Chapter 10. Chinese Family Members Caring for Older Adults in Private, Senior, and Long-Term Care Homes: A Mismatch of Needs and Culturally Appropriate Services

Globally, in developed countries, the proportion of people living longer is growing, requiring families to be caregivers for older adults in private homes. This trend contributes to a decline in hospital deaths (Bone et al. 2018), and a cost-saving potential (Martens et al. 2018) of approximately $221 and $642 billion in the USA annually, which would otherwise be spent on formal care and/or institutionalization (Cohen et al, 2019). “Aging in place” refers to “the option where people can stay in their homes as they age” (Vanleerberghe et al. 2017, p. 2899), with some level of independence (Chum et al. 2020); as long as they receive “support to remain” (Martens et al. 2018, p. 5) in their private homes, though the concept of home lacks specific boundaries (same or different households), except those defined by the families’ themselves (Martens et al. 2018).

Aging in place holds many assumptions about access to support, which has yet to be addressed. Older adults are assumed to be enabled to access health and social services that allow them to die well at home (Bone et al. 2018), with estimates of up to 85% preferring to “age in place” (Lantz & Fenn, 2017, cited by Chum, 2020).  Further, in theory, the “process of deinstitutionalizing care increases the sustainability of care systems and enhances the users’ quality of life” (Vanleerberghe, 2017, p. 2899). Yet, housing-specific characteristics (i.e., spatial capital) and ones’ neighborhood infrastructure (e.g., transportation, proximity of health and social services) appear to pose barriers, rather than create paths to ensure older adults’ quality of lives (Chum et al. 2020).

Indeed, according to Chum and colleagues (2020), the environment may not be conducive to older adults’ declining health status and as a consequence, contribute to increasing social isolation. Paradoxically, healthier peers may stigmatize and intentionally exclude those older adults that do not have ability to engage in the greater community (Chum et al. 2020). Alternatively, residents, who are more autonomous and independent to access select services or activities may benefit from continuous control and development of their self-fulfillment; all of which is assumed to be supported (financially or otherwise) by families (Chum et al. 2020). Moreover, preferences of older adults of location of care, including their desire and degree of family involvement varies by socio-economic and cultural demographics (Kasper et al. 2019).

In light of our recent COVID-19 pandemic in Canada, results of a National Institute of Ageing/ Telus Health National Survey (2021) reported that “91% of Canadians of all ages, and almost all those age 65 years and older plan on supporting themselves to live safely and independently in their own home as long as possible” (p. 3). The assumption is that family caregivers will be primary partners in caring for older adults at home, or else hire help to do so, until this is no longer possible. In this regard, few studies report on the extent of involvement of family caregivers, or how this influences older adults’ quality of life, as it relates to aging in place (Vanleerberghe, 2017). Further, a literature review by Martens and colleagues (2018) stated that aging in place policies entail joint individuals and families, and public responsibility for caregiving, including housing. This raises questions about the agency of family caregivers, particularly the racialized immigrants who experience barriers to access to health and social services (Lai & Surood, 2008; Xiao et al. 2013; Yiu et al. 2020).

A brief review of literature on immigrant family caregiving of older adults

Family caregivers, also known as informal caregivers or care partners of older adults are defined as any family or self-identified significant other who provide unpaid care to an older adult (65 years of age or older), with chronic conditions, and/or disabilities (Cohen et al. 2019). In relation to the older care recipient, family caregivers may influence their access to formal care. On the one hand, studies have shown that families involved in older adults’ care improve outcomes for individuals with dementia and schizophrenia (Flaherty & Bartels, 2019); but on the other hand, informal care may lessen older adults’ access to formal care and support in the community (Huxhold et al. 2014).

In other words, family caregivers can both help or hinder older adults’ wellbeing, depending on the family caregivers’ individual agency; that is, their capability to exercise control over their own or others’ actions (Bandura, 1999). Key factors of a caregiver’s agency include who they are (e.g., family or friend), and the quality of their relationship that enable them to enact their role (Huxhold et al. 2014). Further, caregiving varies by ethnocultural backgrounds and socioeconomic status, both between individuals within a demographic group, and between groups, which has important implications for research into caregivers and related caregiver health and quality of life (Cohen et al. 2019).

To understand how family caregivers perceive the choices they have, in response to public policy of aging in place, we propose that intersectionality can help explain dimensions of caregivers’ agency across their environment (Cohen et al. 2019). According to Manuel (2007, p. 174-175), intersectionality is a key concept that “suggests our lives and the choices we make are best understood as a consequence of our social location” in reference to “the intersections of race [or ethnicity], gender, class, and other forms of identity and distinction.” These intersections of social markers of identity and difference do not function independently but, rather, “act in tandem as interlocking or intersectional phenomena” (p. 175) to shape individual agency.

For family caregivers who identify as ethnic minorities, social locations are distinguished by culture-specific expectations and social norms (Cohen et al. 2019). For example, a study of Mexican informal caregivers in the USA demonstrated that the complexity of language and culture including attitudes, beliefs, and motivations that were unique to certain subpopulations of Hispanic/Latino caregivers (Cohen et al. 2019). Other important intersections include gender disparities in the distribution and caregiving intensity: more often women are assigned to the role, and spend more time in caregiving, and report greater levels of caregiver burden and depression, as well as poorer physical health than men in caregiving roles (Cohen et al. 2019).

In the next section, we will describe the socio-ecological model of health to guide “mapping” one’s social location to aging in different places/locations.

The socio-ecological model of health to map social locations of aging in place

Figure 10.1 Socio-ecological model of older adults’ health in age-friendly cities

The socio-ecological model, originating from Bronfenbrenner in 1989, aims to identify and explain major dimensions of individual psychosocial burden across intersections with the environment, whether older adults (Leung et al. 2021) or caregivers of children with disabilities (Vadivelan et al. 2020).  The socio-ecological model of health assumes interactive influences across individual, social, and physical-environmental levels, which shape choices and responses to healthcare policy (Van Hoof et al. 2018). For this chapter, we interpreted and applied Van Hoof and colleagues’ (2018) criteria for “age-friendly cities” to the socio-ecological model of health to ‘map’ how each level intersects and potentially determines the older adults’ capacity to age in place. (See Figure 10.1).

We used the socioecological model to analyze how the different locations of care (i.e., family caregivers and older adults living in the same or separate households, older adults living in older adults (assisted living) homes, and in long-term care facilities) and how location of care influenced caregivers’ access to services in each environment.

Chinese family caregiving in the Greater Toronto Area, Canada: An exemplar study of the mismatch of needs and community services

In the USA and Canada, there exists diverse heterogeneity in patterns of ethnic minority caregiving (Lai & Surood, 2008; Miyawaki, 2016) that reflect underlying differences in ethnocultural values, beliefs, and attitudes, as well as in generational acculturation to their (host) country. However, regardless of generation, in the USA, compared to non-ethnic counterparts, East Asian and Hispanic caregivers appear to access respite care the least, spend the most caregiving hours per week, and report the longest caregiving duration; demonstrating commitments to respect socio-historical cultural attitudes, regardless of level of acculturation (Miyawaki, 2016).

Chinese socio-historical cultural attitudes towards the care of older adults are largely shaped by Confucian philosophy, and refer to the practice of filial piety (Liu et al. 2021; Miyawaki, 2016). Filial piety is defined as the notion of respect and care for older adult family members and to uphold beliefs of family reciprocity (Miyawaki, 2016). Caregiving for aging parents is a social obligation, and the most common caregiving relationship in Chinese families is that of the parent/parent-in-law and adult child (Miyawaki, 2016). Chinese caregivers tend to use more informal than formal support due to cultural beliefs and/or taboos to use outside formal services (Miyawaki, 2016). In part, this may be because of a tendency to nurture social connections in extended families as alternative caregivers among Chinese (84% to 93%), as compared to their White counterparts (80% to 82%) (Miyawaki, 2016). Additionally, many Chinese family care partners tend to use passive coping strategies, such as forgiveness, tolerance, or contentment, rather than seeking social support and help, to maintain family harmony (Liu et al. 2021). These socio-cultural dispositions are even more pronounced when language barriers (Miyawaki, 2016).

In the U.S., non-Asian majority in general perceive Asian immigrants as “model minority” (Zhou, 2014). This can shape how Asians themselves perceive behaving as citizens, and their choices of and use of health and social services (Liu et al. 2021). For Chinese family care partners these predispositions may create a sense of burden as well as a barrier to meeting filial expectations of aging-parent care (Liu et al. 2021). Whilst caregivers may be open to the idea of using formal caregiver services as an alternative way of fulfilling filial piety; the cultural expectation of filial responsibility may supersede and hinder involving others in caregiving (Miyawaki, 2016). For example, in the U.S., strong patterns to upholding filial piety appears to hold true for Chinese immigrants, regardless of historical acculturation or the number of Chinese community services (i.e., churches, senior service agencies, and in-home caregiving services and care homes) (Miyawaki, 2020). Little is known about this topic in Canada.

Research question

How does the social location of Chinese family care partners of older adults shape caregivers’ access to community-based health and social services in the Greater Toronto Area?

Study Setting

The study took place in the Greater Toronto Area, Canada, with a population of about 6.8 million in 5,903 sq km (PopulationU.com, 2021), which has the most diverse and highest proportion of racialized individuals (63%) in Canada (Yee Hong Centre for Geriatric Care, 2013). In 2021, there were 700,705 people of Chinese descent in Toronto, Canada (PopulationU.com, 2021), of which 10.5%, in 2011, identified as age 65 and over and 97% were immigrants (Zhang, 2019).

Older adults in Toronto are not a homogenous group, yet they are among the most vulnerable groups, as 50% have low incomes ($10K to $30K per year) and those who are racilized have much lower median incomes, than their non-minority counterparts (Toronto City Hall, 2016). Of older adults, who are racialized, nearly 15% do not speak English, and 29% do not use the internet everyday (Toronto City Hall, 2016). Additionally, consultations with older adults reflect difficulty accessing the city’s more than 40 senior services (City of Toronto, 2018), as many older immigrants are excluded from social programs due to a 10-year waiting period for program eligibility (Yee Hong Centre for Geriatric Care, 2013). Altogether, these characteristics suggest the potential for Chinese immigrant older adults to be vulnerable to poverty and isolation (Toronto City Hall, 2016).

Methods

This qualitative study was informed by critical realism that was developed by Roy Bhaskar, a British Philosopher in 1975 (Elder-Vass, 2010). According to Elder-Vass (2010), critical realism consists of three layers, in the shape of a pyramid: The top layer, the “empirical” consists of evidence of what we tell each other happened. The middle is the “actual” and consists of evidence of what is tangible, regardless of whether we are aware of it. The bottom and largest layer is the “real” and consists of “mechanisms” and (social) “structures” that are not measurable but may generate events or experiences to occur (or not occur) for individuals (Elder-Vass, 2010). Please see examples in Figure 10.2.

Figure 10.2 Philosophical underpinnings of critical realism

One’s agency is exercised through mechanisms (e.g., a sense of responsibility), made up of factors, such as one’s insights, disposition, habitual routines, and expectations. These mechanisms shape the production and reproduction of social structures (e.g., stigma) (Elder-Vass, 2010). Social structures are created through interactions within and between social groups that influence the occurrence or non-occurrence of events or experiences (Elder-Vass, 2010). Mechanisms and structures can be internalized, and thus exert pressure on individuals (e.g., peer pressure), in turn, generating some individuals to endure  in certain contexts or under certain conditions (Elder-Vass, 2010).

Participant Recruitment and Sampling

Participants were recruited in-person, through email, and snowball strategies from communities with large Chinese memberships. Inclusion criteria were: Individuals who self-identify as Chinese, 18 years or older, and consider themselves as primary caregivers (care partners) to a Chinese older adult (65 years of age or older). Altogether, 31 people were approached, three declined due to expressed discomfort with being recorded, and no participants withdrew, yielding a total of 28 participants.

Ethical considerations

Prior to study commencement, research Ethics Boards of the participating universities and community organizations provided approval for the study. Each participant provided verbal or written consent. Redaction of identifiable information (such as, names and places) occurred during transcription of the audio-recorded interviews, prior to data analysis. All electronic data were password protected on researchers’ computers and in cloud storage. Potential participants were assured that their (non)participation would not affect in any way the services they received or would receive. In all dissemination activities, participants are only identified by assigned numbers.

Data collection

Participants were interviewed by one of the research team members. Interviews lasted between 45 mins to 1.5 hours, and began with collecting participants’ socio-demographic data, followed by eliciting their’ storied experiences. The latter was guided by semi-structured questions, which were pilot tested with the first three participants. Analysis of the pilot interview data led to one revision:  adding a question about meanings given to the responsibility of caregiving.

Participants chose a language of their preference for interviews: English, Cantonese or Mandarin (the latter two are common Chinese dialects). Given public health restrictions due to COVID-19, all interviews were conducted via the Zoom internet platform or by phone in their homes. Interviews were audio-recorded or in one case, content was manually written verbatim by two research assistants, for transcription. In all but three cases, a second research assistant assisted with writing field notes. In two interviews, the older adult care recipient was present. No repeat interviews were conducted. Prior to analysis, Chinese interviews were translated to English through verification by two researchers fluent in the dialect and English.

Data analysis and interpretation

The researchers analysed data in four steps (comprehension, synthesis, theorization, and reconceptualization) to immerse themselves in the data and to facilitate data interpretation informed by Elder-Vass’ (2010) version of critical realism. In the first step, two researchers engaged in open coding of the first 10 interviews independently. This open coding corresponds to the empirical level of critical realism, used to answer the research question. NVivo12 software facilitated organization and management of data (QSR International Pty Ltd, 2018). They then met to discuss and reach consensus on the code names, producing an initial code list. (Second step). Discussion of codes also generated theoretical memos about possible inferences of patterns for synthesis and theorization; all confirmed by future reference to data. In the third step, the second author led theorization and reconceptualization, through visual mapping of codes and subcategories, strategically laid out to answer the research question. Abstraction of patterns for theorization required working through inferential reasoning to explain patterns (Elder-Vass’ (2010) empirical level). These patterns were used to make deductive inferences that were then explored by the research team, to understand how events and experienced were actualized (the actual level). Last, the research team identified how events and experiences interacted to produce epistemic patterns of mechanisms and structures (the real level). This process continued until all interviews were analyzed and preliminary findings were confirmed by discussion to reach consensus by the research team.

Trustworthiness

We engaged in the following steps to ensure trustworthiness (credibility, plausibility, transferability and authenticity) of the work (Elo et al. 2014). To ensure credibility, prolonged engagement of participants in interviews (minimum 45 minutes) and taking reflective field notes were used. Further, theoretical saturation of patterns appeared after the 25th interview, whereby no new codes were found in analysis of three additional interviews. To ensure plausibility, the research team achieved consensus about the coding scheme. Further, the plausibility of preliminary results was confirmed by research team members who had expertise in the subject matter. To ensure transferability and utility, we balanced description of the findings with raw-data examples in this book chapter. To ensure authenticity, we followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) for transparency and comprehensiveness in research reporting (Tong et al. 2007).

Results

Twenty-eight (28) Chinese family care partners participated, 61% of whom were female, 57% of whom were 55 to 75 years old, and 39% of whom were 18 to 54 years old.  Most 75% reported having university level education, and 68% were children of older adults, while 18% were partners. A bit more than half (57%) of Chinese family care partners lived in separate households from their older care recipients, whereas 43% lived in the same household. All reported to be Canadian citizens; 50% lived in Canada for more than 30 years, and 97% were immigrants to Canada. (See Table 10.1 for detailed characteristics.)

The main theme we found was a cultural mismatch between available resources and the perceived needs of Chinese family care partners and their older care person’s expectations.  Chinese family care partners reported their needs to care for their aging recipients at all levels of the socio-ecological model of health (Figure 10.1). This mismatch was perceived most prominently among Chinese family care partners of older adults who resided in their own (private) homes, as compared to assisted-living or long-term-care facilities. We theorized that a mismatch of culturally appropriate services forced Chinese family care partners to tolerate increasing burdens as older adults transitioned from their own homes, to assisted-living facilities, to long-term care facilities. Figure 10.3 (below) presents the three-part model we developed, based on our interpretation of how agency and place intersect in Van Hoof and colleagues’ (2018)’s socio-ecological model of older adults’ health in age-friendly cities. To note, Chinese family care partners’ narratives included interpretations of what the care recipients/older adults desired or expected; hence, the Chinese family care partners and older adults were conceptualized as a dyad, with shared resources.

Figure 10.3. Socio-ecological model of health for the different locations of care by Chinese family care partners (CFCPs): 3a. Older adults’ (OAs) or Chinese family care partners’ homes, 3b. Assisted living facilities, and 3c. Long-term-care facilities.

Socio-ecological model of health for the different locations of older adults’ care by Chinese family care partners

Figure 10.3a depicts Chinese family care partners and older adult /care recipient living in own home(s) in close physical proximity. In this location, Chinese family care partners expressed needs to access all levels of structure (white arrows). While Chinese family care partners reported having access to a few layers of support (shaded in pink), they (the Chinese family care partners and older adult) did not have access to many areas of community, policy, or societal resources (shaded in yellow).  Figure 10.3b depicts the assisted-living facility location, where Chinese family care partners and older adult did not live in the same household nor necessarily close by. In this location, the Chinese family care partners expressed less need to access all layers of resources (white arrows) and reported access to more layers of resources (shaded in pink). Figure 10.3c depicts older adults in long-term care facilities, whereby the Chinese family care partners and older adults did not live in the same household, nor necessarily close by. In these locations, Chinese family care partners expressed needs to access in the lowest number of resource layers (white arrows), and they reported access to the most layers of resources (shaded in pink).

In all three figures, Chinese family care partners’ access to health and social services for their care recipient depended on community access and policies that matched the shared capacity of Chinese family care partners’ and older adult’s financial circumstances, and the availability (or lack) of culturally acceptable care.

Next, we describe in detail the situation of Chinese family care partners in each of the three locations presented in Figure 10.3

Chinese family care partners caring for older adults in private households (Figure 10.3a)

Chinese family care partners who cared for older adults in the same or different private households (usually in close proximity) appeared to express the most challenges negotiating access to help (informal and formal), and feared disruptions in caregiving. For example, Participant 10 (60-year-old woman, caring for father living with her) talked about her ongoing worry not knowing or fearing about whether she can “handle” her father’s needs, in part due to her own aging:

At my age, sometimes I have the intentions but I don’t have enough energy to accomplish them. It was like this. There are many times you may think that it is okay, but actually you can’t handle it.

For herself and others, her worry was magnified after her father fell out of bed when he got up to use the bathroom:

You know, when the elders get up and go to restroom at night, you need to know it… I worry about if he would fall down. That was torturing. You don’t know how to deal with it. Then I asked my sister to come here. Then we took turns. We took turns to get up at night. You know, we don’t know how to deal with such a situation.

 

Indeed, participants living separately from the relative they cared for perceived barriers to accessing instrumental support (from personal support workers) and government financial support due to institutional (nursing home or long-term care home) policies that limited when and how much support was available to them:

Actually, morning is the worst time, I actually asked the Personal Support Worker (PSW) company manager if they can just come to mom’s place from 7 to 8am, but unfortunately no one wants to come at that time especially in the wintertime. Their window is 2 hours. We can’t wait for that long.  (Participant 15, 60+ year old woman caring for mother in separate household)

 

Anytime they [PSWs] can leave. But I just let it pass. We can’t worry much about it. [I: Yes, yes, yes, with a laugh]. If I ask for one hour and half, they might stay longer. But if their boss doesn’t allow it, then there’s nothing we can do. (Participant 20, 72-year-old woman caring for her mother)

 

In a contrasting case, Participant 19 (63-year-old woman caring for mother in a long term care facility) reflected on her multiple past attempts to get formal home care with caring for her mother in her same household. She was met with resistance from home care administrators:

In the beginning, there was no help. I had to keep telling them, “My mom won’t shower, so what should I do?” They were very reluctant and eventually said ‘There is nothing I can do, but maybe I can send a person to come once a week.’ That’s all.

 

Not only did the majority of Chinese family care partners report resistance from social structures of institutional policy (i.e., municipal) when they sought formal help, they felt that provincial policies concerning access to assisted-living facilities or long-term care facilities were overwhelming:

If it’s [assisted-living or long-term care facility] private, then you’ll have to wait 8 or 10 years, and it still might not be available. (Participant 14, 78-year-old male, caring for spouse)

 

Indeed, this concern appeared validated by Participant 24 (62-year-old woman caring for parents) when she reported that access to an assisted-living facility for her parents appeared to happen by chance, rather than a systematic process of being placed on the local health system wait list:

I was lucky that the social workers know my case, [and] know that I am a cancer survivor caring for two seniors that have very challenging problems. …[so] my mom and dad can go into the nursing home.

 

In a contrasting case, one Chinese family care partners considered the financial cost of transferring her mother to an assisted-living or long-term care facility too high, and anticipated early retirement as the only option to take care of her mother:

So, I financially. I think there’s a big problem [in reference to transferring older adult to assisted-living facility] because I am not working. I need to retire early, forced to retire early because of caregiving… so I just ask for caregiver tax credit. But then, it’s hard. (Participant 7, 39-year-old woman, caring for mother in separate household)

Chinese family care partners caring for Older Adults in assisted-living facilities (Figure 10.3b)

When older adults were located in assisted-living facilities, Chinese family care partners reported partial access to services in the community, but limited access to services and Chinese cultural practices (e.g., food or leisure) that can help Chinese family care partners meet cultural expectations to care for their aging parents. For example, Participant 26 (50-year-old male, caring for in-laws in their different private household) visited several assisted-living facilities only to find that, while there were some for Cantonese speakers, they did not serve Mandarin speakers:

 

I saw some retirement homes is Cantonese, but I didn’t see much for like Chinese local mainland [people].

 

In another example, Participant 25’s mother with dementia lived in an assisted-living facility and though he expressed gratitude for the health and social services his mother received, he described gaps in needed services, due to provincial policy changes and funding cuts:

My mom lives in a senior apartment taking care of by XXX Services. So, every morning the Personal support workers (PSWs) will come to serve her with prescribed medication, and then help her to dress… If there is any problems, my mom pushes the panic button and they (PSWs) come down immediately to check on her… I wish there was more cleaning services, and more day care services, as this was reduced for mom from 5 days to 2 days, due to funding. (71 year old male participant)

 

The majority of participants with older adults in assisted-living facilities continued to report a prominent concern for long wait times and barriers to accessing culturally-inclusive LONG-TERM CARE facilities in their communities. Participant 19 (63-year-old woman, caring for her mother) exemplified the barriers when she spoke of “few choices” prior to her mother being transferred after a three year wait:

Like we had choices, I mean the Community Care Access Centre (CCAC), they gave us choices. Certainly, my mom had language barrier problems. So, because of that, there weren’t that many choices, it was just a few like XX and XX, and others. There were a few that had mixed ethnicity people, but still there were quite a few Chinese people. However, in terms of food, they didn’t serve Chinese food.

Chinese family care partners caring for older adults in long-term care facilities (Figure 10.3c)

When older adults were placed in a LONG-TERM CARE facility, community services, reflecting community and health system support were more accessible, as was transportation arranged when needed for various healthcare (e.g., medical care, rehabilitation). However, financial subsidies for day programs and adequate staffing were not deemed enough:

Since the government provides them [LONG-TERM CARE facility] funding, why does it seem like they [the government] don’t care, like the programs, fees, etc. It’s as though it’s not part of their responsibility. (Participant 19, 63-year-old woman, caring for her mother in a LONG-TERM CARE facility)

 

In all three locations of care, the agency of Chinese family care partners was shared and interdependent with the older care recipients as their trajectory of illness changed. As the older adults became more dependent on Chinese family care partners and less able to make decisions, the Chinese family care partners’ time and effort spent caregiving increased and their agency towards their own self-care and their immediate families lessened.

Discussion

In building our socio-ecological model of health, we found that Chinese family care partners who lived with, or were close to the older adults they cared for, reported pronounced difficulties accessing health and social services in the community. Of Chinese family care partners in the three locations (the other two having relatives living in assisted living or long-term care facilities), those in private households were the least supported by public policies and institutional practices (e.g., accessibility to Personal Support Workers). We theorize that a mismatch between Chinese family care partners’ needs and a lack of culturally appropriate services forced Chinese family care partners s to tolerate increasing caregiving burdens as the older adults they cared for became increasingly dependent on them and their ability to meet their culture’s caregiving expectations lessened.

Our study results reflect previous literature in Canada that suggests provincial governments need to bolster their budgets and change practices for older adults wanting to remain in place in their communities (Béland, & Marier, 2020); however, previous studies do not address continuing assumptions of family caregivers’ agency to supervise and supplement care, and in doing so will prevent older persons from having to enter institutions (assisted living or long-term care facilities). Indeed, empirical evidence suggests variability in the agency of Chinese family care partners. For example, in a study of 13,781 elders in 22 provinces of China (Wang et al. 2023), those who were primarily cared for by sons and daughters-in-law tended to be institutionalized much later than those who were cared for by their spouses. Additionally, elders who relied on care by other relatives and friends, by domestic helpers, and those with no caregivers tended to be institutionalized much earlier than those who were cared for by their spouses (Wang et al. 2023).

Irrespective of whether Chinese family care partners live in China or are immigrants from China to Canada or descendants of Chinese immigrants, our study, and previous literature (Lin, 2019) supports a tendency for Chinese family care partners to view formal care, not as a substitute for family caregiving, but as a supplement. Having said that, while filial piety continues to be a key cultural expectation for Canadian descendants of Chinese immigrants, even in China this expectation is weakening, due to the inability of most young people to fulfill it in historical ways (Lin, 2019). Although China’s healthcare system is based on patrilineal society with Confucian beliefs, filial piety is unsustainable with the growing population over 75 years old, rapid urbanization, and adult children s who tend to live far from their parents (Lin, 2019).

In a systematic review (Choy et al. 2021) of immigrant acculturation (i.e., process of adaptation to a new culture) primarily to a North American or European country, immigrants were significantly reporting more anxiety and depression, due to a combination of intrinsic and extrinsic stressors that increased a sense of marginalization (i.e., the rejection of both the new and their own cultures). A higher risk of depressive symptoms appeared to be a result of interactions that reduced the agency of individuals when they reported: a perceived cultural gap between themselves and their adult children, family dysfunction, poor family relationships, fewer number of children living in proximity, limited assistance from adult children, and ineffective social support (Choy et al. 2021). Moreover, the level of acculturation was reported as a function of interactions, both intrinsic (e.g., lower levels of host language proficiency, female gender, low education) as well as extrinsic social factors of reported greater financial hardships, and less preservation of cultural traditions (Choy et al. 2021).

The differing spatial capital (i.e., type of housing, and its geographic proximity to health and social services), social networks, and cultural norms in Canada and the United States can alter whether Chinese older adults’ desire and Chinese family care partners benefit from residing in the same households. A study in Shanghai, China reported that Chinese family care partners living apart from older adult relatives felt more depressed than those who co-resided (Miyawaki, 2020). In contrast among American Chinese family care partners, higher resilience was interpreted in narratives of female caregivers who lived apart from care recipients; the latter was in conjunction with lower caregiving demands, and availability of social support from families, friends, and community sources (Liu et al. 2021). The authors contend that, despite the strong value of family caregiving, American Chinese family care partners require more infrastructure to support them in accessing public health resources, and policies that broaden their choices (Liu et al. 2021).

Martens and colleagues (2018) assert that enabling older adults to age in place requires “partnerships between individual and public responsibility” (p. 8). Our study suggests that the most vulnerable Chinese family care partners are those whose older adult relatives live with them. According to literature, these are most often C Chinese family care partners PARTNERSs encountering a negative impact to their employment, in order to juggle commitments of caregiving, as well as married women with young children (Cohen et al. 2019). For example, Chinese family care partners in New York reported the most frequent challenge was physical and emotional exhaustion, followed by limited knowledge of the older adults’ medical conditions, navigating the healthcare system, and limited time for self-care/development (Liu et al. 2021). Indeed, in Canada, one’s agency to be healthy is heavily influenced by social determinants, such as employment, and housing; and while “health is not a federal responsibility, many of the socioeconomic determinants of health are heavily influenced by federal policy” (Drummond et al. 2020, p.5). So, while all Chinese family care partners expressed commitment to older adults’ caregiving, more federal and provincial funding and resources are required to assist them to develop a sense of mastery and access to formal and informal support to achieve resilience in caregiving (Drummond et al. 2020; Liu et al. 2021).

Future Directions

Recommendations from this study suggest that in Canada, and elsewhere, such as the USA, aging in place requires a greater range of accessible continuing care services (Drummond et al. 2020) and a greater emphasis to build culturally-reflexive options, defined as putting culture in context (Aronowitz et al. 2015). This refers to creating culturally sensitive interactions with older adults, irrespective of their location of care, to enable accessing formal care that meets communication needs, formal daily assistance, senior daycare, caregiver respite, and various forms of supportive living as the older adults’ needs evolve (Miyawaki, 2020). Moreover, in Canada, as in the USA, there is an urgent need to extend the agency of Chinese family care partners, through training inter-professional teams to accommodate culturally-specific assisted-living and LONG-TERM CARE facilities reflexive of characteristics of acculturation (e.g., limited English-language proficiency), and to being enabled to preserve ones’ cultural diet and lifestyles (Miyawaki, 2020). To begin this process, we support Backman, and colleagues’ (2018) Canadian study that recommends more meaningful conversations during discharge planning of older adults from hospitals; advocating inter-professional teams assist with navigating the healthcare system to prevent systematic barriers in care transitions. To do this, we suggest cultural reflexivity that pays close attention to the structurally situated way that healthcare practices exert pressure on social interactions, and identify contradictions of culture, and external conditions that “enable, constrain, and transform local cultural arrangements” (Aronowitz et al. 2015, p. S405).

In our study, reducing barriers to care transitions from home to institutional care require partnerships between community inter-professional teams and informal caregivers (family, friends, and neighbors) to navigate barriers encountered in municipal and provincial policies. Choi and Park (2021) suggest that healthcare professionals, such as nurse-led-team collaboration, integrated into the community at all levels of the socio-ecological model could collaborate in multiple locations in one’s community, and work across different levels, in contributing to policy, and with individuals in their homes. Further, this would necessarily include community health leaders, community care administrators, and local services providers (Flaherty & Bartels, 2019). Indeed, integrated care professionals might help agencies collaborate in providing community-based older adult care. This could enhance accountability of personal support workers (PSWs) to provide assistance, for follow-up specialists’ appointments, for coordination of healthcare professionals’ care, and for timely access to primary care (Backman et al. 2018).

Several studies also confirm the necessity to look beyond immediate family members for beneficial effects of non-kin networks (i.e., friends or peer networks) for maintaining older adults’ happiness (Huxhold et al. 2014). For example, an effect of such non-kinship networks has been identified as beneficial particularly in the later stages of life. In a study of people aged 75 or older in Japan, close friend networks and neighborhood networks increased the life satisfaction of men and women, respectively (Watanabe, 2021). Hence, we contend that the dyad of Chinese family care partners’ with their care recipients’ have interpersonal agency to together “age well in place.” Together, they are affected by both their local cultural communities and associated policies, along with the government leaders’ inclusion of preferences that demonstrate equity for entitlements and choices beyond health to social determinants of health.

Strengths and Limitations

The study has strengths and limitations, which were methodological and contextual. While all participants were immigrants, they were Canadian citizens, and most had lived in Canada for more than 10 years, and were fluent in English. Thus, we were unable to theorize how acculturation and integration, within the diversity of the group, may have influenced their aging in place. Further, while our participants did reflect a group of older caregivers and adults being cared for (aged 75 years and older) in Canada (Canadian Institutes of Health Research, 2017), our results may not reflect the experiences of younger family caregivers, who are theorized to have less resources (e.g., financial, housing) to manage older adults’ needs (Lai & Surood, 2008). Last, our results represent only Chinese family care partners perspectives, and not their care recipients, though data clearly reflect an entanglement of the two, as dyads (Chinese family care partners and older adults).

Conclusion

We found that Chinese family care partners tolerate an increasing burden when culturally appropriate social structures are limited in their access to older adults (e.g., personal support, transportation, peer support, assisted-living and long-term care facilities) in their community. A shift in health care to integrated team-based care is emerging, with many institutions in North America creating more accessible services for older adults and their families where they live in the community (Drummond et al. 2020; Flaherty & Bartels, 2019). However, we assert that limited cultural sensitivity in health and social services generates barriers for Chinese family care partners to collaborate across intersections of the socioecological environment, due to lack of self-efficacy and support. Hence, we advocate for better interprofessional care, which extend Chinese family care partners’ agency beyond their households to encompass federal social determinants of health, shaping provincial policy and funding, and society’s attitudes to aging in place, whether in private homes, assisted living homes, or long-term care.

References

Aronowitz, R., Deener, A., Keene, D., Schnittker, J., & Tach, L. 2015. Cultural reflexivity in health research and practice. American journal of public health. 105 Suppl 3(Suppl 3), S403–S408. https://doi.org/10.2105/AJPH.2015.302551

Backman, C., Stacey, D., Crick, M., Cho-Young, D., & Marck, P. B. 2018. Use of participatory visual narrative methods to explore older adults’ experiences of managing multiple chronic conditions during care transitions. BMC health services research. 18(1), 1-10. https://doi.org/10.1186/s12913-018-3292-6

Bandura, A. 1999. Social cognitive theory: An agentic perspective. Asian Journal of Social Psychology. 2(1): 21–41. doi:10.1111/1467-839X.00024

Béland, D., & Marier, P. 2020. COVID-19 and Long-Term Care Policy for Older People in Canada, Journal of Aging & Social Policy. 32:4-5, 358-364, DOI: 10.1080/08959420.2020.1764319

Bone, A. E., Gomes, B., Etkind, S. N., Verne, J., Murtagh, F. E., Evans, C. J., & Higginson, I. J. 2018. What is the impact of population ageing on the future provision of end-of-life care? Population-based projections of place of death. Palliative medicine. 32(2), 329-336. DOI: 10.1177/0269216317734435

Canadian Institutes of Health Research. 2017. Infographic: Canada’s seniors population outlook: Uncharted territory. Available at: https://www.cihi.ca/en/infographic-canadas-seniors-population-outlook-uncharted-territory.

Choi, E. J., & Park, M. H. 2021. Preparing for the Trend of Aging in Place: Identifying Interprofessional Competencies for Integrated Care Professionals. Journal of Korean Gerontological Nursing. 23(3), 273-284. https://doi.org/10.17079/jkgn.2021.23.3.273

Choy, B., Arunachalam, K., Gupta, S., Taylor, M., & Lee, A. 2021. Systematic Review: Acculturation strategies and their impact on the mental health of migrant populations. Public Health in Practice. 2, 100069. https://doi.org/10.1016/j.puhip.2020.100069.

Chum, K., Fitzhenry, G., Robinson, K., Murphy, M., Phan, D., Alvarez, J., & McGrath, C. 2020. Examining community-based housing models to support aging in place: A scoping review. The Gerontologist. 142, https://doi.org/10.1093/geront/gnaa142

Cohen, S. A., Sabik, N. J., Cook, S. K., Azzoli, A. B., & Mendez-Luck, C. A. 2019. Differences within differences: Gender inequalities in caregiving intensity vary by race and ethnicity in informal caregivers. Journal of cross-cultural gerontology. 34(3), 245-263. https://doi.org/10.1007/s10823-019-09381-9

City of Toronto. 2018. Toronto Senior Strategy. Available at: https://www.rgptoronto.ca/toronto-seniors-strategy-2-0-approved/https://www.msn.com/en-ca/feed

Drummond, D., Sinclair, D., & Bergen, R., as part of the COVID-19 Health Policy Working Group. 2020. Aging Well. School of Policy Studies, Queen’s University. Available at: https://www.queensu.ca/sps/sites/webpublish.queensu.ca.spswww/files/files/Publications/Ageing%20Well%20Report%20-%20November%202020.pdf

Elder-Vass, D. 2010. The causal power of social structures emergence, structure and agency. London, UK: Cambridge University Press.

Flaherty, E., & Bartels, S. J. 2019. Addressing the community‐based geriatric healthcare workforce shortage by leveraging the potential of interprofessional teams. Journal of the American Geriatrics Society. 67(S2), S400-S408. doi.org/10.1111/jgs.15924

Huxhold, O., Miche, M., & Schüz, B. 2014. Benefits of Having Friends in Older Ages: Differential Effects of Informal Social Activities on Well-Being in Middle-Aged and Older Adults, The Journals of Gerontology: Series B. 69 (3), 366- 375, https://doi.org/10.1093/geronb/gbt029

Kasper, J. D., Wolff, J. L., & Skehan, M. 2019. Care arrangements of older adults: What they prefer, what they have, and implications for quality of life. The Gerontologist. 59(5), 845-855. doi:10.1093/geront/gny127

Lai, D. W., & Surood, S. 2008. Service barriers of CHINESE FAMILY CARE PARTNERSs in Canada. Journal of Gerontological Social Work. 51(3-4), 315-336.

Leung, K.-M., Ou, K.-L., Chung, P.-K., & Thøgersen-Ntoumani, C. 2021. Older Adults’ Perceptions toward Walking: A Qualitative Study Using a Social-Ecological Model. Int. J. Environ. Res. Public Health. 18, 7686. https://doi.org/10.3390/ ijerph18147686

Lin, W. 2019. The relationship between formal and informal care among Chinese older adults: based on the 2014 CLHLS dataset. BMC Health Serv Res. 19, 323. https://doi.org/10.1186/s12913-019-4160-8

Liu, J., Lou, Y., Wu, B., & Mui, A. C. Y. S. 2021. “I’ve been always strong to conquer any suffering:” challenges and resilience of Chinese American dementia caregivers in a life course perspective. Aging & Mental Health. 25(9), 1716-1724. https://doi.org/10.1080/13607863.2020.1793900.

Manuel, T. 2007. Envisioning the possibilities for a good life: Exploring the public policy implications of intersectionality theory. Journal of Women, Politics & Policy. 28(3-4), 173-203. https://doi.org/10.1300/J501v28n03_08

Martens, C. T. 2018. Aging in which place? Connecting aging in place with individual responsibility, housing markets, and the welfare state. Journal of Housing for the Elderly. 32(1), 1-11. DOI: 10.1080/02763893.2017.1393483

Miyawaki, C. E. 2016. Caregiving Practice Patterns of Asian, Hispanic, and Non-Hispanic White American Family Caregivers of Older Adults Across Generations. Journal of Cross-Cultural Gerontology., 31(1), 35–55. https://doi.org/10.1007/s10823-016-9281-5

Miyawaki, C. E. 2020. Caregiving attitudes and needs of later-generation Chinese-American family caregivers of older adults. Journal of Family Issues. 41(12), 2377-2399.

National Institute of Health/Telus Health Report. 2021. Pandemic Perspectives on Long-Term Care: Insights from Canadians in Light of COVID-19. Available at: https://www.cma.ca/sites/default/files/pdf/Activities/National-Institute-on-Ageing-CMA-Report-EN.pdf

Toronto City Hall. 2016. Mapping the Ethnicity of Toronto’s Elders. Presentation by the Social Development, Finance & Administration Division, City of Toronto, to the Toronto Council on Aging’s Age Friendly Toronto Forum. Ryerson University. Available at: https://www.toronto.ca/wp-content/uploads/2017/11/9045-Toronto-Council-on-Aging-03192016-Ethnic-Ancestry.pdf

Tong, A., Sainsbury, P., & Craig, J. 2007. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups, International Journal for Quality in Health Care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042

PopulationU.com. 2021. Toronto Population. Available at: https://www.populationu.com/cities/toronto-population

Vadivelan, K., Sekar, P., Sruthi, S. S., & Gopichandran, V. 2020. Burden of caregivers of children with cerebral palsy: an intersectional analysis of gender, poverty, stigma, and public policy. BMC public health. 20, 1-8. doi.org/10.1186/s12889-020-08808-0

Van Hoof, J., Kazak, J. K., Perek-Białas, J. M., & Peek, S. 2018. The challenges of urban ageing: Making cities age-friendly in Europe. International Journal of Environmental Research and Public Health. 15(11), 2473. ; doi:10.3390/ijerph15112473

Vanleerberghe, P., De Witte, N., Claes, C., Schalock, R. L., & Verté, D. 2017. The quality of life of older people aging in place: a literature review. Quality of Life Research. 26(11), 2899-2907. DOI 10.1007/s11136-017-1651-0

Wang, J., Yang, Q., & Wu, B. 2023. Effects of Care Arrangement on the Age of Institutionalization among Community-dwelling Chinese Older Adults. Journal of Aging & Social Policy., 35(5), 595–610. https://doi.org/10.1080/08959420.2020.1726720

Watanabe, D. 2021. Understanding diversity in later life and a new culture of aging: Sociology of aging in Japan. International Sociology. 36(2), 243-253. DOI: 10.1177/02685809211005355

Xiao, L. D., De Bellis, A., Habel, L., & Kyriazopoulos, H. 2013. The experiences of culturally and linguistically diverse family caregivers in utilising dementia services in Australia. BMC Health Services Research. 13(1). https://doi.org/10.1186/1472-6963-13-427

Yee Hong Geriatric Centre, in partnership with University of Toronto Factor-Inwentash Faculty of Social Work. 2013. The Changing Needs of Chinese Seniors in the Greater Toronto Area. Retrieved Nov. 18, 2021 at: https://www.yeehong.com/centre/publications/needs-study-download/report/

Yiu, H. C., Zang, Y., & Chau, J. P. C. 2020. Barriers and facilitators in the use of formal dementia care for dementia sufferers: A qualitative study with CHINESE FAMILY CARE PARTNERSs in Hong Kong. Geriatric Nursing. 41(6), 885-890.

Zhang, W. 2019. Perceptions of elder abuse and neglect by older Chinese immigrants in Canada. Journal of Elder Abuse & Neglect. 31(4-5), 340-362. https://doi.org/10.1080/08946566.2019.1652718.

Zhou, M. 2014. Segmented assimilation and socio-economic integration of Chinese immigrant children in the USA, Ethnic and Racial Studies. 37(7), 1172-1183, https://doi.org./10.1080/01419870.2014.874566.