Honoring Identity Through Mealtimes in Chinese Canadian Immigrants

Abstract

Mealtimes are opportunities for social interactions and expressions of individual and family identity, and serve as a microcosm of the broader lives of families living with dementia. The Eating Together study and its resulting Life Nourishment Theory (LNT) explicated the importance of mealtimes for honouring individual and family identities in the context of dementia. This sub-study examined a specific ethnocultural group with cultural food-ways and caring expectations, to determine if the concept of honouring identity needed to be modified or extended. Using active interview techniques, two Cantonese speaking researchers completed dyad/triad family and individual interviews with six Chinese Canadian immigrant families, recruited from two service providers in a large, urban, multicultural city. This sub-study provided insight into the challenges and rewards of mealtimes for Chinese immigrant families with dementia in the community and specifically provided further insights into the honouring identity concept. Although LNT and specifically the honouring identity concept was generally confirmed in this group, some culturally-specific themes were also identified. This work serves as a basis for future studies examining the meaning and experience of mealtimes in specific cultural groups living with dementia. Such work would confirm if the LNT can be applied to specific ethnocultural groups as well as the general population living with dementia.

Introduction

There is a growing interest in the health care needs of aging ethnocultural minorities in Canada. ^1,2 In 2006, Chinese seniors (persons aged 65 years and older) accounted for 39% of the Canadian visible minority senior population. ³ In Toronto, home to Canada’s largest visible minority population, Chinese seniors accounted for 36% of citizens. ⁴ Among this demographic, 16% continued to live with their families, 3 times more than the national average ⁵ . Hence, it is timely to address the impact of age-related chronic conditions, such as dementia, with this emerging demographic, especially as they relate to family interactions.

Dementia is a progressive condition that involves memory and psychological changes that require social and care adaptations for those with dementia and their care partners. ⁶ As more seniors choose to live in the community requiring support from informal care partners (family members and friends), ⁷ it is anticipated that informal caregiving in Canada will triple by 2038. ⁸ This potentially stressful role may affect the care partner’s emotional, psychological, and physical health, having consequences both at home and at workplace. ⁹ Mealtimes have been proposed as a mechanism by which families with dementia can maintain their relationships and reaffirm their identities. ^{10 –13} Different cultures and ethnicities place different significance on food, hence influencing the meaning of mealtimes. ^11,13 The Eating Together (ET) study, conducted by Keller et al, examined the meaning and experience of food and mealtimes within the dementia context and developed the Life Nourishment Theory (LNT). ^6,12,13 However, ethnicity was not the focus of the original study and did not influence theoretical sampling; the meaning of mealtimes specific to different ethnocultural groups has yet to be explored.

Older Chinese immigrants are of particular interest for mealtime research as they may hold cultural beliefs and values that are different from those held in Western countries; this may influence how mealtimes happen at home. ¹⁴ Consequently, a study of mealtimes in the Chinese Canadian culture potentially lends a different view to the meaning of mealtimes in people with dementia (PWD) and their caregivers.

This qualitative substudy aims (1) to examine the meaning of the mealtime experience through 6 community-dwelling dyads/triads of Chinese Canadian PWD and their family care partners in the Greater Toronto Area, (2) to specifically explore how honoring identity is experienced in this culture, and (3) to determine whether the LNT needs to be extended due to the findings of this ethnocultural group.

Literature Review

While dementia equally affects all the ethnic groups, ⁹ the health and support services received and the attitudes toward dementia are not consistent. Ethnicity includes not only physical traits but also other health-related factors, including “history, cultural [customs], language, religion, and lifestyle.” ¹⁵ Older ethnocultural immigrants are an especially vulnerable group of people, as language and cultural barriers amplify normal challenges faced by older adults. ¹ There is limited research focused on the prevalence of dementia in subcultural groups of seniors, such as the Chinese, due to barriers to formal diagnosis and cultural beliefs and attitudes about dementia. ¹⁶ Research has identified a powerful social stigma associated with mental illness in the collectivist Chinese culture; having the “dementia” label stigmatizes not only the individual but also cause the whole family to lose face. ^16,17 To minimize the risks of being identified with dementia, PWD draw on strategies such as seeking validation and acknowledgement from others ^18,19 and following daily routines ^20,21 to maintain identity and improve self-confidence. ²⁰ Embracing one’s ethnicity is another coping mechanism used to overcome demands. ²² Hence, mealtimes serve as an ideal avenue to allow individuals to express identity through food choice and provide the necessary routine for families living with dementia to connect and maintain normalcy in the midst of change. ²³

The Life Nourishment Theory

The LNT was used as a guiding framework to explore honoring identity and the role that mealtime plays for these families. To examine the impact of food and mealtimes within the dementia context, Keller et al undertook a 6-year longitudinal grounded theory study, called ET study, to explore the meaning and experiences of food and mealtimes in care partners and care recipients. ¹³ Families living in the community (n = 27) were recruited and followed. The LNT was developed from this work and explains the challenges, interactions, problem-solving approaches, and achievements in the family as they relate to mealtimes. Three interrelated concepts of being connected, honoring identity, and adapting to an evolving life further elaborate on the meaning of the mealtime experience for families living with dementia (Figure 1).

Figure 1.

The Life Nourishment Theory (LNT)—interrelated concepts and subthemes. This article focused on the concept of honoring identity (dark boxes). Potential expansion of themes is indicated after subthemes (hatched lines).

The concept of being connected presents mealtimes as opportunities for families with dementia to interact and strengthen physical, psychological, and emotional bonds with dyad, family, and the wider social network. ¹³ Adapting to an evolving life addresses the process of adjusting to change in families living with dementia—how they become aware of, assign meaning to, and respond to, change. Here, some families may negotiate and transform with change using mealtime strategies, while others may resist change and experience stress. ⁶ In honoring identity, individuals and families maintain and create a sense of self over time, which can be upheld by the diverse activities of mealtimes. The PWD and care partners may experience loss of personal and social identity through decreased engagement in past activities. ^12,18 The LNT reflects how mealtimes mirror the overall impact of dementia on families, demonstrating how changes occur and are adapted to (or not), and highlight the various ways that families cope and create new identities. The focus of this substudy is the concept of honoring identity due to the expected importance of this concept to Chinese Canadians.

Identity in Dementia and the Chinese Culture

Identity involves both individual and social views. ¹² Individual identity is developed through “the continuity of one’s point of view in the world … [including one’s] beliefs, attitudes, hopes, fears, the location of one’s sense of personal agency or intention, and of responsibility for one’s actions.” ¹⁹ Social identity refers to the self that is developed over time through participation in social life and identification with others or a particular group of people. ²⁴ Identity may be threatened when a diagnosis of dementia leads to changes or loss in social roles and statuses. ²⁵

For ethnocultural minorities, identity also involves a cultural aspect. Culture involves shared beliefs, values, customs, behaviors, and artifacts that help society adapt to their immediate environment and are learned from one generation to the next. ^9,15 Culture provides a context in which one can explain the differences in behaviors and experiences expressed among different groups around dementia. ²⁶ A study on the dining experience in Western long-term care facilities reported inadequate nutrition care for the elderly people and a lack of attention given to food preferences of ethnic minorities. ²⁷ For the Chinese, research has found that health and health-related attitudes are influenced by values founded on traditional Chinese philosophies, and an understanding of these cultural values can provide a better foundation for culturally sensitive care. ²

Confucianism is a commonly held Chinese belief and social principle that guides social behavior, interactions, and family relationships. ^16,28 Traditionally, growing old is viewed with positive anticipation; seniors are not only respected for their wisdom but are also viewed as an asset to family and society; as such, they are guaranteed to be cared for in their old age. ^{29 –31} Filial piety is a particularly important component in Confucianism and determines the attitudes and resultant behavior that children should exhibit for their parents, especially as they age or become ill. ¹ Chinese families also believe that it is important to pass on traditional beliefs to future generations, and the consistency of mealtimes help to socialize younger generations to both family traditions and broader cultural norms. ³² Recently, culturalist explanations of behavior during illness have received criticism for their emphasis on a core set of beliefs based on ethnicity, often failing to account for other social determinants of health; ³³ assumptions based on ethnic traits may lead to fallacious stereotyping. ³⁴ Yet, if applied correctly, acknowledging the diverse lived experiences and the impact of social factors and the illness itself, culture is still a valuable consideration when examining caring relationships and dementia. ³³

Undeniably, culture is a dynamic process that varies even within the same ethnic group. ^33,34 For the Chinese, characteristics that can influence how culture is experienced include age, ³⁴ generational differences, ³⁵ immigration status, ³⁶ assimilation, ³⁷ and acculturation. ¹⁴ To our knowledge, no work on community-dwelling seniors with dementia in this cultural group has been conducted with respect to food and mealtimes. At home, differing levels of acculturation are seen in families that adopt the Western culture into their eating habits and combine them with traditional Chinese cuisine. ¹⁴ The majority of older Chinese immigrants hold fast to the traditional Chinese beliefs of Confucianism, filial piety, and the beliefs of how older adults ought to be cared for. However, their children have been found to be more accepting of the Western culture, have a lower level of filial piety, and feel less responsible for fulfilling family obligations. ^35,38 In addition, struggles have been documented within immigrant families as children adopt the mainstream culture and reject traditional food and foodways. ³⁹ This cultural shift may affect the meaning of mealtimes in families with dementia and especially how honoring identity is experienced.

Methods

As the purpose of this study was to confirm and extend the LNT with respect to examining a single cultural group with potentially strong ethnocultural values believed to influence food, interview questions, and deductive coding were based on the themes of the honoring identity concept. Where new data on this concept were identified that could not be coded within the current LNT structure, new codes were applied. As with the main ET study, dyad interviews were conducted with the person with dementia and their primary care partner together, followed by separate individual interviews with each of these participants. ^6,12,13

Our sample included 6 Chinese Canadian (5 men and 1 woman) PWD, aged 80 to 100 years, who met the eligibility criteria (Box 1). Unlike the main ET study, more than 1 family care partner and generation were involved in data collection, as this represented the caring reality of this ethnocultural group; 8 family care partners (2 wives, 3 daughters, and 3 daughters-in-law) were interviewed; 2 third generation, 3 second generation, and 1 senior couple household types made up the sample; the senior couple continued to engage in extended family mealtime activities several times a week. In addition, 3 care partners remained in the workforce while caring for PWD. All participants were immigrants.

Box 1. Eligibility Criteria for Chinese People with Dementia and Care Partners (CPs)

1. Living in the community

2. Primary CP lives in same home or near person with dementia

3. Self report of diagnosis with early to mid stage of dementia, able to speak on mealtime and related experiences (Functional Assessment Scale Test < 6)

4. CP is a close family member of person with dementia

5. Volunteer and provide written consent

6. PWD and primary CP are of Chinese descent (immigrant or Canadian)^a

^aThe last criterion (6) was an additional eligibility criteria for this study, and was not part of the original Eating Together study.

Participants were recruited using convenience sampling from 2 Chinese community agencies in the Greater Toronto Area, which provide dementia services. Participants were identified by the Program Coordinators from both the sites and participants provided consent to be contacted by the researchers. Two Cantonese-speaking interviewers, 1 for each site, telephoned eligible persons to answer any questions concerning the study and to set up interview times. Written consent was obtained from all the participants. At the end of the first interview with a dyad, a time was set up for individual interviews. The Functional Assessment Scale Test ⁴⁰ was used to determine the stage of dementia. Participants ranged from stage 4 (difficulty with complex tasks, like shopping) to stage 6b (requires assistance with some activities of daily living), with the majority in stage 4. ⁴⁰

A semistructured interview guide based on the original ET interviews was modified for this culture, translated into Chinese, and approved by staff at both the facilities and by the Chinese interviewers. This interview guide focused on: the meaning of mealtimes in both care partner and person with dementia, how mealtimes happened in the home and outside of the home, changes since diagnosis with dementia, and coping strategies used by the care partner and person with dementia. Active interviews, which are conversational in nature, were used to conduct the interview. ⁴¹

Interviews were transcribed by the interviewers and a Cantonese-speaking transcriptionist, allowing for an initial level of analysis known as “familiarization.” ⁴² Transcription and translation to English were done simultaneously. For Chinese terms that could not be directly translated into English, fluid descriptions, rather than literal 1-word translations, were used to keep as close to the original meaning as possible. ⁴³ Interviewers met regularly to discuss any discrepancies and to reach a final consensus.

Thematic analysis was conducted to identify emerging themes and to see how these themes related to the LNT. ⁴⁴ A codebook based on concepts and categories from the main ET study was applied to the data; data that did not fit into current themes were identified and labeled. Researchers worked together to analyze all transcripts in an iterative process with the lead author refining themes and labels.

Results

While evidence of being connected and adapting to an evolving life were seen in the data, these were essentially similar to the original ET study; where the LNT could be extended with this substudy, data were in the concept of honoring identity. Honoring identity findings are first presented in areas where they are consistent with the LNT, then in areas where they differ.

Honoring Identity

Honoring individual and family identity was a dominant part of the discussion with these Chinese families. The LNT themes of protecting dignity, having meaningful roles, and reaffirming a sense of self in the world were evident in this sample.

Protecting dignity

Protecting dignity occurs when dyad members acknowledge and value each other’s need for self-esteem, self-respect, and personal pride—regardless of their state. Consistent with previous ET study findings, both personal and cultural identities were acknowledged as care partners made efforts to provide their elder’s favorite cultural foods. For example, a care partner stated that she tried to respect her father’s preferences through keeping cultural observances and eating traditional festival favorites, such as having sweet glutinous cakes during Chinese New Year and moon cakes during the Moon Festival (care partner daughter 3 [CPD3]). Her father gratefully acknowledged his daughter’s efforts in protecting his dignity by providing the help he needed as well as the foods he preferred: “[CPD3] knows what I like to eat, and she would bring those groceries and other things back here … [She] takes care of me” (person with dementia male 3 [PWDM3]).

To protect dignity, Chinese families felt obligated to provide culturally appropriate care for PWD, despite other earnest demands from work and other family members. In this example, the care partner recognized her father-in-law’s preference for cultural foods and found the time to ensure he got to the store to meet this need:

I try to find time every week to go grocery shopping with [PWDM2]. Sometimes when I am really busy, I would drop off [PWDM2] in the grocery store, and then … pick him up afterward. Because seniors need to have Chinese food to eat … [But] I am busy—when I get off work, I have to drive my daughter. [For] the past 2 to 3 weeks, I have been working all full-time. [It] depends on how busy the company is. (CP daughter-in-Law 2 [CPDL2]).

This demonstrates the significance of filial piety in the Chinese culture, yet also shows the role strain on care partners with additional demands from work and children. This finding is consistent with the original ET findings, where care partners wanted to return the care they have received from their loved one with dementia. However, more than half of the ET families were spousal dyads.

Protecting dignity also includes being acknowledged and avoiding threats to dignity. For PWD, being acknowledged by others was “quite important” (CPDL4), as it allowed them to focus on their continued current abilities and strengths. Avoiding directly addressing the diagnosis, such as referring to dementia as, “the condition,” (CPD1) was one way that families protected dignity and individual identity. For the Chinese, where saving face and honoring the family name are fundamental cultural values, there was evidence of conflict between a desire to be accepted by others and the need to conceal the condition of the person with dementia to avoid threats to personal and family dignity. For instance, 1 care partner noticed that her father-in-law finished his meals when he ate with others at the day program, but did not finish his meals at home, despite the family accommodating him for texture and bite size. She attributed this to his “embarrassment [at] being picky about food” in front of others, to which her father-in-law surprisingly agreed (Dyad4); he was attempting to be accepted by not refusing food offered to him at the day program. This closely resembles findings from previous ET studies where families veiled reality of changes and challenges experienced by the person with dementia to protect their dignity and individual and social identity.

Having meaningful roles

Consistent with the LNT, families described meaningful roles within the household that defined who they were “I have always cooked at home. It is traditional. Men go to work, women stay at home and take care of the family and cook. It is simple” (CPW4). Engaging in meaningful and desired meal-related roles helped to honor identities of dyad and triad members. The PWD saw meals as a valued activity for the family, where they could contribute and retain roles: “It is too difficult for them. So if I can help out, I would try my best. [If] there is anything I can do, I would not force them …” (PWDM3). For PWD, mealtimes provided opportunities to continue using their remaining abilities—to feel useful and contribute to the household. Care partners also stressed the importance of continuing food-related roles for PWD:

She feels really good when she can help. When she cooks fish, she makes it really salty. But when it’s done, she would tell everyone she was the one who made it. That makes her really happy because it makes her feel important. (CPD6)

As with the mainstream Western culture, Chinese families negotiated strategies to enable the person with dementia to continue to practice their roles within their capacities, such as doing some of the preparation or leaving detailed instructions:

Sometimes I would tell her, “[PWD female 6 [PWDF6]], today is family day, can you cook … because my mom makes that [dish] very well. So I’ll do all the preparation and I say, “[PWD6] tonight you cook,” and she would do it. But usually we don’t let her touch the stove. She would forget. I don’t want her to deal with the stove! Don’t want her to go into my kitchen! (CPD6).

Families strove to enable meaningful roles in the household, allowing all family members to “help out,” and deemed this as “very important” (CPD6).

Although communal meals with extended family were reported in the main ET study, Chinese Canadians ate frequently together and saw other family members as support to the primary care partners; such support provided relief and allowed families to focus on their most meaningful roles. For one family, informal support through a family friend allowed the family to continue their way of life without having to hire a formal caregiver:

[We have] very good friend who helps the family by tidying things, cleaning the floors, cleaning things, vacuuming … [and] buy [groceries] and bring them here… You can’t find ones like these even if you were hiring! (CPDL4, CPW4, and Dyad 4)

This provided time to focus on those more meaningful roles to the care partners, such as meals with the extended family. The PWD derived joy from being with all of their family, and communal meals were a “very happy” (PWDF6) time for all.

With the progression of dementia, age, and diminishing physical abilities, families also had to alter roles accordingly. Families experienced conflict trying to balance the provision of care for the person with dementia, while honoring their need to practice remaining abilities. Some families indicated that “the roles have changed,” where “someone who was being cared for … [turns] into a caregiver” (CPD1). For instance, some care partners stepped in to remove mealtime roles:

Back then, my father-in-law usually did the cooking. But [now] I would do the cooking again myself … It is not as convenient with my father-in-law cooking. The woks, the utensils, begin to become heavy … For example, doing the dishes, my father-in-law will feel pain in his hands, or be uncomfortable. (CPDL2)

Hence, the dementia condition itself, the dyad’s values and experiences, and their immediate environment all interact and affect families’ decisions and actions around mealtimes. In the main ET study, this was described as negotiating and where possible enabling mealtime roles. Families also described taking over the roles of PWD “for [their] own good” (CP5, Dyad) as well as to make it easier for the multigenerational household, where meals were limited by busy schedules and different preferences. For example, rather than cooking at home, 1 family kept the Winter Festival tradition by eating out, thus negotiating their capacity while honoring family identity:

Many years ago … they would do it. Back then when [CPW4]’s health was better and could cook more, we would eat at home. But now, in these past few years … Can’t do it on time, essentially. So to avoid that, we go out to eat. (CPDL4, Dyad)

Reaffirming self in world

Similar to the main ET study, routines and traditions were seen as a way of reaffirming sense of self and were essential to honoring identity in the Chinese culture. Routines and meal structure, such as having soup at dinner, provided comfort for families and helped maintain the dyad’s unique relationship:

We sit and eat together … And we would always have soup. I think this is our specialty. (CPD2 and Dyad 2)

Interestingly, all participants mentioned having Chinese-style soup as a part of the mealtime routine, and families who experienced increasing difficulty with cooking (due to time limitations or decreasing ability with age) stated that they still tried to provide soup at meals. All families also mentioned going to dim sum (restaurants serving traditional Chinese cuisine of bite-sized food served in small steamer baskets) as a weekly routine; some families reported incorporating routine tasks, such as grocery shopping, into their dim sum routine (Dyads 2 and 4), thus creating new routines and traditions that supported their values and goals. Traditions are important to Chinese families and when living arrangements changed, efforts were made to continue those meaningful mealtime activities. One family created new stories and traditions through a weekly “Family Day” for several generations to gather:

Saturday is our Family Day … My little siblings will come over. Whoever is free will come over to my place. In the past I used to always go to my mom’s place, every Saturday, we’ll cook for everyone, but now, it’s at my place because my mom lives with me now. (CPD6 and Dyad)

Reaffirming sense of self also involves making decisions that follow individual and family values. Chinese care partners indicated that formal services were not adequate; they felt obligated to provide care for PWD at home and felt that formal care was evading one’s responsibilities. For example, this daughter stated:

I couldn’t believe a retirement home has so many people … How can you keep an eye on so many things? Luckily, my mother has me as a daughter to take care of her. Being old is a huge issue. (CPD6)

Despite the busy lives of child–parent care partners, filial piety was evident in our sample. These care partners felt honored to take on this care identity.

Culture-Specific Findings

New themes that stood out from the current LNT were also evident in the stories provided by Chinese participants. Specifically, new ideas that emerged were taking on the role of the elder, transferring culture across the generations, and keeping culture. These are potential expansions of current LNT subthemes (Figure 1).

Taking on the role of the elder

Potentially different from the original ET sample, Chinese PWD described accepting the relinquishing of roles as something to be expected with age. One participant who used to cook for the family gave up his role in cooking with little regret, saying that, although “now [he] cook less … [because his] body is not very good,” he does not have “much worries about eating,” because his daughter-in-law would prepare softer foods and accommodate his needs at mealtimes (PWDM2). Another stated his acceptance of his new role, “As an elder, I’ll eat whatever is prepared!” (PWDM1), which meant eating bread or oatmeal, which was easier for him to eat on his own rather than rice or noodles. The participants indicated a willingness to accept significant changes in the types of food consumed or losing their roles and did not voice regrets. Older care partners also willingly accepted help from adult children to help them manage the role of spousal care partner: “Right now, it’s different … We live in retirement homes and [my daughter] helps me buy groceries … I’m getting older. That’s it” (CPW1). This matter-of-fact acceptance of age-related changes was different from that of the original ET study, which described feelings of loss when they could no longer carry out prior roles. ⁶

Taking on the role of elder was also about how care partners treated the person with dementia. For example, care partners readily acknowledged their elders’ preferences and provided for their needs: “Of course you would accommodate [PWDM4]. If he wants to go to dim sum, then [we] go to dim sum” (CPD4). This supported dignity for PWD; the automatic decision to bend to the desires of the person with dementia demonstrates the view that the elder was to be given preferential treatment. Taking on the role of the elder also meant stepping back from being a decision maker, especially in multigenerational households. The PWD kept the peace at home by stepping back and allowing family members to make decisions. For example, 1 male person with dementia stated: “I’m already several decades old. What is there to argue about?” (PWDM4). Care partners also strived to ensure that mealtimes were enjoyable to honor their relationship and not upset the elder

Sitting together and eat is a very happy experience … All the way through. That is why if we have anything we’re unhappy about … we would not bring it to the table … like before we come together to eat dinner, we would resolve it. (CPD1)

These findings can expand “having meaningful roles” (Figure 1), a theme of honoring identity, to introduce how an “elder” is a new role chosen by some persons with dementia, which absolves them of decision making and food-related roles they held in the past, while having their preferences and needs catered to by the rest of the family.

Transferring culture across generations

For multigenerational households, families gathered nightly for meals, while single-generation households routinely gathered to allow grandchildren and grandparents to connect. The theme, transferring culture across generations describes how mealtimes were used as occasions to transfer cultural values across generations, including filial piety:

I think it is better to eat together. And I think it is very important … Because my daughter would see … besides us, we still have our parents to care for … I believe that she will be more obedient. Like she will learn … And I also think this is better … Having three generations under the same roof is good. (CPDL2)

Children from extended family were also included in family gatherings; children learned to cherish occasions to be with elders, while seniors derived joy from the family support:

When it’s a festivity or holiday … [The grandchildren] usually come out when they can. She really likes it when people are around her. Her grandchildren are very obedient and care for their grandma … She feels very lucky … You know the younger generation; they’re busy all the time. [But] as long as you call them, they will come because grandma called. (CPD6)

Although filial obligation is also seen in the contemporary Western culture, this is more evident in these Chinese Canadian families who lived in multiple-generation households. In the main ET study, only 2 households were multigenerational, which did not allow for the development and exploration of a theme around generational transfer through mealtimes. This new finding from our Chinese families may extend the “reaffirming self in world” theme, part of honoring identity (Figure 1). Filial piety is strong in this culture, and mealtimes allowed families to keep and pass on cultural values.

Keeping culture with food ways

Although similar to transferring culture across generations, another area that distinguished this sample was that Chinese families purposefully used food to preserve traditional culture within a larger contemporary Canadian context. Only 2 families recruited in the main ET study displayed signs of keeping their culture through their food choices and dining ways. In contrast, our Chinese families continued to eat the way they used to in order to uphold traditional individual and family identities:“[PWDM4] always has Chinese dim sum … What people in Hong Kong do most is go to dim sum … where there are a lot of people, and you go every morning” (CPW4). Participants also stated the importance of keeping cultural food traditions: “You know how Chinese people eat, we like lots of plates and dishes, so we can all share it, so it’s happier that way.” (CPD3). However, families did show some signs of acculturation, especially for the younger generations who begin to prefer Western cuisine over Chinese cuisine:

In reality, to [my daughter], Chinese food tastes bad no matter how you cook it! (CPDL2)

Families tried to adjust to differing cultural cuisine preferences between younger and older generations by “accommodating” each other. One person with dementia explains this:

Youths and the seniors are different, right? One has to understand this … You cannot force this, right? You have to accommodate … We are a family. (PWD4)

This allowed families to both maintain the peace and family identity. However, they kept culture for the person with dementia, as a way of honoring their identity: “When we go to a BBQ, we also need to bring a bowl of rice for him (PWD1) … . Yes, we give him a box of rice and BBQ some chicken wings for him. And he’ll be very happy. We put the chicken wings on the rice” (CPW1). In this example, they chose to keep culture while away from home, but then also indicated that they have assimilated to the Western culture by some of their food choices at home:

Every day he eats milk and oatmeal, and bread. It is a routine, he naturally prepares it. Brews coffee … During lunch … him and my mom will usually eat what we call “assorted foods,” such as macaroni in soup, noodles, like that. (CPW1)

Food is linked to one’s identity, and mealtimes help create a sense of belonging and provide a “sense of security” (CPDL5 and Dyad) by upholding cultural identity in the greater world. This finding was strong in this cultural group and could be a subtheme of reaffirming self in world, although acculturation and assimilation were also identified in this sample.

Discussion

The findings in this substudy support previous research findings that mealtimes are important and meaningful events for PWD and their care partners. ^6,12,13 Conducted during the last year of the 6-year longitudinal ET study, this analysis deepens our current understanding of the importance of mealtimes in multicultural, and specifically Chinese families living with dementia. The majority of findings in this substudy were consistent with the LNT concept of honoring identity. Stories from our participants indicated that mealtimes provided rare opportunities for families with dementia to maintain routines and traditions especially important in multigenerational households, where there are conflicting interests. Shared meals with extended families provided a “family support system” (CPD6). This is consistent with the current research that suggests the size of one’s support network and identification with cultural norms lessens caregiver burden. ⁴⁵ However, traditional ideals may not be possible when demands from work and other family members come into play. Formal support services that understand traditional Chinese concepts of filial piety and cultural food ways, as well as the tensions that can result among the generations are needed. These programs need to provide mealtimes and activities with others of the same ethnicity and language, yet also respond to their current needs for texture and preference to support independence in eating.

Mealtimes have been shown to allow individuals and families to maintain and reaffirm their identities. ¹⁰ The concept of honoring identity was most evident in this Chinese substudy, and subthemes under this concept may be extended to include how honoring identity happened for Chinese Canadians. Care partners honored identities of PWD by respecting their food preferences and providing traditional foods at meals. Hence, traditional cultural values affected the way care was provided. The process of acculturation is evident as participants merged traditional foods with Western cuisine, as was expected for immigrant families. ¹⁴ Research indicates that families feel competing social values as they balance traditional filial beliefs in the contemporary social context. ¹ This idea of keeping culture has not been addressed in the LNT, where routines and traditions provided more than family comfort and familiarity but helped to express and reaffirm their cultural identities; this concept may be used to expand the theme of reaffirming self in world.

To adapt to changes with dementia, families took on new roles. As with families in the main ET study, some Chinese families tried to preserve roles for PWD through simplifying their tasks and providing instructions, while others stepped in and removed roles. As was anticipated with filial piety, these families described taking on the role of the elder (PWDM1), which seemed to facilitate removal of roles. As this theme was viewed through the lens of filial piety as well as within a gender-related daily activity and most of our participants with dementia were male, further work is needed to confirm this concept for this ethnocultural group. Prior research has identified that adult children do step in to care for aging parents with deteriorating health, ³⁴ and in the traditional Chinese culture, older adults are cared for in old age and growing old is pleasant and positively anticipated. ^{29 –31} Further work is needed to confirm this positive attitude demonstrated by our sample of “letting go” as one ages and becomes an elder.

For multigenerational families, new findings also included transferring culture across generations, where mealtimes were used as learning opportunities to teach younger generations traditional principles, such as filial piety. Learning and transfer of family culture are part of the LNT; however, there was a strong emphasis on Chinese culture and values being transmitted in this sample. The theme, reaffirming self in world, could be expanded to more explicitly to identify this concept of cultural identity transference. This notion of cultural transfer across generations demonstrates that mealtimes have the potential to bridge the gap between the older and younger generation in the midst of a cultural shift as younger generations adopt the Western culture over traditional beliefs. ^35,38

Limitations

This is the first known qualitative study focused on the identity and mealtimes in Chinese Canadians and it has some limitations. This was a substudy of the original ET study, using the same interview techniques and questions to elicit the meaning of mealtimes in Chinese Canadian families with dementia. Unlike the main ET study, which used grounded theory methodology, this substudy used thematic analysis, as a deductive analysis was used. New subthemes were also identified and categorized within the LNT framework; this may have lead to interpretational bias and may have limited exploration of possible alternative explanations and themes if the data had been analyzed without such a framework. While some quotes and examples clearly belonged to particular subthemes, others were not as distinct and this is a limitation of the current work. Simultaneous translation and transcription of the interviews were also potential limitations, as meaning may become lost in the translation process. Researchers have noted that the language differences are difficult in research as concepts in one language may not be directly conveyed in another. ²⁶ Researchers in this study attempted to limit this loss using fluid description of certain hard-to-understand words, rather than 1-word direct translations, along with reviewing digital recordings and consensus-building for determining the best translation across 3 Cantonese-speaking transcribers.

While culture and traditional beliefs play important roles in explaining the mealtime experience of dementia in Chinese Canadians, one must remember that there are variations within a culture, and other factors (eg, socioeconomic status, individual choice, and the illness itself) can come into play and affect their experience. ^34,46 Our sample unfortunately was too small and relatively homogenous to address these potential issues. All participants were Cantonese speakers who had come from Hong Kong and may have different background, socioeconomic status, and experiences that influence mealtime experiences than other Chinese immigrants. Furthermore, we neither know the exact region from where the participants immigrated nor when they immigrated. Additionally, the unequal gender composition of PWD participants (male, n = 5) may have influenced findings. For instance, men and women may have dissimilar affinity for the role of elder male identity may be less associated with mealtimes, which may affect their willingness to relinquish food-related roles. Finally, the majority of recruited PWD attended adult day programs (n = 5) and received other formal services and may not be representative of a more isolated population. Although our sample is insufficient to ascertain the impact of various cultural factors, it is clear that unique and dynamic cultural factors are at play and should be considered when explaining dementia-related behaviors of ethnocultural minorities.

Implications

Our findings have implications for theory, research, and practice. The findings in this substudy demonstrated that LNT concepts were generally upheld in the Chinese Canadian culture. Their stories also demonstrate the importance of cultural community services for families with dementia that allow them to create and continue social bonds—to express not only their individual and family identities but also cultural identities. Eating traditional foods and continuing cultural routines may also assist PWD in remembering details through context-dependent memories. The meaning of food and mealtimes may differ between nuclear families and multigenerational households, and future research is needed to examine the meaning of mealtimes in families that share meals with multiple generations, to see how the meaning of mealtime potentially shifts. For the LNT, these culture-specific findings primarily expand the concept of honoring identity.

Conclusion

This study examined the meaning and experience of mealtimes in community-living Chinese PWD and their care partners. This study confirmed that, in general, the concepts in the LNT were supported in a sample of Chinese Canadian immigrants. Shared meals in multigenerational households from this substudy suggested that mealtimes were still relevant and necessary for family identity and connection. The Chinese culture has entrenched values around filial piety and cultural transfer, which contributed a greater understanding of how families living with dementia in this cultural group protect dignity and reaffirm sense of (family and cultural) self. Relinquishing roles for PWD also included the notion of taking on the role of the elder, which allowed for saving face when the senior experienced changes in capacity. This concept needs to be further explored in cultures that revere their senior members. Future work should include more diverse participants (eg, different ethnocultural groups and household types), taking note of subtle intraethnic differences, to further substantiate the validity of the LNT to the general population.