Caregiving occupations, health and well-being of Chinese mothers of children with disabilities living in Australia, Singapore and Taiwan

Abstract

Introduction:

Mothers of children with disabilities report increased maternal stress, compromised mental health and reduced leisure and social participation compared with other mothers. The aim of the study was to explore the similarities and differences between three groups of Chinese mothers of children with disabilities in their caregiving occupations and selected maternal variables.

Methods:

An online survey collected mothers’ demography, caregiving occupations and six maternal measures: frequency in participation in health promoting activities, mental well-being, personal well-being, psychological distress, perceived support and perceived stigma. Descriptive and inferential statistics were used to investigate group similarities and differences, and detect associations between variables.

Results:

The survey responses of Chinese mothers (N = 261) from Australia (n = 80), Singapore (n = 95) and Taiwan (n = 86) were analysed. Similarities and differences in caregiving occupations were found between groups. The Kruskal–Wallis test showed no differences in maternal variables between groups. There were associations found between some caregiving occupations and maternal variables when mothers were analysed as a single group.

Conclusion:

The health and well-being of mothers of children with disabilities may be influenced more by their cultural similarities than differences in their socio-political environments. Recognising cultural influences on caregiving occupations is crucial in the delivery of culturally competent and culturally intelligent practice.

Occupational therapy is based on the fundamental premise that occupations are central to the health and well-being of individuals and that human beings experience occupational adaptation when presented with challenges in their environment (de las Heras de Pablo et al., 2017). Mothers are occupational beings with multiple interconnected roles, such as a caregiver, nurturer, educator, protector and many more, whose everyday activities and roles also impact their children and families (Sim et al., 2021b). Hence, a better understanding of maternal occupations and their relationship to the mothers’ health and well-being may be beneficial to both mothers and their families.

Studies involving mothers of children with disabilities (henceforth ‘mothers’) consistently indicate that they experience higher stress, poorer mental health and were time poor as compared with mothers who have typically developing children (Hodgetts et al., 2014; Masefield et al., 2020). The caregiving occupations of mothers can include direct care provision to their children and also indirect care-related activities such as researching, accessing and navigating health, social and disability services for their children, which require substantial effort from mothers (Hodgetts et al., 2014). Consequently, mothers who have less time for themselves have poorer mental health status, fewer healthy behaviours (Bourke-Taylor et al., 2021a) and fewer opportunities for leisure and social participation (Sim et al., 2018).

While literature seems to be highlighting the negative effects associated with caregiving, qualitative research findings have also documented the strategies utilised by mothers to manage their daily occupations and to gain mastery over their challenging caregiving role (McAuliffe et al., 2019; Segal, 2000). For example, mothers found creative ways to manage their time (Segal, 2000) and make intentional plans to integrate personal time into their family routines (McAuliffe et al., 2019), suggesting that mothers do find ways to manage the demands of their caregiving occupations. Additionally, Bourke-Taylor et al. (2022) found participation in health promoting occupations was effective at reducing maternal mental health symptoms, and also increasing maternal well-being and supporting maternal lifestyle goals. While the relationship between maternal occupations and health has been explored amongst some groups of mothers (Bourke-Taylor et al., 2022), there are no similar studies on Chinese mothers, specifically on the association between their caregiving occupations, health promoting participation, health and well-being. These investigations could potentially inform culturally appropriate and evidence-based supports for ethnic Chinese mothers who have children with disabilities.

Chinese communities exist globally in vastly different socio-political landscapes (Goodkind, 2019). The Chinese culture is influenced by Confucianism, where mothers are expected to bring up successful children that can contribute to society (Ng et al., 2021). Chinese societies are also collectivist, which means prioritising commonality for the well-being of the group (Yan et al., 2014). Buddhism and Taoism are major religions in the Chinese culture, sharing the belief that past lives have an influence on current life (Yan et al., 2014). Research has suggested that these cultural beliefs could lead to Chinese mothers who have children with disabilities being blamed for producing ‘bad seeds’ resulting from their deeds in previous lives (Yan et al., 2014). Hence, the culture may have perpetuated negative attitudes towards disabilities, leaving mothers feeling ostracised and unsupported (Sim et al., 2021b; Yang, 2015). Several studies on Chinese mothers of children with disabilities (henceforth Chinese mothers) have documented similar cultural responses, such as loss of face, shame, self-stigmatisation and rejection, attached to their caregiving roles (Ng et al., 2021; Yang, 2015). Many of the above-mentioned studies occurred in a single country or city; hence, the identification of Chinese cultural influences versus socio-political environmental influences are difficult to decipher. Therefore, research involving mothers from the same cultural group but living in different countries may provide insight into socio-political environmental influences on mothers’ caregiving occupations.

The current study is part of a mixed methods study investigating the occupations of Chinese mothers. An initial scoping review identified that Chinese culture shaped maternal occupations of mothers who have children with disabilities and that Chinese mothers’ activity choices were commonly organised around mothers’ culturally perceived roles as carers, teachers, disciplinarians, therapists, coaches, liaisons, advocates and encouragers (Sim et al., 2021b). This signifies a strong cultural influence on the caregiving occupations of Chinese mothers. A follow-on qualitative study focusing on 11 immigrant northeast and southeast Asian mothers living in Australia found that despite multiple difficulties as immigrants and carers, these East Asian mothers experienced positive transformations in their mothering journeys, finding new identities and nurturing occupations for themselves in their new country (Sim et al., 2021a). Sim et al. (2021a) also found that mothers’ occupations were influenced by their support systems, which included extended families, friends, community and systemic supports. Supports were a catalyst to mothers’ transformation and enabled mothers to pursue their personally meaningful occupations (Sim et al., 2021a). However, the level of support and stigma may vary in different environments, and little is known about the interplay between culture, socio-political environment and the occupations of Chinese mothers of children with disabilities.

Current research has neither investigated the caregiving occupations of Chinese mothers and how their caregiving occupations are associated with their health promoting occupations nor explicitly compared the health, well-being, perceived social support and perceived stigma of Chinese mothers living in different socio-political environments. Comparing these variables among mothers across different countries could further our understanding of environmental enablers and barriers that affect mothers’ occupational participation, health and well-being.

We aimed to explore the similarities and differences in caregiving occupations and six maternal variables (health promoting occupations, mental health, mental well-being, personal well-being, perceived stigma and perceived support) amongst Chinese mothers living in three countries, which provided different contexts: Australia, Singapore and Taiwan. Furthermore, we aimed to identify associations between Chinese mothers’ caregiving occupations with the six maternal variables. The caregiving occupations in this study are categorised into direct, indirect, perceived roles and availability of other caregivers as these were found to have influenced the occupations of Chinese mothers in earlier studies (Sim et al, 2021a, 2021b). Our research questions were:

1. What were the similarities and differences in the demographic profile and caregiving occupations of Chinese mothers living in the three countries?

2. Are there similarities and differences in maternal variables (participation in health promoting occupations, mental health, mental well-being, personal well-being, perceived stigma and perceived support) between the three groups of Chinese mothers?

3. Are there significant associations between the caregiving occupations of the Chinese mothers as a single group, with the six maternal variables of interest?

Methods

This exploratory study employed a cross-sectional online survey, provided in three written languages (English, Simplified Chinese and Traditional Chinese) on Qualtrics (Qualtrics, Provo, Utah, USA). The survey was made up of questions on demography, caregiving occupations and six scales that measured maternal variables: participation in health promoting activities, mental health, mental well-being, personal well-being, perceived stigma and perceived support. Four of the scales were validated in both languages, but two needed to be translated into Chinese by the research team.

Participants

Three groups of ethnic Chinese mothers living in three countries (Australia, Singapore and Taiwan) were recruited via convenience, snowball sampling. These countries were selected to represent three different contexts in which Chinese mothers of children with disabilities live. Practical access to respondents, researchers’ networks and similarity in socio-political stability were among the factors considered in the final selection of the countries.

The first group consisted of immigrant Chinese mothers who were an ethnic minority group living in Australia; the second group consisted of Chinese mothers living in multicultural Singapore with Chinese as the ethnic majority and the third group consisted of mothers living in Taiwan with deep Chinese cultural roots.

The inclusion criteria were self-identified ethnic Chinese mothers who had a child with any type of disabilities and living in Australia, Singapore or Taiwan. All mother and child age groups and broad categories of childhood disabilities were included to capture a wide profile of Chinese mothers. Participants who did not indicate their country or their children’s disabilities were excluded.

Data collection

English and Chinese recruitment flyers were advertised on social media platforms, carer support groups, two disability agencies, a community newspaper and community noticeboards between January 2021 and August 2021. Upon accessing the online survey, participants selected their preferred language and viewed the explanatory statement. Online informed consent was obtained from all participants before commencing on the survey.

Measurements

A questionnaire was developed to obtain mothers’ and children’s information and mothers’ caregiving occupations. ‘Caregiving occupations’ for the child with disabilities were measured via multi-response set questions, where participants selected yes for a list of options presented. ‘Caregiving occupations’ included direct, indirect care tasks and perceived maternal roles (Sim et al., 2021b). Direct tasks referred to caregiving assistance given to the child, whereas indirect care tasks referred to tasks that support caregiving. ‘Other carers involved’ was included as this would have direct impact on mothers’ caregiving occupations. Participants were also asked to select the estimated time spent on each of the relevant direct caregiver tasks.

Maternal variables were measured using the following six scales, which were valid and reliable. Five of the scales had validated Chinese versions.

Health promoting activity scale

Health promoting activity scale (HPAS) is an 8-item scale, which measures the frequency of participation in activities that are for enjoyment, health, physical, social or spiritual engagement (Bourke-Taylor et al., 2012a, 2012b) and is used as a measurement for engagement in health promoting occupations. Respondents rate their frequency of participation from 1 (never) to 7 (1 or more times per day), and total score indicates the frequency of participation, with higher scores indicating a higher frequency of participation in health promoting activities (α = 0.78). The HPAS in Chinese had been cross-culturally validated for Chinese mothers by the research team (Sim et al., 2022). Current sample α = 0.75.

Warwick–Edinburgh mental well-being scale

Warwick–Edinburgh mental well-being scale (WEMWS) has 14 statements measuring hedonic and eudaimonic well-being. Respondents rate each item from 1 (none of the time) to 5 (all of the time). Total score indicates overall mental well-being, with higher score indicating better well-being, a = 0.91 (Tennant et al., 2007). There is a valid and reliable Chinese version (Taggart et al., 2013). Current sample α = 0.91.

Personal well-being index

The personal well-being index (PWI) measures personal well-being, where respondents rate their levels of satisfaction on seven life domains items from 1 (no satisfaction at all) to 10 (completely satisfied). The domains include standard of living, health, achieving in life, relationships, safety, community-connectedness, future security and an optional eight item: spirituality (International Well-being Group, 2013). A mean score (over 7 or 8 items) represents overall subjective well-being. PWI had been validated and translated into Chinese with Cronbach’s α between 0.70 and 0.85 (International Well-being Group, 2013). Current sample α = 0.90.

Kesseler-10

The Kesseler-10 (K10) is a 10-item Likert scale that is widely used in cross-sectional surveys to measure psychological distress in populations and can provide a reliable indication of mental health status (Kessler et al., 2002). Respondents rate on a scale from 1 (none of the time) to 5 (all of the time). Higher total scores indicate higher psychological distress and the presence of mental health symptoms. Cronbach’s α is 0.73–0.90 (Webb et al., 2018). It had been validated and translated into Chinese (Bu et al., 2017). Current sample α = 0.92.

The multi-dimensional scale of perceived social support

The multi-dimensional scale of perceived social support (MSPSS) has 12 items that measure the perceptions of support from three sources: family, friends and significant other. Each item is scored on a 7-point subscale, ranging from very 1 (very strongly disagree) to 7 (very strongly agree), and the mean score represents overall perceived support (Zimet et al., 1988). MSPSS has good internal consistency (α = 0.88) and validity, the Chinese version is found valid and reliable for the current population (Wang et al., 2017). Current sample α = 0.93.

Parental perceptions of public attitudes scale

The parental perceptions of public attitudes scale (PPPAS) contained nine statements that measure parental perceived stigma. It is measured on a Likert scale of 0 (completely disagree) to 5 (completely agree) (Colic and Milacic-Vidojevic, 2020). The mean score represents the level of perceived stigma (α = 0.87). Although the scale has yet to be validated with a Chinese population, it has reasonable internal reliability and validity with a population with collectivist culture and was specifically developed for mothers of children with disabilities (Colic and Milacic-Vidojevic, 2020). Current sample α = 0.87.

Data management and analysis

The data were exported from Qualtrics to Excel and imported into SPSS (IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp). Data screening occurred to determine the accuracy and data completeness. All scales were scored according to published directions. Normality tests were conducted on all total scores for the scales, followed by tests for internal consistency. Normality testing using the Shapiro–Wilk’s test showed that data was not normally distributed for four of the scales. Hence, non-parametric tests were utilised in all analyses.

Missing value analysis was completed, and the Little’s Missing Completely at Random (MCAR) test indicated that values were missing at random. Data imputation using series mean yielded similar analysis results, and hence results were derived using the original dataset.

Research question 1 was answered by reporting on the maternal and children characteristics and all categories of caregiving occupations of mothers of the three groups, including time spent on direct tasks, using descriptive statistics. The chi-squared test determined significant differences between nominal variables across the groups of Chinese mothers. Where more than 20% of cells had an expected count lower than 5, Fisher’s exact test was used, reporting only p-values. Post hoc tests using the adjusted standardised residual were used to identify which cells differed significantly. The Bonferroni adjustment was applied using the alpha 0.5/k (where k is the number of cells).

Research question 2 was answered by applying the Kruskal–Wallis H test to determine if there were any significant differences in the six maternal variables between the three groups of mothers.

Research question 3 used the same test for detecting significant differences between caregiving occupations (dichotomous variables), and the six maternal variables (HPAS, WEMWS, PWI, K10, PPPAS and MSPSS) for all three groups of mothers as one single group.

Results

There were 269 survey respondents, and 261 Chinese mothers met the inclusion criteria (N = 261). Chinese mothers from Australia (n = 80), Singapore (n = 95) or Taiwan (n = 86) completed the e-survey on Qualtrics.

The first two sections answer research question 1 with a summary of mothers’ and children’s profile, followed by maternal caregiving occupations, and reports of any significant differences between groups. Research question 2 was addressed by reporting on significant differences in the six maternal variables between groups. The last section answers research question 3, which reported associations between caregiving occupations and maternal variables when participants were analysed as a single group.

Similarities and differences in profile

Table 1 tabulates the demography of mothers. The majority of participants were above 40 years of age, had similar relationship status (either married or partnered) and reported high educational levels (undergraduate and above). More than half of the respondents were employed, of whom half were engaged in full-time paid work. The Australian sample of working mothers reported the highest percentage in part-time employment (52%) in contrast with working mothers from Singapore (24%) and Taiwan (18%).

Table 1.

Demography of participants from Australia (n = 80), Singapore (n = 95) and Taiwan (n = 86).

Mothers’ characteristics (N = 261)	Australia	Singapore	Taiwan	Total
Age range
<30 years old	5 (6%) †	0	3 (4%)	8
31–40 years old	34 (43%)	14 (15%)	28 (33%)	76
41+ years old	41 (51%)	81 (85%)	55 (64%)	177
Relationship status
Married/partnered	72 (90%)	81 (85%)	74 (86%)	227
Separated/divorced/widowed	7 (9%)	11 (12%)	9 (10%)	27
Others	1 (1%)	3 (3%)	3 (3%)	7
Education (N = 259)	(n = 79)	(n = 95)	(n = 85)
High school/secondary and below	10 (13%)	30 (32%)	12 (17%)	54
Post-secondary (Diploma)	10 (13%)	12 (13%)	9 (11%)	31
Undergraduate and above	59 (75%)	53 (56%)	62 (73%)	174
Employment (N = 256)	(n = 76)	(n = 95)	(n = 85)
Yes	37 (49%)	59 (62%)	45 (53%)	141
No	39 (51%)	36 (38%)	40 (48%)	115
Full-time	6 (16%)	35 (59%)	30 (67%)	71
Part-time	19 (52%)	14 (24%)	8 (18%)	41
Temporary	2 (5%)	1 (2%)	1 (2%)	4
Home-based work/own business	10 (27%)	8 (14%)	6 (13%)	24
Other	0	0	1 (2%)	1

^†Percentages were calculated over total number of mothers per country.

Table 2 describes the children’s characteristics. There was variation in the children’s profile across groups, with the highest percentages of autism diagnosis being reported amongst the Australian and Taiwanese samples, whereas the Singaporean sample reported the highest percentages in learning disabilities. The Australian mothers reported the highest mainstream schooling without support (refer Table 2)

Table 2.

Children’s characteristics (N = 216).

Children’s characteristics	Australia	Singapore	Taiwan	Total
Age of child with disability (N = 216)	(n = 57), M = 14.2, SD = 9.9	(n = 85), M = 14.1, SD = 9.0	(n = 74), M = 12.3, SD = 7.7	Overall, M = 13.5, SD = 8.8
Diagnosis a (N = 212)	(n = 56)	(n = 84)	(n = 72)
Physical disabilities	5 (9%) †	4 (5%)	13 (18%)	22
Learning disabilities	16 (29%)	49 (58%)	17 (24%)	82
Mental health disorder	6 (11%)	4 (5%)	10 (14%)	20
Sensory disabilities	6 (11%)	0	1 (1%)	7
Autism	33 (59%)	26 (31%)	37 (51%)	96
ADHD/ADD	11 (20%)	13 (16%)	25 (35%)	49
Intellectual disabilities	8 (14%)	17 (20%)	10 (14%)	35
Medical condition/disorder	5 (9%)	4 (5%)	9 (13%)	18
Child difficulties a (N = 202)	(n = 51)	(n = 80)	(n = 71)
Self-care	13 (26%)	16 (20%)	10 (14%)	39
Mobility	4 (8%)	4 (5%)	10 (14%)	18
Emotional dysregulation	29 (57%)	26 (33%)	31 (44%)	86
Understanding instructions	20 (39%)	25 (31%)	35 (49%)	80
Challenging behaviour	20 (39%)	28 (35%)	13(18%)	61
Medical status	3 (6%)	9 (11%)	9 (13%)	21
Planning/organising tasks	23 (45%)	33 (41%)	26 (37%)	82
Academic learning	23 (45%)	60 (75%)	37 (52%)	120
Social and communication	39 (77%)	45 (56%)	49 (69%)	133
Child’s school a (N = 211)	(n = 56)	(n = 83)	(n = 72)
Mainstream without support	28 (50%)	31 (37%)	25 (35%)	84
Mainstream with support	12 (22%)	12 (15%)	26 (36%)	50
Specialised school	7 (13%)	20 (24%)	5 (7%)	32
Home schooling	0	0	5 (7%)	5
Adult programme	1 (2%)	8 (10%)	2 (3%)	11
Others	8 (14%)	12 (15%)	9 (13%)	29

^aMulti-response set questions, respondents may select more than one item; hence, the number and percentage of participants answering yes to this question is reflected.

^†Percentages were calculated over total number of mothers per country.

ADHD: Attention deficit hyperactivity disorder

Similarities and differences in mothers’ caregiving occupations

The caregiving occupations of the three groups of mothers were reflected by countries as given in Table 3. Mothers’ time spent on each direct care task is tabulated in Table 4 by country.

Table 3.

Mothers’ report of caregiving occupations (for child), roles and supportive others (N = 174).

Caregiving occupations	Australia	Singapore	Taiwan	Total
Direct care tasks a	(n = 44)	(n = 72)	(n = 58)
Self-care	22 (50%) †	28 (39%)	19 (33%)	69
Mobility/transfer	6 (14%)	9 (13%)	9 (16%)	24
Play/leisure	24 (55%)	25 (35%)	30 (52%)	79
Emotional regulation	30 (68%)	41 (57%)	42 (72%)	113
Plan/organise	32 (73%)	52 (72%)	38 (66%)	122
Homework/study	24 (55%)	43 (60%)	40 (69%)	107
Behaviour supervision	26(59%)	40 (56%)	36 (62%)	102
Indirect care tasks a (N = 173)	(n = 44)	(n = 71)	(n = 58)
Learning about condition	35 (80%)	29 (41%)	32 (55%)	96
Liaising with professionals	37 (84%)	34 (48%)	44 (76%)	115
Liaising with school	35 (80%)	49 (69%)	50 (86%)	134
Accessing and researching	31 (71%)	22 (31%)	26 (45%)	79
Preparing activities	32 (73%)	40 (56%)	42 (72%)	114
Attending support group	21 (48%)	20 (28%)	12 (21%)	53
Administration	20 (46%)	28 (39%)	4 (7.0%)	52
Perceived maternal roles a	(n = 42)	(n = 73)	(n = 58)
Teacher	24 (57%)	40 (55%)	38 (66%)	102
Liaison	25 (60%)	30 (41%)	24 (41%)	79
Advocate	17 (41%)	27 (37%)	14 (24%)	58
Disciplinarian	24 (57%)	48 (66%)	29 (50%)	101
Therapist/coach	20 (48%)	26 (36%)	23 (40%)	69
Protector/comforter/encourager	33 (79%)	59 (81%)	47 (81%)	139
Carer	31 (74%)	49 (67%)	50 (86%)	130
Other carers involved a (N = 168)	(n = 39)	(n = 71)	(n = 58)
Spouse/partner	34 (87%)	51 (72%)	52 (90%)	137
Grandparents	10 (26%)	15 (21%)	24 (41%)	49
Brother or sister of child	7 (18%)	19 (27%)	9 (16%)	35
Live-in helper	1 (3%)	17 (24%)	3 (5%)	21
Friends	1 (3%)	2 (3%)	5 (9%)	8
Respite services	5 (13%)	1 (1%)	0	6
Outside groups/organisations	3 (8%)	6 (9%)	6 (10%)	15

^aMulti-response set questions, respondents may select more than one item; hence, the number and percentage of participants answering yes to this question is reflected.

^†Percentages were calculated over total number of mothers per country.

Table 4.

Estimated time spent per day to engage in direct tasks to assist child.

Australian mothers	Time spent per day (Australia) ‡
n = 44	<1 hour	1–2 hours	3–4 hours	>4 hours	Yes ¶	No ¶
Self-care	4 (19%) §	7 (33%) §	3 (14%) §	7 (33%) §	21	23
Mobility/transfer	1 (17%)	2 (33%)	1 (17%)	2 (33%)	6	38
Play/leisure	6 (27%)	9 (41%)	2 (9%)	5 (23%)	22	22
Emotional regulation	7 (25%)	13 (46%)	5 (18%)	3 (11%)	28	16
Plan/organise	9 (30%)	11 (37%)	6 (20%)	4 (13%)	30	14
Homework/study	9 (41%)	8 (36%)	4 (18%)	1 (5%)	22	22
Behaviour supervision	4 (17%)	5 (21%)	6 (25%)	9 (38%)	24	20
Singaporean mothers	Time spent per day (Singapore) ‡
n = 72	<1 hour	1–2 hour	3–4 hour	>4 hour	Yes	No
Self-care	14 (50%)	9 (32%)	4 (14%)	1 (4%)	28	44
Mobility/transfer	5 (56%)	1 (11%)	1 (11%)	2 (22%)	9	63
Play/leisure	13 (52%)	8 (32%)	3 (12%)	1 (4%)	25	47
Emotional regulation	19 (49%)	13 (33%)	6 (15%)	1 (3%)	39	33
Plan/organise	25 (49%)	19 (37%)	5 (10%)	2 (4%)	51	21
Homework/study	10 (24%)	19 (45%)	10 (24%)	3 (7%)	42	30
Behaviour supervision	11 (28%)	17 (44%)	7 (18%)	4 (10%)	39	33
Taiwanese mothers	Time spent per day (Taiwan) ‡
n = 58	<1 hour	1–2 hours	3–4 hours	>4 hours	Yes	No
Self-care	4 (21%)	8 (42%)	3 (16%)	4 (21%)	19	39
Mobility/transfer	2 (22%)	3 (33%)	0	4 (44%)	9	49
Play/leisure	9 (30%)	12 (40%)	7 (23%)	2 (7%)	30	28
Emotional regulation	28 (67%)	10 (24%)	2 (5%)	2 (5%)	42	16
Plan/organise	16 (42%)	13 (34%)	5 (13%)	4 (11%)	38	20
Homework/study	7 (18%)	17 (43%)	8 (20%)	8 (20%)	40	18
Behaviour supervision	11 (31%)	11 (31%)	7 (19%)	7 (19%)	36	22

^‡Duration spent on each direct task for those who selected this task as relevant.

^§Numbers represent the frequency of selection of task; percentages reflect proportion of respondents, who had selected the same task across different time spent.

^¶Yes refers to mothers who selected a particular task to be relevant to the assistance they give their child, whereas no refers to mothers that did not select the task to be relevant to them.

Direct care tasks

All three groups of mothers engaged in the direct caregiving tasks are tabulated in Table 3. No significant difference between groups was detected in terms of the type of direct tasks.

Time spent in direct care tasks

There were, however, significant differences between the three groups of mothers in terms of their time spent assisting children with direct tasks: self-care χ²(2) = 9.05, p = 0.011; emotional regulation χ²(2) = 11.51, p = 0.003 and behavioural supervision χ²(2) = 6.49, p = 0.039. Post hoc tests revealed that the Australian group had the highest mean ranks for time spent on all of the three tasks indicating that they spent the most time on these caregiving occupations. (See Table 4).

Australian and Taiwanese mothers reported spending more than an hour per day across most tasks compared to the Singaporean mothers, who spent less than an hour per day on most tasks. The Singaporean mothers (76%) and Taiwanese mothers (83%) reported spending between 1 to more than 4 hours per day on ‘homework/study’, in contrast with the Australian mothers (41%) who reported spending less than an hour on ‘homework/study’.

Indirect care-related tasks

Engagement in indirect care tasks was compared between groups, and some significant differences were detected (see Table 3). There was a significantly lower proportion of Singaporean mothers learning about their children’s condition (χ²(2) = 16.47, p < 0.001) and liaising with professionals (χ²(2) = 19.43, p < 0.001). There was a significantly higher proportion of Australian mothers engaged in researching services (χ²(2) = 17.08, p < 0.001), and attending support groups (χ²(2) = 8.96, p = 0.011). There was a significantly lower proportion of Taiwanese mothers engaged in administration (χ²(2) = 22.73, p < 0.001).

Perceived maternal roles

Significant differences between groups were found only in mothers who perceived their role as carers. There is a significantly lower proportion of Singaporean mothers perceiving themselves as carers as compared to Taiwanese mothers χ²(2) = 6.35, p = 0.042. The least selected role across all three groups was ‘advocate’ for all groups.

Other carers

The availability of other carers (see Table 3) was compared between groups. Spouses/partners were the most frequently reported as helpers for mothers for all groups (>70%). It was observed that Singaporean mothers were getting help from varied sources of support as compared with the Australian and Taiwanese groups, who relied mostly on grandparents as the next line of help. The Australian mothers reported the highest use of respite care. Few mothers relied on organisations outside the family for all groups.

Differences in maternal variables across groups

The Kruskal–Wallis H test showed no significant differences between groups in the six maternal variables: participation in health promoting activities, mental health, mental well-being, personal well-being, perceived stigma and perceived support.

Associations between caregiving occupations and maternal variables as a single group

The Kruskal–Wallis H test detected significant differences in some of the caregiving occupations (direct care tasks, indirect care tasks, perceived roles and availability of other carers), with the six variables when analysing mothers as a single group.

Direct care tasks

Maternal mental well-being (WEMWS) χ²(1) = 7.77, p = 0.005, personal well-being χ²(1) = 9.78, p = 0.002 and psychological distress (K10) χ²(1) = 9.99, p = 0.002 were significantly different between mothers who assisted their children in ‘emotional regulation’ compared to those that did not. Similarly, there were significant differences in mental well-being (WEMWS) χ²(1) = 9.62, p = 0.002, personal well-being χ²(1) = 6.32, p = 0.012, psychological distress (K10) χ²(1) = 8.56, p = 0.003, social support (MSPSS) χ²(1) = 5.56, p = 0.018 and stigma (PPPAS) χ²(1) = 12.35, p < 0.001), between mothers who assisted their children in ‘behavioural supervision’ and those who did not.

Indirect care-related tasks

Overall, poorer mental well-being (WEMWS) χ²(1) = 6.60, p = 0.010, personal well-being (PWI) χ²(1) = 5.45, p = 0.020 and higher psychological distress (K10) χ²(1) = 9.36, p = 0.002 were reported by mothers who did attend support groups compared to the group who did not.

Perceived roles

Mothers who perceived themselves to be carers had lower mental well-being (WEMWS) χ²(1) = 5.92, p = 0.015 and lower personal well-being (PWI) χ²(1) = 4.89, p = 0.027 than mothers who did not identify themselves as carers.

Other carers

Mothers who received help from their spouse reported better perceived support (MSPSS) χ²(2) = 4.25, p = 0.039 and better personal well-being (PWI) χ²(1) = 3.89, p = 0.049 compared to mothers who did not receive support from a spouse. Mothers who had friends helping as carers were found to report higher participation in health promoting activities (HPAS) χ²(1) = 4.29, p = 0.038 and higher personal well-being scores (PWI) χ²(1) = 4.41, p = 0.036.

Discussion

This study described the profile and caregiver occupations of Chinese mothers who have children with disabilities residing in Australia, Singapore and Taiwan. There were similarities and differences found in their caregiving occupations between groups, but no differences were found in their maternal variables. As a single group, there were aspects of caregiving occupations found to be associated with frequency of participation in health promoting occupations (HPAS), mental well-being (WEMWS), personal well-being (PWI), mental health (K10), perceived stigma (PPPAS) and perceived support (MSPSS).

Similarities between mothers

There were no significant differences found between the three groups of mothers in terms of their participation in health promoting activities, mental health, well-being, perceived support and stigma. This finding was unexpected because we had thought that environmental factors such as stigma and support and might be different between Australia, Singapore and Taiwan and might affect maternal participation and well-being. We expected lower levels of stigma reported by the Australian mothers because of the inclusiveness found in Australian society. The higher perceived social support for mothers from Singapore and Taiwan was attributed to easier access to their extended family. Surprisingly, our findings imply that despite environmental differences, mothers’ perceived levels of support and stigma were the same.

The similarities in perceived stigma support the idea that the maternal perceived stigma could be a combination of actual stigma from others and culturally induced stigma from within themselves (Siu and Hui, 2021; Yang, 2015). Our findings show that being in an environment with lesser Chinese influence did not correspondingly lessen mothers’ perceived stigma. A plausible explanation was that mothers’ perceived stigma could be self-perpetuating and culturally ingrained, which is supported by studies that found Chinese mothers had high levels of self-stigma and low self-esteem (Lu et al., 2015; Yang, 2015). This finding suggests that cultural identity may have a greater influence on mothers than socio-political environmental influences.

The similarities in maternal perceived support imply that mothers managed to source for support despite issues with stigma when living in a society with greater Chinese cultural influence or being immigrants with less familial support. In multiple studies, Chinese mothers reported receiving support from multiple sources including families, parent groups, schools and services (Siu and Hui, 2021; Zhao and Fu, 2022). Hence, the Chinese mothers appear to be resilient and capable to adapt and build positive environments around themselves over time (Zhao and Fu, 2020). This finding also suggests that cultural characteristics had a larger influence on mothers’ support-seeking behaviours rather than the availability of supports in the environment.

Mothers’ support-seeking emphasised immediate and extended family support, reflective of East Asian societal norms, where familial relationships and kinship responsibility are upheld (Huang et al., 2020). The high spousal involvement in our sample highlighted the valuable role of fathers in mothers’ carer journeys (Sim et al., 2021a). However, other studies have found that Chinese fathers were less likely to seek help, were more fearful about handling their children’s disabilities and tended to perceive their children more negatively than mothers (Hu, 2020), which may sometimes lead to martial stress (Huang et al., 2011). Studies also had contrasting findings on the close partnership between Chinese mothers and fathers of children with disabilities (Huang et al., 2011; Sim et al., 2021a), suggesting the importance in assessing the supports available for parents and to facilitate their parenting occupations, as well as focusing on enabling valued family occupations (Bhopti et al., 2020).

The lack of differences in frequency of participation in health promoting activities indicate that Chinese mothers found similar opportunities to engage in heath promoting occupations despite their different environments. Hence, it is probable that the Chinese mothers had similar beliefs about healthy behaviours that influence their choice of engagement in healthy occupations rather than influence by their living environment.

Similarities in reports of maternal well-being and mental health further reinforce the notion that similar cultural factors might have outweighed the influence of difference in environmental factors. Further studies would need to be made to ascertain this postulation.

Our participants also reported many similarities in their caregiving occupations, reflecting how they valued education and socially acceptable behaviour, congruent with Confucianism (Ng et al., 2021). Interestingly, a higher percentage of mothers spending longer periods on homework assistance amongst Singaporean and Taiwanese mothers, contrasted with the Australian mothers. A possible explanation for this difference could be due to acculturation changes experienced by the Australian immigrant mothers, resulting in the diminishing effects of the ‘Tiger mum’, a term used to describe Chinese mothers who are strict disciplinarians and have high expectations for their children’s success (Sim et al., 2021a). Consequently, the Australian mothers could have reduced anxiety over their children’s learning, and hence spend less time on their children’s learning as compared with other mothers. Another possible reason could be that the Australian mothers’ children had received better support in Australian schools, which were more inclusive and well-resourced, hence lessening the necessity for mothers’ homework assistance. Nevertheless, the overall high involvement of time spent on homework, still highlight that the Chinese mothers take their children’s education seriously and hence highly value their role as ‘teacher’.

These common culturally driven factors that impact Chinese mothers’ choices in activities and health behaviours, highlight the need to assess mothers’ current and past cultural influences and avoid stereotypical assumptions to deliver culturally intelligent practice. Culturally intelligent practice refers to the ability to understand, correctly infer and manage cultural diversity (Majda et al., 2021) and is very important in upholding client-centredness in occupational therapy practice.

Differences between mothers

Caregiving occupation

Our findings showed that Australian mothers spent comparatively more time engaging in direct and indirect care tasks, and reported more perceived roles as compared to Singaporean mothers. This difference could be partially explained by the differences in their employment profile, where full-time working mothers would need to outsource the care of their child to grandparents, live-in helpers, nannies or childcare. This explanation was supported by our findings (Table 3), where Taiwanese grandparents were commonly involved in the care of their grandchildren and Singaporean mothers were relying on a variety of caregiving help, whereas Australian mothers had to be more self-reliant as they were immigrants with presumably less family support. This finding implies the need to assess and activate mothers’ support network and to engage in the capacity building of other carers to provide useful support to mothers.

The higher engagement of respite services amongst the Australian mothers might be attributed to the better accessibility to respite services in Australia. In Taiwan, only lower socio-economic families can access subsidised respite (Huang et al., 2009). In Singapore, after-school care and day care are the forms of ‘respite’ (de Souza, 2020), and there are strict criteria for live-in respite at children’s disability homes (Ministry of Social and Family Development, 2019). Thus, it is probable that mothers from Singapore and Taiwan would more likely turn to family, friends or hire foreign domestic workers for help. This finding reminds therapists of the need to assess Chinese mothers’ social support network and involve other significant carers who were supporting mothers and have influence over their caregiving occupations.

Employment

The differences found in engagement in employment could be attributed to different country policies. The higher employment rate amongst Singaporean and Taiwanese mothers could be due to the belief and necessity of dual income as compared to Australian mothers. In Australia, there is a family-friendly welfare system but overall high childcare cost (Organisation for Economic Co-operation and Development, 2020), which may be less incentivising for Australian mothers to work full-time and utilise childcare services. There are also differences in the availability and acceptability of part-time work between Australia and Asia (Fagan et al., 2014).

Studies had found that mothers who participate in work had better well-being and health (Ejiri and Matsuzawa, 2019) than those mothers who did not. Siu and Hui (2021) found that mothers who only participated in unpaid homemaking reported higher parental stress and poorer general health. These findings imply that some of the Chinese mothers of children with disabilities might potentially have better well-being working than being a homemaker, but they would need to have access to other forms of care support to work (Scott, 2018). Our study, however, did not explore the association between well-being measures and work status. Future studies could usefully compare the impacts of different workplace practices, and how work contributes to the occupational well-being of mothers of children with disabilities,

Social supports system

It is noteworthy that a higher proportion of Australian mothers were engaging in support groups. This could be due to their accessibility and availability to support groups in Australia. Studies on Chinese mothers had found that appropriate social support had a strong association with family quality of life, psychological well-being, life satisfaction and resilience (Lei and Kantor, 2023). However, our sample of mothers who attended support groups reported poorer mental health, well-being and life satisfaction than those who did not. One plausible explanation was that most of the support group attendees were Australian mothers who spend much more time caring for their children and perceived their main occupational role as carers. Noteworthy, we also found when analysing the participants as a single group, that mothers who perceive themselves as carers also report poorer mental and personal well-being. This highlights the importance of facilitating mothers’ access to support groups and the crucial role carer support groups can play in improving mothers’ health and well-being, particularly if they have limited family support as in the case of immigrant families (Siu and Hui, 2021).

Our results also highlighted the importance of friendships for Chinese mothers and their possible contribution to mothers’ health promoting occupation and well-being. These relationships could be developed in a network of Chinese mothers of children with disabilities where they could safely engage in stigma-free friendships (Sim et al., 2021a). To increase these opportunities, therapists could organise self-care sessions or collaborate with mothers to set up peer-led networks or peer-mentoring programmes. These platforms could be used to facilitate healthy social participation and mutual support amongst mothers and also provide opportunities for them to engage in communal healthy occupations. Future studies could look into the effectiveness of different social support models appropriate for Chinese mothers of children with disabilities.

Implications

Our findings showed that mothers who assisted their children in emotional regulation and challenging behaviours had lower well-being, life satisfaction, mental health and higher levels of stigma, hence exposed to higher mental health risk, consistent with previous studies reporting their higher stress and depressive symptoms (Ng et al., 2021). These findings imply that a more robust screening service might be needed to reach out to Chinese mothers at risk of mental health issues. Occupational therapists can play an important role in identifying maternal health risks, referring Chinese mothers to suitable services and setting up of services focusing on facilitating the health promoting occupations of mother–child dyads. Mother-focused programmes such as funded maternal peer support programmes and programmes focusing primarily on mothers’ health and well-being (Bourke-Taylor et al., 2022) could be made more available for Chinese mothers of children with any type of disabilities, and not just limited by well-meaning organisations focusing on specific disabilities. Furthermore, using a family-centred framework in occupational therapy practice, including facilitating valued family occupations and using family-centred coaching, would potentially lead to more culturally-appropriate support for Chinese mothers, who feel highly responsible for managing family occupations and tend to prioritise their family’s needs over their own.

Limitations

Sample sizes were small, and hence results cannot be generalised to all the mothers of children with disabilities in these countries. Snowball sampling might have biased the profile of respondents. Self-reported questionnaires assumed reasonable self-awareness and hence a high level of subjectivity in interpretation and answering the questions. Data collection took place over the COVID-19 period, which might have impacted participants’ reports of their perceptions.

Conclusion

Our study provided a glimpse of the caregiving occupations of Chinese mothers of children with disabilities living in three countries. There were no significant differences found between groups in terms of their participation in health promoting occupations, mental health, personal well-being, perceived social support and perceived stigma, suggesting that the health and well-being outcomes of mothers of children with disabilities may be more influenced by their cultural similarities as compared to differences in their socio-political environments.

Future studies could explore mechanisms of mothers’ gathering of helpful resources in their environments. Specific contextual measures, such as socio-economic status, housing, family make-up, employment and funding policies, could be included to further our understanding of the influence of environmental context. Future research can also investigate specifically Chinese mothers’ motivations underlying their choice in health promoting occupations.

Key findings

• There are similarities and differences found in the caregiving occupations of Chinese mothers of children with disabilities living in three different countries.

• There are aspects of caregiving occupations that were found to influence mothers’ participation in health promoting occupations, health and well-being.

• The health and well-being outcomes of Chinese mothers of children with disabilities may be more influenced by similarities in culture than their contextual differences.

What the study has added

The caregiving occupations of Chinese mothers of children with disabilities have influence on their health promoting occupations, mental health and well-being. There appeared to be a stronger influence from mothers’ cultural similarities than the differences in their contextual environments on their occupations, health and well-being. Therapists need to sharpen their cultural understanding when working cross-culturally.