Cultural Beliefs on Disease Causation in the Philippines PDF

J Community Genet (2014) 5:399–407 DOI 10.1007/s12687-014-0193-1 COUNTRY REPORT Cultural beliefs on disease causation in the Philippines: challenge and implications in genetic counseling Peter James B. Abad & Michael L. Tan & Melissa Mae P. Baluyot & Angela Q. Villa & Gay Luz Talapian & Ma. Eloui...

J Community Genet (2014) 5:399–407 DOI 10.1007/s12687-014-0193-1 COUNTRY REPORT Cultural beliefs on disease causation in the Philippines: challenge and implications in genetic counseling Peter James B. Abad & Michael L. Tan & Melissa Mae P. Baluyot & Angela Q. Villa & Gay Luz Talapian & Ma. Elouisa Reyes & Riza Concordia Suarez & Aster Lynn D. Sur & Vanessa Dyan R. Aldemita & Carmencita David Padilla & Mercy Ygona Laurino Received: 9 January 2014 / Accepted: 29 June 2014 / Published online: 16 July 2014 # Springer-Verlag Berlin Heidelberg 2014 Abstract The provision of culturally competent health care is indigenous as well as imported and borrowed elements. As part an important professional issue recognized by the pioneer genetic of this endeavor, we will describe in this paper seven common counselors in the Philippines. Being an archipelago consisting of Filipino cultural beliefs: namamana, lihi, sumpa, gaba, pasma, 7,107 islands, the Philippines has approximately 175 namaligno, and kaloob ng Diyos. We will also share examples ethnolinguistic groups with their own unique cultural identity on how these common beliefs provide explanation as cause of and health practices. The emphasis on culture in our genetic illness and its implications in our genetic counseling profession. counseling training recognizes its crucial role in molding an individual’s conceptualization of health, as well as other life Keywords Cultural beliefs. Philippines. Genetic counseling aspects, especially since the Filipino culture is a mixture of P. J. B. Abad Introduction College of Nursing, University of the Philippines Manila, Manila, Philippines In the field of genetic counseling, cultural sensitivity and com- M. L. Tan petence remain to be major concerns in clinical practice and College of Social Sciences and Philosophy, University of the research primarily because the client base of genetic counselors Philippines Diliman, Quezon City, Philippines comes from diverse cultural backgrounds and ethnicities. In the United Kingdom, for example, transcultural genetic counseling P. J. B. Abad (*) : M. M. P. Baluyot : A. Q. Villa : G. L. Talapian : M. E. Reyes : R. C. Suarez : A. L. D. Sur : V. D. R. Aldemita : service is instituted to provide culturally appropriate genetic C. D. Padilla : M. Y. Laurino counseling to patients coming from various cultural backgrounds Department of Pediatrics, College of Medicine and Philippine (e.g., Asian and culturally deaf patients) (Karbani 2002; General Hospital, University of the Philippines Manila, Manila, Middleton et al. 2007). Being an archipelago consisting of Philippines e-mail: [email protected] 7,107 islands, cultural influence in the Philippines is important to recognize given the existence of 175 ethnolinguistic groups M. E. Reyes : R. C. Suarez : C. D. Padilla each with their own unique cultural identity and health beliefs Newborn Screening Reference Center, National Institutes of Health, and practices (Summer Institute of Linguistics 2012). University of the Philippines Manila, Manila, Philippines Culture is defined as the “totality of socially transmitted M. M. P. Baluyot : A. Q. Villa : A. L. D. Sur : C. D. Padilla : pattern of thoughts, values, meanings, and beliefs” (Purnell M. Y. Laurino 2005). It is not limited to any specific ethnic group, geograph- Institute of Human Genetics, National Institutes of Health, University ical area, language, religious belief, manner of clothing, sex- of the Philippines Manila, Manila, Philippines ual orientation, and socioeconomic status (Fisher 1996). In G. L. Talapian Revisiting usog, pasma, and kulam, Tan explains that “culture Department of Obstetrics and Gynecology, St. Luke’s Medical is inscribed in our bodies and in our minds” (Tan 2008). As Center, Quezon City, Philippines such, the relationship of culture and health is important to M. Y. Laurino understand as it impacts an individual’s worldview and Institute for Public Health Genetics, University of Washington, decision-making process (Purnell 2005). Like in other fields Seattle, USA of medicine, the impact of cultural beliefs is increasingly 400 J Community Genet (2014) 5:399–407 being recognized as an essential component in the genetic with an in-depth discussion of the EM of illness. Rather, EM counseling process (Cohen et al. 1998; Edwards et al. 2008; was used to facilitate the exploration of the abovementioned Penn et al. 2010). seven common Filipino cultural beliefs. Cultural awareness is a prerequisite prior to achieving cultural competency. It is the understanding that a cultural divide exists between the patient and health professional Filipino cultural beliefs (Winkelman 2009). Though challenging to always be cogni- zant to cultural awareness, Abad (2012) suggests that the use Seven common Filipino cultural beliefs are presented in this of explanatory models (EM) of illness could facilitate this paper—namamana, lihi, sumpa, gaba, pasma, namaligno, and task. It provides a framework on the understanding of a patient kaloob ng Diyos. Table 1 presents the Filipino words depicting on the cause of his/her illness, and this may include the the cultural beliefs and their corresponding English translation. meanings and values he/she associates with the condition (Winkelman 2009; Kleinman et al. 1978). Eliciting the EM Namamana of genetic illnesses is an important first step since it ensures that the patient and the health care provider (e.g., genetic BA, a 6-year-old girl, was first brought to clinic due to counselor) are communicating in the same contextual frame- the prompting of her school teacher. She was observed work, thus minimizing the cultural barrier that initially exists to be of significant short stature when compared to her between the two (Winkelman 2009; Abad 2012). peers. However, no pediatric genetics consults were In a way, our popular understanding about health is linked previously pursued because short stature was said to to our natural environment and history. As a result, the Filipi- be “namamana” in their family. During her evaluation no culture has evolved as a mixture of indigenous as well as with a medical geneticist, she was diagnosed to have imported and borrowed elements. There is a combination of achondroplasia. The family was shocked upon hearing pre-colonial folk traditions with Catholic religious concepts this information. brought during the Spanish colonization in the fifteenth to Namamana is the Filipino language translation of acquir- eighteenth century, while the cosmopolitan elements are asso- ing a behavioral or disease trait from a parent. It is a belief that ciated with Western allopathic medicine shared by the Amer- when a relative has the condition, it is possible that he/she will icans in the late eighteenth century until present times. As pass on the trait to the younger generation. In a study con- such, each of us has our own context of experiences which ducted to explore the Filipino EM of cleft lip with or without propel us to socially interact, as well as instruct cultural cleft palate found out that the most frequent explanation given practices to succeeding generations. by the respondents as an etiology of the condition is inheri- Since genetic counseling is an emerging field in the Philip- tance (Daack-Hirsch and Gamboa 2010). The concept of pines, it is an opportune time for us to explore on the common namamana is not limited only to the occurrence of cleft lip cultural beliefs that influence Filipino people’s conceptualiza- with or without cleft palate. Like the case example, genetic tion of genetic conditions with the goal of providing culturally conditions with accompanying physical deformities such as competent genetic counseling services in the country. For this achondroplasia—unano, maliit na tao, and pandak are the paper, our specific objectives are as follows: (1) to discuss colloquial terms—are also explained by namamana. But like seven common Filipino cultural beliefs used to explain a BA’s case, individuals with achondroplasia may not seek number of genetic conditions (i.e., namamana, lihi, medical care to discuss clinical management issues since their sumpa, gaba, pasma, namaligno, and kaloob ng Diyos) short stature is not of concern for the family. and (2) to increase cultural awareness on these seven beliefs so that genetic counselors in the Philippines, and in other parts of the world, are able to provide cultur- Table 1 Filipino word/s depicting cultural beliefs and their English ally appropriate genetic counseling to their clients of translation Filipino descent. To illustrate the concepts of the seven common Filipino Filipino word depicting cultural English translation beliefs cultural beliefs, a brief hypothetical case scenario is used as an introduction for each of the cultural beliefs. Our discussion is Namamana Inheritance limited only to the popular explanation of certain genetic Lihi Conception or maternal cravings conditions, and this likely represents the perspective of the Pasma Hot and cold syndrome major ethnolinguistic groups in the country. It is important to Sumpa and gaba Curse highlight that these common cultural beliefs may not necessar- Namaligno Mystical and supernatural causes ily be the same when compared with the worldview of the Kaloob ng Diyos God’s will Philippines’ indigenous peoples. In this paper, we will not deal J Community Genet (2014) 5:399–407 401 In the Philippines, another example of a disorder believed Among the general public, on the other hand, knowledge of to be namamana is neural tube defects. In an informal discus- inheritance has been shown to be greatly influenced by social sion, parents of children with neural tube defects admitted at a relationship and kinship (Richards and Ponder 1996; tertiary government hospital acknowledged genetic inheri- Timmermans and Wal 2004). For example, in the study of tance as a possible etiology of the condition (Abacan 2011, Richards and Ponder (1996), they found out that lay people unpublished research). They verbalized that birth defects, know more the proportion of shared genes between parents especially those manifesting with physical deformity, are said and offspring compared to a sister, uncle, or grandmother. to be namamana or nasa lahi (in the blood). Although recent They explained that this is attributed to the nearer and more literature suggests that there is conflict in this popular belief of straightforward social relationships between parents and their neural tube defects among women with affected children offspring rather than to a sister (or brother) and uncles (or (personal communication with Dr. M Abacan 2011), the con- aunts). Given the differences on how genetic inheritance is cept of namamana is still an important issue. To explain, understood, we recognize the need to further distinguish the nervous system anomalies such as neural tube defects remain namamana Filipino cultural belief since it provides a glimpse in the top three of the most common birth defects reported per on the understanding of genetic inheritance in the Philippines. 10,000 admissions in a government tertiary hospital (Padilla et al. 2011). Furthermore, this concept is congruent with Lihi published studies reporting the increased recurrence risk when a family member is previously diagnosed to have this condition LC is a 25-year-old female who was seen at the local (Barlow-Stewart 2007). Considering the increased risk of re- health clinic due to flu-like symptoms. During exami- currence associated with neural tube defects, the concept of nation, she was noted to have crab-like arms and legs namamana can be incorporated in the genetic counseling ses- and her family history revealed that both her parents and sion as a factor that could contribute to the occurrence of neural a maternal aunt also have the same condition. No prior tube defects in a succeeding pregnancy. In turn, many parents consultations were pursued due to their family’s belief will ask what methods are available to decrease the recurrence that her maternal grandmother had taken a “lihi” for risk, and this will be an appropriate avenue to explain the value crabs while pregnant, hence giving birth to children with of folic acid supplementation. Anchoring on namamana in crab-like limbs. On consult, she was diagnosed to have public health education campaigns in the promotion of folic ectrodactyly, or split hand and foot malformation. acid supplementation among women of childbearing age may be helpful in improving adherence. Like namamana, lihi is a concept used to explain why Although this concept of namamana can be readily ex- some children are noted to have certain specific characteris- plained in conditions with autosomal dominant inheritance, tics. An ethnographic study done in a municipality in the other conditions with other modes of inheritance may be more Philippines referred to lihi as a term for conception (Jocano difficult to explain using this concept. Especially for conditions 1973), while some literature referred to it as maternal cravings with recessive patterns of inheritance wherein there are no (Daack-Hirsch and Gamboa 2010). During the lihi period, predecessors who have the condition, some Filipinos may find also referring to the first trimester of pregnancy, the pregnant it difficult to grasp the concept since namamana is equated with woman experiences a number of physical discomforts includ- “the passing on of a trait to the younger generation.” Having ing feelings of dizziness, nausea, irritability, and general said this, genetic counselors attempting to explain other pat- weakening of the body (Jocano 1973). It is also during this terns of inheritance might need to use a different approach in time that the pregnant woman develops intense craving for people who have this concept of namamana. certain foods and intense liking for certain objects. Studies had previously reported that cultural and lay beliefs The period of lihi is accompanied by a number of beliefs pertaining to genetic inheritance are not consistent with the (Jocano 1973; Tan 2008). It is believed that an offspring will scientific explanation based on Gregor Mendel’s inheritance take the features of the food that the mother has craved for patterns (Richards and Ponder 1996; Solomon et al. 2012). while she is in the lihi period. Like LC’s case, their family is Like in namamana, the admixture of each of the parent’s known by their neighbors as the “family of crabs” since the blood in the offspring gives rise to a trait. Similarly in other children have crab-like arms and legs (Sanchez 2011). As cultures, the Xhosa speakers in South Africa, inheritance was mentioned, it is believed that their condition was brought understood as the passing down of traits possessed by either about by their grandmother’s craving or lihi for crab. In the the father or mother (Solomon et al. 2012). There is a notion perspective of medical genetics, their physical features corre- that the presence of physical resemblance in the offspring can spond to ectrodactyly which is also known as split-hand/split- be attributed to stronger genes. In some instances, inheritance foot malformation. It is a genetic congenital anomaly where referred to the passing of traits by the mother who gave birth to all or part of one or more fingers is absent, and the the child and in no instance that the father contributed to it. hands and feet of people with this condition are 402 J Community Genet (2014) 5:399–407 described as “claw-like” (Durowaye et al. 2011). Anoth- Manifestations of this will depend on where the lamig settles er example of a disorder associated with lihi is lamellar in the woman’s body and results in pasma or the palpable ichthyosis. An affected person manifests dry, thickened, “knots” in muscles or subcutaneous tissues (Jocano 1973; Tan and flaky skin which resembles fish scales. A case on 2008). In post-partum psychosis, or colloquially known two siblings with lamellar ichthyosis was featured in a among Filipinos as nabaliw, the cold elements of lamig or local television program (GMA Network Inc. 2012). hangin settles in the mind causing post-partum depression and Local folks explain the cause as lihi since the mother psychosis disrupting well-being. was reportedly attracted to the look of crocodile skin, In order to prevent entry of cold elements, folk and thus, the children acquired the skin of a reptile. beliefs recommend the following: (a) massage therapy Together with namamana, lihi is an important cultural or hilot to break the knots; (b) avoiding cold environ- belief among Filipinos that explain a number of physical ment, delaying bathing among post-partum mothers, deformities. As discussed, lihi refers to maternal cravings and avoiding certain foods known to be “extremely and this usually occurs during the first trimester of pregnancy cold” or “extremely hot”; and (c) performing pasuob (Jocano 1973). This is similar with antojos, a Mexican belief where a post-partum mother is wrapped in blanket during pregnancy wherein an infant may be born with some while sitting on burnt herbal leaves. In the pasuob, characteristics based on the object of maternal cravings sweat is produced hence eliminating the cold elements (Barragan et al. 2011). (Maciocia 1998). Comparing with other belief systems, pasma is similar to Pasma the Chinese concept of yin and yang. Yin and yang refers to the balance between the two opposite, complementary, interde- MP is a 30-year-old female who had just delivered her pendent forces of nature (Tang et al. 2008). Disease occurs first child via a caesarian section. The delivery was when there is an imbalance in the yin-yang, flow of the blood, complicated by severe blood loss and late post-partum or disharmony between the natural elements of hot and cold hemorrhage, requiring several blood transfusions and (Low and Ang 2010). Among Chinese-Australians, a recur- prolonged hospital stay. Fourteen days post-partum, ring belief about the cause of cancer is an imbalance of the yin the patient complained of uncontrollable emotions. and the yang (Yeo et al. 2005). The similarities between She was admitted with the impression of post-partum pasma and yin-yang can probably be explained by Chinese psychosis. Assessment revealed a family history of de- influence to the Filipino’s belief system as a result of active pression disorder. During admission, a family member trade and social relations between the two that started even asks, “Kaya po ba siya nagkaganyan ay dahil po ba sa before the Philippines’ colonial era (before 1500s) (Doeppers pagligo niya pagkatapos manganak?” (Free translation: 1972). Pasma is also quite similar with the Mexican cultural Is the reason for her condition a result of her taking a belief of cuarentena which refers to the 40-day period bath after giving birth?). And, a family member an- following birth wherein the mother was prohibited from swers, “Siguro napasok siya ng lamig?” (Free transla- taking a bath to prevent becoming cold so that she may tion: Probably, a cold air entered her body?). recover from childbirth easily and to prevent chronic illness (Barragan et al. 2011). Pasma and cuarentena The interaction of hot and cold elements is the basis of the can both have Spanish roots since the two countries pasma concept (Tan 2008), and this is evident in MP’s case were once Spanish colonies. It can also be attributed example. Pasma is roughly defined as an “exposure illness” to the trade and cultural exchange between the two which occurs when a condition considered to be “hot” is countries in 1500s–1800s as both are the end points of attacked by a “cold” element and vice versa (Tan 2008). An the Manila-Acapulco galleon trade (Bjork 1998). individual’s homeostasis is attained by a balance between the hot and cold elements, and an illness is caused by a dominance Sumpa and gaba of either hot or cold. Specifically, childbirth and the process of delivering a baby are considered by the Filipino folk belief as AS, a 12-year-old girl, is noted to have baldness and “dangerously hot” in nature (Tan 2008). This means that a senile appearance, and her mother shared that these woman who recently gave birth should not be exposed in hot features started when she was 5 years old. At her genet- environment and must not eat “hot” foods because these ics consult, she was diagnosed to have Progeria and was would just aggravate her condition (Tan 2008). Similarly, featured in the local media. Her father referred to her as she should not be exposed to extremely cold environment “sumpa” of the family. Her mother narrated that her (e.g., taking a bath). It is a belief that childbirth leaves the husband would always beat AS and blamed her for their woman with open pores making the mother susceptible to the life struggles. This became habitual and her mother entrance of “lamig” or “hangin” which are elements of cold. decided to take AS and her younger sisters away. J Community Genet (2014) 5:399–407 403 GV is a 33-year-old married woman who sought Namaligno consult at the cancer genetics clinic due to changes in bowel movement and sudden weight loss. She JH, a 28-year-old female, was admitted in the emergen- was diagnosed with colon cancer, and her family cy room for severe abdominal pain and increased ab- history is significant for multiple members with dominal girth. Physical examination and series of diag- previous diagnosis of cancer (e.g., kidney, endo- nostic tests revealed that she has ovarian cancer. She had metrial, renal, and liver cancers). With resignation, several prior consultations with a traditional healer who the patient shared during the clinic visit that the told her that the increase in abdominal girth was due to a cancers in the family are due to “gaba.” “maligno” or a supernatural being who took fancy at her. Her family history showed that her mother and Sumpa and gaba are beliefs in the Filipino culture two maternal aunts died of early-onset breast and pertaining to a curse. In sumpa, the curse is inflicted by a ovarian cancers. human being. Like in AS’s case, she is seen as a curse in the family and explains why they are poor. In contrast, gaba is a Beliefs in supernatural beings are widespread in the Phil- curse inflicted by a divine being and it is usually God. This is ippines. Specifically, namaligno is a Filipino belief that a inflicted to a person because he/she committed a social sin. disease is caused by an intervention of a supernatural or a Like GV, the medical family history is noted to have numerous mystical being (Abad 2013). A genetic condition which has cases of cancer because of the belief that their ancestors were been associated with having a mystical etiology is Marfan not giving back to the community. This means that their syndrome. In an informal interview, the respondents verbal- family is perceived to be “business sharks” and exploits the ized that a person with Marfan syndrome looked like a kapre, less fortunate. Gaba is predominantly a belief of Filipinos in a mythical tree giant of Philippine folklore. A kapre is a dark the central islands of Visayas. giant who likes to smoke huge rolls of cigars and hide within The impact of sumpa and gaba is shared with the whole and atop large trees such as an old acacia and mango trees. A family and extends to the next generation (Tan 2008). To end person with Marfan syndrome was said to be born of a mother its effect, the inflicted person and family members may pursue who was impregnated by a kapre. The kapre must have ritualistic activities and wear amulets. been in love with the mother and sneaked into her bed Gaba and sumpa are two interrelated concepts. As when the father was out or asleep. Another theory was discussed earlier, gaba is a curse that is inflicted by a that the kapre possessed the husband, thus impregnating higher being when one commits a social wrongdoing. the wife with his own physical characteristics, such as Sumpa, on the other hand, is a curse that is inflicted by long limbs and hands. another human being, i.e., when one does foul things to Usually, namaligno is used as an explanation in conditions another who is capable of inflicting a curse. The usual which remain to be mysteries because of the absence of an scenario is a person or a member of a family is cursed apparent cause. One of this is the occurrence of sudden because a wrongdoing was committed to the person unexpected nocturnal death syndrome (SUNDS) which is who inflicted the curse, which is used as a form of common in the Philippines (Gervacio-Domingo et al. 2007). vengeance or retribution. Gaba is a cultural belief that Locally, it is known as the bangungot. Current literature about is quite similar with the concept of bad karma. bangungot refers to it as the Brugada syndrome, but this is still A belief of the Buddhists, bad karma is said to have contentious because of lack of molecular and genetic studies afflicted a person when his/her illness is a result of a to prove this claim (Gaw et al. 2011). Filipino folklore tells misdeed in the present or previous life (Kaufman 2005). that the cause of bangungot as a deed of a mythical creature Aside from yin and yang imbalance, a number of called batibat, a huge dark monster covered with thick black Chinese-Australians believe that bad karma can cause hair. Batibat is known to attack unsuspecting victims at night, cancer in the family (Yeo et al. 2005). Bad karma has oftentimes, torturing them by sitting on their chest until the also been comprehensively documented as a perceived victims helplessly gasps for his breath eventually succumbing cause of astrocytoma in an adolescent of Cambodian to death. It is important to note that bangungot is described descent (Eisenbruch and Handelman 1990). Like gaba, similar to nightmares, and it is oftentimes accompanied by sumpa has been attributed as a cause of cancer. In a tightening of the chest. study of South Asian immigrant in Canada, it is found that among various explanations for the occurrence of Kaloob ng Diyos cancer which include negative influence of lifestyle, many women attributed cancer as being inflicted by CA is a 33-year-old who came for genetic counseling other persons, usually in the form of curses (Johnson because of recurrent pregnancy loss. She is a gravida 7 et al. 1999). para 0 wherein all pregnancies terminated before 12- 404 J Community Genet (2014) 5:399–407 week age of gestation as early embryonic demise or child. This acceptance aids in the better understanding blighted pregnancy. When her psychosocial status was of genetics concepts and eventually in the whole genetic assessed, her acceptance of the situation was embodied counseling process. with the belief in God’s will. She was asked how she was coping with the losses and she responds “Siguro, kaloob ng Diyos ito.” (Free translation: Perhaps it is God’s will that all these happened). Implications in genetic counseling Kaloob ng Diyos means God’s will. When a Filipino Previous research has shown that cultural beliefs and patient’s individual experiences an unexpected event in their life, explanatory models of illness may influence their understand- whether negative or positive, it is typically attributed to ing of their condition, how they decide regarding medical the grace of God. This concept helps families cope and management and treatment options, and how they cope with accept their life experiences. It provides access to per- the condition (Bailey et al. 2000; Barlow-Stewart et al. 2006; sonal empowerment and hope to families. As a means Barragan et al. 2011; Shyu et al. 2010). Thus, awareness of for coping, this concept allows affected families to cultural beliefs and acknowledgment of personal and patient’s emotionally move toward acceptance. cultural context have been recommended in order to have It is common among Filipinos, especially those de- successful genetic counseling consultations and positive pa- vout to their religion, to surrender their problems to a tient outcomes (Sussner et al. 2011; Sussner et al. 2010; higher being, usually God. This highlights the Filipino Zimmerman et al. 2006). In this paper, we provided an over- value of religiosity and faith to a higher being, as view of the seven common cultural beliefs in the Philippines someone who is all-knowing and almighty. This, how- that are relevant in the practice of genetic counseling. More- ever, should not be seen as a weakness on the part of over, we emphasize that these cultural beliefs of disease the patient but willingness to offer his/her predicament causation are not uniquely present in the Philippine society. to God to attain a higher level of enlightenment. This is As discussed, there are similar beliefs that are being held onto quite similar to the Filipino attitude of bahala na. For by other cultures. both kaloob ng Diyos and bahala na, what actually In general, Foster (2014) suggested that disease etiologies happens is that people do whatever they can and then in the non-Western world can be categorized into naturalistic resign themselves to whatever will happen (Tan 2008). or personalistic. Naturalistic disease etiologies stem from nat- This attitude recognizes the limitations of the human ural causes or elements like hot, cold, and balance of body being such that the intercession of a higher being is systems. Personalistic disease etiologies, on the other hand, sought when humanly skills are not enough to overcome can be explained by an “active, purposeful intervention” of an a problem. agent who can be another human being, a spirit, or a super- God’s will or kaloob ng Diyos is an almost universal natural entity (Foster 2014). On this note, pasma can be explanation of disease causation. It has been documented as categorized under the naturalistic causes while sumpa, gaba, a perceived cause of cancer among Arab-Americans (Mellon namaligno, and kaloob ng Diyos fall under the personalistic et al. 2013) and Chinese-Australians (Yeo et al. 2005), dis- etiologies. Namamana and lihi can be vaguely categorized as ability among Somali immigrants in the USA (Carrie et al. naturalistic because neither of them is caused by imbalance of 2001), cleft lip with or without cleft palate among Filipinos natural elements; rather they are caused by inheriting a trait (Daack-Hirsch and Gamboa 2010), childhood genetic disor- from a parent and maternal impression, respectively. ders like albinism, club foot, cleft lip, and cleft palate among The personalistic disease etiologies of sumpa, gaba, and South African grandmothers (Penn et al. 2010), and disease in namaligno are important for health professionals because general among South Asian immigrants in the USA (Tirodkar these are the usual reasons why Filipino patients seek the help et al. 2011). While it may be possible that religious beliefs of a traditional folk healer. The current health system of the including God’s will may become a barrier in seeking medical Philippines is an example where “dual consultation” or the help, this is not always the case. In a study on African- simultaneous access to both traditional and Western medicine American women and their uptake of genetic testing found (Penn et al. 2010) is being practiced. Like in the namaligno that women’s relationship with God may influence their deci- case example, the role of the traditional folk healer as part of sion to participate in genetic risk assessment and testing the informal health sector is emphasized. It is a common (Hughes et al. 2003). As a personal observation, this belief practice especially among Filipinos in the rural areas to ini- in God’s will is actually even helpful in the acceptance of the tially seek advice from the traditional folk healers. As a result, genetic condition. Some parents indicate that their child they influence the concept of disease causation and the deci- was “God-given” including their genetic condition. As sion making of the patient, and it may lead to a situa- such, they come to terms with the diagnosis of their tion in which a patient’s condition may worsen due to J Community Genet (2014) 5:399–407 405 the delay of clinical diagnosis and pursuance of the our rich diversity and it can also be seen as a challenge toward recommended clinical management. better health when the health care provider and the patient are Indeed, the strong influence of culture on an individual’s coming from different perspectives. Genetic counselors can understanding of genetic conditions is partly attributed to the use the Kleinman’s explanatory models of illness to elicit minimal or even non-existent basic comprehension of genetic cultural health beliefs and practices in the clinical setting. terminologies and concepts (Abad 2012). This limited knowl- Kleinman’s framework consists of eight questions surround- edge on genetic concepts is not only a concern in developing ing the client’s perceived etiology, pathophysiology, treat- countries like the Philippines. There are a number of studies in ment, and management modality for a given condition developed countries which suggests that there are still a num- (Kleinman et al. 1978). ber of popular concepts about genetics that are not congruent Once cultural health beliefs and practices are known, inter- with the perspectives of the biomedical model (Christensen ventions can be properly instituted so that despite these be- et al. 2010; Molster et al. 2009; Richards and Ponder 1996; liefs, genetic counselors can ensure that surveillance, manage- Shaw and Hurst 2008; Smerecnik et al. 2008; Timmermans ment, and other medical recommendations are done. For and Wal 2004). The findings of these studies point to a need example, in the Witness Project, cultural health beliefs were for more initiatives that will improve the general public’s used as interventions to improve the uptake of mammography genetic literacy. Genetic counselors should provide culturally among African-American women (Bailey et al. 2000). In this sensitive and appropriate materials when providing genetics community-based program, focused group discussions were education, whether in the clinical setting, in the classroom, or done to elicit existing cultural health beliefs of African- in the public setting. It should be written and conveyed in a American women on cancer. Cultural health beliefs elicited language that is understandable by the intended audience among others include the fatalism attitude toward cancer, that (George 1998; Richards and Ponder 1996). it is a punishment from God, and the stigma that comes with In order to provide a truly culturally sensitive and compe- the diagnosis of cancer. In the project, these issues were tent genetic counseling, the genetic counselor must be able to addressed and incorporated in the messages and educational build trust and rapport with their clients. A study of Mexican materials that were given to participants. They also used role women that dealt with cultural health practices during preg- models to dispel certain misconceptions about cancer and the nancy revealed that women have never disclosed any fatalistic attitude toward it. pregnancy-related cultural health practice to their health care The selected Filipino cultural beliefs discussed in this paper provider because they were afraid that their health care pro- can guide in the provision of psychosocial support as it pro- vider might be dismissive and judgmental of their beliefs vides clues on the coping mechanisms of Filipino patients and (Barragan et al. 2011). Similarly, in a study in Taiwan, parents their families. For example, when a genetic condition appears of children with autism were open to discuss their beliefs in to have no apparent cause, the patient and the family may the supernatural etiology of their child’s condition after a resort to use these beliefs as a form of rationalization to trusting relationship with the researchers have been explain why they are affected. This is also illustrated in the established (Shyu et al. 2010). These highlight the need for study of Barragan et al. (2011) where they suggested that health care providers, and specifically genetic counselors, to cultural health practices may help patients comprehend and be open-minded, non-judgmental, and engaging when it make sense of a disease condition that is otherwise over- comes to their client’s cultural health beliefs and practices. whelming, and to have a perceived sense of control of the Mismatch between the family’s traditional beliefs and the eventual outcomes of the condition. Sometimes, patients may “Western” biomedical model can be a barrier in communica- also resort to these beliefs because these offer an explanation tion and may influence participation in genetics services in- that is external to them which is easier to accept rather than to cluding surveillance, management, and referral to genetic resort to an explanation that is internal to them (i.e., genetic counseling (Barlow-Stewart et al. 2006). Furthermore, with- mutation). For example, when patients are aware of a family out full recognition and consideration of the cultural beliefs history of a probable X-linked condition, they may point to a that surround the client’s and their families’ understanding of a curse that is inflicted upon them to explain why male members genetic condition, a genetic counseling session might be sub- of the family are affected and dying at a young age. Curse, in optimally provided (Cohen et al. 1998). A patient may be this case, is easier for them to accept as an explanation dissatisfied with their genetic counseling session, and this may compared to when provided an alternative explanation of likely lead to poor adherence to the recommended medical genetic mutation because in the former, an intervention can care and negative health outcomes. It should be emphasized be done to somehow stop the cycle of the curse, while in the that the “divergence between the clinician’s and patient’s latter no similar intervention can be instituted. It is also explanations of illness can impede progress toward improving important to recognize that some of these Filipino beliefs are health outcomes” (Daack-Hirsch and Gamboa 2010). Like a embodied in larger sociological and economic factors. Tan double-sided coin, culture can be perceived as the source of (2008) emphasized that bahala na (and, by extension, kaloob 406 J Community Genet (2014) 5:399–407 ng Diyos) are not just forms of fatalism or passive acceptance. Bailey EJ, Erwin DO, Belin P (2000) Using cultural beliefs and patterns to improve mammography utilization among African-American The families of a child with genetic problems will seek profes- women: the Witness Project. J Natl Med Assoc 92(3):136–142 sional medical care but may, early on, invoke bahala na and Barlow-Stewart K (2007) Fact sheet 59 neural tube defects—spina bifida kaloob ng Diyos when they realize they cannot afford the and anencephaly. The Australasian Genetics Resource Book. needed interventions. 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