Filipino Help-Seeking for Mental Health Problems (PDF)

Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 https://doi.org/10.1007/s00127-020-01937-2 REVIEW Filipino help‑seeking for mental health problems and associated barriers and facilitators: a systematic review Andrea B. Martinez1,2 · Melissa Co3 · Jennifer Lau2 · June...

Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 https://doi.org/10.1007/s00127-020-01937-2 REVIEW Filipino help‑seeking for mental health problems and associated barriers and facilitators: a systematic review Andrea B. Martinez1,2 · Melissa Co3 · Jennifer Lau2 · June S. L. Brown2 Received: 3 January 2020 / Accepted: 7 August 2020 / Published online: 20 August 2020 © The Author(s) 2020 Abstract Purpose This systematic review aims to synthesise the evidence on behavioural and attitudinal patterns as well as barriers and enablers in Filipino formal help-seeking. Methods Using PRISMA framework, 15 studies conducted in 7 countries on Filipino help-seeking were appraised through narrative synthesis. Results Filipinos across the world have general reluctance and unfavourable attitude towards formal help-seeking despite high rates of psychological distress. They prefer seeking help from close family and friends. Barriers cited by Filipinos living in the Philippines include financial constraints and inaccessibility of services, whereas overseas Filipinos were hampered by immigration status, lack of health insurance, language difficulty, experience of discrimination and lack of acculturation to host culture. Both groups were hindered by self and social stigma attached to mental disorder, and by concern for loss of face, sense of shame, and adherence to Asian values of conformity to norms where mental illness is considered unaccepta- ble. Filipinos are also prevented from seeking help by their sense of resilience and self-reliance, but this is explored only in qualitative studies. They utilize special mental health care only as the last resort or when problems become severe. Other prominent facilitators include perception of distress, influence of social support, financial capacity and previous positive experience in formal help. Conclusion We confirmed the low utilization of mental health services among Filipinos regardless of their locations, with mental health stigma as primary barrier, while resilience and self-reliance as coping strategies were cited in qualitative stud- ies. Social support and problem severity were cited as prominent facilitators. Keywords Help-seeking · Mental health service use · Barriers and facilitators · Mental health · Filipinos · Philippines Introduction country with the third highest rate of mental health problems in the Western Pacific Region. Suicide rates are pegged Mental illness is the third most common disability in the at 3.2 per 100,000 population with numbers possibly higher Philippines. Around 6 million Filipinos are estimated to live due to underreporting or misclassification of suicide cases with depression and/or anxiety, making the Philippines the as ‘undetermined deaths’. Despite these figures, govern- ment spending on mental health is at 0.22% of total health expenditures with a lack of health professionals working * Andrea B. Martinez in the mental health sector [1, 3]. Elevated mental health [email protected]; [email protected] problems also characterise ‘overseas Filipinos’, that is, Fili- 1 Department of Behavioral Sciences, College of Arts pinos living abroad. Indeed, 12% of Filipinos living in and Sciences, University of the Philippines Manila, Manila, the US suffer from psychological distress , higher than Philippines the US prevalence rate of depression and anxiety. Long 2 Department of Psychology, Institute of Psychiatry, periods of separation from their families and a different cul- Psychology and Neuroscience, King’s College London, tural background may make them more prone to accultura- London, England tive stress, depression, anxiety, substance use and trauma 3 Health Service and Population Research Department, especially those who are exposed to abuse, violence and Institute of Psychiatry, Psychology and Neuroscience, King’s discrimination whilst abroad. College London, London, England 13 Vol.:(0123456789) 1398 Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 One crucial barrier to achieving well-being and improved Eligibility criteria mental health among both ‘local’ and overseas Filipinos is their propensity to not seek psychological help [7, 8]. Not Inclusion criteria for the studies were the following: (1) only are help-seeking rates much lower than rates found in those that address either formal help-seeking behavior OR general US populations , they are also low compared to attitude related to a mental health AND those that discuss other minority Asian groups. Yet, few studies have been barriers OR facilitators of psychological help-seeking; published on Filipino psychological help-seeking either in (2) those that involve Filipino participants, or of Filipino the Philippines or among those overseas. Most available descent; in studies that involve multi-cultural or multi-ethnic studies have focused on such factors as stigma tolerance, loss groups, they must have at least 20% Filipino participants of face and acculturation factors [12, 13]. with disaggregated data on Filipino psychological help- To date, no systematic review of studies on Filipino psy- seeking; (3) those that employed any type of study designs, chological help-seeking, both living in the Philippines and whether quantitative, qualitative or mixed-methods; (4) must overseas, has been conducted. In 2014, Tuliao conducted a be full-text peer-reviewed articles published in scholarly narrative review of the literature on Filipino mental health journals or book chapters, with no publication date restric- help-seeking in the US which provided a comprehensive tions; (5) written either in English or Filipino; and (6) avail- treatise on cultural context of Filipino help-seeking behav- able in printed or downloadable format. Multiple articles ior. However, new studies have been published since based on the same research are treated as one study/paper. which examine help-seeking in other country contexts, such Exclusion criteria were: (1) studies in which the reported as Norway, Iceland, Israel and Canada [6, 14–16]. Alongside problems that prompted help-seeking are medical (e.g. can- recent studies on local Filipinos, these new studies can pro- cer), career or vocational (e.g., career choice), academic vide basis for comparison of the local and overseas Filipinos (e.g., school difficulties) or developmental disorders (e.g., [7, 8, 12, 17]. autism), unless specified that there is an associated men- This systematic review aims to critically appraise the tal health concern (e.g., anxiety, depression, trauma); (2) evidence on behavioural and attitudinal patterns of psy- studies that discuss general health-seeking behaviors; (3) chological help-seeking among Filipinos in the Philippines studies that are not from the perspective of mental health and abroad and examine barriers and enablers of their help- service users (e.g., counselor’s perspective); (4) systematic seeking. While the majority of studies undertaken have been reviews, meta-analyses and other forms of literature review; among Filipino migrants especially in the US where they and (5) unpublished studies including dissertations and the- needed to handle additional immigration challenges, study- ses, clinical reports, theory or methods papers, commentar- ing help-seeking attitudes and behaviours of local Filipinos ies or editorials. is important as this may inform those living abroad [10, 13, 18]. This review aims to: (1) examine the commonly Search strategy and study selection reported help-seeking attitudes and behaviors among local and overseas Filipinos with mental health problems; and (2) The search for relevant studies was conducted through elec- expound on the most commonly reported barriers and facili- tronic database searching, hand-searching and web-based tators that influence their help-seeking. searching. Ten bibliographic databases were searched in August to September 2018: PsychInfo, Global Health, Med- Line, Embase, EBSCO, ProQuest, PubMed, Science Direct, Methods Scopus and Emerald Insight. The following search terms were used: “help-seeking behavior” OR “utilization of men- The review aims to synthesize available data on formal tal health services” OR “access to mental health services” help-seeking behavior and attitudes of local and overseas OR “psychological help-seeking” AND “barriers to help- Filipinos for their mental health problems, as well as com- seeking” OR “facilitators of help-seeking” AND “mental monly reported barriers and facilitators. Formal psychologi- health” OR “mental health problem” OR “mental disorder” cal help-seeking behavior is defined as seeking services and OR “mental illness” OR “psychological distress” OR “emo- treatment, such as psychotherapy, counseling, information tional problem” AND “Filipino” OR “Philippines”. Filters and advice, from trained and recognized mental health care were used to select only publications from peer-reviewed providers. Attitudes on psychological help-seeking refer journals. Internet searches through Google Scholar and web- to the evaluative beliefs in seeking help from these profes- sites of Philippine-based publications were also performed sional sources. using the search term “Filipino mental health help-seeking” as well as hand-searching of reference lists of relevant stud- ies. A total of 3038 records were obtained. Duplicates were 13 Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 1399 removed and a total of 2659 records were screened for their of York (https ​ : //www.crd.york.ac.uk/PROSP ​ E RO; ID: relevance based on their titles and abstracts. CRD42018102836). Preliminary screening of titles and abstracts of articles resulted in 162 potentially relevant studies, their full-text Data extraction and quality assessment papers were obtained and were reviewed for eligibility by two reviewers (AM and MC). Divergent opinions on the Data extracted by the main author were crosschecked by a results of eligibility screening were deliberated and any fur- second reviewer (JB). A data extraction table with thematic ther disagreement was resolved by the third reviewer (JB). headings was prepared and pilot tested for two quantitative A total of 15 relevant studies (from 24 papers) published in and two qualitative studies to check data comparability. English were included in the review and assessed for qual- Extraction was performed using the following descriptive ity. There were seven studies with multiple publications data: (1) study information (e.g. name of authors, publica- (two of them have 3 papers) and a core paper was chosen tion date, study location, setting, study design, measurement on the basis of having more comprehensive key study data tools used); (2) socio-demographic characteristics of partici- on formal help-seeking. Results of the literature search are pants (e.g. sample size, age, gender); and (3) overarching reported in Fig. 1 using the PRISMA diagram. A proto- themes on psychological help-seeking behavior and atti- col for this review was registered at PROSPERO Registry of tudes, as well as barriers and facilitators of help-seeking. the Centre for Reviews and Dissemination of the University ELECTRONIC DATABASES IDENTIFICATION PyschInfo (634), Global Health (40), MedLiner (1,1190), Embase (764), EBSCO (7), ProQuest (136), PubMed (15), Science Direct (43), Scopus (10), Emerald Insight (17) and Google Scholar (179) (n = 3,035) Records idenfied through database searching Addional records idenfied through (n = 3,035) Philippine-based publicaons (n = 3) SCREENING Records aer duplicates are removed (n = 2,659) Records excluded due to obviously unmet inclusion criteria as indicated in the tle Records screened via tles and abstracts and abstract such as studies on Mexican (n = 2,659) migrants, editorials, leers-to-the-editor, commentaries, errata (n = 2,497) Full-text arcles excluded, with reasons ELIGIBILITY (n = 138): 60 = No formal help-seeking report Full-text arcles assessed for eligibility 17 = Did not meet minimum number of (n = 162) Filipino parcipants in mul-ethnic studies 17 = Review papers 13 = No disaggregate data on Filipino parcipants in mul-ethnic study 9 = Quantave studies that did not use standardized/validated measures 9 = Medical problems or health care in INCLUDED Studies included in the review: general (n = 15) 5 = Mulple arcles from the same research [NOTE: papers from the same research are 4 = Theory/methods papers treated as one study; total papers = 24] 4 = Not service-user perspecve Fig. 1  PRISMA flow diagram 13 1400 Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 Two reviewers (AM and MC) did quality assessment and friends, perceived severity of mental illness, awareness of the studies separately, using the following criteria: (1) of mental health issues, self-stigmatizing beliefs, treatment relevance to the research question; (2) transparency of the fears and other individual concerns; (2) socio-cultural bar- methods; (3) robustness of the evidence presented; and (4) riers/facilitators, which include the perceived social norms soundness of the data interpretation and analysis. Design- and beliefs on mental health, social stigma, influence of reli- specific quality assessment tools were used in the evalu- gious beliefs, and language and acculturation factors; and (3) ation of risk of bias of the studies, namely: (1) Critical systemic/structural and economic barriers/facilitators, which Appraisal Skills Programme Qualitative Checklist ; include financial or employment status, the health care sys- and (2) Quality Assessment Tool for Quantitative Studies tem and its accessibility, availability and affordability, and by the Effective Public Health Practice Project. The ethnicity, nativity or immigration status. appraisals for mixed-methods studies were done separately for quantitative and qualitative components to ensure trust- worthiness of the quality of each assessment. Results For studies reported in multiple publications, quality assessment was done only on the core papers. All the Study and participant characteristics papers (n = 6) assessed for their qualitative study design (including the 4 mixed-methods studies) met the minimum The 15 studies were published between 2002 and 2018. quality assessment criteria of fair (n = 1) and good (n = 5) Five studies were conducted in the US, four in the Philip- and were, thus, included in the review. Only 11 out of the pines and one study each was done in Australia, Canada, 13 quantitative studies (including the 4 mixed-methods Iceland, Israel and Norway. One study included partici- studies) satisfied the minimum ratings for the review, with pants working in different countries, the majority were five getting strong quality rating. The two mixed-methods in the Middle East. Data extracted from the four studies studies that did not meet the minimum quality rating for done in the Philippines were used to report on the help- quantitative designs were excluded as sources of quan- seeking behaviors and attitudes, and barriers/facilitators titative data but were used in the qualitative data analy- to help-seeking of local Filipinos, while the ten studies sis because they satisfied the minimum quality rating for conducted in different countries were used to report on qualitative designs. help-seeking of overseas Filipinos. Nine studies were quantitative and used a cross-sectional design except for one cohort study; the majority of them used research-val- Strategy for data analysis idated questionnaires. Four studies used mixed methods with surveys and open-ended questionnaires, and another Due to the substantial heterogeneity of the studies in terms two were purely qualitative studies that used interviews of participant characteristics, study design, measurement and focus group discussions. Only three studies recruited tools used and reporting methods of the key findings, nar- participants through random sampling and the rest used rative synthesis approach was used in data analysis to inter- purposive sampling methods. All quantitative studies pret and integrate the quantitative and qualitative evidence used questionnaires in measures of formal help-seeking [26, 27]. However, one crucial methodological limitation behaviors, and western-standardized measures to assess of studies in this review is the lack of agreement on what participants’ attitudes towards help-seeking. Qualitative constitutes formal help-seeking. Some researchers include studies utilized semi-structured interview guides that were the utilization of traditional or indigenous healers as formal developed to explore the psychological help-seeking of help-seeking, while others limit the concept to professional participants. health care providers. As such, consistent with Rickwood A total of 5096 Filipinos aged 17–70 years participated and Thomas’ definition of formal help-seeking , data in the studies. Additionally, 13 studies reported on the extraction and analysis were done only on those that reported mean age of participants, with the computed overall mean utilization of professional health care providers. age at 39.52 (SD 11.34). The sample sizes in the quantita- Using a textual approach, text data were coded using both tive studies ranged from 70 to 2285, while qualitative stud- predetermined and emerging codes. They were then ies ranged from 10 to 25 participants. Of the participants, tabulated, analyzed, categorized into themes and integrated 59% (n = 3012) were female which is probably explained into a narrative synthesis. Exemplar quotations and by five studies focusing on Filipino women. Ten studies author interpretations were also used to support the narra- were conducted in community settings, five in health or tive synthesis. The following were the themes on barriers social centre-based settings and 1 in a university (Table 1). and facilitators of formal help-seeking: (1) psychosocial bar- riers/facilitators, which include social support from family 13  Table 1  Study and participant characteristics Study Participant characteristics Location Setting Methodology Questionnaire used on Quality assessment score help-seeking Abe-Kim et al. (2007) 508 Filipino Americans US Community-based Quantitative Study-specific question- Strong* Supplementary paper: in multi-ethnic study, Cross-sectional study naire on help-seeking Nguyen and Lee (2010) with 53.74% (n = 273) design (derived from sources, need for females and 46.26% National Latino and services, treatment (n = 235) males and Asian American Study, satisfaction mean age of 41.904 (SD 2002–2003) 16.11) Bernardo and Estrellado 70 Filipino women, with Philippines Center-based women Quantitative Help-seeking intention Moderate* (2017) mean age of 39.13 (SD shelters Cross-sectional study scale 9.175) design Locus of hope scale Cabbigat and Kangas 117 Filipinos with 80.34% Philippines Local government, social Quantitative Study-specific question- Moderate* (2017) (n = 94) females and welfare agencies and Cohort analytic study naire on help-seeking 19.66% (n = 23) males non-government organi- design behavior and mean age of 42.66 zations Help-seeking preferences (SD 8.268) Attitudes Towards Ser- vices for Children and Adolescents (parent- Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 report section of the child and adolescent services assessment) David (2010) 118 Filipino Americans US Community-based Quantitative Inventory of attitudes Moderate* with 47.46% (n = 56) Cross-sectional study toward seeking mental females and 52.54% design health services (n = 62) males and Cultural mistrust inven- mean age of 30.20 tory (SD = 10.65) Loss of Face Question- naire Asian value scale Gong et al. (2003) 2285 Filipino Americans, US Community-based Quantitative Study-specific question- Moderate* Supplementary papers: with 50.60% (n = 1156) Cross-sectional study naire on help-seeking Abe-Kim et al., (2004) females and 49.40% design (derived from based on Kleinman , Nicdao et al. (2015) (n = 1128) males and Filipino American (1978) typology of help- mean age of 41.662 (SD Epidemiological Study, seeking sources: lay 13.398) 1995–1999) system, professional care system and folk system Research-designed ques- tionnaire on loss of face Green and Ayalon (2016) 85 Filipino migrant home Israel Community-based Quantitative Study-specific question- Strong* care workers with 86% Cross-sectional study naire on social support, (n = 73) females and design formal and informal 14% (n = 12) males and report of abuse mean age of 37.04 (SD 6.70) 13 1401  Table 1  (continued) 1402 Study Participant characteristics Location Setting Methodology Questionnaire used on Quality assessment score help-seeking 13 Hechanova et al. (2013) 365 overseas Filipino Philippines with Employment agencies Mixed methods using Semi-structured open- Weak*/ Fair** workers with 52.88% overseas Filipino and university-based surveys, interviews and ended questionnaire Supplementary paper: (n = 193) females and participants mostly counseling centers chat conversations Intention to seek Hechanova et al. (2011) 47.12% (n = 172) males in Middle East counseling inventory and mean age of 33.14 (adapted version) (SD 7.72) Hermannsdottir and 209 Filipino immigrants Iceland Community-based Quantitative Psychological help- Moderate* Aegisdottir (2016) with 67% (n = 140) Cross-sectional study seeking attitudes and females and 33% (n = 69) design intentions males and mean age of Beliefs about psychologi- 38.72 (SD 11.33) cal services scale Study-specific question- naire on system barriers Ho et al. (2018) 175 Filipino participants Multi-country study in Community-based Mixed methods using Attitudes and understand- Moderate */Good** for survey and focus Fiji, Cambodia and surveys and focus group ing towards mental group discussion with the Philippines discussions disorder 45.71% (n = 80) females Attitudes Toward Seeking and 54.29% (n = 95) Professional Psychologi- males and mean age of cal Help—Short Form 30.49 (SD 9.70) and semi-structured guide for interview and focus group discussion Semi-structured interview guide for focus group discussion Nguyen (2011) 269 Filipino Americans US Community-based Quantitative Study-specific question- Strong* Supplementary paper: in multi-ethnic study, Cross-sectional study naire Nguyen (2012) with 57.25% (n = 154) design (derived from females and 42.75% California Health Inter- (n = 115) males and view Survey, 2001) mean age of 61.8 (SD 9.9) Shoultz et al. (2010) 10 Filipino American US Women’s support agency Mixed methods using Semi-structured interview Weak* / Good** women with age range surveys, individual inter- guide on help-seeking from 34 to 52 years old views and focus group behavior discussions Perceptions of the Accept- ability of violence Straiton et al. (2018) 14 Filipino women with Norway Community-based Qualitative using in-depth Semi-structured interview Good** Supplementary paper: mean age of 33.7 interviews guide with open-ended Straiton et al. (2017) questions Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413  Table 1  (continued) Study Participant characteristics Location Setting Methodology Questionnaire used on Quality assessment score help-seeking Thompson et al. (2002a) 487 Filipino women par- Australia Community-based Mixed methods using Semi-structured interview Strong*/Good** ticipated with mean age multiple follow-up guide Supplement papers: of 41.034 (SD 11.19) surveys, in-depth inter- General Health Question- Kelaher et al. (2000), views and focus group naire Thompson et al. (2002b) discussions (derived from Filipina cohort of Australian Longitudi- nal Study on Women’s Health, 1996) Tuliao et al. (2016) 359 Filipino university Philippines University-based Quantitative Perceived likelihood of Moderate* Supplementary paper: students with 52.09% Cross-sectional study seeking help (adapted Tuliao and Velasquez (n = 187) females and design version) (2017) 47.91% (n = 172) males Online counselling atti- and mean age of 17.69 tude scale (SD 0.97) Self-stigma of seeking help scale Self-concealment scale Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 Interpersonal support evaluation list Inventory of attitudes toward seeking mental health services Loss of face scale Intent to seek counseling inventory General Help Seeking Questionnaire Vahabi and Wong (2017) 25 Filipino women, Canada Community-based Qualitative Semi-structured focus Good** age range from 25 to Focus group discussion group discussion guide 60 years old *Quality assessment based on the criteria of EPHPP Quality Assessment Tool for quantitative studies **Quality assessment based on the criteria of CASP Qualitative Checklist for qualitative studies 13 1403  1404 13 Table 2  Report on formal help-seeking behaviors Study Reports of formal help-seeking behaviors Outcome measures Quantitative studies Abe-Kim et al. (2007) 2.60% (n = 13) used mental health specialty service and 5.20% (n = 26) Validated research questionnaire from National Latino and Asian Ameri- used general medical provider, or total of 7.68% (n = 39) sought formal can Study help Bernardo and Estrellado (2017) All participants (n = 70) had sought assistance from the women’s shelter Validated research questionnaire Cabbigat and Kangas (2017) 39.32% (n = 46) sought help within 6 to 12 months following their child’s Validated research questionnaire abuse and/or for child/family problems and 46.15% (n = 54) within 18 to 24 months David (2010) No reports on formal help-seeking behavior Gong et al. (2003) 4.42% (n = 101) used the general medical sector only, 0.61% (n = 14) Validated research questionnaire from Filipino American Community relied solely on mental health care system and 0.35% (n = 8) used both Epidemiological Study mental health specialists and general practitioners, or total of 5.38% (n = 123) sought formal help Green and Ayalon (2016) 4.7% reported solely formally, 17.5% (n = 15) reported the abuse experi- Validated research questionnaire ence to a social worker, 8.8% (n = 7) to a nurse or physician Hermannsdottir and Aegisdottir (2016) 12.4% (n = 26) participants had prior counseling experience Validated research questionnaire Nguyen (2011) 2.2% (n = 6) of Filipino participants had sought care from a mental health Validated research questionnaire from California Health Interview Survey specialist Tuliao et al. (2016) 22.19% (n = 79) sought help from mental health professional Standardized measures Qualitative studies Hechanova et al. (2013) 10.68% (n = 39) sought online counseling services mostly through chat Semi-structured open-ended questionnaire and email with an average of 2 sessions Shoultz et al. (2010) Participants were receiving help from an agency that supports victims of Semi-structured interview guide intimate partner violence Straiton et al. (2018) None of the women had sought help for mental health problems Semi-structured interview guide with open-ended questions Vahabi and Wong (2017) Only one participant indicated that she had used a counselor/ psychother- Semi-structured focus group discussion guide apist; participants neither used existing mental health services nor knew what services were available to them Mixed methods Ho et al. (2018) No reports on formal help-seeking behavior Thompson et al. (2002) No reports on formal help-seeking behavior Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 1405 Formal help‑seeking behaviors supported by the findings of Shoultz and her colleagues who reported that Filipino women did not believe in disclosing 12 studies examined the formal help-seeking behaviors of their problems to others. Filipinos (Table 2), eight of them were from community- Local vs overseas Filipinos Filipinos, regardless of loca- based studies and four were from centre-based studies. tion, have negative attitudes towards help-seeking, except Nine studies reported on formal help-seeking of overseas later-generation Filipino migrants who have been accultur- Filipinos and three reported on local Filipinos. ated in their host countries and tended to have more positive attitudes towards mental health specialists [10, 13, 15, 34]. Community-based vs health/social centres Data from quanti- However, this was only cited in quantitative studies. Qualita- tative community studies show that the rates of formal help- tive studies reported the general reluctance of both overseas seeking behaviors among the Filipino general population and local Filipinos to seek help. ranged from 2.2% to 17.5%. This was supported by reports from qualitative studies where participants did not Barriers in formal help‑seeking seek help at all. The frequency of reports of formal help- seeking from studies conducted in crisis centres and online All 15 studies examined a range of barriers in psychologi- counseling tended to be higher. For instance, the rate of cal help-seeking (Table 3). The most commonly endorsed engagement in online counseling among overseas Filipinos barriers were: (1) financial constraints due to high cost of was 10.68% , those receiving treatment in crisis cent- service, lack of health insurance, or precarious employ- ers was 39.32% while 100% of participants who were ment condition; (2) self-stigma, with associated fear of victims of intimate partner violence were already receiving negative judgment, sense of shame, embarrassment and help from a women’s support agency [8, 32]. being a disgrace, fear of being labeled as ‘crazy’, self- blame and concern for loss of face; and (3) social stigma Local vs overseas Filipinos’ formal help-seeking The rate that puts the family’s reputation at stake or places one’s of formal psychological help-seeking of local Filipinos was cultural group in bad light. at 22.19% while overseas rates were lower and ranged from 2.2% of Filipino Americans to 17.5% of Filipinos Local vs overseas Filipinos In studies conducted among in Israel. Both local and overseas Filipinos indicated that overseas Filipinos, strong adherence to Asian values of con- professional help is sought only as a last resort because they formity to norms is an impediment to help-seeking but cited were more inclined to get help from family and friends or only in quantitative studies [10, 13, 15, 34] while perceived lay network [7, 16]. resilience, coping ability or self-reliance was mentioned only in qualitative studies [14, 16, 33]. Other common barriers Attitudes towards formal help‑seeking to help-seeking cited by overseas Filipinos were inacces- sibility of mental health services, immigration status, sense 13 studies reported on participants’ attitudes towards seek- of religiosity, language problem, experience of discrimina- ing formal help. Seven studies identified family and friends tion and lack of awareness of mental health needs [10, 13, as preferred sources of help [7, 14, 16] rather than mental 18, 34]. Self-reliance and fear of being a burden to others health specialists and other professionals even when they as barriers were only found among overseas Filipinos [6, were already receiving help from them [17, 32]. When Fili- 16, 32]. On the other hand, local Filipinos have consistently pinos seek professional help, it is usually done in combina- cited the influence of social support as a hindrance to help- tion with other sources of care or only used when the seeking [7, 17]. mental health problem is severe [14, 16, 33]. Other studies Stigmatized attitude towards mental health and illness reported that in the absence of social networks, individuals was reported as topmost barriers to help-seeking among prefer to rely on themselves [32, 33]. overseas and local Filipinos. This included notions of mental Community-based vs health/social centres Community- illness as a sign of personal weakness or failure of character based studies reported that Filipinos have negative attitudes resulting to loss of face. There is a general consensus in marked by low stigma tolerance towards formal help-seeking these studies that the reluctance of Filipinos to seek pro- [7, 14, 16]. However, different findings were reported by fessional help is mainly due to their fear of being labeled studies conducted in crisis centres. Hechanova et al. found a or judged negatively, or even their fear of fueling negative positive attitude towards help-seeking among users of online perceptions of the Filipino community. Other overseas Fili- counseling , whereas Cabbigat and Kangas found that pinos were afraid that having mental illness would affect Filipinos in crisis centres still prefer receiving help from their jobs and immigration status, especially for those who religious clergy or family members, with mental health units are in precarious employment conditions [6, 16]. as the least preferred setting in receiving help. This is 13 1406 Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 Table 3  Key themes on barriers to formal help-seeking Key barrier themes Studies on local Studies on Total (n = 15) Filipinos (n = 4) overseas Filipinos (n = 11) (A) Systemic, structural and economic barriers 1. Financial constraints (e.g., high cost of service, lack of health insurance, fear of losing 2 10 12 (80%) job, precarious nature of employment) 2. Inaccessibility of mental health services (e.g., lack of familiarity or information on 2 6 8 (53%) available mental health services, different structure of mental health system, lack of time, geographical dispersal) 3. Immigration/Residency status (e.g., nativity, fear of deportation) N/A 7 7 (47%) (B) Socio-cultural barriers 1. Social stigma (e.g., attack on family reputation or negative perception of one’s cultural 2 8 10 (67%) group, preservation of the family’s dignity, fear of social exclusion, being labelled as ‘crazy’) 2. Sense of religiosity (e.g., preference for religious clergy, strong religious belief, reli- 2 6 8 (53%) ance on faith organizations) and/or spirituality 3. Language difficulty (e.g., lack of language proficiency in the host country) 0 6 6 (40%) 4. Adherence to Asian cultural values of conformity; lack of acculturation 1 4 5 (33%) 5. Use of alternative health care (e.g., indigenous healing methods, use of herbal medi- 0 2 2 (13%) cines, consultation with elders in the community) (C) Psychosocial barriers 1. Self-stigma (e.g., concern for loss of face, sense of shame or embarrassment, fear of 2 9 11 (73%) being judged negatively, fear of negative reactions from family or friends, sense of being a disgrace, self-blame, fear of being labeled as ‘crazy’, sense of being weak) 2. Influence of social support/network (e.g., presence of and preference for family and 3 6 9 (60%) friends as source of help, lack of friends to provide influence) 3. Previous negative experience of help-seeking (e.g., experience of discrimination, lack 1 7 8 (53%) of trust on or rapport with healthcare provider) 4. Concerns on confidentiality and privacy, treatment fears e.g., concerns on trustworthi- 2 5 7 (47%) ness or competence of the mental health care provider, effect of medication) 5. Lack of awareness of mental health need (e.g., low perception of distress; normaliza- 1 6 7 (47%) tion of mental health problems) 6. Misconceptions about mental illness (i.e., on nature, causes and effects of mental 2 4 6 (40%) health problems) 7. Sense of self-reliance (e.g., perceived resilience, coping ability, sense of self-respon- 0 3 3 (20%) sibility) 8. Fear of hurting or becoming burden to others 0 3 3 (20%) Facilitators of formal help‑seeking stigma tolerance as enablers of help-seeking [15, 30, 32, 34], while studies done on local Filipinos reported that awareness All 15 studies discussed facilitators of formal help-seeking, of mental health issues and previous positive experience of but the identified enablers were few (Table 4). Among the seeking help serve as facilitator [7, 12]. top and commonly cited factors that promote help-seeking Community-based vs health/social centres Those who are: (1) perceived severity of the mental health problem or were receiving help from crisis centres mentioned that pre- awareness of mental health needs; (2) influence of social vious positive experience with mental health professionals support, such as the presence/absence of family and friends, encouraged their formal help-seeking [8, 17, 31]. On the witnessing friends seeking help, having supportive friends other hand, community-based studies cited the positive influ- and family who encourage help-seeking, or having others ence of encouraging family and friends as well as higher taking the initiative to help; and (3) financial capacity. awareness of mental health problems as enablers of help- seeking [12, 14, 16]. Local vs overseas Filipinos Studies on overseas Filipinos frequently cited financial capacity, immigration status, lan- guage proficiency, lower adherence to Asian values and 13 Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 1407 Table 4  Key themes on facilitators in help-seeking Key facilitator themes Studies on local Studies on Total (n = 15) Filipinos (n = 4) overseas Filipinos (n = 11) (A) Systemic and economic facilitators 1. Financial capacity (e.g., higher socio-economic status, employment status, medical 1 4 5 (33%) insurance, higher income) 2. Immigration/Residency status (e.g., nativity status, being US-born Filipino American, N/A 3 3 (20%) later-generation immigrants) 3. Accessibility of mental health services (e.g., technological access, presence of techni- 0 2 2 (13%) cal infrastructure, perception of ease of use, familiarity with health care services) (B) Socio-cultural facilitators 1. Language proficiency (e.g., bilingualism, proficiency of the language of host culture) 0 4 4 (27%) 2. Lower adherence to Asian cultural values (e.g., higher levels of acculturation/assimila- 0 3 3 (20%) tion) 3. Higher level of spirituality 0 2 2 (13%) (C) Psycho-social facilitators 1. Perception of distress (e.g., awareness of mental health need; higher severity of mental 2 5 7 (47%) health problems) 2. Influence of social support (presence/absence of family and friends, witnessing friends 2 4 6 (40%) seeking help, having supportive friends and family who encourage help-seeking, others taking the initiative to help) 3. Self-stigma tolerance (e.g., concern for loss of face, lower/higher tolerance of stigma) 1 3 4 (27%) 4. Previous experience in help-seeking (e.g., positive experience with mental health 2 2 4 (27%) professionals, establishing rapport with mental health providers) 5. Higher awareness of mental health issues 2 0 2 (13%) 6. Sense of anonymity 1 1 2 (13%) Discussion minorities but is in sharp contrast with the increased use of professional help among West African migrants in The To the best of our knowledge, this is the first systematic Netherlands. review conducted on psychological help-seeking among Most of the studies identified informal help through fam- Filipinos, including its barriers and facilitators. The hetero- ily and friends as the most widely utilized source of support, geneity of participants (e.g., age, gender, socio-economic while professional service providers were only used as a status, geographic location or residence, range of mental last resort. Filipinos who are already accessing specialist health problems) was large. services in crisis centres also used informal help to sup- plement professional help. This is consistent with reports Filipino mental health help-seeking behavior and attitudes on the frequent use of informal help in conjunction with The rate of mental health problems appears to be high among formal help-seeking among the adult population in UK. Filipinos both local and overseas, but the rate of help-seek- However, this pattern contrasts with informal help-seeking ing is low. This is consistent with findings of a study among among African Americans who are less likely to seek help Chinese immigrants in Australia which reported higher psy- from social networks of family and friends. Filipinos chological distress but with low utilization of mental health also tend to use their social networks of friends and family services. The actual help-seeking behavior of both local members as ‘go-between’ for formal help, serving to and overseas Filipinos recorded at 10.72% (n = 461) is lower intercede between mental health specialists and the indi- than the 19% of the general population in the US and vidual. This was reiterated in a study by Shoultz et al. (2009) 16% in the United Kingdom (UK) , and even far below in which women who were victims of violence are reluctant the global prevalence rate of 30% of people with mental to report the abuse to authorities but felt relieved if neigh- illness receiving treatment. This finding is also compa- bours and friends would interfere for professional help in rable with the low prevalence rate of mental health service their behalf. use among the Chinese population in Hong Kong and Different patterns of help-seeking among local and over- in Australia , Vietnamese immigrants in Canada , seas Filipinos were evident and may be attributed to the dif- East Asian migrants in North America and other ethnic ferences in the health care system of the Philippines and 13 1408 Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 their host countries. For instance, the greater use of general health. Despite the recent ratification of the Philippines’ medical services by overseas Filipinos is due to the gate- Mental Health Act of 2018 and the Universal Health Care keeper role of general practitioners (GP) in their host coun- Act of 2019, the current coverage for mental health services tries where patients have to go through their GPs before provided by the Philippine Health Insurance Corporation they get access to mental health specialists. In contrast, local only amounts to US$154 per hospitalization and only for Filipinos have direct access to psychiatrists or psychologists acute episodes of mental disorders. Specialist services without a GP referral. Additionally, those studies conducted for mental health in the Philippines are restricted in tertiary in the Philippines were done in urban centers where par- hospitals located in urban areas, with only one major mental ticipants have greater access to mental health specialists. hospital and 84 psychiatric units in general hospitals. While Filipinos generally are reluctant to seek help, later- Overseas Filipinos cited the lack of health insurance and generation overseas Filipinos have more positive attitudes immigration status without health care privileges as financial towards psychological help-seeking. Their exposure and barrier. In countries where people have access to universal acculturation to cultures that are more tolerant of mental health care, being employed is a barrier to psychological health stigma probably influenced their more favorable atti- help-seeking because individuals prefer to work instead of tude [41, 48]. attending medical check-ups or consultations. Higher income is also associated with better mental health and Prominent barrier themes in help-seeking Findings of stud- hence, the need for mental health services is low, whereas ies on frequently endorsed barriers in psychological help- poor socio-economic status is related to greater risk of devel- seeking are consistent with commonly reported impediments oping mental health problems [57, 58]. Lack of familiarity to health care utilization among Filipino migrants in Aus- with healthcare system in host countries among new Filipino tralia and Asian migrants in the US [47, 50]. The same migrants also discourages them from seeking help. barriers in this review, such as preference for self-reliance Studies have shown that reliance on, and accessibility as alternative coping strategy, poor mental health aware- of sympathetic, reliable and trusted family and friends are ness, perceived stigma, are also identified in mental health detrimental to formal help-seeking since professional help help-seeking among adolescents and young adults and is sought only in the absence of this social support [6, 8]. among those suffering from depression. This is consistent with the predominating cultural values Social and self-stigmatizing attitudes to mental illness are that govern Filipino interpersonal relationships called kapwa prominent barriers to help-seeking among Filipinos. Social (or shared identity) in which trusted family and friends are stigma is evident in their fears of negative perception of the considered as “hindi-ibang-tao” (one-of-us/insider), while Filipino community, ruining the family reputation, or fear of doctors or professionals are seen as “ibang-tao” (outsider) social exclusion, discrimination and disapproval. Self-stigma. Filipinos are apt to disclose and be more open and manifests in their concern for loss of face, sense of shame honest about their mental illness to those whom they con- or embarrassment, self-blame, sense of being a disgrace or sidered as “hindi-ibang-tao” (insider) as against those who being judged negatively and the notion that mental illness are “ibang-tao” (outsider), hence their preference for family is a sign of personal weakness or failure of character. members and close friends as source of informal help. The deterrent role of mental health stigma is consistent with For Filipinos, it is difficult to trust a mental health specialist the findings of other studies [51, 52]. Overseas Filipinos who is not part of the family. who are not fully acculturated to the more stigma-tolerant Qualitative studies in this review frequently mentioned culture of their host countries still hold these stigmatizing resilience and self-reliance among overseas Filipinos as beliefs. There is also a general apprehension of becoming a barriers to help-seeking. As an adaptive coping strategy for burden to others. adversity , overseas Filipinos believe that they were bet- Practical barriers to the use of mental health services like ter equipped in overcoming emotional challenges of immi- accessibility and financial constraints are also consistently gration without professional assistance. It supports rated as important barriers by Filipinos, similar to Chinese the findings of studies on overseas Filipino domestic workers Americans. In the Philippines where mental health ser- who attributed their sense of well-being despite stress to vices are costly and inaccessible , financial constraints their sense of resilience which prevents them from develop- serve as a hindrance to formal help-seeking, as mentioned ing mental health problems and among Filipino disas- by a participant in the study of Straiton and his colleagues, ter survivors who used their capacity to adapt as protective “In the Philippines… it takes really long time to decide for mechanism from experience of trauma. However, self- us that this condition is serious. We don’t want to use our reliant individuals also tend to hold stigmatizing beliefs on money right away” [14, p.6]. Local Filipinos are confronted mental health and as such resort to handling problems on with problems of lack of mental health facilities, services their own instead of seeking help [51, 64]. and professionals due to meager government spending on 13 Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 1409 Prominent facilitator themes in help-seeking In terms of ena- to overcome [16, 72] also discourages Filipinos from seek- blers of psychological help-seeking, only a few facilitators ing help. were mentioned in the studies, which supported findings in Synthesis of the studies included in the review also found other studies asserting that factors that promote help-seeking conflicting findings on various cultural and psychosocial are less often emphasized [42, 51]. influences that served both as enablers and deterrents to Consistent with other studies [44, 49], problem severity Filipino help-seeking, namely: (1) level of spirituality; (2) is predictive of intention to seek help from mental health concern on loss of face or sense of shame; and (3) presence providers [18, 30] because Filipinos perceive that profes- of social support. sional services are only warranted when symptoms have disabling effects [5, 53]. As such, those who are experienc- Level of spirituality Higher spirituality or greater religious ing heightened emotional distress were found to be recep- beliefs have disparate roles in Filipino psychological help- tive to intervention. In most cases, symptom severity seeking. Some studies [8, 14, 16] consider it a hindrance to is determined only when somatic or behavioral symptoms formal help-seeking, whereas others [10, 15] asserted that manifest or occupational dysfunction occurs late in the it can facilitate the utilization of mental health services [15, course of the mental illness. This is most likely due to 73]. Being predominantly Catholics, Filipinos had drawn the initial denial of the problem or attempts at maintain- strength from their religious faith to endure difficult situ- ing normalcy of the situation as an important coping mecha- ations and challenges, accordingly ‘leaving everything to nism. Furthermore, this poses as a hindrance to any God’ which explains their preference for clergy as attempts at early intervention because Filipinos are likely to sources of help instead of professional mental health provid- seek professional help only when the problem is severe or ers. This is connected with the Filipino attribution of mental has somatic manifestations. It also indicates the lack of pre- illness to spiritual or religious causes mentioned earlier. ventive measure to avert any deterioration in mental health On the contrary, Hermansdottir and Aegisdottir argued that and well-being. there is a positive link between spirituality and help-seeking, More positive attitudes towards help-seeking and higher and cited connectedness with host culture as mediating fac- rates of mental health care utilization have been found tor. Alternately, because higher spirituality and religios- among later-generation Filipino immigrants or those who ity are predictors of greater sense of well-being , there have acquired residency status in their host country [10, 15]. is, thus, a decreased need for mental health services. Immigration status and length of stay in the host country are also associated with language proficiency, higher accul- Concern on loss of face or sense of shame The enabler/ turation and familiarity with the host culture that are more deterrent role of higher concern on loss of face and sense of open to discussing mental health issues , which present shame on psychological help-seeking was also identified. fewer barriers in help-seeking. This is consistent with facili- The majority of studies in this review asserted the deterrent tators of formal help-seeking among other ethnic minorities, role of loss of face and stigma consistent with the findings such as acculturation, social integration and positive attitude of other studies , although Clement et al. stated that towards mental health. stigma is the fourth barrier in deterring help-seeking. Mental illness is highly stigmatized in the Philippines and Cultural context of Filipinos’ reluctance to seek help Several to avoid the derogatory label of ‘crazy’, Filipinos tend to explanations have been proposed to account for the general conceal their mental illness and consequently avoid seeking reluctance of Filipinos to seek psychological help. In Fili- professional help. This is aligned with the Filipino value of pino culture, mental illness is attributed to superstitious or hiya (sense of propriety) which considers any deviation from supernatural causes, such as God’s will, witchcraft, and sor- socially acceptable behavior as a source of shame. The cery [68, 69], which contradict the biopsychosocial model stigmatized belief is reinforced by the notion that formal used by mental health care professionals. Within this cul- help-seeking is not the way to deal with emotional prob- tural context, Filipinos prefer to seek help from traditional lems, as reflected in the response of a Filipino participant folk healers who are using religious rituals in their heal- in the study by Straiton et. al., “It has not occurred to me ing process instead of availing the services of professionals to see a doctor for that kind of feeling” [14, p.6]. However, [70, 71]. This was reaffirmed by participants in the study of other studies in this review [12, 13] posited contrary views Thompson and her colleagues who said that “psychiatrists that lower stigma tolerance and higher concern for loss of are not a way to deal with emotional problems” [74, p.685]. face could also motivate psychological help-seeking for The common misconception on the cause and nature of men- individuals who want to avoid embarrassing their family. tal illness, seeing it as temporary due to cold weather or As such, stigma tolerance and loss of face may have a more as a failure in character and as an individual responsibility nuanced influence on help-seeking depending on whether 13 1410 Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 the individual avoids the stigma by not seeking help or pre- services to gain a better understanding of how specific vent the stigma by actively seeking help. factors prevent or promote formal help-seeking behaviors. Moreover, the majority of the studies in this review Presence of social support The contradictory role of social were descriptive cross-sectional studies, with only one networks either as helpful or unhelpful in formal help-seek- cohort analytic study. Future research should consider a ing was also noted in this review. The presence of friends longitudinal study design to ensure a more rigorous and and family can discourage Filipinos from seeking profes- conclusive findings especially on testing the effectiveness sional help because their social support serves as protec- of interventions and documenting best practices. Because tive factor that buffer one’s experience of distress [77, 78]. of the lack of quantitative research that could triangulate Consequently, individuals are less likely to use professional the findings of several qualitative studies on the detrimen- services [42, 79]. On the contrary, other studies have found tal role of resilience and self-reliance, quantitative studies that the presence of friends and family who have positive using pathway analysis may help identify how these bar- attitudes towards formal help-seeking can promote the utili- riers affect help-seeking. A preponderance of studies also zation of mental health services [8, 80]. Friends who sought focused on discussing the roles of barriers in help-seeking, formal help and, thus, serve as role models , and those but less is known about the facilitators of help-seeking. who take the initiative in seeking help for the distressed indi- For this reason, factors that promote help-seeking should vidual also encourage such behavior. Thus, the positive be systematically investigated. influence of friends and family on mental health and formal help-seeking of Filipinos is not merely to serve only as emo- tional buffer for stress, but to also favourably influence the Practice, service delivery and policy decision of the individual to seek formal help. implications Findings of this review also indicate several implications for practice, service delivery, intervention and policy. Research implications of findings Cultural nuances that underlie help-seeking behavior of Filipinos, such as the relational orientation of their interac- This review highlights particular evidence gaps that need tions , should inform the design of culturally appro- further research: (1) operationalization of help-seeking priate interventions for mental health and well-being and behavior as a construct separating intention and attitude; improving access and utilization of health services. Inter- (2) studies on actual help-seeking behavior among local ventions aimed at improving psychological help-seeking and overseas Filipinos with identified mental health prob- should also target friends and family as potential and sig- lems; (3) longitudinal study on intervention effectiveness nificant influencers in changing help-seeking attitude and and best practices; (4) studies that triangulate findings of behavior. They may be encouraged to help the individual qualitative studies with quantitative studies on the role of to seek help from the mental health professional. Other resilience and self-reliance in help-seeking; and (5) factors approaches include psychoeducation that promotes mental that promote help-seeking. health literacy and reduces stigma which could be under- Some studies in this review reported help-seeking taken both as preventive and treatment strategies because intention or attitude as actual behaviors even though they of their positive influence on help-seeking. Strategies to are separate constructs, hence leading to reporting biases reduce self-reliance may also be helpful in encouraging and misinterpretations. For instance, the conflicting find- help-seeking. ings of Tuliao et al. on the negative association of This review also has implications for structural changes loss of face with help-seeking attitude and the positive to overcome economic and other practical barriers in association between loss of face and intention to seek help Filipino seeking help for mental health problems. Newly demonstrate that attitudes and intentions are separate con- enacted laws on mental health and universal health- structs and, thus, need further operationalization. Future care in the Philippines may jumpstart significant policy research should strive to operationalize concretely these changes, including increased expenditure for mental health terms through the use of robust measurement tools and treatment. systematic reporting of results. There is also a lack of data Since lack of awareness of available services was also on the actual help-seeking behaviors among Filipinos with identified as significant barrier, overseas Filipinos could mental illness as most of the reports were from the general be given competency training in utilizing the health care population and on their help-seeking attitudes and inten- system of host countries, possibly together with other tions. Thus, research should focus on those with mental migrants and ethnic minorities. Philippine consular agen- health problems and their actual utilization of healthcare cies in foreign countries should not merely only resort 13 Social Psychiatry and Psychiatric Epidemiology (2020) 55:1397–1413 1411 to repatriation acts, but could also take an active role in Open Access This article is licensed under a Creative Commons Attri- service delivery especially for overseas Filipinos who bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long experience trauma and/or may have immigration-related as you give appropriate credit to the original author(s) and the source, constraints that hamper their access to specialist care. provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not Limitations of findings permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a A crucial limitation of studies in this review is the use of copy of this licence, visit http://creat​iveco​mmons​.org/licen​ses/by/4.0/. different standardized measures of help-seeking that ren- der incomparable results. These measures were western- based inventories, and only three studies mentioned using References cultural validation, such as forward-and-back-translations, 1. WHO (2017) Mental health atlas 2017. World Health Organization to adapt them to cross-cultural research on Filipino partici- 2. Redaniel MT, Lebanan-Dalida MA, Gunnell D (2011) Suicide in pants. 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