{"id":126,"date":"2023-11-15T14:04:24","date_gmt":"2023-11-15T19:04:24","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/intersections\/?post_type=chapter&p=126"},"modified":"2024-09-29T19:28:14","modified_gmt":"2024-09-29T23:28:14","slug":"chapter-10-chinese-family-members-caring-for-older-adults-at-home-or-in-long-term-care-homes-a-mismatch-of-needs-and-services","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/intersections\/chapter\/chapter-10-chinese-family-members-caring-for-older-adults-at-home-or-in-long-term-care-homes-a-mismatch-of-needs-and-services\/","title":{"raw":"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","rendered":"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"},"content":{"raw":"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). \u201cAging in place\u201d refers to \u201cthe option where people can stay in their homes as they age\u201d (Vanleerberghe et al. 2017, p. 2899), with some level of independence (Chum et al. 2020); as long as they receive \u201csupport to remain\u201d (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\u2019 themselves (Martens et al. 2018).\r\n\r\n \r\n\r\nAging 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 \u201cage in place\u201d (Lantz & Fenn, 2017, cited by Chum, 2020). \u00a0Further, in theory, the \u201cprocess of deinstitutionalizing care increases the sustainability of care systems and enhances the users\u2019 quality of life\u201d (Vanleerberghe, 2017, p. 2899). Yet, housing-specific characteristics (i.e., spatial capital) and ones\u2019 neighborhood infrastructure (e.g., transportation, proximity of health and social services) appear to pose barriers, rather than create paths to ensure older adults\u2019 quality of lives (Chum et al. 2020).\r\n\r\n \r\n\r\nIndeed, according to Chum and colleagues (2020), the environment may not be conducive to older adults\u2019 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).\r\n\r\n \r\n\r\nIn light of our recent COVID-19 pandemic in Canada, results of a National Institute of Ageing\/ Telus Health National Survey (2021) reported that \u201c91% 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\u201d (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\u2019 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).\r\n

A brief review of literature on immigrant family caregiving of older adults<\/h3>\r\nFamily 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\u2019 care improve outcomes for individuals with dementia and schizophrenia (Flaherty & Bartels, 2019); but on the other hand, informal care may lessen older adults\u2019 access to formal care and support in the community (Huxhold et al. 2014).\r\n\r\n \r\n\r\nIn other words, family caregivers can both help or hinder older adults\u2019 wellbeing, depending on the family caregivers\u2019 individual agency; that is, their capability to exercise control over their own or others\u2019 actions (Bandura, 1999). Key factors of a caregiver\u2019s 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).\r\n\r\n \r\n\r\nTo 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\u2019 agency across their environment (Cohen et al. 2019). According to Manuel (2007, p. 174-175), intersectionality is a key concept that \u201csuggests our lives and the choices we make are best understood as a consequence of our social location\u201d in reference to \u201cthe intersections of race [or ethnicity], gender, class, and other forms of identity and distinction.\u201d These intersections of social markers of identity and difference do not function independently but, rather, \u201cact in tandem as interlocking or intersectional phenomena\u201d (p. 175) to shape individual agency.\r\n\r\n \r\n\r\nFor 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).\r\n\r\n \r\n\r\nIn the next section, we will describe the socio-ecological model of health to guide \u201cmapping\u201d one\u2019s social location to aging in different places\/locations.\r\n

The socio-ecological model of health to map social locations of aging in place<\/h3>\r\n

Figure 10.1\u00a0Socio-ecological model of older adults\u2019 health in age-friendly cities<\/h6>\r\n\"\"\r\n\r\nThe 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).\u00a0 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 \u201cage-friendly cities\u201d to the socio-ecological model of health to \u2018map\u2019 how each level intersects and potentially determines the older adults\u2019 capacity to age in place. (See Figure 10.1).\r\n\r\n \r\n\r\nWe 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\u2019 access to services in each environment.\r\n

Chinese family caregiving in the Greater Toronto Area, Canada: An exemplar study of the mismatch of needs and community services<\/h3>\r\nIn 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).\r\n\r\n \r\n\r\nChinese 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).\r\n\r\n \r\n\r\nIn the U.S., non-Asian majority in general perceive Asian immigrants as \u201cmodel minority\u201d (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.\r\n

Research question<\/h3>\r\nHow does the social location of Chinese family care partners of older adults shape caregivers\u2019 access to community-based health and social services in the Greater Toronto Area?\r\n

Study Setting<\/h3>\r\nThe 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).\r\n\r\n \r\n\r\nOlder 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\u2019s 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).\r\n

Methods<\/h3>\r\nThis 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 \u201cempirical\u201d consists of evidence of what we tell each other happened. The middle is the \u201cactual\u201d and consists of evidence of what is tangible, regardless of whether we are aware of it. The bottom and largest layer is the \u201creal\u201d and consists of \u201cmechanisms\u201d and (social) \u201cstructures\u201d 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.\r\n

Figure 10.2 Philosophical underpinnings of critical realism<\/h6>\r\n\"\"\r\n\r\nOne\u2019s agency is exercised through mechanisms (e.g., a sense of responsibility), made up of factors, such as one\u2019s 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\u00a0 in certain contexts or under certain conditions (Elder-Vass, 2010).\r\n

Participant Recruitment and Sampling<\/h4>\r\nParticipants 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.\r\n

Ethical considerations<\/h4>\r\nPrior 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\u2019 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.\r\n

Data collection<\/h4>\r\nParticipants were interviewed by one of the research team members. Interviews lasted between 45 mins to 1.5 hours, and began with collecting participants\u2019 socio-demographic data, followed by eliciting their\u2019 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:\u00a0 adding a question about meanings given to the responsibility of caregiving.\r\n\r\n \r\n\r\nParticipants 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.\r\n

Data analysis and interpretation<\/h4>\r\nThe 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\u2019 (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\u2019 (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.\r\n

Trustworthiness<\/h4>\r\nWe 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).\r\n

Results<\/h3>\r\nTwenty-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.\u00a0 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.)\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
Table 10.1 Socio-demographic data of the Chinese family care partners\u00a0<\/strong><\/td>\r\n<\/tr>\r\n
<\/td>\r\nCaregivers (N=28)<\/strong><\/td>\r\n<\/tr>\r\n
Frequency (n)<\/strong><\/td>\r\nPercentage %<\/strong><\/td>\r\n<\/tr>\r\n
Age<\/strong><\/td>\r\n<\/tr>\r\n
18 to 54 years old<\/td>\r\n11<\/td>\r\n39<\/td>\r\n<\/tr>\r\n
55 to 75 years old<\/td>\r\n16<\/td>\r\n57<\/td>\r\n<\/tr>\r\n
Prefer not to say<\/td>\r\n1<\/td>\r\n4<\/td>\r\n<\/tr>\r\n
Self-Identified Center<\/strong><\/td>\r\n<\/tr>\r\n
Female<\/td>\r\n17<\/td>\r\n61<\/td>\r\n<\/tr>\r\n
Male<\/td>\r\n11<\/td>\r\n39<\/td>\r\n<\/tr>\r\n
Citizenship Status<\/strong><\/td>\r\n<\/tr>\r\n
Canadian citizen<\/td>\r\n28<\/td>\r\n100<\/td>\r\n<\/tr>\r\n
Permanent resident<\/td>\r\n0<\/td>\r\n0<\/td>\r\n<\/tr>\r\n
Relationship with Older Adult<\/strong><\/td>\r\n<\/tr>\r\n
Spouse\/Partner<\/td>\r\n5<\/td>\r\n18<\/td>\r\n<\/tr>\r\n
Child<\/td>\r\n19<\/td>\r\n68<\/td>\r\n<\/tr>\r\n
Grandchild<\/td>\r\n2<\/td>\r\n7<\/td>\r\n<\/tr>\r\n
In-laws<\/td>\r\n2<\/td>\r\n7<\/td>\r\n<\/tr>\r\n
Education<\/strong><\/td>\r\n<\/tr>\r\n
High school<\/td>\r\n2<\/td>\r\n7<\/td>\r\n<\/tr>\r\n
College<\/td>\r\n5<\/td>\r\n18<\/td>\r\n<\/tr>\r\n
University<\/td>\r\n21<\/td>\r\n75<\/td>\r\n<\/tr>\r\n
Living with Older Adult<\/strong><\/td>\r\n<\/tr>\r\n
Yes<\/td>\r\n12<\/td>\r\n43<\/td>\r\n<\/tr>\r\n
No<\/td>\r\n16<\/td>\r\n57<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n \r\n\r\nThe 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\u2019s expectations.\u00a0 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)\u2019s socio-ecological model of older adults\u2019 health in age-friendly cities. To note, Chinese family care partners\u2019 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.\r\n
Figure 10.3. Socio-ecological model of health for the different locations of care by Chinese family care partners (CFCPs): 3a. Older adults\u2019 (OAs) or Chinese family care partners\u2019 homes, 3b. Assisted living facilities, and 3c. Long-term-care facilities.<\/h6>\r\n\"\"\r\n

Socio-ecological model of health for the different locations of older adults\u2019 care by Chinese family care partners<\/h3>\r\nFigure 10.3a<\/strong> 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).\u00a0 Figure 10.3b<\/strong> 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<\/strong> 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).\r\n\r\n \r\n\r\nIn all three figures, Chinese family care partners\u2019 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\u2019 and older adult\u2019s financial circumstances, and the availability (or lack) of culturally acceptable care.\r\n\r\n \r\n\r\nNext, we describe in detail the situation of Chinese family care partners in each of the three locations presented in Figure 10.3\r\n

Chinese family care partners caring for older adults in private households (Figure 10.3a)<\/h3>\r\nChinese 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 \u201chandle\u201d her father\u2019s needs, in part due to her own aging:\r\n\r\n \r\n
At my age, sometimes I have the intentions but I don\u2019t 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\u2019t handle it.<\/blockquote>\r\n \r\n\r\nFor herself and others, her worry was magnified after her father fell out of bed when he got up to use the bathroom:\r\n\r\n \r\n
You know, when the elders get up and go to restroom at night, you need to know it\u2026 I worry about if he would fall down. That was torturing. You don\u2019t 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\u2019t know how to deal with such a situation.\r\n\r\n <\/blockquote>\r\nIndeed, 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:\r\n\r\n \r\n
Actually, morning is the worst time, I actually asked the Personal Support Worker (PSW) company manager if they can just come to mom\u2019s 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\u2019t wait for that long.\u00a0 (Participant 15, 60+ year old woman caring for mother in separate household)\r\n\r\n \r\n\r\nAnytime they [PSWs] can leave. But I just let it pass. We can\u2019t 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\u2019t allow it, then there\u2019s nothing we can do. (Participant 20, 72-year-old woman caring for her mother)\r\n\r\n <\/blockquote>\r\nIn 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:\r\n\r\n \r\n
In the beginning, there was no help. I had to keep telling them, \u201cMy mom won\u2019t shower, so what should I do?\u201d They were very reluctant and eventually said \u2018There is nothing I can do, but maybe I can send a person to come once a week.\u2019 That\u2019s all.\r\n\r\n <\/blockquote>\r\nNot 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:\r\n\r\n \r\n
If it\u2019s [assisted-living or long-term care facility] private, then you\u2019ll have to wait 8 or 10 years, and it still might not be available. (Participant 14, 78-year-old male, caring for spouse)\r\n\r\n <\/blockquote>\r\nIndeed, 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:\r\n\r\n \r\n
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.\r\n\r\n <\/blockquote>\r\nIn 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:\r\n\r\n \r\n
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\u2026 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)<\/blockquote>\r\n

Chinese family care partners caring for Older Adults in assisted-living facilities (Figure 10.3b)<\/h3>\r\nWhen 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:\r\n
 \r\n\r\nI saw some retirement homes is Cantonese, but I didn\u2019t see much for like Chinese local mainland [people].\r\n\r\n <\/blockquote>\r\nIn another example, Participant 25\u2019s 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:\r\n\r\n \r\n
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)\r\n\r\n <\/blockquote>\r\nThe 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 \u201cfew choices\u201d prior to her mother being transferred after a three year wait:\r\n\r\n \r\n
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\u2019t 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\u2019t serve Chinese food.<\/blockquote>\r\n

Chinese family care partners caring for older adults in long-term care facilities (Figure 10.3c)<\/h3>\r\nWhen 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:\r\n\r\n \r\n
Since the government provides them [LONG-TERM CARE facility] funding, why does it seem like they [the government] don\u2019t care, like the programs, fees, etc. It\u2019s as though it\u2019s not part of their responsibility. (Participant 19, 63-year-old woman, caring for her mother in a LONG-TERM CARE facility)\r\n\r\n <\/blockquote>\r\nIn 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\u2019 time and effort spent caregiving increased and their agency towards their own self-care and their immediate families lessened.\r\n

Discussion<\/h3>\r\nIn 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\u2019 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\u2019s caregiving expectations lessened.\r\n\r\n \r\n\r\nOur 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 (B\u00e9land, & Marier, 2020); however, previous studies do not address continuing assumptions of family caregivers\u2019 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).\r\n\r\n \r\n\r\nIrrespective 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\u2019s 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).\r\n\r\n \r\n\r\nIn 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).\r\n\r\n \r\n\r\nThe 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\u2019 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).\r\n\r\n \r\n\r\nMartens and colleagues (2018) assert that enabling older adults to age in place requires \u201cpartnerships between individual and public responsibility\u201d (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\u2019 medical conditions, navigating the healthcare system, and limited time for self-care\/development (Liu et al. 2021). Indeed, in Canada, one\u2019s agency to be healthy is heavily influenced by social determinants, such as employment, and housing; and while \u201chealth is not a federal responsibility, many of the socioeconomic determinants of health are heavily influenced by federal policy\u201d (Drummond et al. 2020, p.5). So, while all Chinese family care partners expressed commitment to older adults\u2019 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).\r\n

Future Directions<\/h3>\r\nRecommendations 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\u2019 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\u2019 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 \u201cenable, constrain, and transform local cultural arrangements\u201d (Aronowitz et al. 2015, p. S405).\r\n\r\n \r\n\r\nIn 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\u2019s 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\u2019 appointments, for coordination of healthcare professionals\u2019 care, and for timely access to primary care (Backman et al. 2018).\r\n\r\n \r\n\r\nSeveral 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\u2019 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\u2019 with their care recipients\u2019 have interpersonal agency to together \u201cage well in place.\u201d Together, they are affected by both their local cultural communities and associated policies, along with the government leaders\u2019 inclusion of preferences that demonstrate equity for entitlements and choices beyond health to social determinants of health.\r\n

Strengths and Limitations<\/h3>\r\nThe 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\u2019 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).\r\n

Conclusion<\/h3>\r\nWe 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\u2019 agency beyond their households to encompass federal social determinants of health, shaping provincial policy and funding, and society\u2019s attitudes to aging in place, whether in private homes, assisted living homes, or long-term care.\r\n

References<\/h3>\r\n

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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<\/p>\r\n

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Vanleerberghe, P., De Witte, N., Claes, C., Schalock, R. L., & Vert\u00e9, 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<\/p>\r\n

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\u2013610. https:\/\/doi.org\/10.1080\/08959420.2020.1726720<\/p>\r\n

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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<\/p>\r\n

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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.<\/p>\r\n

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.<\/p>\r\n

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.<\/p>","rendered":"

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). \u201cAging in place\u201d refers to \u201cthe option where people can stay in their homes as they age\u201d (Vanleerberghe et al. 2017, p. 2899), with some level of independence (Chum et al. 2020); as long as they receive \u201csupport to remain\u201d (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\u2019 themselves (Martens et al. 2018).<\/p>\n

 <\/p>\n

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 \u201cage in place\u201d (Lantz & Fenn, 2017, cited by Chum, 2020). \u00a0Further, in theory, the \u201cprocess of deinstitutionalizing care increases the sustainability of care systems and enhances the users\u2019 quality of life\u201d (Vanleerberghe, 2017, p. 2899). Yet, housing-specific characteristics (i.e., spatial capital) and ones\u2019 neighborhood infrastructure (e.g., transportation, proximity of health and social services) appear to pose barriers, rather than create paths to ensure older adults\u2019 quality of lives (Chum et al. 2020).<\/p>\n

 <\/p>\n

Indeed, according to Chum and colleagues (2020), the environment may not be conducive to older adults\u2019 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).<\/p>\n

 <\/p>\n

In light of our recent COVID-19 pandemic in Canada, results of a National Institute of Ageing\/ Telus Health National Survey (2021) reported that \u201c91% 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\u201d (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\u2019 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).<\/p>\n

A brief review of literature on immigrant family caregiving of older adults<\/h3>\n

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\u2019 care improve outcomes for individuals with dementia and schizophrenia (Flaherty & Bartels, 2019); but on the other hand, informal care may lessen older adults\u2019 access to formal care and support in the community (Huxhold et al. 2014).<\/p>\n

 <\/p>\n

In other words, family caregivers can both help or hinder older adults\u2019 wellbeing, depending on the family caregivers\u2019 individual agency; that is, their capability to exercise control over their own or others\u2019 actions (Bandura, 1999). Key factors of a caregiver\u2019s 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).<\/p>\n

 <\/p>\n

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\u2019 agency across their environment (Cohen et al. 2019). According to Manuel (2007, p. 174-175), intersectionality is a key concept that \u201csuggests our lives and the choices we make are best understood as a consequence of our social location\u201d in reference to \u201cthe intersections of race [or ethnicity], gender, class, and other forms of identity and distinction.\u201d These intersections of social markers of identity and difference do not function independently but, rather, \u201cact in tandem as interlocking or intersectional phenomena\u201d (p. 175) to shape individual agency.<\/p>\n

 <\/p>\n

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).<\/p>\n

 <\/p>\n

In the next section, we will describe the socio-ecological model of health to guide \u201cmapping\u201d one\u2019s social location to aging in different places\/locations.<\/p>\n

The socio-ecological model of health to map social locations of aging in place<\/h3>\n

Figure 10.1\u00a0Socio-ecological model of older adults\u2019 health in age-friendly cities<\/h6>\n

\"\"<\/p>\n

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).\u00a0 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 \u201cage-friendly cities\u201d to the socio-ecological model of health to \u2018map\u2019 how each level intersects and potentially determines the older adults\u2019 capacity to age in place. (See Figure 10.1).<\/p>\n

 <\/p>\n

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\u2019 access to services in each environment.<\/p>\n

Chinese family caregiving in the Greater Toronto Area, Canada: An exemplar study of the mismatch of needs and community services<\/h3>\n

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).<\/p>\n

 <\/p>\n

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).<\/p>\n

 <\/p>\n

In the U.S., non-Asian majority in general perceive Asian immigrants as \u201cmodel minority\u201d (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.<\/p>\n

Research question<\/h3>\n

How does the social location of Chinese family care partners of older adults shape caregivers\u2019 access to community-based health and social services in the Greater Toronto Area?<\/p>\n

Study Setting<\/h3>\n

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).<\/p>\n

 <\/p>\n

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\u2019s 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).<\/p>\n

Methods<\/h3>\n

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 \u201cempirical\u201d consists of evidence of what we tell each other happened. The middle is the \u201cactual\u201d and consists of evidence of what is tangible, regardless of whether we are aware of it. The bottom and largest layer is the \u201creal\u201d and consists of \u201cmechanisms\u201d and (social) \u201cstructures\u201d 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.<\/p>\n

Figure 10.2 Philosophical underpinnings of critical realism<\/h6>\n

\"\"<\/p>\n

One\u2019s agency is exercised through mechanisms (e.g., a sense of responsibility), made up of factors, such as one\u2019s 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\u00a0 in certain contexts or under certain conditions (Elder-Vass, 2010).<\/p>\n

Participant Recruitment and Sampling<\/h4>\n

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.<\/p>\n

Ethical considerations<\/h4>\n

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\u2019 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.<\/p>\n

Data collection<\/h4>\n

Participants were interviewed by one of the research team members. Interviews lasted between 45 mins to 1.5 hours, and began with collecting participants\u2019 socio-demographic data, followed by eliciting their\u2019 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:\u00a0 adding a question about meanings given to the responsibility of caregiving.<\/p>\n

 <\/p>\n

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.<\/p>\n

Data analysis and interpretation<\/h4>\n

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\u2019 (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\u2019 (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.<\/p>\n

Trustworthiness<\/h4>\n

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).<\/p>\n

Results<\/h3>\n

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.\u00a0 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.)<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Table 10.1 Socio-demographic data of the Chinese family care partners\u00a0<\/strong><\/td>\n<\/tr>\n
<\/td>\nCaregivers (N=28)<\/strong><\/td>\n<\/tr>\n
Frequency (n)<\/strong><\/td>\nPercentage %<\/strong><\/td>\n<\/tr>\n
Age<\/strong><\/td>\n<\/tr>\n
18 to 54 years old<\/td>\n11<\/td>\n39<\/td>\n<\/tr>\n
55 to 75 years old<\/td>\n16<\/td>\n57<\/td>\n<\/tr>\n
Prefer not to say<\/td>\n1<\/td>\n4<\/td>\n<\/tr>\n
Self-Identified Center<\/strong><\/td>\n<\/tr>\n
Female<\/td>\n17<\/td>\n61<\/td>\n<\/tr>\n
Male<\/td>\n11<\/td>\n39<\/td>\n<\/tr>\n
Citizenship Status<\/strong><\/td>\n<\/tr>\n
Canadian citizen<\/td>\n28<\/td>\n100<\/td>\n<\/tr>\n
Permanent resident<\/td>\n0<\/td>\n0<\/td>\n<\/tr>\n
Relationship with Older Adult<\/strong><\/td>\n<\/tr>\n
Spouse\/Partner<\/td>\n5<\/td>\n18<\/td>\n<\/tr>\n
Child<\/td>\n19<\/td>\n68<\/td>\n<\/tr>\n
Grandchild<\/td>\n2<\/td>\n7<\/td>\n<\/tr>\n
In-laws<\/td>\n2<\/td>\n7<\/td>\n<\/tr>\n
Education<\/strong><\/td>\n<\/tr>\n
High school<\/td>\n2<\/td>\n7<\/td>\n<\/tr>\n
College<\/td>\n5<\/td>\n18<\/td>\n<\/tr>\n
University<\/td>\n21<\/td>\n75<\/td>\n<\/tr>\n
Living with Older Adult<\/strong><\/td>\n<\/tr>\n
Yes<\/td>\n12<\/td>\n43<\/td>\n<\/tr>\n
No<\/td>\n16<\/td>\n57<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

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\u2019s expectations.\u00a0 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)\u2019s socio-ecological model of older adults\u2019 health in age-friendly cities. To note, Chinese family care partners\u2019 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.<\/p>\n

Figure 10.3. Socio-ecological model of health for the different locations of care by Chinese family care partners (CFCPs): 3a. Older adults\u2019 (OAs) or Chinese family care partners\u2019 homes, 3b. Assisted living facilities, and 3c. Long-term-care facilities.<\/h6>\n

\"\"<\/p>\n

Socio-ecological model of health for the different locations of older adults\u2019 care by Chinese family care partners<\/h3>\n

Figure 10.3a<\/strong> 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).\u00a0 Figure 10.3b<\/strong> 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<\/strong> 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).<\/p>\n

 <\/p>\n

In all three figures, Chinese family care partners\u2019 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\u2019 and older adult\u2019s financial circumstances, and the availability (or lack) of culturally acceptable care.<\/p>\n

 <\/p>\n

Next, we describe in detail the situation of Chinese family care partners in each of the three locations presented in Figure 10.3<\/p>\n

Chinese family care partners caring for older adults in private households (Figure 10.3a)<\/h3>\n

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 \u201chandle\u201d her father\u2019s needs, in part due to her own aging:<\/p>\n

 <\/p>\n

At my age, sometimes I have the intentions but I don\u2019t 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\u2019t handle it.<\/p><\/blockquote>\n

 <\/p>\n

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

 <\/p>\n

You know, when the elders get up and go to restroom at night, you need to know it\u2026 I worry about if he would fall down. That was torturing. You don\u2019t 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\u2019t know how to deal with such a situation.<\/p>\n

 <\/p><\/blockquote>\n

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:<\/p>\n

 <\/p>\n

Actually, morning is the worst time, I actually asked the Personal Support Worker (PSW) company manager if they can just come to mom\u2019s 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\u2019t wait for that long.\u00a0 (Participant 15, 60+ year old woman caring for mother in separate household)<\/p>\n

 <\/p>\n

Anytime they [PSWs] can leave. But I just let it pass. We can\u2019t 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\u2019t allow it, then there\u2019s nothing we can do. (Participant 20, 72-year-old woman caring for her mother)<\/p>\n

 <\/p><\/blockquote>\n

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:<\/p>\n

 <\/p>\n

In the beginning, there was no help. I had to keep telling them, \u201cMy mom won\u2019t shower, so what should I do?\u201d They were very reluctant and eventually said \u2018There is nothing I can do, but maybe I can send a person to come once a week.\u2019 That\u2019s all.<\/p>\n

 <\/p><\/blockquote>\n

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:<\/p>\n

 <\/p>\n

If it\u2019s [assisted-living or long-term care facility] private, then you\u2019ll have to wait 8 or 10 years, and it still might not be available. (Participant 14, 78-year-old male, caring for spouse)<\/p>\n

 <\/p><\/blockquote>\n

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:<\/p>\n

 <\/p>\n

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.<\/p>\n

 <\/p><\/blockquote>\n

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:<\/p>\n

 <\/p>\n

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\u2026 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)<\/p><\/blockquote>\n

Chinese family care partners caring for Older Adults in assisted-living facilities (Figure 10.3b)<\/h3>\n

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:<\/p>\n

 <\/p>\n

I saw some retirement homes is Cantonese, but I didn\u2019t see much for like Chinese local mainland [people].<\/p>\n

 <\/p><\/blockquote>\n

In another example, Participant 25\u2019s 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:<\/p>\n

 <\/p>\n

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)<\/p>\n

 <\/p><\/blockquote>\n

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 \u201cfew choices\u201d prior to her mother being transferred after a three year wait:<\/p>\n

 <\/p>\n

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\u2019t 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\u2019t serve Chinese food.<\/p><\/blockquote>\n

Chinese family care partners caring for older adults in long-term care facilities (Figure 10.3c)<\/h3>\n

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:<\/p>\n

 <\/p>\n

Since the government provides them [LONG-TERM CARE facility] funding, why does it seem like they [the government] don\u2019t care, like the programs, fees, etc. It\u2019s as though it\u2019s not part of their responsibility. (Participant 19, 63-year-old woman, caring for her mother in a LONG-TERM CARE facility)<\/p>\n

 <\/p><\/blockquote>\n

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\u2019 time and effort spent caregiving increased and their agency towards their own self-care and their immediate families lessened.<\/p>\n

Discussion<\/h3>\n

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\u2019 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\u2019s caregiving expectations lessened.<\/p>\n

 <\/p>\n

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 (B\u00e9land, & Marier, 2020); however, previous studies do not address continuing assumptions of family caregivers\u2019 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).<\/p>\n

 <\/p>\n

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\u2019s 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).<\/p>\n

 <\/p>\n

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).<\/p>\n

 <\/p>\n

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\u2019 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).<\/p>\n

 <\/p>\n

Martens and colleagues (2018) assert that enabling older adults to age in place requires \u201cpartnerships between individual and public responsibility\u201d (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\u2019 medical conditions, navigating the healthcare system, and limited time for self-care\/development (Liu et al. 2021). Indeed, in Canada, one\u2019s agency to be healthy is heavily influenced by social determinants, such as employment, and housing; and while \u201chealth is not a federal responsibility, many of the socioeconomic determinants of health are heavily influenced by federal policy\u201d (Drummond et al. 2020, p.5). So, while all Chinese family care partners expressed commitment to older adults\u2019 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).<\/p>\n

Future Directions<\/h3>\n

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\u2019 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\u2019 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 \u201cenable, constrain, and transform local cultural arrangements\u201d (Aronowitz et al. 2015, p. S405).<\/p>\n

 <\/p>\n

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\u2019s 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\u2019 appointments, for coordination of healthcare professionals\u2019 care, and for timely access to primary care (Backman et al. 2018).<\/p>\n

 <\/p>\n

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\u2019 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\u2019 with their care recipients\u2019 have interpersonal agency to together \u201cage well in place.\u201d Together, they are affected by both their local cultural communities and associated policies, along with the government leaders\u2019 inclusion of preferences that demonstrate equity for entitlements and choices beyond health to social determinants of health.<\/p>\n

Strengths and Limitations<\/h3>\n

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\u2019 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).<\/p>\n

Conclusion<\/h3>\n

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\u2019 agency beyond their households to encompass federal social determinants of health, shaping provincial policy and funding, and society\u2019s attitudes to aging in place, whether in private homes, assisted living homes, or long-term care.<\/p>\n

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