Hawaii, the melting pot of the Pacific, has beep the stepping stone for various Asian migrant groups in the past; two centuries. The Japanese, Chinese, and Filipino populations who occupied the lowest socio-cultural strata originally came to Hawaii as plantation laborers. Currently, most of these Japanese and Chinese immigrants have established, themselves in the local Society anti-have moved up the socioeconomic ladder, but there are significant numbers of Filipinos who still are in the lowest socioeconomic positions.
To better understand and identify problems arid needs of the Filipinos, We must consider-the past social and historical setting in which they developed and also how such social forces effected their behavior and values. As_ nurses this knowledge enables us to integrate these beavior and beliefs into, our care plans and use them as working tools.
In the Phillippines, the nuclear family and the extended family are basic units of social organization. This includes several generations linked by descent and marriage, Power and authority remain with the elders. Many of the kinsfolk live under the same roof ör as close to- each other in the same province or village. Married couples and their children are merged as minor cooperating units in the larger whole. Godparents of the children are included in the privileges and responsibilities. There is communal pride. The rule is "keep watch over your brothers and care for your parents and other relatives." Membership in family unions is more important than a trade union.1
The Filipino immigrants with close family ties who came to Hawaii represent and face a great social change because they were thrown upon their own resources and assumed responsibilities without assistance and cooperation, of older and younger relatives. It was necessary to adapt to the new environment, to new customs, standards, laws, and language. Due to their physical, temperamental, and cultural differences, they hada tendency to segregate themselves from other ethnic groups.
In 1930, 53-percent of the Filipinos were in their twenties and many of them were single. There were five males to every female. This abnormal sex ratio along with the severance of kinship controls and the waning of traditional responsibilities enhanced the status of woman in the family in Hawaii.2
It was not uncommon to find a group of five to six single men living together in the plantation home. Position of each member depended on his age. The eldest became the head of the household. If the age range did not vary greatly, then the education, length of residence, and type of work performed on the plantation were the determining factors. The head of the household assumed the role of both father and mother of the family and exercised a great deal of power. He was advisor and consultant on personal and group problems within the household and outside thecommunity. Often his decisions were accepted. The financing of each household varied. Each member was responsible Co purchase certain food items or expenses were divided equally among the members at the end of each month. Usually art automobile Was purchased on a partnership basis.
The most popular pastime for the Filipinos on the plantations was to dress up, (sometimes beyond their economic means) and to gather in the Aala district of Honolulu during the weekends. Aala district was their point of assembly and dispersion via Oahu Railway and taxi. They packed the pool rooms to capacity or gathered on the sidewalk to spend the night. They played pool, not because of their adeptness, but because the pool rooms were owned by Filipinos who understood them and their problems. This relationship was characterized by warmth, sympathy, and understanding of a primary group.5
The society of Hawaii has not revered the Filipino immigrants since their arrival into Hawaii and has always assigned them minor roles. Of the older Filipinos, 98.2 percent have an eighth grade education or less and this is one of the barriers in securing any type of gainful employment. His level of skills remain within the unwanted labor market. Many are forced to supplement their limited monthly income with whatever menial jobs they can find such as yardwork, janitorial, or fishing, etc., which creates a socioeconomic problem for an elderly man to support himself or his family. Many of the immigrants came to Hawaii principally to earn enough to live comfortably in the Philippines. They sent part of their earnings back home to attain their goals or to assist in educating their younger brothers and sisters. The majority of these immigrants are now experiencing financial difficulties.
Most of the residents in Hawaii are Ilocano. Their attitude toward life is different. To them health is not as important as work. "Hospital" has a connotation as a place where people go to die. They do not attend to, and are frequently not able to express or recognize the importance of symptoms. Many have lived with pain for a long time and have adapted to it so that they either ignore or exaggerate the symptoms. They refuse to be hospitalized if they are still ambulatory so in this debilitated physical condition they become more vulnerable to other diseases.
Many are disabled from gout. They take up drinking to relieve the pain or as a coping mechanism. Ironically, alcohol also precipitates acute gouty arthritis in susceptible individuals.4
Many Filipinos retired from the plantation under social security benefits, some benefits under union management contracts, or private pension contracts which provided early retirement from ages 55 to 62 years of age. A great number of them moved into the Palama-Kalihi districts. They rented small rooms with communal kitchens and bathrooms. Many were encouraged to live in larger rooms with accommodations but refused the opportunity. Their rooms are filthy and odorous. Because of their high tolerance level of substandard living, one cannot consider this deviant behavior. Living alone can be very frightening for them because in case of illness or injury them have no one to call or assist them. With this fear of the unknown and feelings of insecurity and distrust they have a tendency to perceive rejection or to isolate themselves.
Their physical and environmental limitations combined with lack of motivation limit their achievement. Many of them are without family and they live in a world dominated by leisure time, but with limited income, which increases their chances of ill health. The limitations on activities, and their physical debilitation and small rooms are a marked contrast between their former plantation home environment where they raised their own vegetables and poultry and participated in primary group activities.
Aging Filipinos also must cope with failing vision and hearing-sensory perceptions which have a major impact on the maintenance of reality orientation. They may not notice a gradual loss of hearing and they miss or misinterpret important clues. Too much input also can be confusing and distorted which results in faulty interpretation and arousal of fears and isolation. Failing vision can be hazardous especially at nights when they must use the communal bathrooms.
Their nutritional status is very low. They have no energy or financial means to shop for proper food or to store their perishables. Most of their meals consist of canned foods, bagaong, a highly salty fish sauce, or salty dried fish and rice. Fifty percent of their meals are eaten in restaurants. The disabled Filipino who lives alone in a small room with no plumbing facilities is prone to becoming dehydrated with electrolyte imbalance. Some of them may have faulty dentures. The social and environmental factors which stimulate the appetite are lacking. Many of the single men are not active in the senior citizens' planned activities except for the meals on wheels. Gradually more Filipinos are taking advantage of the free balanced meal. The elderly Filipino couples are more active in the senior citizen programs than the single men. Some of the aging Filipinos do not want to be called "senior citizen or elderly," and they will remark, "I am not a senior citizen, I am a Philippine citizen." After explaining that a senior citizen is one who is 60 years old and above, they will accept your definition-depending upon how you approached them I5
A great number of the Filipinos are not aware or familiar with the availability of free services and financial assistance. They are reluctant to ask for help as they feel that it may affect their status in Hawaii. Also they feel that when you do a favor for them they are obligated to reciprocate. Such practice is normal in the Philippines. Sometimes it takes the outreach worker about two or three visits before they can be convinced of the free services and help. In order to help and to relate to the Filipinos, you have to do it more on a closer and personal basis. You cannot jump right into whatever it is you wish to accomplish. To be successful you must first establish rapport and trust with the Filipino.1
Retirees living on the plantation pay about $15 per month for their rent and are able to live marginally without social welfare. Many of the married or widowed elders live with their children and grandchildren in the same household. The first generation of the immigrant parents maintain a strong sense of obligation.
Ms. Bernice Atkins: nurse aide, talking to a patient.
Filipinos are clannish and they are able to tolerate the existence of other racial groups. This results in group sanctions and living to the expectations of their group by individual members and as a means of creating a closer friendship among themselves. Today, one may observe these primary group behaviors in Aala Park. Chee fu, a type of lottery, is played daily. Other activities are card games, cockfights, and dice. Some will save their money for months to spend their evenings in taxi dance halls. The dancers give them a feeling of importance and acceptance which elevates their ego esteem and also meets their sexual gratifications.
Filipino patients who are institutionalized are very passive, but independent. Most of the patients are the immigrants that arrived here to work on the sugar plantations in the early 1900s. Their ages range from 65 years to 90 years of age. The majority of them are single, widowed, or divorced men and have no relatives or friends. The nursing staff is their only "significant other." There are very few married patients in institutions due to strong family ties. Usually the parents are cared for at home by family members and they provide their parents with lots of emotional and physical support. If the parents are institutionalized, one may observe the rule, keep watch over your brothers and care for your parents and other relatives.
Due to their difficulty in communicating and socializing with other ethnic patients, the Filipino patients tend to sit alone on the sideline and watch the activities that are happening about the wards. If you plan to train or teach procedures, plan to relate to him on a one-one interaction. You will be even more successful if you are the initiator in a conversation, otherwise you will be just sitting.
I find myself using touch when I make my rounds or spend a few minutes conversing with them. When they see me coming, they reach out for me to squeeze their hand and greet me with a big smile. Touch connotates many meanings such as communicating to him that "I care." Touch is an acknowledgment of inclusion, a chance to reinforce his identity and call him by his name.
Because of limited vocabulary in the English language, I use common words in English, Hawaiian, Japanese, and Filipino languages with gestures of my hands and body, speaking slowly, e.g.:
You sacit? Do you have pain? I will point to the anatomy.
Good leg-stand up, (this is done with a demonstration).
Go holo-holo. Go out of the room.
Today, ta-a? Did you move your bowels today?
You kau kau. Eat. (Pau kau kau? Are you through eating?)
Mahea you go? Where are you going?
It is important to give the patient time to react to your message. This feedback tells me whether he received my message and understood me. If I get a negative feedback such as a puzzled look, or a stare, I try again or get some Filipino staff member to interpret or clarify my statement. This clarification helps to prevent frustration and anxiety for both patient and nurse. For the single Filipino patient who had been making his decisions all his life, it gives him an opportunity to make decisions in his plan of care.
I like to encourage the patients to actively participate in their activities of daily living rather than doing for them as they may think the staff wants them to be passive. I usually use one action verb at a time because overloading him with words only confuses him. They are praised for each small accomplishment in order to promote a feeling of self-worth and hope.
I also strongly believe that one can change a patient's behavior by assigning the same staff member to the patient for about a month. It helps the patient to identify who his nurse is. Mr. F was a Filipino man about 67 years old and was married to a Portuguese woman who rarely visited him. He had a CVA with left hemiplegia. He spoke English well and his life style differed from the early immigrants who came to Hawaii. He was depressed and hostile and would strike at you if you persisted. Being aware of this behavior I remained closely to the aide to assist her and to react appropriately to his hostility. Our expected outcomes were:
1. To let Mr. F have some control of his plan of care in decision making.
2. To develop a trusting relationship between patient and aide.
3. To increase socialization.
4. To restore bowel and bladder control.
5. To increase participation in ADL.
Using our expected outcomes as the criteria, our deadline for our evaluation was one month. The first day Mr. F was hostile and would not let the aide and I give him a bath. He stated, "I'm not dirty, I'm clean." There was distrust and anger in his voice. I told him that I was concerned and cared about him, but for us to help him we must work together. I also told him that the aide was learning and would be assigned to him for about a month. He would contribute to her learning to become an efficient nurses' aide. I demonstrated a bed bath to the aide and Mr. F was very cooperative and acceptive. All procedures were explained to Mr. F and what was expected of him. We allowed him to make decisions in his plan of care or matters pertaining to him. By the end of the month he was toilet trained and was going to the day room via wheelchair. The aide was able to observe the behavioral changes of Mr. F as she cared for him. She was proud of the accomplishment- expected outcomes were all met.
In summary, basic human needs do not change appreciably over the years although their priority may assume different positions throughout life. Good health, ability to overcome physical deficits, and finances are the most important factors in old age adjustments. For the aging Filipino men disengage- ment may or may not be a coping mechanism. Since their arrival from the Philippines, they have clung to their traditions and values and have segregated themselves from other ethnic groups. In a passive state they may derive as much satisfaction as an actively involved participant. Lack of education, the language barriers, lack of experience in social relationship, and meaningful activities create fear and distrust of the unknown. All must be considered carefully in planning their nursing care.
- 1. Cerezo, Ρ, Workshop. Cross cultural communication: the Filipino in Hawaii. International Institute of Hawaii. Hono- lulu, Hawaii, May 15, 1970.
- 2. Luis A, Sensano H: Some Aspects of Filipino Family, Vol 3, 1937, ρ 56.
- 3. Kaneshiro K; Assimilation in the Slum Area of Honolulu. Vol 4, 1938, ρ 65.
- 4. Agmata H, Health Educator, Hawaii State Health Department, Kinau Hale, Honolulu, Hawaii, Interview, Feb 8, 1974.
- 5. Ramos J, Supervisor, Kalihi Kai Areawide Opportunities for Senior Citizens, Kalakaua Playground, Honolulu, Hawaii, Interview, Feb 7, 1974.