseases
Filipino adolescents appear to be at high risk for contracting sexually transmitted diseases. In San Francisco, they have sexual activity rates similar to those of white students and higher than those of Chinese students (36,37). Filipino adolescents are less likely to have knowledge of HIV prevention, to talk with their parents about sexual issues, or to use contraception once sexually active (21,37,38). Furthermore, a study of Filipino adolescents in Los Angeles revealed that knowledge of HIV prevention was not associated with condom use at last intercourse. Rather, high self-efficacy with respect to condom use (i.e., confidence in one’s ability to put a condom correctly on oneself or partner) and carrying condoms was associated with high condom use at last intercourse (39). These findings suggest that traditional variables related to AIDS risk behavior among non-Asian populations may not explain condom use among Filipinos. Future studies should identify determinants of AIDS risk behavior among Filipinos as a first step toward developing culturally relevant AIDS prevention programs for these groups. For example, research examining communication about sex in Filipino families revealed that respect for parental authority directly conflicts with open discussions with children that are promoted in U.S. culture. Recognizing generational differences in acculturation that may lead to impaired transmission of values may be important in developing interventions addressing adolescent sexual health (38).
Tobacco use and substance abuse
Filipino adolescents have prevalence rates similar to those of whites for inhalant, tobacco, and alcohol use (40). Multiple studies that include API subgroup analyses show that Filipinos use alcohol, tobacco, and drugs at rates that are much higher than previously reported from surveys that aggregate APIs and thus probably have an unrecognized need for treatment (41,42).
Substance abuse in Filipino youth also appears to be related to mental health problems. A study in San Francisco found that Filipinos attribute taking drugs to feeling isolated and depressed shortly after immigrating to the United States and indicate that gang members initiate other youths into drug use (42). Among Filipino adolescent females in California, cigarette smoking is associated with depression and low self-esteem. In contrast, alcohol use is associated with high self-esteem in Filipino males (43).
Injury and violence prevention
A study in Hawaii revealed that Filipino parents have had to alter their child management style in the United States. Although they are less likely to exhibit verbally and physically aggressive behavior toward their children than Polynesian American parents, Filipino parents are faced with the need for more direct parental involvement than was customary in the Philippines, where the extended family shared in the training and discipline of children (44).
Several studies conducted with small samples of Filipinos show differences in self-esteem and depression scale scores based on sex and immigration status. In Hawaii, Filipino females have higher mean depression scores than Filipino males, as measured by the Center for Epidemiologic Studies Depression Scale (45). Research from the Children of Immigrants Longitudinal Study reveal that low self-esteem was associated with being Filipino (46). Similar findings were supported in a separate qualitative study in two California cities (47). This study found that when asked what it means to be Filipino, the most prevalent response consisted of statements about family as the center. The family can offer a positive base of Filipino identity for Filipino youth; however, it also is a source of stress and alienation that has been associated with depression and suicidal thoughts. Interviews in high schools revealed that counselors were “concerned about the mental health of Filipino students as a group” because they are averse to seeking counseling for fear that their parents will find out (47).
Relevant diseases in Filipino adults
It is imperative to consider adult diseases among Filipinos so that preventive measures can be started in childhood. Given the relatively limited data on Filipino children’s health, examining diseases of Filipino adults provides some insight regarding the prevalence of certain conditions that may be higher among Filipino children than children of other races. For example, Filipino adults have a higher prevalence of diabetes and hypertension than whites and other API subgroups (48-51).
The use of BMI to define overweight and obesity across populations has been questioned in numerous studies because the relationship between BMI and risk for diabetes, hypertension, and metabolic syndrome in the Filipino adult populations differs from that in white populations (52,53). For example, compared with white women, Filipino women have a higher prevalence of diabetes and metabolic syndrome despite the fact that 90% of Filipino women were not defined as obese (54). This study suggests that the high prevalence of diabetes in Filipinos may be missed by health care providers because they are not obese by Western standards.
Our literature review yielded two important findings. First, it identified disparities in Filipino child health and health care, a critical first step because considering social and cultural factors that influence health and health care can help us to begin to understand these disparities. Some factors may be protective in terms of health outcomes or they may increase risk. Second, we identified areas of Filipino child health in need of more research.
Filipino children and adolescents: health disparities do exist and health care disparities remain to be determined
Our literature review suggests that disparities in Filipino child and adolescent health do exist and are notable with regard to gestational diabetes, neonatal mortality and low birth weight, malnutrition, overweight, physical inactivity, tuberculosis, dental caries, and substance abuse. In addition, there is a high prevalence of diabetes, hypertension, and metabolic syndrome among Filipino adults, which is significant because of growing evidence that these diseases are affected by events during gestation and early childhood (55,56) and by health-related behavior that is established in childhood and adolescence, such as eating preferences, exercise patterns, and tobacco use (56).
Factors that may contribute to health disparities for Filipino children
Social and cultural factors appear to play an important role in the health of Filipino children. Fundamental values in Filipino culture include respect for authority figures, pakikisama, and hiya (57). In general, Filipino adolescents are less willing than white adolescents to openly disagree with their parents, and they place less emphasis on autonomy (58). Pakikisama (family unity and closeness) emphasizes smooth interpersonal relationships and reflects a high value on family, harmony, and conflict avoidance (57). Filipinos often focus on child-rearing practices that develop group-oriented behaviors in their children, whereas mainstream U.S. culture often emphasizes independent, individualistic, and self-reliant behaviors. Hiya is shame and is a motivating factor behind behavior. Filipino culture, like other Asian cultures, holds that a child’s behavior is a reflection of family upbringing. This cultural perception may explain a delay in seeking services for stigmatized problems, such as teen pregnancy and mental illness (59-62).
Lack of communication and cultural understanding between Filipino youths and their parents may be a source of intergenerational conflict, especially during adolescence when Filipino youths may become more assertive because of their Western acculturation towards individuality (63). Intergenerational conflict may affect where a child or an adolescent receives help and support. In an unpublished survey of 254 Filipino youths aged 15 to 17 years in Vallejo, California, 65%–85% felt their parents would not be supportive if they were aware of an alcohol or drug problem or unwanted pregnancy. Also, 76% knew of no place in the Filipino community where they would feel safe seeking help with personal problems (47). This finding is of special concern given the empirical evidence that depression affects Filipino youths and that adolescent health risk behaviors increase with each generation of Filipino youth. These behaviors include early sexual activity, nonuse of birth control, delinquency, use of violence, and substance abuse (12).
The cultural and social factors presented are meant to increase awareness. However, given the heterogeneity of this group (i.e., variability in immigration history and demographics), it is important never to assume that every Filipino family adheres to particular values.
There are inadequate data to allow for any firm conclusions regarding disparities experienced by Filipino children and adolescents in the areas of health care access, use, and quality; injury and violence prevention; chronic conditions such as asthma; and mental illness. Filipinos and other API subgroups need to be included in research in these areas so that we can determine where disparities exist and monitor progress in addressing these disparities over time (2,64). In addition, the quality of data must be examined by developing valid and reliable research instruments for use with this population. Measures used with other immigrant groups can be modified. For example, a Short Acculturation Scale for Hispanics has been cross-culturally validated for use with Filipino adults, and the Center for Epidemiologic Studies Depression Scale and State-Trait Anxiety Inventory has been evaluated for use in Filipino adolescents (65-67). When collecting data, researchers need to know immigration status variables such as whether subjects are first or second generation immigrants and the time subjects have been in the United States (68).
Finally, interventions need to be designed to achieve equity in health and health care for Filipino youths. Whenever possible, the strengths of Filipino communities (i.e., emphasis on family and interpersonal relationships) should be used. Some interventions have been implemented. For example, the National Institutes of Health (NIH) National Heart, Lung, and Blood Institute funded a community-based partnership to investigate health practices related to cardiovascular disease in the Filipino community (69). Currently, the NIH National Center on Minority Health and Health Disparities is funding a project that is using community-based participatory research (i.e., research that encourages investigators and community members to collaboratively answer questions posed by the community, collect data locally, and communicate results directly to the community for its use ) to improve health care access and health status for cardiovascular disease for Filipino Americans with hypertension living in New York City (70). Similar community-based participatory research has been described in the area of teen pregnancy prevention in Filipino families (38,59).
Clinical care implications
The social and clinical factors discussed here have significant implications for Filipino children who depend primarily on their parents to access and receive appropriate medical services. For example, health screening and education for stigmatized problems (e.g., tuberculosis) need to take cultural beliefs such as hiya into consideration (62).
For those who care for Filipino adolescents, discussing and assuring confidentiality may assist in getting these young people to open up about their problems. Both physical and mental health care practitioners can help parents develop communication skills for interacting with their often more acculturated children. Cross-cultural awareness can bridge the intergenerational and intercultural gaps between parents and children and facilitate the development of a bicultural identity (71). Increased ethnic identity and a greater appreciation of the struggles of immigrant families could improve intergenerational communication and lead to increased self-esteem and fewer risk behaviors among youths, a perspective with some empirical support (59,73,74).
To address the Healthy People 2010 goals for APIs, health services research needs to include API subgroups. On the national level, APIs can be oversampled in national surveys such as the National Health and Nutrition Examination Survey. On the state and local level, increased funding should be made available for regions where there are substantial numbers of APIs (67). For example, the California Health Interview Survey conducted by the Center for Health Care Policy at the University of California, Los Angeles, is the first large-scale state survey to include API subgroups (75).
The need for cultural sensitivity and culturally effective care will only increase as health providers attempt to meet the needs of an increasingly racially diverse population (76,77). Proposed bills requiring cultural competency should be supported and such training should include information on Filipinos as well as other API subgroups.
The year 2006 marked the centennial anniversary of the start of Filipino immigration to the United States. Despite their long history in the United States, Filipinos are understudied in medical research. This review reveals that Filipino children and adolescents are an important, yet hidden, minority group with multiple health needs. Since APIs are the fastest growing minority group within the United States, it is imperative that we address gaps in knowledge for all API subgroups. After understanding their health needs and recognizing their social and cultural strengths, we can then develop culturally appropriate interventions that work toward the goal of a healthier Filipino population with an improved quality of life.