Open access peer-reviewed chapter

Creating a Culture of Mental Health in Filipino Immigrant Communities through Community Partnerships

By Aviril Sepulveda, Dean M. Coffey, Jed David, Horacio Lopez, Kamil Bantol and Joyce R. Javier

Reviewed: May 18th 2021Published: September 8th 2021

DOI: 10.5772/intechopen.98458

Downloaded: 40

Abstract

One out of five children in the United States has a mental, emotional, or behavioral health diagnosis. Behavioral health issues cost America $247 billion per year and those with mental health disorders have poorer health and shorter lives. Evidence-based parenting interventions provided in childhood have proven to be effective in helping parents to prevent disruptive, oppositional and defiant behaviors, anxiety and depressive symptoms, tobacco, alcohol, and drug misuse, aggression, delinquency, and violence. Yet, few parents participate in such programs, especially hard-to-reach, underserved minority and immigrant populations. The Robert Wood Johnson Foundation has identified a culture of health action framework that mobilizes individuals, communities, and organizations in order to examine ways to improve systems of prevention, invest in building the evidence base for such systems, and provide evidence-based information to decision makers. The overarching goal of this effort was to create a culture of mental health among Filipinos, a large, yet understudied immigrant community that is affected by alarming mental health disparities, including high rates of adolescent suicide ideation and attempts. Our impact project focused on increasing the reach of the Incredible Years® because maximizing the participation of high-risk, hard-to-engage populations may be one of the most important ways to increase the population-level impact of evidence-based parenting programs. If the approach succeeded with Filipinos, comparable strategies could be used to effectively reach other underserved populations in the U.S., many of whom are reluctant to seek behavioral health services. In this chapter we discuss 1) the state of the literature on the topic of Filipino adolescent mental health disparities; 2) our wicked problem and the impact project aimed at ameliorating this issue; 3) how our team formed and implemented our impact project; 4) outcomes and results of our efforts; 5) challenges we faced and how they were overcome; 6) the leadership and health equity skills that were most helpful in addressing our problem; and 7) a toolkit that could assist other communities addressing youth mental health and prevention of suicide and depression.

Keywords

  • Filipino
  • suicide prevention
  • mental health stigma
  • community-based participator research

1. Introduction

1.1 Filipinos are a large yet invisible minority affected by significant youth behavioral health disparities

According to the 2010 US Census, Asians surpassed Hispanics as the largest group of new immigrants to the United States [1]. With a population of over 3.4 million, the Filipino population is the second-largest Asian subgroup in the United States and the largest Asian population in California. Despite their size, Filipinos are among the least studied groups when it comes to health, due to a lack of research that disaggregates Asian ethnic groups. In contrast to the “model minority myth” ascribed to Asians in general, the few studies on Filipino youth reveal higher rates of behavioral problems such as depressive symptoms, anxiety, and substance use compared to other Asian subgroups and ethnic groups [2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14]. For example, data from the US Youth Risk Behavioral Surveillance System found that Filipino youth have higher rates of adolescent female suicidal ideation (45.6%) compared with non-Hispanic white (26.2%), Hispanic (33.4%), and African-American (25.3%) females [13]. Filipino parents are exposed to multiple adversities, including intimate partner violence, loss of social status, discrimination, and high rates of major and postpartum depression, placing their children at risk for future behavioral health problems [15, 16, 17, 18, 19, 20, 21, 22, 23, 24].

Despite these disparities, Filipino adults and children have low rates of mental health care utilization, including low engagement in parenting interventions, particularly in Los Angeles County [4, 16, 19, 25, 26, 27, 28, 29, 30]. Due to stigma associated with mental health problems, many Filipinos access mental health services at lower rates and often as a last resort [7, 14, 15]. They are encouraged to keep problems within the family to avoid bringing shame (hiya) to the family [7, 11]. Given these unique aspects of the U.S. Filipino immigrant population, one of the authors (JJ) used a community-partnered participatory approach over the past 16 years to optimize the well-being of Filipino families [4, 5, 7, 8, 10, 11, 12, 28, 29, 31, 32, 33]. She learned that trusted community-based organizations such as churches can serve as gatekeepers to behavioral preventive services, such as parenting programs [8, 11].

1.2 Harsh discipline may be associated with Filipino youth’s increased risk for mental health and behavioral health problems

The prevalence of physical punishment in the Philippines is 75% [34]. In a population-based study in the Philippines, the number of abused children from 1998 to 2002 increased five-fold; 90% of adolescent respondents endorsed having been physically maltreated while 60% reported being psychologically abused at least once in their lifetimes [35]. An international study of harsh discipline found that compared to five other countries, Filipino mothers reported the highest rates of harsh verbal discipline (71%) and harsh physical discipline with an object (56%) [34]. In our pilot work, 82% of Filipino immigrant parents of children ages 6–12 years old reported using physical punishment. Growing evidence also suggests that harsh discipline may be associated with Filipino youth’s increased risk for subsequent unhealthy coping, low self-esteem, depression, anxiety, and physical abuse [23, 36, 37, 38, 39, 40].

1.3 Parenting plays a critical role in the development of childhood behavior problems

Parenting practices strongly affect child behavior problems, perhaps even playing a causal role [41]. Child behavior affects parenting in a transactional manner [42, 43, 44, 45]. Children’s challenging behaviors (e.g., high activity level and poor emotional regulation) can elicit coercive and detached parenting, with low nurturance/affection [46]. This parenting style may exacerbate the child’s behavior problems [41, 47, 48, 49]. In contrast, parental affection, supervision and firm behavioral control predict long-term positive outcomes [50, 51, 52, 53, 54]. Parent training programs alter parents’ behavior and, presumably in response, children’s behavior [55, 56]. They also prevent punitive parenting and challenging child behaviors early, and interrupt this dysfunctional coercive cycle before the child’s behaviors become more serious, requiring more intensive treatment.

1.4 Parenting interventions during middle childhood may have the potential to decrease harsh discipline in Filipino immigrant families

Middle childhood is a distinct developmental period with respect to understanding children’s perceptions of their parents’ behavior and how these perceptions relate to children’s behavioral and psychological adjustment. Dramatic changes in cognitive development take place between the ages of 5 and 7 years [57, 58]. For example, children’s beliefs become better predictors of their subsequent behavior [59, 60]. About the age of 8 years, the meaning that children attach to their parents’ behavior becomes more salient. They notice differences among the discipline practices of their own parents and parents of peers [61]. This is relevant to Filipino immigrant families in the United States because of differences in child rearing practices between mainstream U.S. culture and Filipino culture [62, 63]. For example, Filipino parents are more likely to show their love indirectly through actions, while there is more emphasis on verbal communication of love and praise in mainstream U.S. culture [64].

The Incredible Years® Parent Training Program(IY) developed by Dr. Carolyn Webster-Stratton is one of the best-studied evidence-based parent training programs [55, 65]. The Incredible Years® programs are published in a series by developmental level for babies, toddlers, preschool and school age children. There is also the Advanced IY Program that is focused on promotion of positive communication within the family and between adults. Current evidence suggests that parent behavior-management programs like IY are promising treatments for reducing internalizing symptoms in clinically-referred preschool children and high-risk Chinese immigrant school-age children who have been referred to child protective services [66, 67, 68, 69].

Filipino children growing up in the United States acculturate at a faster rate than their foreign-born parents, leading to conflict in the home [67, 68, 69, 70, 71]. These weakened family bonds have been linked with negative psychological outcomes such as depression among children of immigrants [72, 73]. For Filipinos, family conflict is significantly associated with depression, suicide-related behaviors, and substance use [74, 75]. Social cognitive theory suggests that childhood internalizing symptoms may have roots in dysfunctional parenting behaviors and family environments [76]. For instance, depressive behaviors may be both modeled and selectively reinforced by parents [77]. IY addresses problems associated with differential rates of acculturation between immigrant children and parents and targets many of the proposed mechanisms and risk factors for internalizing distress, such as harsh and unpredictable or critical parenting behaviors. Parents also learn cognitive strategies for themselves that they are encouraged to model and teach their children, such as self-praise; how to challenge negative thoughts; how to give positive attention through academic, social and emotional coaching; and how to get support.

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2. Wicked problem impact project (WPIP) description

Our work together as a team in the Robert Wood Johnson Foundation (RWJF) Clinical Scholars Program was built on the foundation created by our Team Leader (JJ). This included a needs assessment of the Filipino community that generated the consensus that the greatest community needs were the behavioral problems among Filipino adolescents that were exacerbated by the low utilization rates of services to address these problems. A suggested solution was also offered by the community to use an evidence-based parenting intervention during middle childhood before the children in this age group became adolescents [8, 11]. The importance of this first step cannot be stated too strongly. This project began as a community-defined problem with a community-defined solution.

The feasibility of such a project was tested with a pilot study that showed the intervention was acceptable by the parents participating in the first four IY pilot groups. Parents in the group reported lower parenting stress, increased use of positive verbal discipline and decreased use of physical punishment [10]. Focus groups conducted at the end of the pilot study identified a significant barrier to recruitment of immigrant Filipino parents as the cultural stigma associated with seeking help outside the extended family system [30]. These same groups proposed the novel solution to this problem of producing video recordings of testimonials by Filipino parents who participated in the groups about how the groups improved their parent–child relationship and how parents could incorporate their Filipino family values when using these parenting techniques [29].

The culturally-tailored video of parent testimonials was produced in partnership with a Community Advisory Board (CAB) using constructs from the Health Belief Model and Theory of Planned Behavior [78, 79]. We evaluated the video, entitled “Para Sa Kinabukasan Ng Ating Mga Anak: For Our Children’s Future” (https://www.youtube.com/watch?feature=player_embedded&v=Md3jOFiXhtc) in a randomized controlled trial that involved screening nearly 600 Filipinos over a 16-month period in 23 community sites. A total of 215 parents and grandparents enrolled in the study. Compared to a control video, caregivers who watched the culturally-tailored video had significantly greater odds of enrolling in IY parent groups [4].

The RWJF Clinical Scholars Program to create a culture of health in the United States through the support and leadership training of teams to address a wickedhealth problem was a good fit for the next steps to bring about change in the community. Dr. Javier recruited an interdisciplinary team consisting of a well-respected Filipino community pediatrician (HL), a senior psychologist who was an expert in IY training and implementation (DC), an occupational therapist who was a cultural arts leader in the Filipino community (JD), and another occupational therapist who was promoting community action to address the problem of post-partum depression in new mothers (AS). Together, we formed Team Kapwa, named for a word which signifies a Filipino cultural value of shared identity. Participation in the Clinical Scholars Program caused us to narrow our focus to one wicked problem – the high rates of suicidality among Filipino adolescents, while expanding our influence and impact through high quality leadership training.

During the laying of the foundation and initial pilot research, the wicked problem grew more implacable. Suicide became the leading cause of death among Asian American and Pacific Islander youth ages 12–19 years; and among 10 to 14-year-old Asian or Pacific Islander females in the United States, suicide was tied with unintentional injuries as the leading cause of death [80, 81]. Our challenge was to use the positive parenting interventions from Incredible Years School Age Parent Program with the communication interventions from the IY Advanced Program with Filipino parents of children ages 8 to 12 years. Together, we believed that these two programs, focused on enhancing the parent–child relationship and developing effective family communication, would increase two protective factors against suicide: family connectedness and other adult caring to reduce these high rates of adolescent suicidality in the Filipino community.

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3. Methods

3.1 Project

Evidence-based parenting programs do a wonderful job assisting parents who enroll in them. However, our biggest challenge was getting parents to participate, especially parents living in low-income, under-resourced communities. We could not address the wicked problem of mental health disorders among Filipino youth in our healthcare system alone. Our project used a community based participatory research model to connect our interdisciplinary team with service providers, community and faith leaders, consumers, and researchers to address the barriers to participation in behavioral health programs and prevent the wicked problem of adolescent suicidality in the Filipino community. The project addressed systemic gaps in our community that continue to contribute to the lack of utilization of mental health services and parenting programs in our community.

Exacerbating these systemic gaps to participating in effective parenting programs was the barrier of stigma associated with discussing mental health issues like suicide (i.e., suicide ideation and attempts may be under-reported because of its non-acceptance by the Catholic church and the associated shame to the family. We addressed this challenge by continuing to engage faith-based leaders in our planning and implementation activities. We offered IY as a prevention program rather than restricting it to children with behavior problems in order to overcome the stigma associated with accessing parenting programs, and the shame related to having a child with mental health problems.

3.2 Conceptual framework

Based on Bronfenbrenner’s social ecological model, our strategy to implementing parenting interventions addresses multiple levels of influence [82]. Bronfenbrenner’s social ecological model describes the levels of relationship among the family and the social systems and institutions that impact the functioning of the family (Figure 1). For example, we addressed the personal level by promoting the social and emotional competence of the child and teaching effective coping strategies to parents. On the interpersonal level we promoted healthy caregiver-child interaction, family functioning, school functioning, the home environment, while enhancing positive family/peer norms and the development of social networks. At the community level we offered IY as a community resource and promoted positive community norms (ie, decreasing the stigma associated with participation in parenting programs) (Figure 2).

Figure 1.

Social ecological model applied to parenting interventions.

Figure 2.

Logic model for creating a culture of mental health in Filipino immigrant communities through community partnerships.

3.3 Approach

Our project was designed to reflect the first two phases of a three-phase community-based participatory research initiative [83]. Phase 1 was the partnered planning of the initiative. Phase 2 was the implementation of the initiative, which from a community perspective is a pilot to determine what works in the community. Phase 3 was the initiation of community dissemination beyond agencies in the implementation phase based on a partnered analysis of Phase 2. Each phase has a cycle of activities that we refer to as the plan-do-evaluate cycle.

Phase 1 involved a series of meetings to address barriers and needs in the community in order to develop a shared understanding of mental health, by which we could facilitate implementation of a culturally-congruent educational campaign that can improve mental health awareness in our community. We formed a Steering committee of seven members who would meet monthly to plan activities and conduct focus groups with Filipino community members and create a shared definition of mental health for Filipino youth. Based on prior studies, we developed an educational campaign strategy and planned a conference that combined science, art, and faith to engage the community in a dialog about mental health. This conference included activities such as presentations about mental health issues in the Filipino community by consumers, researchers, and community leaders; trainings in discussion of mental health issues; and screening of digital stories and dance performances about mental health stigma in the Filipino community. Our primary community partners included: Asian Pacific Counseling and Treatment Center; local churches; schools (both parochial and public); Kayamang ng Lahi, a Philippine cultural music and dance troupe; Search to Involve Pilipino Americans; and the Filipino Cultural School.

Phase 2 included training providers and community members to be group leaders in the Incredible Years® Parent Training Program and implementing the program. We continued to meet with our CAB, which was comprised mostly of Filipino parents who have helped us determine best practices/strategies for engaging parents to participate in the Incredible Years®. From our CAB we learned to incorporate kapwa, a core Filipino value defined as community, togetherness, or a sense of shared identity, and adopted the name Team Kapwa for our impact team. In order to contribute to the lack of research on Filipino youth prevention efforts and lack of preventive programs for depression and suicide in this community, we conducted a pilot study evaluating the Incredible Years® School Age Basic and Advance Program to Filipino parents of children ages 8–12 years old.

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4. Outcomes

4.1 Creating a shared definition of mental health in the Filipino community

With the goal of creating a shared definition of childhood mental health in the Filipino community, we conducted focus groups in community organizations serving a large number of Filipino Americans. A total of thirty-seven (37) adults participated, many of whom were parents/grandparents, primary care or mental health providers, Incredible Years graduates, college students, and community advocates. Ages ranged from 18 to 79 years old which allowed the groups to have a depth in perspectives from multiple generations. A majority of participants also had previous experience working with Filipino youth, namely as caregivers or health providers.

We first asked participants to share words--both positive and negative--that came to mind when hearing “Filipino” and “mental health”. The results highlighted the prevalence of mental health stigma. Participants commonly used the words judgmental, shame, crazy, and defect, indicating that mental illness continues to be negatively viewed in the community. Participants also described mental health as “hereditary” which coincides with the belief among Filipinos that mental health issues are solely genetic and passed down from generations. We used a word cloud to visualize these results (Figure 3). Remarkably, the most frequently shared word was “family” to describe mental health. Participants noted that an individual’s mental health status is often dependent on family dynamics and communication. This reinforced the importance of our work with the Incredible Years® parenting workshops, given that fostering strong family relationships was seen as having the most influence in improving mental health status of Filipino youth.

Figure 3.

Initial impressions of focus group participants to the terms,FilipinoandMental Health.

Next, we provided focus group participants with several definitions of mental health. These included definitions by the World Health Organization, Centers for Disease Control and Prevention, and Philippine Mental Health Association. Using the choices that were reviewed and identified by our steering committee, we then asked participants to highlight words and phrases regarding mental health that they felt most resonated with Filipino parents. Word cloud results showed that there was great variability in what the community sees as optimal mental health (Figure 4). For instance, participants chose the words and phrases, “well-being, peace of mind, productive, sense of identity, contribute to community, coping with normal stressors, and self-worth.” These words are interconnected, yet they also describe different ways to achieve mental health and well-being. This served as a lesson for Team Kapwa: When approaching people about our project, we must appeal to the various mental health goals that the community values. We highlighted not just the potential for academic and social skill development, but also lessons on coping skills and dealing with everyday stressors.

Figure 4.

Community preferred definitions of mental health synthesized from four standard definitions of mental health.

4.2 Filipino family wellness - community conversations

Team Kapwa conducted a community-wide conference that sought to decrease mental health stigma and create a culture of mental health in the Filipino community. Flyers were sent to all previous study participants and disseminated in our team’s social media site (facebook.com/filipinofamilyhealthLA). Our partners also distributed flyers throughout their organizations. In total, 130 people attended the event, many of whom were community members, students, parents, children, and IY graduates.

The conference successfully combined science and the arts to engage the community in a dialog about mental health. Dr. Javier presented compelling mental health statistics about suicide and health disparities among Filipino youth and also included a screening of the culturally tailored video, Para Sa Kinabukasan Ng Ating Mga Anak(For Our Children’s Future). This was followed by a screening of Silent Sacrifices: Voices of the Filipino American Family, which was presented by Dr. Judy Patacsil. Silent Sacrifices was a documentary that tackled issues such as family conflict, generational gaps and depression among Filipino youth. Several community members shared their mental health experiences through a segment called “Kwentuhan” (Storytelling). The purpose of these stories was to highlight the prevalence of mental health disorders and the importance of seeking help. For example, one speaker shared how, despite being a nurse in a hospital Neonatal Intensive Care Unit (NICU), she was unsuccessful in helping her daughter cope with postpartum depression.

The conference also featured programs by Filipino organizations, including a folk dance by the group, Kayamanan Ng Lahi, and a play by the drama group, StanD, that addressed the stigma of mental illness among family members. Lastly, we offered breakout sessions to introduce participants to mental health resources in the community. These sessions introduced resources such as One Degree--a non-profit that works with low-income families, the Los Angeles Department of Mental Health, and demonstration of the Incredible Years®. A copy of the program can be found in Figure 5.

Figure 5.

Filipino family wellness community conversations conference program.

After the conference, we asked participants to give us feedback on why they attended the event. Their answers highlighted the growing change in attitudes regarding mental health in the Filipino community. We learned that the community was ready to start conversations about mental health. According to one participant, “I think it’s important to create discussion and dialogue as a form of normalizing [mental health] and education.”

Other comments showed that the community was starting to see the importance of mental health care. One participant noted, “[I attended the event] to learn more about mental health and wellness specifically within the Pilipino community.” Most importantly, we learned that the Filipino community was ready to take action and combat mental health stigma. One participant stated simply but powerfully, “We can no longer afford to be a silent minority. Too many of our youth are dying.”

4.3 Sustainability

Sustainability required building upon the strength of our community organizations. To accomplish this, Team Kapwa developed partnerships with 12 new organizations that included public and private schools, school districts, a Filipino cultural school, community-based organizations and churches. Additionally, 15 Incredible Years® parent graduates became members of our Community Advisory Board, allowing us to hear directly from parents and learn ways to tackle mental health stigma in the Filipino community. We trained 45 health care professionals, parent champions, and community members to be Incredible Years® group leaders. We also started a social media group to reach the community digitally and have accumulated over 200 followers in the first 8 months. Finally, we have several pre-health and pre-mental health undergraduate and graduate level students, including our fifth author, who have dedicated their time to participate in and volunteer for this initiative. Team Kapwa believes it is critical to train the next generation of providers to conduct community-based participator research in the Filipino community.

Beyond this project, Team Kapwa’s ultimate goal was to offer the Incredible Years® program to all families beginning from infancy to adolescence. We took several steps to achieve this. Drs. Javier and Sepulveda received funding to conduct IY Baby pilot groups, offering the groups in primary care and for mothers with postpartum depression who have babies in a NICU. We also successfully advocated for the Los Angeles County Department of Mental Health to add the briefer Incredible Years® Attentive Parenting Program as a billable prevention intervention. The goal to create sustainability accomplished its first steps with families in the Filipino community. To date, 100 Filipino parents have completed IY School Age groups, 70 new parents have enrolled, and at the end of the impact project funding period, Team Kapwa continued to work toward sustainability by expanding the research base with Filipino families and youth by conducting a program evaluation using a randomized pilot study to offer the Incredible Years® Advance Program for parents of children ages 8–12 years old. A notable difference in the recruitment for this new study were several parents who joined the study to address early indications of depression and self-harm in their pre-adolescent children.

This chapter describes the seminal work to address the wicked problem of suicide among Filipino adolescents by the Robert Wood Johnson Foundation Clinical Scholars Program. Team Kapwa promoted the protective factors of family connectedness and other adult caring by offering Incredible Years® parenting workshops suggested by the Filipino immigrant community. The approach used by Team Kapwa may best be discussed in terms of the three guiding principles of the American Psychological Association’s Task Force on Immigration [84]. The first principle is that “immigrants are resilient and resourceful” (p. 132). This impact project could not have been done without the involvement of community partners who defined the problem and offered their community defined solution, to provide parent training to parents of Filipino pre-adolescents to enhance the parent–child relationship before the children became adolescents. One of the strengths of this work with immigrant families was the partnership of the team with the community agencies and leaders as well as with parents participating in the workshops.

The second guiding principle is that “immigrants, like all human beings, are influenced by social contexts” (p. 134). Trust between the research team and the community, together with a sense of kapwa,the Filipino cultural value of shared identity with one another, produced a relationship that grew over years of interaction between the team and community members. This is especially true of cultures that are collectivistic. The use of the Incredible Years,® which was suggested during the community needs assessment, was very adaptable to the cultural values of the parents. Out of this relationship came a cohesive Community Advisory Board and willingness to participate in the production of a culturally tailored video for recruitment of parents to participate in groups with other Filipino parents. Melissa Veluz-Abraham, a mother who participated in a parent group described her experience this way:

“We strongly believe the cultural sensitivity that these classes provide is important to the Filipino parents and grandparents participating in the program. There is a sense of kapwa, a Filipino term that refers to connection with another person. That connection can be through shared experiences as Filipinos; … experiences of how we were raised and the challenges those experiences may bring in our own child-rearing realities today. Kapwa also refers to consideration for the other; a sense of empathy for another human being. This was strong in our parent group that met every Saturday. There was a sense of support in that we all wanted to become better parents and caregivers, and we provided each other encouragement and compassion as we tried out and practiced the useful concepts and exercises that the program shared with us. The honesty that participants had in this space allowed us to learn from one another and helped us become the best caregivers that we can be for our children.”

The use of Bronfenbrenner’s social ecological model was effective in identifying avenues of influence and opportunities to promote change through considering the multiple levels of social context within the Filipino community and greater. It provided a conceptual foundation for the work of Team Kapwa.

Perhaps, the third guiding principle will be the most important for teams working with other cultural groups; to “use the lens of culture with the increasingly diverse immigrant-origin population.” Team Kapwa completed focus groups with diverse generations within the Filipino community to create a shared definition of mental health (manuscript in preparation). In this activity, Team Kapwa again engaged the community to obtain their wisdom and expertise around the very culturally loaded and often stigmatized topic of mental health. The information obtained informed a values-based approach to engaging the community to increase engagement and participation in community activities to promote mental health. This was demonstrated in their use of the culturally-tailored video produced by members to the team prior to involvement in the RWJF Clinical Scholars Program that enhanced engagement of the Filipino community. The low-cost video production and digital storytelling by Team Kapwa and families from the Filipino community increased the impact and acceptance of their work in the Filipino community and beyond.

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5. Key challenges for the future

There is still much to be done in the areas of engagement and sustainability. A reliable plan for sustainability is essential now with Filipino parents using the Incredible Years® parent workshops as less stigmatized avenues to seek mental health treatment services for their children in their own communities. To that end, Team Kapwa has applied for $250,000 in outreach funds from the Los Angeles County Department of Mental Health as part of the California Department of Public Health’s California Reducing Public Disparities Project (CRDP) to fund these ongoing outreach parent groups in the Filipino community.

While this impact project had a focus on a specific problem in the Filipino community, there are lessons that were learned by Team Kapwa that may be helpful to other interprofessional teams and community activists interested in addressing wicked problems in their own communities. Without a doubt, the most effective part of such a project is beginning with a thorough community needs assessment that engages community leaders to identify and define the problem as well as to offer their ideas for solutions. The ongoing development of a Community Advisory Board is desirable to engage ongoing community support for the project. In terms of having an impact with a low budget, the use of culturally tailored engagement video and digital storytelling (available at filipinofamilyhealth.com) can amplify the voices of the community and enhance the willingness of the community to listen to important public health messages and respond. It is one way to use the lens of culture to engage diverse and hard-to-reach immigrant communities. The Leader Learning section that follows has suggestions for leadership skills that Team Kapwa found helpful in promoting a culture of health within the Filipino community and beyond.

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6. Leader learning

Addressing complex problems calls for a variety of leadership skills that are necessary to understand and tackle abstract issues around the problem, engage the community, and produce systems to promote change. Awareness is one lesson that resonated with all the leaders in the group. Awareness of self, others, the culture, the community and the systems are catalysts to understanding the problem. Joyce Javier considered self-awareness as an important skill in her understanding what motivates her and others. Apple Sepulveda’s recognition of the commonality of her own experiences and that of the community and how sharing her story was not only healing to her but also helped heal and empower other members of the community. Jed David’s self-awareness has led him to take a deeper dive to knowing himself. The self-assessments that were an integral part of the Clinical Scholars Program led him to understand himself as a leader, identify areas for individual growth and increase impact. Dean Coffey grew in his conscious awareness of the inequities in the healthcare system; inequities created and sustained by poverty with wide gaps in economic resources that resulted in significant differences in the opportunity to live healthy lives. Horacio Lopez expressed appreciation for the development of his own leadership skills and growing awareness needed to acquire more skills to become an even more effective leader.

Communication, the exchange of ideas through language, gesture, and written information, was an essential leadership tool. Learning to communicate with each other as a team and with members helped Team Kapwa exchange clear ideas with one another. This communication fostered collaboration and partnership that helped us expand our networks and partners. The art of conversation that comes with effective communication skills helped us make adaptations to our messages to fit the varied types of audiences.

Negotiation, the art and method for reaching agreements, was not only important in accomplishing tasks but also in achieving outcomes. In solving complex problems, the solutions are often ambiguous. Critical solutions require negotiation skills to engage the interests of two opposing ideas. Negotiation in engaging stakeholders, community members, and even the team members was very useful in not just accomplishing the objectives of the project but also in persuading others to increase motivation and buy-in of key community leaders and organizations.

Experiential learning in the Clinical Scholars Program was transformational through a variety of learning experiences that met the needs of different learners where they were and helped us to move forward through a deeper understanding of ourselves and others. The training was transformative for us in further developing our educational philosophy that learners learn best when they are actively engaged and interested in the subject matter being taught. It is a process of collaboration that works best when the learner is relaxed, engaged and enjoying the process, even when it is more challenging for her/him/them.

Conflict management, the process of mitigating the negative impacts of the conflict and increasing its positive aspects, was also a very useful skill. As leaders, it is important to be able to manage conflict necessary to promote the performance and learning of the team. We acknowledged that conflict is a part of life and a learning opportunity. The different leaders on this team had different styles, and by knowing the different patterns of approaching conflicts and the different alternatives we can embrace, improves relationships among one another and with our community partners.

Collaboration was essential. Leadership is not working alone. As one of our trainers stated, “Power shared is power multiplied.” One of the important transformations experienced is the realization that leadership is not an individual skill but a shared skill. Each person on a leadership team brings a unique skill set and influential personality qualities that empower the team in different ways. Being a lone leader is not as effective, but together, much more can be achieved. Fostering collaboration entails partnering with the community. Listening to the community and asking them for ways to help with solving the complex problems they are facing. The phrase, “Nothing about us, without us,” is a tenet we hold dear and follow. By listening to and partnering with stakeholders to identify community-defined solutions to health disparities in the Filipino community, this is how we can most effectively address these issues.

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7. Tool kit

This toolkit is to provide communities with a collection of related information, resources, and tools that they can use to guide and adapt as they address similar issues:

https://clinicalscholarsnli.org/wp-content/uploads/2020/07/Toolkit-for-Prevention-of-Behavioral-Health-Disparities-in-an-Immigrant-Community.pdf

7.1 Building a culture of mental health in immigrant Filipino families

This project aims to create a culture of mental health among Filipinos, a large, yet understudied immigrant community that is affected by alarming mental health disparities, including high adolescent suicide ideation and attempts. The project also entails to implement the Incredible Years in community settings and measure mental health stigma, parenting practices, parenting parental stress, and child problem behaviors.

Over the past 10 years, a series of studies that first identified Incredible Years as a community-defined solution to preventing Filipino adolescent behavioral health problems, then pilot tested Incredible Years to assess the feasibility and acceptability of this program, and finally developed a theory-based motivational video to increase enrollment rates in Incredible Years. The success of these pilots underscores our ability to build trust with community organizations serving large Filipino populations and to overcome logistical challenges involved in implementing the intervention.

7.2 Preliminary research

  1. Pilot/Feasibility Study Conducted with Filipino Families

  2. Development and Evaluation of Theory-based Recruitment Video to Promote Enrollment:

  3. Creating a multidisciplinary team of clinicians and a steering committee to address barriers and needs in the community

  4. Creating a Shared Definition of Mental Health through focus groups

  5. Organized a conference that combined science, art, and faith to engage the community in discussing mental health issues, and screening of digital stories and dance performances about mental health stigma in the Filipino community.

  6. Developing community partnerships

  7. Implementation of Incredible Years Program to families

7.3 The team

The team members were recruited by the Principal Investigator, Joyce Javier, based on experience needed for the project. The team was comprised of these professionals who contributed in the following ways:

  1. Joyce Javier, MD, MPH, MS, a General Pediatrician in an academic setting and project lead, oversaw project activities and evaluation, led the steering committee and coalition, identified systemic gaps and developed and implemented recommendations for change.

  2. Dean Coffey, PsyD, a Clinical Psychologist, served as the agency mentor for Incredible Years® at Children’s Hospital Los Angeles. He provided expertise, training and supervision in the Incredible Years® implementation.

  3. Jed David, an Occupational Therapist at CHLA, had been on the Community Advisory Board for prior projects of Dr. Javier. He is a Tagalog and Visayan-speaking Occupational Therapist with public policy background, a Tagalog-speaking Incredible Years® workshop leader, and a Philippine cultural arts liaison who provided input regarding use of the arts to engage Filipinos in mental health services.

  4. Horacio Lopez, MD is a Tagalog-speaking Community Pediatrician who serves the Historic Filipinotown in Los Angeles and worked with Dr. Javier in her past projects. He also served as a liaison to Filipino community physicians and health care organizations.

  5. Aviril Sepulveda, MS, OTD, OTR/L is a Tagalog-speaking Occupational Therapist and Incredible Years® workshop leader. She provided expertise in maternal depression and addressing barriers to mental health care.

  6. Ana Jayme, AMFTis a Tagalog-speaking Marriage & Family Therapist, Steering Committee Member, and Incredible Years® Parent Groups Leader.

  7. Shelina Miranda, MSW, MPH is Tagalog-speaking Associate Clinical Social Worker and Incredible Years® Parent Group Leader.

Primary funding for this initiative came from the Robert Wood Johnson Clinical Scholars Program.

7.4 Recommended articles and scientific literature

  1. Filipino Health and Mental Health Disparities, Use of Community-Based of Participatory Research

    1. Jocano, Landa, F. Filipino Value System: A Cultural Definition. Punlnad Research House. Metro Manila. 1997

    2. Javier JR, Huffman LC, Mendoza FS. Filipino Child Health in the United States: Do Health and Health Care Disparities Exist? Preventing Chronic Disease. April 2007;4(2):A36. PMID:17362627.

    3. de Leon, Mendoza, F. Celebrating the Creative Living Presence: A Culture of Healing: Guideposts for Education, Governance, and Wellness in Philippine Society. Asian Societal Institute. 2017

    4. Javier JR, Supan J*, Lansang A*, Beyer W, Kubicek K, & Palinkas LA. Preventing Filipino mental health disparities: Perspectives from adolescents, caregivers, providers, and advocates. Asian American Journal of Psychology. 5(4) 316–324. 2014 Dec. PMID: 25667725

    5. Coffey DM, Javier JR, Schrager SM. Preliminary Validity of the Eyberg Child Behavior Inventory with Filipino Immigrant Parents. Child & Family Behavior Therapy.37:1–15. 2015. PMID: 27087739

    6. Flores N*, Supan J*, Kreutzer C, Coffey DM, Javier JR. Prevention of Filipino Youth Behavioral Health Disparities: Identifying Barriers and Facilitators of Participation in an Evidence-Based Parenting Intervention among Filipino Parents. Prev Chronic Dis.12:E178. 2015 Oct 22. PMID: 26491813

    7. Javier JR, Coffey DM, Schrager SM, Palinkas LA, Miranda J. Parenting Intervention for Prevention of Behavioral Problems in Elementary School-Age Filipino-American Children: A Pilot Study in Churches. J Dev Behav Pediatr. 37(9):737–745. 2016 Nov/Dec.PMID: 27626390

    8. Javier JR, Galura K*, Aliganga FAP*, Supan J*, Palinkas LA. Voices of the Filipino Community Describing the Importance of Family in Understanding Adolescent Behavioral Health Needs. Fam Community Health. 2018 Jan/Mar;41(1):64–71. PMID:29135796

    9. Javier JR, Reyes A*, Coffey DM, Schrager SM, Samson A*, Palinkas L, Kipke MD, Miranda J. Recruiting Filipino Immigrants in a Randomized Controlled Trial Promoting Enrollment in an Evidence-Based Parenting Intervention. J Immigr Minor Health. 2018 May 17. PMID:29774510

    10. Javier JR. The use of an educational video to increase suicide awareness and enrollment in parenting interventions among Filipinos. Asian American Journal of Psychology. Vol.9, No 4, 327–333. 2018 December. DOI: 10.1037/aap0000144. PMID: pending

    11. Javier JR, Coffey, DM, Palinkas LA, Kipke MD, Miranda J, Schrager SM. Promoting Enrollment in Parenting Programs Among a Filipino Population: A Randomized Trial. Pediatrics. pii: e20180553. 2019 Jan 24. doi: 10.1542/peds.2018-0553. [Epub ahead of print]. PMID: 30679379

    12. Maramba DC, ed. Family and Educational Environments: Contexts and Counterstories of Filipino Americans. Charlotte, NC: Information Age Publishing, Inc.; 2013. Endo R. & Rong X, ed. Educating Asian Americans: Achievement, Schooling, and Identities.

    13. Nadal KL, Monzones J. Filipino Americans and Neuropsychology. In: Fujii D, ed. The Neuropsychology of Asian Americans. Boca Raton, FL: Taylor and Francis; 2010:47–70.

    14. David EJ. Cultural mistrust and mental health help-seeking attitudes among Filipino Americans. Asian American Journal of Psychology.2010;1(1):57–66.

    15. David EJ. A colonial mentality model of depression for Filipino Americans. Cultur Divers Ethnic Minor Psychol.2008;14(2):118–127.

    16. Wolf D. Family secrets: transnational struggles among children of Filipino immigrants. Sociol Perspect.1997;40(3):457–482.

    17. Javier JR, Chamberlain LJ, Rivera KK, Gonzalez SE, Mendoza FS, Huffman LC. Lessons learned from a community-academic partnership addressing adolescent pregnancy prevention in Filipino American families. Progress in Community Health Partnerships.2010;4(4):305–313. PMID:21169708.

    18. Pesigan IJ, Luyckx K, Alampay LP. Brief report: identity processes in Filipino late adolescents and young adults: parental influences and mental health outcomes. J Adolesc.2014;37(5):599–604.

    19. Hayes DK, Ta VM, Hurwitz EL, Mitchell-Box KM, Fuddy LJ. Disparities in self-reported postpartum depression among Asian, Hawaiian, and Pacific Islander Women in Hawaii: Pregnancy Risk Assessment Monitoring System (PRAMS), 2004–2007. Maternal and child health journal.2010;14(5):765–773.

  2. Recommended Literature on Mental Health Stigma (theWicked Problemidentified in this project)

    1. Developing a Research Agenda for Understanding the Stigma of Addictions Part I: Lessons From the Mental Health Stigma Literature

    2. Developing a Research Agenda for Reducing the Stigma of Addictions, Part II: Lessons From the Mental Health Stigma Literature

    3. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. (Chapter 4 Mental Health Care for American Indians and Alaska Natives)

    4. Combating Stigma Within the Michigan Mental Health System: A Toolkit for Change

    5. Anti-Stigma: A Guide to Reducing Addiction-Related Stigma

    6. Gee GC, Spencer MS, Chen J, Takeuchi D. A nationwide study of discrimination and chronic health conditions among Asian Americans. Am J Public Health. Jul 2007;97(7):1275–1282. PMID:17538055.

    7. B4Stage4: Changing the Way We Think About Mental Health

    8. Children’s Mental Health Ontario’s Youth Action Committee Mental Health Awareness Toolkit

  3. Recommended Literature: Community-Based Participatory Research CBPR Principles and application:

    1. Wells K, Miranda J, Bruce ML, Alegria MA, Wallerstein N. Bridging Community Intervention and Mental Health Services Research. American Journal ofPsychiatry. 2004;161(6):955–963.

    2. Applying Community-Based Participatory Research Principles to the Development of a Smoking-Cessation Program for American Indian Teens: “Telling Our Story

    3. Community Engagement Principles for Community-Campus Partnerships for Health

    4. Understanding the Community and its Culture

  4. Recommended Literature Learning from Others, Having Conversations about Health and Mental Health in Diverse Populations

    1. Chung B, Jones L, Jones A, et al. Community Arts Events to Enhance Collective Efficacy and Community Engagement as a Means of Addressing Depression in an African American Community. American Journal of Public Health. 2009;99(2):237–244.

    2. Corbie-Smith G, Goldmon M, Isler MR, et al. Partnerships in Health Disparities Research and the Roles of Pastors of Black Churches: Potential Conflict, Synergy, and Expectations. Journal of the National Medical Association.102(9):823–831.

    3. Baezconde-Garbanati L, Murphy ST, Moran MB, Cortessis VK. Reducing theExcess Burden of Cervical Cancer Among Latinas: Translating Science into Health Promotion Initiatives. Californian journal of health promotion.11(1):45–57.

    4. Native American Mental Health Model: West, A. E., Williams, E., Suzukovich, E., Strangeman, K., & Novins, D. (2012). A Mental Health Needs Assessment of Urban American Indian Youth and Families. American Journal of Community Psychology, 49(3–4), 441–453. https://doi.org/10.1007/s10464-011-9474-6

  5. Recommended Literature: Promoting Mental Health Awareness in the Community

    1. Promoting Mental Health Awareness With Public Service Announcements Public service announcements (PSAs)

    2. Developing A Stigma Reduction Initiative Summary

    3. Public Service Announcements: Placing Drop-In Articles: Flyers of our initiatives workshops have been included in church newsletters.

  6. Recommended Literature: Promoting Parent–Child Relationships Using an Evidenced-Based Model:

    1. The Incredible Years: A training series for the prevention and treatment of conduct problems in young children. 2nd ed. Washington, DC: American Psychological Association; 2005.

    2. https://filipinofamilyhealth.com

    3. Perceptions of Parenting: Mapping the Gaps between Expert and Public Understandings of Effective Parenting in Australia

    4. Lau AS, Fung JJ, Ho LY, Liu LL, Gudiño OG. Parent Training With High-Risk Immigrant Chinese Families: A Pilot Group Randomized Trial Yielding Practice-Based Evidence. Behavior therapy.2011;42(3):PMID: 21658524.

  7. Recommended Tools: Action Planning Documents:

    1. Creating a Vision: FastTrack Leadership Communication Compass

    2. Team Charter: WPIP Team Charter

    3. Team Values: FastTrack Leadership Values Checklist

    4. Team member Individual Development Plan:

    5. Models and Framework for Understanding Social Determinants of Health

    6. Evaluation Planning: W.K. Kellogg Foundation Evaluation Handbook W.K. Kellogg Foundation Logic Model Development

    7. University of Kansas Community Toolbox

    8. Change Management Communication Strategies

    9. Periodic Table for High Concern Communication

    10. High Stress Risk Communications

    11. Advanced Risk Communication/Message Mapping Template

    12. Leading Systems Change

    13. 5 R Framework

    14. Creating Mental Model Using Causal Loop Diagramming.

    15. Understanding Political Systems and Stakeholder Analysis

    16. Decision Analyses Matrices

A more comprehensive toolkit can be found athttps://clinicalscholarsnli.org/community-impact

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8. Challenges, successes, and lessons learned

8.1 Challenges

The team was challenged by conflicting demands of clinical work, research, life events, and community outreach. We have tackled these challenges by keeping the lines of communication open, being flexible, and staying resilient, leveraging the team’s strengths, and prioritizing projects and opportunities. Another challenge for us is community engagement as it takes time and effort, and some degree of patience. We have developed the tenacity and continue to build new relationships and nurture existing ones. We also use social networks and share our stories.

8.2 Shifts in thinking

While working on the project, we have developed new mindsets toward the value of authenticity, shared experiences, interconnectedness of the people experiencing the Wicked Problem, including the team members.

8.3 Successes

Through community presentations, we have increased the awareness about Filipino mental health and suicide. The Community Wellness Conference raised the visibility of the problem of suicide among adolescents and has ignited the interest of the Los Angeles County Department of Mental Health to continue the work. Through parenting workshops, we are contributing to strengthening parent–child relationships. Parents are also able to build a community and share experiences with other parents.

8.4 Community leadership

Community leadership starts with community. There is strength in numbers, the power of the team of 5, along with our partners, parents, and grandparents is so much more impactful than the power of one. Working with many sectors, disciplines, institutions, academia, sectors such as academia, school districts, governmental agencies, hospitals, schools, and community-based organizations have their own culture and ways of getting things done. Navigating the systems requires flexibility and adaptability to handle different styles.

8.5 Overall lessons learned

As a team, we learned that working with the community on wicked problems such as mental health is a marathon not a sprint. Community partnership takes time. Kapwa, the spirit of interconnectedness, is critical to this work. We are all connected, what happens to me, happens to you, what happens to him or her, happens to us. It takes some vulnerability to share our stories and transformation come with being able to share our personal stories with others, and theirs with us.

If you are going to tackle this issue in your community, the FIRST thing you should do is … involve the community. Ask the community their needs, their strengths, their proposed solutions. Listen to them and include them in all aspects of the project.

If you are going to tackle this issue in your community, we would NOT recommend … developing your own plan or recommendations without community buy-in or input.

Wisdom we wished we had at the start but learned along the way:

Dr. Joyce Javier: The importance of sharing our own stories. Focusing on what you are most passionate about gets things done.

Dr. Dean Coffey: How powerful the cultural concept of Kapwa (shared identity) is in working together as a team on a shared objective. His one piece of advice for doing projects like this is: work for a cause you believe in and the rest will fall in place.

Dr. Aviril Sepulveda: The power of vulnerability and sharing stories can make one more effective in getting crucial messages across; tapping into one’s strength and empowering volunteers and community members is a strong way to achieve success.

Jed David: The importance of self-care for the team; leading with kapwa (shared identity) means leading with empathy.

Dr. Horacio Lopez: The Incredible Years is a powerful tool; when it comes to parenting skills, there is always more to learn and that makes each of us a better parent.

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License, which permits use, distribution and reproduction for non-commercial purposes, provided the original is properly cited.

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Aviril Sepulveda, Dean M. Coffey, Jed David, Horacio Lopez, Kamil Bantol and Joyce R. Javier (September 8th 2021). Creating a Culture of Mental Health in Filipino Immigrant Communities through Community Partnerships, Leading Community Based Changes in the Culture of Health in the US - Experiences in Developing the Team and Impacting the Community, Claudia S. P. Fernandez and Giselle Corbie-Smith, IntechOpen, DOI: 10.5772/intechopen.98458. Available from:

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