Lessons Learned From a Community–Academic Partnership Addressing Adolescent Pregnancy Prevention in Filipino American Families

Abstract

Background

Filipino Americans have more adolescent pregnancies than other Asian-Pacific Islanders (APIs). Few community–academic collaborations have addressed adolescent pregnancy prevention in this community.

Objectives

We sought to describe the lessons learned from and impact of a community-based teen pregnancy prevention program for Filipino Americans implemented by a Filipina pediatrics resident.

Methods

We formed a community–academic partnership between the Filipino Youth Coalition, a community-based organization (CBO) in San Jose, California, and the Stanford School of Medicine’s Pediatric Advocacy Program. We developed a culturally tailored parent–teen conference addressing adolescent pregnancy prevention in Filipino Americans. We qualitatively and quantitatively evaluated this intervention by collecting both pre- and post-conference data using a convenience sample design.

Lessons Learned

Engaging particular aspects of Filipino culture (i.e., religion and intergenerational differences) helped to make this community–academic partnership successful. For physicians-in-training who are conducting community-based participatory research (CBPR), project challenges may include difficulties in building and maintaining academic–community relationships, struggles to promote sustainability, and conflicting goals of “community insiders” and “academic outsiders.” Authors offer insights and implications for residents interested in practicing CBPR.

Conclusion

CBPR is a key tool for exploring health issues in understudied populations. CBPR experiences can provide meaningful educational opportunities for physicians-in-training and can build sustained capacity in CBOs. They can also help residents to develop analytic skills, directly affect the health of the communities they serve, and, for minority physicians, give back to the communities they call home.

Filipinos are the second largest API subpopulation in the United States but are underrepresented in medical research.^1,2 Many studies that include API youth report aggregated results, which mask key variations in health status among API subgroups.¹ Examination of U.S. teen pregnancy rates may suggest that teen pregnancy is not a concern for APIs. However, Weitz et al..³ scrutinized teen pregnancy among APIs and reported that among California’s 6 largest API groups (Chinese, Filipino, Vietnamese, Korean, Indian, and Japanese), Filipinos have the largest proportion of births to teens (6%). Compared with white teens, Filipino teens are more likely to request a pregnancy test and no other services from a provider, suggesting that they are sexually active but not looking for birth control.³ Among APIs with AIDS in San Francisco between 1980 and 2001, the API subgroup of Filipino adults and adolescents represented the largest proportion (35%).⁴ Among foreign-born APIs in the United States, the Philippines is the most common country of birth.^5,6 Compared with white and Chinese adolescents, Filipino adolescents are less likely to talk about sex, HIV, and sexually transmitted diseases (STDs)^1,7 with their parents and partners.

The CBPR approach is one method that has been used to examine parent–adolescent communication about sex in the Filipino American community.⁸ In a CBPR study of Filipino American adolescents, parents, and grandparents, focus group results revealed that communication problems stemmed from family struggles with acculturation.⁸ The authors state, “Parents and grandparents in our study believed that acculturation had destroyed the traditional respect for elders that allowed civil and orderly intergenerational communication to occur, while adolescents believed that acculturation had taught them benefits of open dialogue that their parents refused to accept” (p. 55). The researchers concluded that future interventions addressing adolescent sexual health in the Filipino community should recognize that generational differences in acculturation might lead to impaired transmission of values.

To our knowledge, no interventions using CBPR have been developed to address teen pregnancy prevention in the Filipino community. However, the literature addressing teen pregnancy prevention in other populations is informative, because it prompts the consideration of parental factors and cultural values when addressing teen pregnancy prevention. For example, Meschke et al.⁹ determined that the connections between adolescent sexual behaviors and parental characteristics (i.e., communication, values, monitoring and control, warmth and support) are well-established. Nevertheless, there are few intervention programs with designs that address parent–adolescent processes.⁹ Another study found that when implementing culturally sensitive interventions in the Hispanic community, programs need to balance the often-competing values and goals of prevention programs with those of Hispanic youth culture and experiences.¹⁰ They report that the involvement of both male partners and family members in programs is challenging but important, and that the implicit adolescent pregnancy prevention program goals of continued education and female self-sufficiency are often at odds with traditional Hispanic cultural values.

A few but growing number of physician researchers have expertise in community-based approaches to research. Rosenthal et al.¹¹ describe the task of introducing a community research curriculum to physicians enrolled in a health services research fellowship. They noted that, when integrating community-partnered research approaches into traditional research training, it was critical for training programs to address the building of academic–community relationships, balancing goals of education, scholarship, relationships, research products, and sustainability. They concluded that training physicians in CBPR principles has potential benefits for communities, training programs, and fellows. To our knowledge, no studies have described challenges faced by pediatric residents conducting CBPR.

In this paper, we describe the establishment of a community– academic partnership intended to address teen pregnancy in Filipino adolescents by developing a culturally relevant intervention. Further, we present descriptive data from a parent–teen conference addressing teen pregnancy prevention. Finally, we discuss what we have learned about the feasibility, acceptability, and potential of the CBPR model as it relates to engaging an understudied population and physicians-in-training who are interested in addressing child health inequities.

METHODS

Context of Community Partnership

At the beginning of this project, the first author was a pediatric resident who entered Stanford’s Pediatric Advocacy Program. This program develops longitudinal partnerships in local communities to realize its mission: improving health status, while reducing health disparities, of children in Silicon Valley and its surrounding communities through education, service, and research. Residents in this program use the principles and values of CBPR as they engage in these collaborative endeavors.

The pediatric resident (J.J.) grew up in a Filipino immigrant family and recognized that teen pregnancy was a recurring issue in her community. Thus, as a first-year resident, she approached the Filipino Youth Coalition (FYC), a CBO founded in 1992 that serves at-risk middle and high school students in San Jose and Milpitas, California. FYC offers youth violence prevention/intervention, mentorship, and after-school programs in 4 school districts. The FYC has a strong history of community-based social activism; local youth and community members originally formed the organization in response to the murder of a young Filipino boy during a home robbery.

An inquiry was posed to the FYC executive director and staff: Was the prevention of teenage pregnancy important and, if so, was FYC interested in collaborating with the pediatrics resident to address the issue together? The FYC director shared her concern about teen pregnancy and pointed out that although the FYC received numerous referrals involving Filipino American teens with unplanned pregnancies, it did not have a teenage pregnancy prevention program. She elaborated that the FYC only became involved “after the fact,” when an already pregnant adolescent needed a referral to reproductive services or when family conflict or domestic violence complicated the picture. Furthermore, the need in the community tended to be overlooked because of lack of data on teen pregnancy rates in the Filipino community. As a result, culturally appropriate programs to prevent teen pregnancy had not been developed. The FYC was an ideal partner to address this issue because of a shared interest in the topic and its organizational assets, which included a bilingual, bicultural staff and a trusted voice among families and schools.

Building Trust

Over the next 2 years, the pediatric resident developed a relationship with the FYC by becoming involved in various activities. The FYC’s connections with schools facilitated her ability to provide sexual health and contraception teaching to eighth graders during after school programs. Per FYC’s request, she met with Filipino parents to encourage communication with their teens on sexual health. She also provided technical assistance to FYC by developing a survey tool that was used to collect quantitative information from Filipino American teens who they serve, and participating in a conference targeting API-American girls and covering topics such as peer pressure and self-esteem.

The Community–Academic Participatory Process

After working with FYC for 1 year in these activities, the pediatric resident and the FYC applied for funding from the American Academy of Pediatrics CATCH program. This grant specifically targets pediatric residents with an interest in partnering with the community to address a child health topic. The objectives of the project were to (1) develop a culturally appropriate conference addressing teen pregnancy and (2) address the paucity of data on Filipino youth by surveying conference participants about their attitudes and ability to communicate about sex. In this project, FYC’s role and responsibilities were to collaborate with Stanford to develop a health education conference targeting Filipino parents and teens addressing teen pregnancy prevention. The FYC also agreed to help to recruit parents and adolescents and host the conference and planning meetings.

Conference Planning

With funding secured, a community workgroup convened to plan the conference. This committee included the FYC executive director (S.G.), FYC staff members who worked with youth at school sites, a well-respected pastor from a local church, Filipino community members with experience in community organizing, a community-based Filipino pediatrician, a medical student to assist with the project (K.R.), and a Filipina pediatrics resident (J.J.). Early on, committee members focused on identifying the target population: teens, parents, or both. After extensive discussion, the committee decided to target both parents and teens, with the goal of fostering communication skills in Filipino families. Committee members agreed that communication breakdown (e.g., sex is considered a taboo subject) and family conflict is often magnified in Filipino immigrant families when Western and Filipino cultures collide. The majority of committee members also believed an essential component of the conference should be an emphasis on Filipino history and culture.

To determine conference content, parents and teens were invited to separate planning meetings to discuss why teen pregnancy is an issue in the Filipino community. Three parents attended the parent meeting. FYC’s executive director attributed lower participation to the fact that both parents often have one or more jobs and thus, do not have the luxury of time to attend voluntary meetings. The teen turnout was larger with 14 girls and 16 boys attending. Males and females were separated, reconvening for group discussion. The issue of teen pregnancy in the Filipino community was discussed. Major themes were identified and then brought back to the community workgroup to determine the goals for the intervention (Table 1). These themes were subsequently used to develop a conference that covered the following areas: Knowledge, relationships, and culture. The workgroup members agreed to advertise the event as the “Healthy Teens, Happy Families” conference. Conference workshops included role playing on how to talk about sex, sexual health and contraception education, intergenerational conflict, and gender roles (Table 2). A video addressing cross-cultural conflict in the Filipino American immigrant family entitled, “Silent Sacrifices” was selected for presentation at the conference after it was viewed by the workgroup.¹² The workgroup suggested including a health fair to represent a wide array of public health providers and community based organizations. Finally, the workgroup felt it important to serve Filipino food and showcase Filipino cultural folkdance as entertainment (Table 3).

Table 1.

Themes From Conference Planning Meetings

Parents	Adolescents
Knowledge: How to Talk About Sex and Contraception / STDs	Knowledge: Contraception / STDs / Where to Get Help
Relationships: Lack of Quality Time With Their Children	Self-Empowerment, Male–Female Relationships
Differences in Filipino and European American Culture	Differences in Filipino and European American Culture

Table 2.

Demographics of Conference Participants Who Completed the Preconference Survey

	Adolescents (n = 30)	Parents (n = 24)
Age (mean in years)	16.8	43.5
Gender
Female	70%	62%
Male	30%	38%
Household Income ($)
< 40,000	—	17%
40,001–70,000	—	33%
70,001–100,000	—	17%
> 100,000	—	25%
Missing	—	8%
Average Number of People in Household	—	4.23
Primary Language
English	82%	36%
Tagalog	9%	9%
Bilingual	9%	36%
Missing	1%	19%
Place of Birth
United States	83%	25%
Outside the United States	17%	67%
Missing	—	8%
Education
Some college	—	27%
College	—	46%
Graduate school	—	27%

Table 3.

“Healthy Teens, Happy Families” Conference Schedule

Time	Event
9:00–9:30 am	Registration and Breakfast
	Surveys
9:30–10:15 am	Introduction
	Opening Remarks
	Introduction for Key Note Speaker
	Key Note Speaker: Director of Santa Clara   County Department of Children and Family   Services
10:15–11:15 am	Workshop I*
	Teens: Gender Roles
	Parents: How to Talk About Sex
11:15–12:15 pm	Workshop II
	Teens: Body Image/Self-Esteem
	Parents: Teenagers 101/Consent and Laws
12:15–1:15 pm	Lunch
	Filipino Food
	Health Fair (Booths, Raffle)
1:15–1:30 pm	Entertainment:
	Performance by Filipino Dance Troupe
1:30–2:45 pm	Workshop III
	Teens: STDs, Drugs, Alcohol, Tobacco
	Guest Speaker (Teenage Mom)
	Parents: Cross-Cultural Conflicts /
	Generation Gap
2:45–3:30 pm	Workshop IV: Bringing Us All Together
	(Parents and Teens)
	“Silent Sacrifices” Video
	Wrap-Up With All
3:30–4:00 pm	Closing
	Raffle
	Surveys
	Acknowledgements
	Entertainment

^*Only adolescents participated in the workshops identified as being for teens, and only parents participated in the workshops identified as being for parents.

Evaluation Methods

Using a convenience sample design, parent and adolescent conference participants were asked to complete pre- and post-conference paper surveys, with items addressing attitudes, knowledge, and communication about sex. We used a convenience sample of conference attendees because funding was only obtained for the evaluation of this conference. Participants received a raffle ticket in exchange for completing the pre- and post-conference surveys. The survey items were adapted from the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System instrument and used Likert scales (1 = strongly disagree to 5 = strongly agree) to identify themes of concern among conference attendees. Six weeks later, a telephone interview was conducted with a subset of parents and teens to assess attitudes, knowledge, and communication about sex.

Descriptive statistics were used to examine pre-conference survey items addressing sociodemographics. We performed McNemar’s test and Wilcoxon rank-sum test to test for preconference to post-conference changes on survey items. Data from the surveys were analyzed using SPSS 17.0 (SPSS, Inc., Chicago, IL). Stanford University’s institutional review board approved all research procedures.

RESULTS

There were 35 adolescents and 25 parents who attended the conference. Table 2 depicts the demographics of the conference participants who completed the pre-conference survey. The preconference data suggest that Filipino youth and parents agree that teen pregnancy is a problem in the Filipino community and that religion is an important part of life. Conversely, youth and parents disagreed on other items. Filipino youth reported feeling uneasy discussing their concerns about sex with parents, whereas parents believed they were open to these discussions (p < .001). Similarly, youth felt that if they broached the subject of sex that their parents would think they were having sex, whereas parents did not believe that to be the case (p < .005). These results suggested gaps in understanding between Filipino American youth and parents and supported the FYC decision to recruit a pastor to lead a parent workshop on how to convey their values to youth through open discussion.

Results from the telephone interview and the post-conference survey suggested that the conference was well received. Both parents and youths reported that the factual content of the conference was helpful (mean scores of 4.5 and 4.7 for adolescents and parents, respectively). After the conference, the majority of parents who completed the telephone survey (n = 10) talked with their adolescents about sex (70%; n = 7). Interestingly, all of the surveyed parents who attended the conference with their adolescents talked about sex (100%; n = 6), suggesting the importance of parents attending the conference with their adolescent.

Post-conference qualitative comments from parents included, “It makes parents aware that they should communicate and feel comfortable with open communication,” and “The conference was good for sharing the truth about teen pregnancy.” In addition, the conference was praised as a means of breaking down communication barriers, with one parent commenting, “I want it to be seen by a lot of teens and parents.” The youth generally agreed with the parents’ perspective on the conference, with one adolescent commenting, “I liked that the conference was raising awareness about minorities and tried to get parents and teens involved.” Conference participants also made suggestions for improving the conference, with one parent recommending to “cover more topics (such as) popularity, the “in” crowd, self-esteem, and confidence.”

Mutual Capacity Building

A significant outcome of this collaboration was the capacity created at the FYC. A final report on survey data was presented to the FYC board to educate community leaders about the importance of this issue. These results were also shared with the community workgroup to elicit suggestions for improvements and for future sources of funding. Tools were provided to enhance parent–adolescent communication (i.e., role playing with parents, video and discussion, gender role exercises with teens used by staff) and local community resources addressing sexual health were organized, creating a new community resource guide. The success of the first conference enabled the FYC to secure funding from a private foundation for a second conference. We also agreed to collaborate again and use suggestions from the first conference to plan the second.

Capacity building among academic partners also occurred. Consistent with other community–academic partnerships,¹³ this partnership allowed academic partners to gain knowledge in implementing CBPR methods and expose trainees (both residents and medical students) to the process of developing community–academic collaborations.¹⁴ Practicing CBPR principles gave trainees skills in relationship building, communication, collaboration, negotiation, and leadership.

LESSONS LEARNED

This community–academic collaboration demonstrated that CBPR is a key tool for exploring health issues in the Filipino community, a large yet understudied population (Table 4). This project would not have been possible without the assets, resources, and relationships provided by the CBO. As described in other projects using participatory research,¹⁵ CBOs are ideal partners because they serve the racial and ethnic minority communities that are targeted. The FYC emphasized the importance of outreach to promote awareness of a problem in the Filipino community and the importance of education (e.g. parenting skills education) in empowering families to solve problems by their own initiative or with help from the community. In this partnership, the FYC, a well-known entity with deep community roots, was able to recruit Filipinos to attend a public conference on a very culturally sensitive subject. In return, academic partners brought technical assistance with survey development, data collection and analysis, grant-writing skills, and expertise of health professionals to the project. The unique lessons learned from this project include the importance of engaging aspects of Filipino culture when practicing CBPR and discovering ways to overcome challenges to engaging in CBPR for physicians-in-training.

Table 4.

Lessons Learned

Engaging Unique Aspects of Filipino Culture

Importance of Religion

Acknowledging Cultural Values

Addressing Intergenerational Conflict Between Parents and Teens

Incorporating Filipino Dancing and Food

Challenges to Engaging Physicians-in-Training in CBPR

Relationship Building and Maintenance

Sustainability

Insider–Outsider Conflict

Engaging Unique Aspects of Filipino Culture

By developing a community workgroup to assist in planning of the parent–teen conference, we were able to culturally tailor the conference content. For instance, the decision to invite a well-trusted pastor to speak to parents at the conference underscores the importance of addressing distinct features of local culture (e.g., religious beliefs) when tailoring an intervention in a specific community. The decision to show and discuss a video addressing cross-cultural conflict in the Filipino American family was a unique, culture-specific aspect of the conference, one rarely seen in traditional teen pregnancy prevention curricula. During breakout sessions after the video, many parents shared relief in knowing that they were not alone in facing problems caused by communication breakdown. Culture-specific tailoring of the conference was important because our workgroup believed that increased awareness of ethnic identity and a greater mutual appreciation of the struggles inherent in the immigrant family experience could improve intergenerational communication and lead to increased self esteem and fewer risk behaviors among the youth. This perspective has empirical support.^16,17

Overcoming Challenges Faced by Physicians-in-Training Engaged in CBPR

We describe 3 challenges faced by physicians-in-training engaged in CBPR: relationship building and maintenance, sustainability, and inside–outsider conflict.

Relationship Building and Maintenance

Similar to Rosenthal et al.’s description of engaging physician research fellows in CBPR,¹¹ we found that a barrier to engaging residents is the demands inherent in relationship building and maintenance. Pediatrics residents are distinct from fellows because they are full-time clinicians who often work 80 hours per week. Thus, pediatric residents are limited in the times they are available for meetings with community partners. We overcame this barrier by holding meetings in the early evenings or during the day when the pediatric resident had elective time dedicated to community projects. A second strategy used was to recruit a medical student (K.R.) to assist with the project (with literature review, data input, recruitment of Filipino undergraduate students to assist with the conference, development of community resource guide, and attending community meetings). The medical student continued to communicate and work with FYC when the pediatric resident was unavailable owing to particularly demanding clinical rotations.

Maintaining a relationship with community partners is challenging because physicians-in-training have little control over their schedules. The first author was fortunate because Stanford’s Pediatric Advocacy Program allowed residents to pursue longitudinal projects over 3 years of residency and provided mentorship and training regarding the importance of listening to the community and building trust with a community over time. Thus, the first author was able to develop a relationship with FYC over the course of 2 years, apply for grant funding during the second year, and then continue the relationship in her last year of residency, when the conference took place.

Sustainability

This partnership informed the career path of the lead author, convincing her to pursue fellowship research training to build on her foundation in CBPR methods and strengthen her analytical skills so that she could bring these assets to her future work with underserved communities. She sustained involvement with this project beyond residency graduation during her 3 years of fellowship training, and presently uses CBPR principles to address mental health issues among Filipino youth. As mentioned, FYC sustained this project by receiving subsequent funding for a second teen pregnancy prevention conference. Although these methods were unique to this partnership, other models to sustain partnerships exist, including developing longitudinal group projects for residents or encouraging residents to become involved with faculty projects involving established community partners.¹¹

Addressing Inside–Outsider Conflict

As described by Chavez et al.,¹⁸ researchers of color “bridge the gap between communities of color and institutions of research, bringing knowledge across in both directions”(p. 90). As a researcher and as a member of the Filipino American community, the first author experienced some degree of inside–outsider conflict.¹⁹ As an insider who is Filipino American, she may have had an easier time gaining the trust the trust of community members, an observation described in another study targeting the Filipino population for cancer screening.²⁰ As a member of an academic institution, the first author saw herself as a privileged outsider who wanted to focus on the strengths of her community and yet was wary about exposing negative aspects of Filipino culture. For instance, fundamental values in Filipino culture include respect for authority figures, pakikisama (family unity and closeness), and hiya (shame).²¹ In general, Filipino adolescents are less willing than non-Hispanic white adolescents to openly disagree with their parents, and they place less emphasis on autonomy.²² Pakikisama emphasizes smooth interpersonal relationships and reflects a high value on family, harmony, and conflict avoidance.²³ Hiya is a motivating factor behind behavior, such as the denial of existence of a problem. Filipino culture, like other Asian cultures, holds that a child’s behavior is a reflection of family upbringing. This cultural perception may explain a delay in seeking services for problems, such as teen pregnancy because of fear of being stigmatized.²³

The first author overcame inside–outsider conflict by learning about the FYC’s services and offering ways in which she could use her skills to address the needs of their population (e.g., workshops for parents and educational sessions for adolescents). By developing trust over time with the FYC and maintaining respect with that relationship, we were able to have open and honest discussions of how to address the above aspects of Filipino culture in our intervention (showing the “Silent Sacrifices” video to conference participants to encourage discussion). The FYC staff also provided a cultural lens in their interpretation of the survey data results. For instance, they thought that parents may have been self-censoring and conforming to socially acceptable answers to avoid shame.¹⁸

LIMITATIONS

This project and the process we used to evaluate it had several limitations. First, the use of a convenience sample and relatively small sample size limit the generalizability of our results. Future studies should use the CBPR approach with larger populations of Filipino Americans. Next, although survey items were adapted from a national survey that assesses adolescent risk behaviors (the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System), these items have not yet been validated in the Filipino population.

Although community members were involved in leadership roles in planning the conference and giving feedback regarding the survey data results, they did not participate in data collection or analysis and did not have opportunities to make substantive decisions regarding the selection of what community health indicators should be included in the survey. Per Hancock et al.,²⁴ community health indicators are often created and employed by outside professionals; thus, involving community members in the process of developing community health indicators can be an important part of CBPR. With community involvement, community indicators will be relevant to both policymakers and the general public and will have the following qualities: Face validity (they make sense to people), theoretical and empirical validity (they measure an important health determinant), social value (they measure things people care about), and valency (they are powerful and carry social and political punch).²⁴

Another limitation was that we did not have any adolescents served by FYC represented in our community workgroup. This is important because communities have multiple levels of stakeholders whose needs and priorities may differ.^25,26 For instance, when survey participants answered the item, “What offers the most danger for youth?”, adolescents ranked domestic violence, mental/emotional abuse, and alcohol use as their top three items, whereas parents highly ranked drugs, teen pregnancy/violence in media, and domestic violence/gangs as high-priority topics. This draws attention to the challenges inherent in targeting both parents and teens in our project. In the future, it may be beneficial to separate community workgroups for youth and adults to address the power differential between youth and adults as described in other partnerships.¹³ Also, involving adolescents in decisions about content may have changed the focus of the conference. We addressed this limitation during the planning of a second conference by developing a teen advisory workgroup.

CONCLUSION

This community–academic partnership identified a key concern in the Filipino community, engaged both sides of an issue (adolescents and parents), and energized the community to generate another conference, thereby demonstrating the ability of CBPR to create a sustainable activity in a population that has traditionally been out of the reach of researchers. Further research needs to incorporate unique aspects of Filipino culture and replicate this community-driven model with larger Filipino populations. To make an impact on the health of communities they serve, it is important to address challenges to engaging physicians-in-training in CBPR. CBPR experiences can provide meaningful educational opportunities for physicians-in-training and can build sustained capacity in CBOs. Residents can develop analytic skills, directly affect the health of the communities they serve, and, for minority physicians, give back to the communities they call home.