The Filipino Concept of Mental Illness and Nurses’ Attitudes: A Scoping Review

Rica Rose May A. Rubio

Western Mindanao State University College of Nursing, Zamboanga City, 7000 Zamboanga del Sur, Philippines

*Correspondence Author’s Email: rubio.rrm@gmail.com / rica.rubio@wmsu.edu.ph

ABSTRACT

Negative attitudes can arise from not recognizing the influence of culture among nurses caring for patients with mental problems. Although nurses' attitudes toward these patients have been extensively studied, few involve Filipino nurses. This scoping review provides an overview of the perception of mental illness in Filipino culture, along with the attitudes of the Filipino nurses towards dealing with patients with mental health issues. From July to December 2022, searches were made in the databases of Google Scholar, PubMed, and PsychInfo, and the reference lists of identified articles were guided by the PRISMA-ScR. Twenty-one articles met the inclusion criteria. The review showed mental illnesses implicate the role of cultural beliefs on supernatural beings, curses, retribution from God, imbalance between hot and cold elements, spirit possession, softness in character, engaging in evil acts, family, shame, and saving face, which can lead to stigmatization of patients with mental illness (n = 18), and the attitudes of Filipino nurses towards these patients were also shown but were not conclusive (n= 3). Hence, it is recommended that further studies on Filipino culture and mental health nursing and on the experiences of Filipino nurses in caring for patients with mental illnesses, the influence of religion, spirituality, and family, and somatization of mental distress is necessary. Emphasis on filial piety as a framework for future research on the mental illness of Filipinos is recommended because the family can both be a source of mental distress and a source of personal strength in overcoming stigma. In addition, this review can be used to improve the quality of nursing care and perform mental health care training and education programs to reduce mental illness stigma in the Philippines.

Keywords: Filipino Culture; Mental Health; Nursing; Stigma

INTRODUCTION

Culture is a social construct that encompasses more than just race and ethnicity and considers things like age, gender, education, religion, financial situation, occupation, and physical and mental disabilities to create a treatment plan that is patient-centered and culturally sensitive (Stubbe, 2020). It impacts all parts of a person's life, including how they feel, comprehend, communicate, and deal with emotional and mental suffering. It instills values and beliefs that have an impact on people's viewpoints on health and illness as well as their attitude and conduct. All healthcare professionals, including nurses, must therefore be able to give care that recognizes this influence (Purnell, 2002; Campinha-Bacote, 2002). Research has demonstrated that negative and stigmatizing attitudes can emerge due to a lack of comprehension regarding the impact of culture. This unfortunate trend has been observed among both physicians and nurses operating in mental health facilities and primary healthcare centers. (Dalky, Abu- Hassan, & Dalky, 2020; Salama et al., 2021; Ercan & Delba, 2021).

Given the substantial influence of culture on nurses' perceptions of individuals with mental illness, this review was undertaken with this crucial aspect in mind. Although nurses’ attitudes toward patients with mental health issues have been examined for a long time, there hasn't been much study on this subject specifically involving Filipino nurses.

Thus, this review purports to grasp the influence of culture on the attitudes of Filipino nurses by understanding how Filipinos conceptualize mental illness, thereby improving the quality of nursing care. In addition, it can help future studies, education initiatives, and trainings in mental health care that aim to lessen the stigma around mental illness in Philippine society.

METHODOLOGY

The framework presented in Arksey and O'Malley's scoping review (2005) and the updated methodology by Peters et al. (2020) served as a guide for this review. This type of review is extremely beneficial when a body of literature hasn't been completely reviewed yet or possesses qualities that make a more accurate systematic review challenging (Peters et al., 2015).

The stages of the framework are, in order, as follows: (1) Identifying the research topic or question. The first step in this stage is to identify the research question that will be covered in the review. The formulation of search techniques is guided by the research question. The PCC mnemonic (population, concept, and context) is advised for creating clear and meaningful questions and inclusion criteria for a scoping review (Peters et al.,2020); (2) Identifying relevant studies. This stage includes the use of electronic search and other search strategies, what keywords are to be used, and the inclusion and exclusion criteria for selecting articles. This stage includes the identification of articles using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guideline (Tricco et al., 2018). This method has not yet been registered but can be obtained from the corresponding author upon request. (4) Data collection This stage includes quality assessment of articles, data extraction and charting, and data summary and synthesis. This stage includes presenting narratively the charted information of the articles in two ways: first, the article characteristics (e.g., authors, date published, etc.), and second, the key findings that answer the review questions stated in stage 1, presented thematically.

RESULTS

Stage 1: Identifying the research topic or questions.

The research questions were created based on the presumption that culture has a significant impact on how people with mental illness are treated and how their attitudes are shaped, and that this impact can lead in stigmatizing and negative attitudes that have been observed even among nurses working in mental health facilities. The following questions served as the basis for this analysis because they addressed the possibility that Filipino nurses share the presumption: a) What is the Filipino concept of mental illness? b) What are the attitudes of Filipino nurses towards patients with mental illness?

Stage 2: Identifying relevant studies.

Search Scheme

From July to December 2022, the databases of Google Scholar, PubMed, and PsychInfo were searched for prospective papers relating to the issue. As the topic has not been thoroughly studied yet and has a heterogenous nature, the search range was increased from a 10-year range to not earlier than 2000 and to all types of study designs and methodologies. All the reference lists of eligible papers were manually searched for additional studies that might be relevant to this review.

Search Terms

The search keywords "Filipino culture" AND "mental illness", "attitudes of Filipino nurses" AND "mental health" OR "mental illness" yielded a huge number of unrelated articles. The inclusion and exclusion criteria were used to minimize the number.

Search Parameters

The articles eligible for review include full-text articles that were electronically available and published in the English language from 2000 to 2022. All types of study designs were considered to include gray literature. Grey literature is becoming increasingly important in all kinds of reviews since it helps to eliminate publication bias (Godin et al., 2015). According to Adams, Smart, and Huff (2017), there are different shades of gray literature. The first level, which has a high amount of outlet control and credibility, is books, magazines, and government reports. Next are the annual reports and news articles with moderate outlet control and reliability. Blogs, emails, and tweets fall under the last level, with limited channel control and legitimacy.

Articles discussing the attitudes of Filipino student nurses and nurse educators towards patients with mental illness were excluded from the review and synthesis, as were articles concerning the attitudes of healthcare professionals other than Filipino nurses (unless they included data from Filipino nurses). Additionally, materials such as blogs, emails, and tweets were also excluded from consideration.

Stage 3: Study selection.

The identification of articles was done using the PRISMA-ScR and is presented using the PRISMA framework (see figure 1). After duplicates were removed, 701 articles were screened on titles, excluding 541 articles. The abstracts of the remaining 145 articles were then screened following the inclusion and exclusion criteria, resulting in 23 articles eligible for full review. However, two more articles were removed because they were unrelated to Filipino nurses' views toward patients with mental illnesses. As a result, only 21 papers were considered for synthesis. Due to the scarcity of research on this topic, research involving Filipino nurses living and working in other countries with other health professionals was included for review.

Figure 1: The Article Selection and Screening Process

Stage 4: Data Collection

Quality Assessment of Articles

The quality assessment of the articles in this review was done in two ways: first, by selecting studies based on the criteria established in this review, and second, by quality assessment.

Articles that met the criteria were chosen for further assessment. The search parameters covered the predefined inclusion and exclusion criteria for this review. Among the gray literature, blogs, emails, and tweets were excluded as they fall under the final level of communication with low outlet control and low credibility.

Each article was rated for quality using the revised four quality assessment (QA) questions developed by Mengist, Soromessa, and Legese (2020). The questions were as follows: QA1: Are the inclusion and exclusion criteria for the review defined and appropriate? QA2: Is it likely that the search uncovered all relevant articles on the subject? QA3: Did the selected articles have blind reviewers who assessed the study's quality or validity? and QA4: Were the Filipino conceptualization of mental illness and the Filipino nurses’ attitudes mentioned in the article adequately described?

Data Extraction and Charting

A charting format was created for this study and pilot tested on three papers to guarantee that all important and related results were collected. The chart included the following characteristics: Author, Year published, Country, Population, Aim of Study, Methods/Design, Key Findings.

Stage 5: Data summary and synthesis.

Article Characteristics

Twenty-one articles met the inclusion criteria. Out of the eighteen articles for the Filipino concept of mental illness in Table 1, four were of qualitative design: one survey-correlational, one cross-sectional, one monograph, five literature reviews, one systematic review, and the rest were gray literature (four news articles and one book). The majority of the articles were from the Philippines (n = 12), the United States (n = 4), Australia (n = 1), and Canada (n = 1).

Table 1: Characteristics of the Selected Articles Relevant to Review Question No. 1

Note: NA = not applicable

All three articles for the second review question were of quantitative design. Out of the three articles, two were cross-sectional and one was correlational in design. The articles were from Kuwait, the Philippines, and Qatar (Table 2).

Table 2: Characteristics of the Selected Articles Relevant to Review Question No. 2

The Filipino Concept of Mental Illness

Tuliao (2014), de Torres (2002), and Abad et al. (2014) mentioned in their reviews that mental disorders implicate the involvement of supernatural beings like spirits and deities, or humans with extraordinary powers, in Filipinos' perception of mental illness. The beliefs in witches, supernatural beings, a mystic creature underneath the earth, or a mythical tree giant are widespread. Similarly, Tan (2008) documented some Filipino beliefs that physical and mental illnesses are caused by a curse inflicted by a human being, God's retribution inflicted on a person because he or she committed a social sin, and an "exposure illness" caused by an imbalance between the hot and cold elements in the environment.

In a study by Gingrich (2006), Filipinos were more inclined to attribute dissociative disorder symptoms to spirit possession or to having offended the spirit (Tan, 2008) than to those of a mental disorder. This notion is evidenced in various news reports by Roxanne (2016), Jimenez (2016), and Ambrad (2018) on students in the local towns of Misamis Oriental, La Union, and Cebu who were reportedly possessed by evil spirits. Locals claimed the students were possessed by supernatural forces enraged by the school library's demolition (Roxanne, 2016).

For Thompson et al. (2002), mental problems are related to the ‘softness’ of one’s character and attributes. Hechanova, Tuliao, and Hwa (2011) believed it to be related to problems in relationships, and according to Tuliao (2014), mental disease is caused by indulging in the wicked behaviors of criminals, murderers, rapists, and those who are engaged in sexual aberrations.

Moreover, Sanchez and Gaw (2007) reported that in Filipino culture, a person with mental illness is seen as the family's mental illness, which could bring shame upon the family and should be kept a secret from the public. For Fogel and Ford (2005), the family may discourage the member from seeking care because they believe it is a punishment from God or the spirits for the family's previous bad actions. Tanaka et al. (2018) revealed that the possibility of "bad blood" being passed down through families pushed families to negate the presence of mental health concerns. Hence, it is common for Filipinos to describe mental distress as physical ailments because physical manifestations are more socially acceptable, according to Gong, Gage, and Tacata (2003). Avoidance of seeking help prevents the exposure of a possible acquired behavioral trait from the earlier generation of the family. It is thought that if a relative has the condition, the trait can be passed down to the next generation (Abad et al., 2014).

Tuliao (2014) discovered that among Filipinos, loss of face is directly connected with perceived stigma for both seeking and receiving psychological care. To save face, Filipinos may claim to understand diagnosis and treatment even when they are at a loss (Sanchez & Gaw, 2007). According to Ordonez and Gandeza (2004), most Filipinos would answer "yes" without hesitation to most queries. It does not necessarily imply that they understand the query, nor does it imply that they agree with the health care provider's decision or proposal. As Filipinos in general tend to react with "yes" or "no" without describing their situation, "yes" in most circumstances just implies "I heard you." Sanchez and Gaw (2007) believed that embarrassment may be the reason that prevents them from asking relevant questions.

The shame that mental illness bring to the family may result in stigmatization, discouraging them from obtaining professional mental health services (Tuliao, 2014) and from being labeled as crazy. According to Martinez et al. (2020). Rivera and Antonio (2017) reported that stigmatizing attitudes toward people with mental conditions in the contemporary Philippines exist and are rampant. The stigmatizing behaviors, as reported by Shahani (2014) and Rivera and Antonio (2017), seem to be uninhibited, such that derogatory terms like "abnoy" and "baliw" are easily incorporated in casual conversations of Filipinos, either with humor or with hatred.

Attitudes of Filipino Nurses towards Patients with Mental Illness

With regards to Filipino nurses’ attitudes toward patients with mental issues, the study by Cruz and Mariano (2019) has shown that 116 Filipino nurses showed an overall positive attitude, with higher scores for attitudes toward functioning and prognosis of depressed patients. Most of the nurse respondents had favorable attitudes toward the evaluation and treatment of depressive illnesses, and there were no significant differences in the overall scores of the nurses’ attitudes in relation to their sociodemographic profile (i.e., age, sex, years of experience, or previous work experience in a psychiatric institution).

Meanwhile, Al-Awadhi et al. (2017) investigated nurses' attitudes toward mentally ill patients in a general hospital in Kuwait. The study enlisted the help of 308 nurses. Eighty-five percent (n = 240) were non-Arabs from Asian nations such as India, the Philippines, Indonesia, and Pakistan. In general, the average scores across the four subscales of the Community Attitudes Toward the Mentally Ill questionnaire indicate that the nurse respondents held predominantly negative perspectives regarding mental illness. According to Al-Awadhi et al. (2017), the negative attitudes and presence of stigma among the nurse participants were possibly due to their religio-cultural beliefs and practices. Another investigation was conducted by Ghuloum et al. (2022) in Qatar, encompassing 406 nurses hailing from India, the Philippines, and North Africa. The study revealed that nurses exhibited more pronounced stigmatizing attitudes toward individuals with mental illness than with physicians. However, according to the authors, the 116 Asian nurses in this study have significantly lower stigma due to their cultural beliefs related to the cause of mental illness.

DISCUSSION

This review developed to investigate the influence of Filipino culture on nurses' attitudes toward patients with mental illnesses. The literature suggested that Filipino beliefs in supernatural beings, malevolent spirits, curses, and an imbalance between the hot and cold elements are causes of physical and mental illnesses. They sought treatment from folk healers and herb doctors which is in accordance with their cultural beliefs. In addition, Tan’s (2008) documentation of the Filipino concept of mental illness suggests that physical and mental illnesses are punishments from God. Similarly, a study by Zolezzi et al. (2017) showed that half (50.2%) of the student respondents in Qatar believed that mental illness was a punishment from God. Additionally, participants in a study by Daher-Nashif et al. (2021) described dementia as a test from God or a punishment from God that would lessen the punishment on the day of final judgment. Also, it is viewed as a form of retribution for sinful action or because of spiritual weakness, such as a lack of confidence or trust in God (Webb, 2012). Such beliefs could make people deny their mental illness and consider their condition a religious faith- related issue to avoid being stigmatized (Freire, Moleiro, & Rosmarin, 2016). Hence, the religion and spirituality of Filipinos can be pursued further in future studies relative to this topic.

Moreover, according to the review of Filipino culture, mental illness is a family mental disorder that can bring shame to the family. Filipinos place a high value on family, which is a nuclear unit that is functionally extended, meaning that in addition to parents and kids, other members of the household are also members of the immediate family (Diaz & Caboral-Stevens, 2021). This reverence for family is greatly influenced by the values of ‘filial piety’ and ‘saving face’. Filial piety is defined as the duties and allegiance that a person has towards one's parents, family, and ancestors, whereas saving face is the idea of acting and interacting with others in a way that fosters pride and honor for the family (Camorongan, 2007).

The values of filial piety and saving face are cultural characteristics common to Asian families. In traditional Asian households, the family is valued more highly than the individual since the individual is considered the product of all the generations that have come before them (Camorongan, 2007). Hence, the family's interests govern all decisions, including the choice to seek treatment for a mental illness. The inability to receive prompt mental health care may exacerbate stress or crises for everyone involved because mental illness is still frequently seen as a flaw, failure, or weakness for the entire family (Chen 2021). According to the study by Pan and Tang (2021), filial piety may even positively contribute to teenage depressive symptoms. Studies on this topic are particularly important because they could significantly aid in the recovery from mental illness.

To prevent shame, loss of face, and the subsequent damage to the victim's self-worth and self- esteem, the family opts to avoid seeking professional help and prefers to go to folk healers for treatment. It is common for Filipinos to somatize mental distress because physical manifestations are more socially acceptable. However, there is little research on the somatization of mental distress. Research in this context would be valuable to nurses and other healthcare providers, as it can help differentiate a mental illness from a physical one.

Moreover, the studies on the attitudes of Filipino nurses toward patients with mental illness are scarce, and the results of the three articles are not conclusive as to whether the Filipino nurses have positive or negative attitudes. Cruz and Mariano (2019) conducted their research in a private tertiary hospital in Quezon City, Philippines, involving 116 nurses who showed good attitudes but still had inadequate knowledge and some negative attitudes toward depressed patients. The findings cannot be generalized to all Filipino nurses. While the findings of research conducted in two different countries (Kuwait and Qatar) by Al-Awadhi et al. (2017) and Ghuloum et al. (2022) revealed negative and stigmatizing views of nurses on patients with mental illness, The data on Filipino nurses in these two studies was undetermined as they were categorized together with nurses from other countries like India, Indonesia, Pakistan, and North Africa.

De Jacq, Norful, and Larson's (2016) integrative analysis of nurses' attitudes toward mental illness in 20 countries revealed that, globally, nurses tend to have diverse opinions toward various aspects of mental disease, and this could be largely attributed to cultural differences. Indeed, culture greatly influences nurses' views toward mental illness and shapes the stigma associated with it. To help Filipino nurses avoid stigmatizing ideas and enhance their ability to care for patients with mental illnesses, it is crucial to understand one's own culture as well as the cultures of others (Man, 2019; Rubio, 2022).

Since the concepts of culture, mental health, and nursing are complex and have several dimensions, it is important for Filipino nurses to be receptive to individual differences, including their own, in their perception of these concepts during clinical practice. But it is also important to incorporate these concepts into undergraduate nursing education in the Philippines to develop the readiness of the students to be mental health nurses who can deliver effective mental health services to a multicultural population. Nurses who have a solid foundation and an understanding of cultures are less likely to have stereotypical beliefs and think narrowly when caring for patients with mental illnesses.

Finally, it is important to note that this review has its limits. Since the search parameters were restricted to printed materials that were available to the author and published online articles, it is possible that some primary studies on the topic were not included. Another limitation is that only English-language articles involving Filipinos were included. It is likely that articles that were pertinent to the objectives of this review were left out because the period covered 2000 to 2022. Given that there were just three articles for synthesis to answer the second review question, it is challenging to draw broad conclusions regarding the attitudes of Filipino nurses.

CONCLUSION

This review has shown the complexity of the information related to the topic in this area. In terms of how Filipinos conceptualize mental illness, eighteen articles have shown that mental illnesses implicate the role of cultural beliefs on supernatural beings, curse, retribution from God, imbalance between hot and cold elements, spirit possession, softness in character, engaging in evil acts, family shame, and saving face, which can lead to stigmatization of patients experiencing mental issues and problems. While three articles have shown the attitudes of Filipino nurses toward patients with mental illness but were not conclusive, the evidence base in relation to this aim is relatively weak, and there continues to be uncertainty in the field.

However, considering all the information derived from this review, stigma towards people with mental illness in the contemporary Philippines exists and is pervasive. Therefore, it is recommended to do further related studies on Filipino culture and mental health nursing because the Filipino population is becoming increasingly diverse and enhancing the ability of the nurses to care for patients with mental illness is essential for quality nursing care. To give a richer context and in-depth analysis of the Filipino nurses’ attitudes, future reviews should include the Filipino nurses' experiences in caring for patients with mental illnesses while considering their own cultural background and beliefs. Other future studies to pursue are the influence of religion and spirituality on the mental health of Filipinos, the somatization of mental distress in the Philippines, and the influence of family on the mental health of Filipinos. Emphasis should be placed on filial piety, which can be used as a framework and as a starting point for future research on the mental illness of Filipinos, because the family can be a key source of personal strength to overcome mental illness stigma, but it can also be a source of conflict, especially if one does not conform to accepted norms. In addition, the data from this review can be used to inform mental health care trainings and education programs intended to reduce mental illness stigma in the Philippines.

Conflict of Interest

The authors declare that they have no conflict of interests.

ACKNOWLEDGEMENT

The author would like to thank all those who, in one way or another, helped in the writing of this paper. The author declares no funding or conflicting interests and that no individual or organization may profit or lose through the publication of this paper.

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