Social Science & Medicine 75 (2012) 2250e2257

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Social Science & Medicine

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The impact of migratory separation from parents on the health of adolescents in the Philippines
Chantal Smeekens a, *, Margaret S. Stroebe a, b, Georgios Abakoumkin c
a

Department of Clinical & Health Psychology, Utrecht University, P.O. Box 80140, 3508 TC Utrecht, The Netherlands Department of Clinical Psychology & Experimental Psychopathology, University of Groningen, The Netherlands c Department of Early Childhood Education, University of Thessaly, Volos, Greece
b

a r t i c l e i n f o
Article history: Available online 1 September 2012 Keywords: Philippines Health Adolescent Health psychology Family Labour migration Cognitive stress model Separation reactions

a b s t r a c t
In the Philippines, as in several other low and middle-income countries in the world, it is usual for parents to leave the country to work abroad in order to improve the situation of their children who remain behind. However, stressful life events such as the separation from a parent are known to have a severe impact on physical and mental health of children. This study, conducted in 2008e2009, explored health consequences of migratory separation for remaining-behind adolescent children, comparing them with those whose parents remained at home. Participants were 205 high school students from the Philippines. It was found that adolescents with a parent abroad, particularly the mother, reported poorer physical health than those with both parents at home, while socioeconomic status did not have impact. The parenteabroad adolescents reported a high level of missing their parent(s) and felt emotionally lonelier than the parent-at-home group. Emotional loneliness and stress due to parental absence were associated with poorer health. Avoidant coping appeared to moderate the parental absence-health relationship. Paradoxically, it seems that, although many parents work abroad to improve the lot of their children, the latter suffer emotional stress and physical health detriments. While Lazarus and Folkmans (1984) cognitive stress model is generally applicable for migratory separation, cultural aspects need attention, both in theoretical implementation and interpretation. Limitations and implications are further discussed. 2012 Elsevier Ltd. All rights reserved.

Introduction Stressful life events are known to have severe health implications for those experiencing them (Folkman, 2011; Lazarus & Folkman, 1984; Miller, Chen, & Cole, 2009). For adolescents, family issues are a main source of stress (Brodzinsky et al., 1992). Poverty, divorce of parents and the experience of loss or absence of a parent have frequently been identied as predictors of mental health problems among children and adolescents (e.g., Grant et al., 2006). Likewise, the extreme case of separation from a loved person through his or her death has been found to impact strongly on both mental and physical health of survivors (Miller et al., 2009; Stroebe, Schut, & Stroebe, 2007). In the context of such ndings, it becomes important to investigate whether temporary loss of parents

* Corresponding author. Present address: The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts Causeway, Cambridge CB1 8RN, United Kingdom. Tel.: 44 1223 742089. E-mail addresses: cs662@medschl.cam.ac.uk (C. Smeekens), M.S.Stroebe@uu.nl (M.S. Stroebe), gabak@uth.gr (G. Abakoumkin). 0277-9536/$ e see front matter 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2012.08.025

through migratory separation affects the health of children left behind: are there negative health consequences following this type of separation too? Migratory separation can be dened as the relocation abroad of parents entering a foreign work force (cf. Pottinger, 2005). One focus of investigation in this latter area of research has been on the people themselves who go abroad for long periods of time, away from their loved ones and homeland (e.g., De Castro, Gee, & Takeuchi, 2008; Lu, 2010). However, as indicated above, children too can suffer from various types of separation, and we need to establish the impact on these young people of the absence of a parent living and working abroad. Indeed, being separated from a parent as a result of such labour migration is an increasing issue for young people in low- and middle-income countries in contemporary society, and yet this topic has received far less scientic attention than the other types of loss illustrated above. Little is known about whether negative consequences of separation undermine the potential advantages due to parental employment and nancial improvement, or what factors may be associated with high risk of health detriments for young people left behind. The aim of the current study was therefore to investigate whether

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adolescents in the Philippines whose parents work overseas differ in health from adolescents whose parents are both living with them, focussing on under-researched physical health. We also try to identify those who might be at particular risk of poor adaptation to separation. In the following sections, we rst describe the situation in the Philippines, indicating why it is useful to conduct a study of migratory separation in this country. Then we summarize the evidence that is available on the health consequences of this type of loss. To understand the impact of migratory separation more precisely, it is important to consider possible mediators and moderators (risk factors) of its link with ill-health. A theoretical model derived from cognitive stress theory (Folkman, 2011; Lazarus & Folkman, 1984) provides a framework for systematic examination of such variables. Therefore, this model and its implications for our study are then described, which leads to the formulation of hypotheses. Migratory separation in the Philippines There are good reasons to study the impact of migratory separation on young people in the Philippines. The Philippines is one of the largest labour migrant-sending countries in the world. It is estimated that a quarter of under-aged people in this country are living separated from their parents because the latter are working as Overseas Filipino Workers (OFW) (Parreas, 2006; Reyes, 2008; Scalabrini Migration Center, 2004). In the Philippines, a relatively poor country, the main reason for parents to work abroad is to improve the economic situation of their remaining-behind families. But is this an advantage or a disadvantage? On the one hand, nancial remittances could make education, health care and nutritious food more accessible and may help to improve the left-behind childrens health situation (Bryant, 2005; Garcia Dungo, 2007; Scalabrini Migration Center, 2004; Yang, 2004). Most of the relevant evidence is based on cross-sectional surveys (although some of the studies are purely descriptive). It has been reported that children in the Philippines with a parent abroad perceived themselves as healthier (University of the Philippines, Tel Aviv University, & Kaibigan, unpublished manuscript) and suffered less often from illnesses than other children (Asis, 2006a). This could possibly be explained by a growth in socioeconomic status through nancial remittances, as socioeconomic status (SES) is positively associated with physical health (Cohen, Kaplan, & Salonen, 1999; Miller et al., 2009). On the other hand, concerns have also been expressed that this culture of migration (Asis, 2006b; Yang, 2004) may not bring solely positive effects. Left-behind OFW children generally miss their absent parent (Garcia Dungo, 2007; Scalabrini Migration Center, 2004; University of the Philippines et al., unpublished manuscript) and emotional, psychosocial and behavioural problems have been reported (Garcia Dungo, 2007; Parreas, 2002, 2006; Scalabrini Migration Center, 2004), in particular in cases of maternal absence (Asis, 2006a; Battistella & Conaco, 1998; Garcia Dungo, 2007; Parreas, 2006). At the same time, some families appear to have fewer problems (Battistella & Conaco, 1998). Furthermore, because problems may also occur among non-OFW children and adolescents, it is important to include control groups of non-OFW. It remains crucial to establish whether the distress of parental absence outweighs the advantages of income growth for young people left behind in the Philippines (cf. Rossi, 2008). Health consequences of migratory separation: evidence from other countries Evidence from other countries is based mainly on crosssectional studies. These investigations suggest that there are

indeed negative mental and physical health outcomes among leftbehind children of parents who have gone to another country or area to work. Detrimental effects on mental health have been better documented than those on physical health. For example, studies of within-country migration in China (Liu, Li, & Ge, 2009; Liu, Sun, Zhang, Wang, & Gua, 2010; Zhao et al., 2009) examined the mental health impact of parental labour migration to urban areas in China on children remaining behind in rural areas. Children with a migrated parent reported poorer mental health than their counterparts with both parents at home. The results of a matched control-group study conducted in Jamaica suggested a relationship between the separation of migrated parents and their 9e10 year old children and childrens experience of stress, grief and loss (Pottinger, 2005). It would seem that migratory separation of a parent has an impact across a range of different mental health consequences. Regarding physical health, the well-established relationship between stressors and health outcomes (Folkman, 2011) would suggest negative outcomes for those with parents abroad. However, ndings have been conicting. Left-behind children from parents who migrated within China reported poorer health-related quality of life (Jia, Shi, Cao, Delancey, & Tian, 2010), were more overweight, had lower height and ate less-healthy diets than those with parents at home (Gao et al., 2010). However, Nguyen, Yeoh, and Toyota (2006) reviewed studies on migratory separation in Asia and reported contradictory ndings; sometimes the migratory separation of a family member led to poorer physical health outcomes for those left behind, while in other studies it was associated with better health outcomes. In a longitudinal study in rural Mexico migratory separation from a father was found to be related to child illness (Schmeer, 2009), while Kanaiaupuni and Donato (1999) found that for young children in Mexico, nancial remittances compensated for maternal absence and provided access to better food and health. While providing useful leads, it is evident that research has provided limited information so far on the mediators and/or moderators of the relationship between migratory separation and health. Intervening variables: a theoretical perspective The picture that emerges from studies in the Philippines and other countries regarding the consequences of parental migration is unclear. Socioeconomic growth may lead to better physical health while the psychological difculties of migratory separation may cause poorer outcomes. In our view, a useful strategy to clarify the complex relationship between migration and health is to start from a theoretical perspective which systematically describes the relevant variables in adaptation to stressful life events. Cognitive stress theory (Folkman, 2011; Lazarus & Folkman, 1984) provides a taxonomy to organize research and test relationships between the occurrence of a stressor (in our case, separation), processes of coping and appraisal (e.g., how migratory separation is evaluated by adolescents), and outcome (most importantly here, physical health). Slavin, Rainer, McCreary, and Gowda (1991) developed an adaptation of the stress process model with attention to culturallyrelevant dimensions. Using this, it is possible to document how cultural characteristics might play a role in the appraisal process and health outcomes in the Philippine setting. Thus, Fig. 1 shows the stress model adjusted to migratory separation in the Philippines. Key variables can be seen in Fig. 1. In addition to the denition of the stressful event and outcomes that have featured already above, the Figure includes three components that can be integrated in an empirical investigation, as intervening variables. These include primary and secondary appraisal processes, and specic

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Potentially stressful event: Parental overseas migration ______________________ Cultural context: The Philippines is one of the largest migrant-sending countries in the world

Primary appraisal: Socioeconomic status Gender of parent abroad ______________________ Cultural context: Family characteristics Gender roles Poverty in the Philippines Secondary appraisal: Emotional stress Loneliness Avoidant coping ______________________ Cultural context: Coping style Value of family and togetherness

Adaptional outcomes: Physical health ______________________ Cultural context: Tendency to somatization in Asian cultures Views on health Lifestyle in the Philippines

Fig. 1. The cognitive stress model adjusted to migratory separation in the Philippines.

situational/environmental factors. We have focused our investigation on those variables that emerged from qualitative research in the Philippines and the general scientic literature in this area as most central. Primary appraisal refers to the assessment of the event: in our case, appraisal in terms of missing the parent is highly relevant. Secondary appraisal has to do with assessment of ones ability to cope with the stressor (Lazarus & Folkman, 1984). This process can reduce or strengthen the outcomes of stress, relating here to physical health. One particular coping style, namely, avoidant coping, has been strongly associated with negative physical health outcomes (e.g., Ruchkin, Eisemann, & Hgglf, 2000) also for adolescents (Kardum & Krapic, 2001). Avoidance-focused coping strategies could be particularly relevant in collectivistic cultures with a less direct way of controlling stressful situations, as in the Philippines (Chun, Moos, & Cronkite, 2007). A distinction can be made between cognitive and behavioural avoidant coping, whereby cognitive avoidance mainly involves strategies such as not thinking about the problem (e.g., Trying not to think of the absent parent), while behavioural avoidance involves behaving in a certain way that avoids the problem (e.g., Getting away from missing him/her by doing something distractive with friends) (Brodzinsky et al., 1992). Furthermore, in the situation of OFW adolescents, appraisals of loneliness might strongly inuence outcomes. Children of Filipino migrants reported higher levels of loneliness (Asis, 2006a; Battistella & Conaco, 1998). Weiss (1973) described loneliness as a response to the absence of some specic social provision. Family members in the Philippines provide alternative social support to that of parents, which might lead to less loneliness (Reyes, 2008). However, this may not protect adolescents fully from feeling lonely. Weiss (1973) division between loneliness of social isolation (the lack of provision in social integration) and emotional loneliness (a lack of attachment) is of relevance. Emotional loneliness seems particularly meaningful for the current study. Family and togetherness are important in the Philippines (Medina, 2001) and may be available still to adolescents with a parent abroad, so social loneliness might not be as common. There may be less compensation for emotional loneliness and this could impact Filipino adolescents physical health outcomes. However, if experienced by children of migrant parents, both types of loneliness are expected to have an impact on health outcomes. Finally, a situational/environmental factor that may help unravel the positive impact of nancial gains versus negative consequences of separation is socioeconomic status. As discussed earlier, higher socioeconomic status seems to protect against negative health consequences. Therefore, it appeared reasonable to examine socioeconomic status as a possible moderator of the relationship

between the stressful event of separation and the outcome of poor physical health. Aims of the current study The purpose of the current study in the Philippines was to gain understanding of the consequences for adolescents of having either one or both parents working abroad (classied here as the Overseas Filipino Worker group: OFW). In particular, given the paucity of well-controlled quantitative research and its potential importance for adjustment among young persons, the focus here was on the relationship of such parental absence with physical health, by comparing the OFW group with adolescents whose parents were both living with them in the Philippines (non-OFW). Furthermore, our investigation was designed to examine a number of key variables that we expected to mediate or moderate the relationship between migratory separation and physical health. Thus, the following hypotheses were formulated on migratory separation and physical health: (1) We expected the OFW adolescents to have poorer physical health compared to non-OFW group. (2) We expect two variables to have a role in the relationship between OFW status and physical health: namely (a) socioeconomic status would moderate this relationship (with the poorest health outcomes for the low SES OFW group and the best health for the high SES nonOFW group); and (b) within the OFW group maternal absence (OFW with a mother abroad or both parents abroad) would be associated with poorer physical health outcomes as compared to paternal absence. Further hypotheses could be derived from cognitive stress theory as described above (Lazarus & Folkman, 1984): (3) It was expected that (a) missing the absent parent more and (b) perceiving the migratory separation as more stressful would be associated with poorer physical health. (4) In addition, following the theorys construct of secondary appraisal (Lazarus & Folkman, 1984), it was hypothesized that (a) feelings of loneliness (social and emotional loneliness) would mediate the relationship between OFW status and physical health. Further, it was hypothesized that (b) avoidant coping would have a moderating effect on the relationship between OFW status and physical health; the higher score on avoidant coping, the stronger the relationship of OFW status with poor physical health will be. Method Participants Initially, 267 adolescents lled in the questionnaire. Adolescents who had a parent who passed away, whose parents were divorced or had a parent worked in a different area in the Philippines were

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excluded from the study (n 44). Also, those with poor knowledge of English (n 13) were excluded from the study (based on a question about their uency in reading and writing) as well as those with unreliable questionnaires (n 5) (e.g., lots of missing data). Participants were 205 Filipino adolescents aged 13e18 (M 14.58, SD 1.04) years, with 65 males and 139 females (one participant did not indicate gender). One hundred and eight of them formed the OFW group and had one or both of their parents working abroad. Fifty nine participants in the OFW group had a mother, 40 had a father, and 9 had both parents working abroad. The control group (non-OFW) consisted of 97 adolescents whose parents lived with them. Of the adolescents with a parent abroad, 73 attended a private school and 35 a public school. The schools were located in the rural municipality of Isabela; a northern province of the Philippines. Among the control group these numbers were 72 and 25 respectively. Participants came from different ethnic groups, with the majority being Ibanag, but also including Tagalog and Illocano. Procedure Data collection took place late 2008 to early 2009. The study was conducted in accordance with general ethical principles of Utrecht University, The Netherlands. In addition, adjustments concerning participants consent as well as permissions to conduct the study were necessary in order to adapt to the local situation in the Philippines. The study was approved by the Cagayan Valley Programme on Environment and Development (CVPED) of Isabela State University e Cabagan. Permission to conduct the research was obtained from the mayor of the municipality, local authorities and the school principals. Finally, guidance counsellors of the respective schools were asked for their cooperation. The guidance counsellors, who volunteered to cooperate with the researcher, approached the adolescents and asked them whether they would be willing to participate in a study on your health, your family life and your habits. It was made clear to them both by the guidance counsellor and later by the researcher that they were free to refuse if they did not wish to participate. Concerning the practice followed with regard to participants consent: we would like to mention that it is not customary in the Philippines to ask for (written) parental consent. Moreover, many of the adolescents parents e or guardians e live and work far away, and it is also to be expected that some parents may not be able to read and write. Therefore, the procedure was adopted whereby adolescents themselves, with the aid of guidance counsellors, decided whether to participate. Guidance counsellors are at the schools for the adolescents interests, being condantes for them rather than authority gures. In line with this role, they acted in the interest of the adolescents and they did not put any pressure on them to participate. Overall, this procedure was followed to both preserve participants rights and to conform to local customs. The individuals who agreed to participate were invited to take a seat in a classroom that was reserved for the study. There, the informed consent and short instructions for lling in the questionnaire were given. Both were explained verbally in English and Ibanag and could be read in the English introduction letter that was attached to the questionnaire. It was chosen to administer the questionnaire in English. In the area, various different languages are spoken, but students are not necessarily able to understand these languages in written form, as school materials are written in English. In fact, English is one of the ofcial languages in the Philippines and it is understood well by most. Participants were given the opportunity to ask for verbal translations in their own language (Tagalog, Ibanag or Illocano).

Measures OFW category and background: Questions were asked about overseas labour migration of parents and the adolescents background (i.e., ethnic group, age, gender), to use as control variables. Physical health: Physical health was measured with the Physical Health Questionnaire (PHQ; Schat, Kelloway, & Desmarais, 2005). The scale consists of fourteen items that assess somatic symptoms experienced in the last few weeks, measured on a 7-point Likert scale (1 Not at all, 7 All the time), a .72. Socioeconomic status: School type (public or private) was taken as an indicator for socioeconomic status. In the Philippines, private schools are considered to be better (Battistella & Conaco, 1998), and nancial resources are often used to send children to more expensive private schools (Bryant, 2005). In the rural Isabela province, socioeconomic status (SES) is not accurately measurable by income, as many inhabitants live from their own agricultural products. Moreover, most adolescents do not know the income of their parents. Furthermore, a control measure showed that adolescents attending the private school had signicantly more (M 6.15, SD 1.97) appliances (1e10) at home than adolescents attending a public school (M 4.23, SD 2.05), t(202) 1.92, p < .001. Maternal absence: The OFW group was asked about the gender of the parent(s) abroad, forming a group with only the father abroad and a group with only the mother and both parents abroad. Missing parents: A single-item measure was chosen to obtain an overall idea of the extent that adolescents missed their absent parent. As it was expected that the adolescents generally miss their parent to some degree and that social desirability could have an impact, there were 4 Yes answer categories (Yes, a lot, Yes, Yes, a bit, Yes, a little bit), and No. Perceived stress (due to missing the parent): The Homesickness Questionnaire (HQ) (Archer, Ireland, Amos, Broad, & Currid, 1998) was adapted to the situation of migratory separation, to measure stress due to missing the parent. The scale measures features associated with separation and loss and consists of 16 items (e.g., It upsets me if I am unable to contact my parent who is working in another country). Answers were given on a 5-point Likert scale (1 Not at all, 5 Always). The scale had a Cronbachs a of .67 after deletion of one item. Loneliness: Loneliness was measured by four items (adopted from Stroebe, Stroebe, Abakoumkin, & Schut, 1996), using a 5-point Likert scale (1 Never, 5 Very often). Two items measured Emotional Loneliness (e.g., I often feel lonely even when I am with other people, a .44) and two items measured Social Loneliness (e.g., I have a really nice set of friends, a .75). Avoidant coping: Avoidant coping was assessed with the Coping Scale for Children and Youth (CSCY; Brodzinsky et al., 1992). The scale consists of 29 items that measure coping styles that children and youth may use when having a problem. In the current study only Cognitive Avoidance (11 items) and Behavioural Avoidance (6 items) were used, since avoidant coping is particularly related to negative health outcomes (Ruchkin et al., 2000). A 5-point Likert scale was used (1 Never, 5 Always). A sample item of Cognitive Avoidance is I put the problem out of my mind (a .60). A sample item of Behavioural Avoidance is I tried to get away from the problem for a while by doing other things (a .82). Results First, we examined whether gender and age of the adolescents were related to the variables physical health and migratory separation of a parent. Age correlated with physical health (r .22, p < .01) and therefore all analyses with the variable physical health

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were controlled for age. Controlling for age did not change the pattern of the results, unless mentioned otherwise. Physical health was not signicantly associated with gender, t(202) 1.82, ns; hence, data were collapsed across gender for all analyses. Table 1 presents means and standard deviations of the two groups for all measures. Parental migration and physical health A two-way between groups analysis of variance (ANOVA) was conducted to test whether separation from a parent working overseas (OFW) and socioeconomic status (SES; private school or public school) were associated with the adolescents physical health. The variable OFW had a main effect on physical health, F(1,199) 9.08, p < .01, with adolescents with a parent working overseas reporting poorer physical health (M 5.09, SD .78) than adolescents with both parents at home (M 5.43, SD .63). The main effect of SES was not signicant, F(1,199) 2.55, ns. No interaction effect between the variables was found either, F(1,199) < 1; therefore, SES did not moderate the relationship between OFW status and physical health. Thus, our main hypothesis (1) could be conrmed, as adolescents with a parent overseas (OFW) reported poorer health than their nonOFW counterparts. However, Hypothesis 2a regarding the moderator role of SES was not conrmed. We then divided the OFW adolescents into a group whose mother was working abroad (mother absent) and a group for whom only the father was working abroad (only father absent), and conducted a one-way ANOVA of OFW status (non-OFW vs. OFW mother absent vs. OFW father absent) on the physical health scores. This analysis yielded a signicant result, F(2,200) 5.78, p < .01. As indicated by post-hoc comparisons (Bonferroni), this result was due to the difference between the mother absence group (M 5.07, SD .75) and the non-OFW group (M 5.43, SD .63), which conrms Hypothesis 2b. Cognitive stress theory: testing for mediation and moderation We analysed whether adolescents were missing their absent parent, and whether missing the parent and stress due to missing the absent parent was associated with physical health outcomes. It appeared that the majority of the OFW adolescents reported missing their absent parent very much (M 4.59, SD 1.01). Due to this strongly skewed distribution, the 1-item measure was omitted from further analyses and Hypothesis 3a could not be conrmed. Then, we examined whether stress due to missing the absent parent (adapted Homesickness Questionnaire (HQ); Archer et al., 1998) would be associated with physical health outcomes. This was indeed the case (r .31, n 96, p < .01): More stress experienced by participants was associated with poorer physical health; this supports Hypothesis 3b. Two sets of regression analyses following the procedure suggested by Baron and Kenny (1986) were performed to test whether

Table 1 Means and standard deviations of measures by OFW status. Non-OWF M Physical health** Emotional loneliness* Social loneliness Cognitive avoidant coping Behavioural avoidant coping 5.43 2.35 2.17 2.90 2.73 SD .63 .82 .98 .60 .58 OFW M 5.09 2.65 2.44 2.84 2.87 SD .78 .89 1.05 .67 .61

Note: Group means comparisons according to t-tests. *p < .05; **p < .01.

the (secondary appraisal) variables social and emotional loneliness mediated the relationship between the absence of a parent and physical health. First, the mediator (loneliness) was regressed on the independent variable (OFW status). Second, the dependent variable (physical health) was regressed on the independent variable (OFW status). And third, the dependent variable was regressed on the independent variable controlling for the mediator. All variables were standardized for the analyses. With regard to the rst set, OFW did not predict social loneliness, b .13, R2 .02, F(1,190) 3.46, ns. Therefore, further regression analyses on social loneliness were omitted. Then, a regression analysis was performed and showed that OFW predicted emotional loneliness, b .17, R2 .03, F(1,193) 5.83, p < .05, with adolescents with a parent abroad feeling more emotionally lonely than those with both parents at home. The next regression analysis showed that OFW status, as already reported above, predicted physical health, b .23, R2 .05, F(1,201) 11.30, p < .01. In the last step, when entering OFW status into the equation while controlling for emotional loneliness, the mediator was signicant, b .22, t(191) 3.18, p < .01, and the relationship between OFW and physical health remained signicant as well, b .20, t(191) 2.86, p < 01; physical health was predicted by both OFW status as well as emotional loneliness, R2 .10, F(2,191) 11.07, p < .001. This means that emotional loneliness did not substantially affect the relationship between OFW and physical health and was therefore not found to be a mediator. This did not conrm Hypothesis 4a. Finally, Hypothesis 4b was examined, namely, that cognitive and behavioural avoidant coping would moderate the relationship between the absence of a parent and physical health. Two regression analyses were conducted. In a rst step of each regression, physical health was regressed on the independent variable and the moderator (OFW status and the respective coping variable). In a second step, the interaction term was entered into the equation. All variables were standardized for the analyses. First, the moderator role of cognitive coping was examined. Both OFW status, b .23, t(198) 3.41, p < .01, as well as cognitive coping, b .17, t(198) 2.54, p < .05, predicted physical health, R2 .08, F(2,198) 8.69, p < .01. When the interaction term was entered in the second step, both predictors remained signicant, while their interaction only approached signicance, b .12, t(197) 1.73, p .09. Nevertheless, this trend was in the predicted direction. As depicted in Fig. 2, panel (a), the relationship between OFW status and physical health tended to be stronger among participants with higher cognitive coping scores: for those who applied avoidant cognitive coping to a higher degree, the absence of a parent appeared to affect their health more than for those who did not engage so much in avoidant coping. Second, the moderator role of behavioural coping was examined. Again, both OFW status, b .20, t(195) 2.89, p < .01, as well as behavioural coping, b .21, t(195) 3.02, p < .01, predicted physical health, R2 .09, F(2,195) 9.90, p < .001. This time, the interaction was signicant, b .15, t(194) 2.20, p < .05, while both predictors remained signicant as well, R2 .11, F(3,194) 8.35, p < .001. As can be seen in Fig. 2, panel (b), behavioural coping exhibited a similar moderation pattern as cognitive coping: The more participants applied this coping strategy, the more did their health suffer when a parent was absent. Finally, it should be noted that the above picture did not change considerably when controlling for age. The only notable change was that the interaction between OFW status and cognitive coping became signicant. Overall then, hypothesis 4b was supported: High avoidant coping made the relationship between OFW status and physical health stronger as compared to low avoidant coping.

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Fig. 2. Physical health by OFW status and avoidant coping. Panel (a) cognitive avoidant coping; and panel (b) behavioural avoidant coping.

Discussion The primary aim of the current study was to explore the relationship between parental migratory separation and physical health of the remaining-behind adolescent children. Conrming our main hypothesis, adolescents with a parent abroad reported poorer physical health compared to adolescents with both parents living with them at home. The difference was still signicant when age was controlled for. A major explanation for the current nding lies within cognitive stress theory (Lazarus & Folkman, 1984). However, although the emotional stress of missing a parent led to poorer physical health among the OFW adolescents, it did not fully explain the missing-parent effect. Still, there is evidence that Asians tend to somatize psychosocial or emotional problems and this could explain the relation between emotional stress and health (Chun et al., 2007; Wong, Tran, Kim, Van Horn Kerne, & Calfa, 2010). Additional hypotheses were explored to investigate the relationship between migratory separation and physical health. Socioeconomic status was expected to improve and lead to better physical health (Scalabrini Migration Center, 2004; University of the Philippines et al., unpublished manuscript; Yang, 2004). However, here socioeconomic status did not relate to the health outcomes in adolescents. How could these contradictory ndings between the current and previous studies be explained? First, socioeconomic status may relate more to actual bodily outcomes than to scores on the Physical Health Questionnaire, if these scores reect somatization of psychological stress rather than actual biomedical health states. Second, transnational families may not always spend their remittances wisely in terms of health; they might rather buy luxury goods such as cigarettes and soft drinks. In the Philippines, so-called western diseases and problems such as obesity have emerged, in particular among people from higher income groups (Dahly, Gordon-Larsen, Popkin, Kaufman, & Adair, 2010). Third, the operationalization of socioeconomic status by using school type might have been rather weak (we return to this later). We conclude, therefore, that improvement in socioeconomic status, due to having a parent working overseas, was not sufcient to compensate for other lacks such as the emotional burden resulting from the absence of a parent. As hypothesized, the adolescents whose mother worked overseas reported signicantly poorer health outcomes compared to the group with both parents at home. Previous studies from the Philippines provide support for the view that mothers are important sources of support for physical and emotional health (Medina, 2001), whose absence could be emotionally stressful for left-behind children (Asis, 2006a; University of the Philippines et al., unpublished manuscript). Although there was no difference in

social loneliness, possibly because extended families in the Philippines are close, emotional loneliness was a predictor of physical health outcomes. Following cognitive stress theory (Lazarus & Folkman, 1984), it was expected that an avoidant coping style would moderate the relationship between OFW status and physical health. This was conrmed in our analysis; behavioural avoidant coping had a negative impact on physical health, especially when a parent is working abroad. Cognitive avoidant coping was also a signicant moderator after controlling for age. Interventions directed at altering (avoidant) coping strategies which have been used to deal with the stress of parental absence might be benecial to leftbehind adolescents. There were some limitations to our study. A main challenge was to adapt the questionnaire to the adolescents situation in the Philippines. The questionnaire was not in the participants rst language, which could have led to interpretation issues. An example is the interpretation of the answer categories on the Likert scales. In Filipino language there is only one word for often and always. During pilot testing it became evident that the adolescents understood that the answer possibilities were in ascending order, from never (1) to always (5) and no problems related to this scale emerged. Nevertheless, cross-cultural differences in interpretation of scales and questions could still remain, which makes comparisons with studies from other countries difcult. Another example is the statement I decided to stay away from people and be by myself, from the Behavioural Avoidant Coping-subscale. This situation could be more problematic than in a western culture, because in the Philippines it is perceived as normal to be together with others often (Medina, 2001). The limitations in the questionnaire, mainly involving cultural and language issues, suggest the need for further studies to adapt existing scales and to develop questionnaires from Filipino cultural perspective. Another issue concerns two measures that were used, namely, assessment of socioeconomic status (SES) by means of school type, and of the extent that participants missed their parents using a single-item measure. Regarding SES, a direct income measure may seem more appropriate. However, indirect measures like school type might often be applicable or even preferable in some countries or regions, like the Isabela province, where direct assessment of income is highly problematic (see also Piovesan, Padua, Ardenghi, Mendes, & Bonini, 2011). Moreover, in support of the current measure, school type was related to number of appliances at home, a common measure of family assets. The assessment of missing the parent through a single-item measure makes it less reliable. The study investigated the experience of migration for a specic segment of the population, particularly with

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C. Smeekens et al. / Social Science & Medicine 75 (2012) 2250e2257 Bryant, J. (2005). Children of international migrants in Indonesia, Thailand, and the Philippines: A review of evidence and policies. Innocenti working paper no. 200505. Florence: UNICEF Innocenti Research Centre. Carlton, B. S., Goebert, D. A., Miyamoto, R. H., Andrade, N. N., Hishinuma, E. S., Makini, G. K., Jr., et al. (2006). Resilience, family adversity and well-being among Hawaiian and non-Hawaiian adolescents. International Journal of Social Psychiatry, 52(4), 291e308. Chun, C. A., Moos, R. H., & Cronkite, R. C. (2007). Culture: a fundamental context for the stress and coping paradigm. In P. T. P. Wong, & L. C. J. Wong (Eds.), Handbook of multicultural perspectives on stress and coping (pp. 29e53). New York: Springer. Cohen, S., Kaplan, G. A., & Salonen, J. T. (1999). The role of psychological characteristics in the relation between socioeconomic status and perceived health. 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respect to socioeconomic status. Filipinos working overseas and adolescents attending high schools are generally not from the poorest families. In the Philippines there are large differences between poor and rich. Among the poorest, socioeconomic improvement might predict greater changes in physical health outcomes. Therefore, changes in socioeconomic status might be of greater signicance for the health of adolescents from the poorest families than for those in our sample. Although the interpretation that the absence of a parent leads to poorer physical health of the remaining-behind adolescent children seems highly plausible, caution is needed: It is possible that the causal relation between migratory separation and physical health outcomes is the other way around. Poor physical health of children could be a reason for parents to go abroad rather than a consequence of migration. The current patterns of ndings, as well as limitations of this investigation, call for a longitudinal follow-up study among leftbehind adolescents, starting before parents departure. This would give valuable information about the relationship between migratory separation and physical health; in particular about causality and changes over time. An extension to other health variables such as psychosomatic health, health risk behaviour and nutritional status would be valuable, besides extending the study to include the parents working abroad and remaining behind. A further step would be to examine factors that may contribute to better physical health and well-being outcomes, such as resilience of the left-behind adolescents and family support (e.g., Carlton et al., 2006), aspects that seem likely to be strong features within Filipino society. In conclusion, the current study indicated that labour migration and consequently, migratory separation from parents, is not always associated with better physical health outcomes for their leftbehind adolescent children. Paradoxically, this parental absence was related to poorer physical health among the left-behind adolescents in our study. The adolescents also reported missing their parents very much and in our investigation, higher levels of emotional stress among them were associated with poorer physical health. The ndings provide some insights to the ambiguous character of labour migration and the difculties that it brings for left-behind adolescent children in the Philippines. Acknowledgements We gratefully acknowledge the help of the following in the Philippines: Prof. C. Conaco (University of the Philippines e Diliman), the CVPED (Cagayan Valley Programme on Environment and Development), the participating high school students, and Maricel Angolluan (interpreter). Also, we thank the anonymous reviewers for their thoughtful comments. References
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