Research ArticleOriginal Research

Pakikisama: Filipino Patient Perspectives on Health Care Access and Utilization

Charles G. Jose, Rachel Lucy, Alma Manabat Parker, Joana Clere, Linda Montecillo and Allison M. Cole
The Journal of the American Board of Family Medicine March 2024, 37 (2) 242-250; DOI: https://doi.org/10.3122/jabfm.2023.230165R2

Abstract

Purpose: Filipinos have unique social determinants of health, cultural values, and beliefs that contribute to a higher prevalence of cardiovascular comorbidities such as hypertension, diabetes, and dyslipidemia. We aimed to identify Filipino values, practices, and belief systems that influenced health care access and utilization.

Methods: We conducted 1-on-1 semistructured interviews with self-identified Filipino patients. Our qualitative study utilized a constant-comparative approach for data collection, thematic coding, and interpretive analysis.

Results: We interviewed 20 Filipinos in a remote rural community to assess structural and social challenges experienced when interacting with the health care system. Our results suggest that Filipinos regard culture and language as pillars of health access. Filipinos trust clinicians who exhibited positive tone and body language as well as relatable and understandable communication. These traits are features of Pakikisama, a Filipino trait/value of “comfortableness and getting along with others.” Relatability and intercultural values familiarity increased Filipino trust in a health care clinician. Filipinos may lack understanding about how to navigate the US Health care system, which can dissuade access to care.

Conclusions: For the Filipino community, culture and language are fundamental components of health access. Health care systems have the opportunity to both improve intercultural clinical training and increase representation among clinicians and support staff to improve care delivery and navigation of health services. Participants reported not routinely relying on health care navigators.

Introduction

Filipino-Americans and Filipino immigrants (FA-FI) combined make up the third largest Asian subpopulation in the United States.1 Because most current health equity and outcomes research and data collection practices commonly aggregate Filipinos with other Asian subgroups, little is known about factors contributing to these health inequities or strategies to address them.3 Like other minority populations in the US, Filipinos experience significant health disparities, including a higher prevalence of diabetes compared with Asians overall and non-Hispanic White patients. A study evaluating Asian Americans’ access to care compared with that of non-Hispanic Whites concluded that Asian Americans aggregately, and Filipinos as a subgroup, are less likely to have private or employee-based insurance coverage and more likely to rely on Medicaid.4 Specifically for Filipino adults, lower socioeconomic status resulted in a lower probability of access to employer-based plans.5 Providing culturally sensitive care can improve overall health outcomes for marginalized populations,6 including FA-FI who may lack understanding of the health system.7

The overall objective of this qualitative research study was to identify cultural and systemic challenges in how Filipinos experience and access health care. Findings may be useful to guide health systems seeking to implement changes that will improve access to care for FA-FI communities.

Methods

Study Design

This qualitative study aimed to understand how Filipinos perceive and experience health care in a rural community. We conducted semistructured interviews with FA-FI and performed qualitative thematic analysis of interview transcripts, using a constant comparative method. The interview script used open-ended questions to identify cultural and perceived patterns of health care seeking behavior and built on initial factors (ie, cost, access, trust, cultural factors) affecting health care utilization identified by a 2019 Filipino Community Health Survey conducted by Ketchikan Public Health Department (Table 2). The study protocol and ethical considerations were approved by the PeaceHealth Institutional Review Board.

View this table:
Table 2.

Interview Script for Key-Informant Interviews

Setting

Our study was conducted in a remote rural community (Frontier and Remote Area Category 2, Rural Urban Continuum8 Code 7) in Southeast Alaska. At the time of this study, the Filipino community was estimated to be 6.7% of the total population of approximately 8000 residents (9.5% when including Filipino mixed race). The local health care system is composed of multiple independent primary care clinics and a Critical Access Hospital with an embedded primary care clinic.

Participants

Eligible individuals were those who self-identified as Filipino, lived in the area, and had 1 or more encounters with the local health care system in the last 2 years. The local Filipino community includes recent and established immigrants as well as Filipino-Americans born in the United States. No participants were excluded based on primary or preferred language.

Recruitment

Participants were identified through an in-person Filipino community event held at the town mall in October 2021. This event was open to all members of the public and included 600 attendees with a diverse range of ethnic and demographic backgrounds. At the event, a member of the research team distributed flyers about the study. After the event, information about the study was also shared via radio, print, social media, and word-of-mouth. Interested individuals were contacted after the event and offered an opportunity to enroll. Participants were also asked to recommend peers for participation using a snowball recruitment method. Recruitment of the study population was purposeful to ensure a diverse sampling was achieved (Table 1). Participation was voluntary and those who completed the interview were compensated with a $40 gift card for a local vendor.

View this table:
Table 1.

Participant Characteristics (n = 20)

Data Collection

The interview guide was designed by the multicultural study team, including both FA-FI, to explore challenges and barriers with respect to US Health care cost and access in addition to Filipino cultural factors affecting health (Table 2). It was then pilot-tested in a 1-on-1 interview format with a Filipino community member interviewee. Open-ended questions were refined by the study team before formal data collection.

From April to June 2022, semistructured 1-on-1 interviews (n = 20) were conducted face-to-face in the participant’s preferred language. All participants selected English as their preferred language for participation. Each interview lasted between 15 to 60 minutes. All participants provided verbal informed consent before the interview. Participants varied in age, gender, preferred language, and socioeconomic status (Table 1). The interviewer was a member of the local Filipino community and an experienced community outreach professional. All interviews were audio-recorded and transcribed for review by the coding team. Interviews were conducted until saturation for identified themes was reached, and the team determined additional interviews were not yielding further insights.

Data Analysis

Transcribed interviews were deidentified and provided a unique identifier (eg, 1 to 20). Initial data analysis began after the first 2 interviews and ongoing analysis was completed in real time as data were collected. Interviews were thematically analyzed using a team-based constant comparative method. We developed a codebook inductively using an emergent coding approach based on our interview guide. The final codebook was tested on 2 randomly selected transcripts and resulted in an intercoder reliability of 89%. Four researchers continued coding the remaining 18 transcripts.

Transcript excerpts were organized by their respective consensus codes and were then reviewed in a group setting with the entire research team. Initial meetings focused on reconciling coding discrepancies and subsequent sessions focused on deriving cross-cutting themes. Further descriptive analysis resulted in 3 cross-cutting themes (Figure 1).

Figure 1.
Figure 1.

Deriving cross-cutting themes.

Results

We identified 3 cross-cutting themes related to health care access: (1) culture and language influence on health care access, (2) relational, community-based care experience, and (3) structure of the current health care system as a barrier to accessing care.

Culture and Language Influence on Health Care Access

Filipinos share a sense of duty that prioritizes the needs of others in the community before themselves.

“We care for each other. We give advice to others. We help, we share what we have.” (#6, 4.26)

We found that younger individuals report that they assist with bridging cultural and language differences between older Filipinos and the health care system. Younger family members reported serving as health care navigators for their elders.

“A lot of my family they kind of understand [English] and they'll, they'll bring, um, my mom” (1973, 6.27)

Participants reported that when they do seek health care, clear communication and Pakikisama, or a “feeling of comfortableness,” with the clinician were important positive qualities that helped promote health care access. Access is viewed as not only being able to see a clinician, but also being “understood” by that clinician.

The cultural value of Pakikisama, which conveys that a person belongs to a group and there is a value placed on being dedicated to that group. Participants described putting the needs of others before self as a factor in delaying access to care for themselves or not accessing care at all (Table 3).

View this table:
Table 3.

Participants Quotes Organized by Cross-Cutting Themes

“I do believe [Filipinos] are very hard working and dedicated to their families, and stubborn, especially, [when it comes to] taking [care] of themselves. [Filipinos] would take [care] of other family members before themselves. [They] are friendly, warm, caring, and it comes from everywhere depending on the family dynamics.” (#18, 5.24)

“I feel we’re hard workers and we try and strive to put money aside so we could have food on the table, shelter over our head and things like that. So, I can see why health can be put on the back burner.” (#16, 5.24)

Participants reported barriers in speaking about matters of health that are perceived as sensitive or private, for example reproductive health care.

“[Even though] many of us grew up in the United States, we see our families, or our parents and the older generation really find it very taboo to talk about sex education or birth control or even understanding the menstrual cycle.” (#16, 5.24)

Relational, Community-Based Care Experience

Participants reported that they value trusting and positive relations with a health care clinician. Individual experiences with health care are often shared among the community. In turn, these experiences and stories serve as guidance for other Filipinos in the community considering seeking health care.

“There are just some [physicians] whose answers are more real, [and who give more] real world answers than the medical aspect of it. They try to make things very relatable and understand[able].” (#16, 5.24).

Participants highlighted that feeling heard and understood were positive features that helped determine how they select and why they stay with a particular primary care clinician. A “relatable and understandable” style of interaction was valued, both explicit in the style of speech and implicit in the overall tone and open body language.

“It’s usually not just business with them. [They always ask] ‘Hey, how's it going?’ Small talk is not necessary, but it definitely helps you get to know what's actually going on versus what you think's going on.” (#15, 5.24)

Other factors that contributed to trust and rapport included: personable qualities, familiarity of language and culture, and appropriate clarity of communication.

“I changed my doctor because she didn’t understand me, or I didn’t understand her.” (#8, 5.05)

“[Even when I was given the option to transfer to a Filipino Tagalog speaking physician], I declined because I was more comfortable just staying with him and [we have a] good relationship.” (#10, 5.18)

Clinicians who were more transactional or ‘by the book’ were perceived less positively. Participants described the importance of connecting in a relational way and how that came across in interactions. For example, 1 participant said,

“A lot of it has to do with how they speak to you and how [they] address your concerns. Because going to the doctor can be scary and a lot of it is kind of overwhelming because it's your body and it's your health. It can be very complicated if the doctor or even the front desk people that you're trying to work with are not being very endearing when you’re scared and it’s your health and you just want to make sure that you're okay. A lot of people don't like to go to the doctor anyways and like me, I don't really particularly like going to the doctor. So, without that extra sense of security and extra sense of calmness, I think it's really hard to want to go to the doctor. (#11, 5.18)

Structure of the Current Health care System as a Barrier to Accessing Care

Participants described cost of health care as a significant burden.

“[My friend] went [to the ER] and the next thing he has like a $1500 bill (laughing). Right now [he still has a] $100 balance… That’s how [the] hospital works. You know, when you see a doctor, even if you don’t do anything [you get charged] a lot.” (#3, 4.25)

When patients received clear and supportive information about health care costs, they reported positive feelings toward health care.

“Everything was clear… when I went to check out up front, [the girls] up front also gave me the information of who to call regarding [the cost] out of pocket [for treatment] … so it’s like, I got the full 360 of what needs to be done after my business, everything was taken care of. I left knowing what I need to do and how to do it.” (#9, 5.17)

Participants reported that interpreter services are not always routinely offered or being unaware of the availability of interpreter services.

“I have never used the interpretation services at the doctor’s office, and I didn’t know they had this available.” (#12, 5.19)

Discussion

Primary Outcomes

Although the US medical system commonly interprets health care access as the ability to provide timely, high-quality services,9 equitable access for immigrants also requires health care system cultural humility and language accommodation.10,11 Our findings are consistent with current research supporting the notion that race and cultural concordance increases the likelihood that a person will seek care and may improve health outcomes.12–15 In our study, FA-FI identified the Filipino trait called Pakikisama (“getting along with others16”) that is important in garnering trust from patients. Pakikisama applies to the friendliness and relatability of a clinician and is promoted by positive tone and body language as well as relatable and understandable communication.3 Interpersonal competencies and professional attributes that help develop trust with patients, such as the ability to weave an attitude of learning about cultural differences into patient encounters, are training priorities for practicing clinicians and medical trainees.17–19 Cultural humility may increase trust in the health care system20 and in turn may maximize primary care utilization21 and decrease preventable utilization of high cost services22,23 (ie, emergency department visits and inpatient admissions).

Our findings support the need to improve language accommodations in the clinical setting. Although interpreter services are the standard of care,24 we found that FA-FI participants were unaware of the service availability. Rural health systems report significant barriers in offering and providing interpreter services.25 This is especially important given that the high prevalence of English proficiency among Filipinos may mask communication challenges1 (ie, difficulty communicating feelings, symptoms, as well as intimidation). Elderly individuals and recent immigrants are more likely to experience language barriers in health care.26 These subpopulations are known to have more limited English proficiency, less education, and lower perceived cultural understanding.1

Differences between the US and Philippine health care systems may create barriers to access. Filipinos are accustomed to either a social health insurance program, in which all residents can access care,27 or a private cash-for-service payment system. Unfamiliarity with costs and payment in the US health care system may dissuade individuals from seeking care in the US. We found that participant experience with unanticipated and high ER costs negatively impacted access in the communities. These anecdotes may permeate to other members of the Filipino community, discouraging others from seeking care.

In our study, family members or close friends operated as patient navigators or support figures to help participants with limited language capabilities and less experience navigating the health care system.28 Race and language concordant patient navigators have been shown to improve timeliness and access to care29 and may be a useful strategy for meeting the health care access needs of Filipino and Filipino American populations without burdening family members and caregivers. Health care systems may consider improved care coordination and recruitment of multicultural staff into navigator roles.30

Strengths and Limitations

Our results pertaining to FA-FI patients in a rural community may be applicable to medical practices serving multicultural populations31,32 (ie, Latinx and Native American or Alaska Native communities). Partnering with a community organization allowed participants to provide frank information about health care. Although the principal investigator of the study was a health care clinician in the community, interviews were conducted by a study team member unaffiliated with the local health care system to minimize response bias.

Our findings may be limited by the self-selection of participants, as we may not have fully assessed perspectives of nonparticipants such as those with multiple jobs and family obligations precluding their ability to invest time in an interview. Because recruitment began at a single event, we may have reached only a subset of the population. Snowball sampling, advertising and personal referrals were used to reach additional participants to address this limitation. All participants selected to conduct interviews in English, which may have limited participants responses if a particular message or idea lacked a direct English translation; this may also reflect participants’ conscious or subconscious desire to fit the “model minority,” as the ability to speak English is equated to a higher level of intelligence.33 We recognize that the experiences of FA-FI in a frontier community may not represent the experiences of all FA-FI in the United States. Findings may be influenced by the specifics of the local community and health care system, potentially impacting the generalizability of our findings to other communities. Further research to explore the degree to which these findings apply to the multitude of diverse FA-FI communities within the US is needed.

Many participants provided additional commentary after ending the official interview, indicating that the population may have felt more comfortable sharing information outside of a formal recorded setting. These data were not included in our analysis, nor were data pertaining to faith, nutrition, women’s health, and culturally taboo topics.

Conclusions

Acknowledgment of patient cultural values can foster higher levels of trust in the health care system, which is a fundamental component of relational care to Filipinos and can improve health utilization patterns. The current health care system is challenging to navigate for FA-FI populations; there is an overreliance on family members to serve as health care navigators and interpreters. Reframing health care access to include intercultural factors may help improve health outcomes for Filipino communities.

Notes

  • This article was externally peer reviewed.

  • Funding: This project was supported by Community Solutions for Health Equity, a program of Community Catalyst, with funding from the Robert Wood Johnson Foundation; and by the National Center For Advancing Translational Sciences of the National Institutes of Health under Award Number UL1 TR002319. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

  • Conflict of interest: The authors have no conflicts of interest to declare.

  • To see this article online, please go to: http://jabfm.org/content/37/2/242.full.

  • Received for publication April 28, 2023.
  • Revision received August 6, 2023.
  • Revision received October 6, 2023.
  • Accepted for publication October 19, 2023.

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