The Association Between Filial Discrepancy and Depressive Symptoms: Findings From a Community-Dwelling Chinese Aging Population

Abstract

Background:

The relationship between filial piety and depressive symptoms has been widely discussed, but limited research focused on the gap between filial expectations and filial receipt. This study aims to investigate the association between filial discrepancy and depressive symptoms.

Methods:

Data were derived from the Population Study of Chinese Elderly (PINE), a community-engaged, population-based epidemiological study of U.S. Chinese older adults aged 60 and older in the greater Chicago area. Depressive symptoms were measured by the Patient Health Questionnaire-9. Overall filial discrepancy was evaluated by filial receipt minus expectations. Levels of overall filial discrepancy divided older adults into four groups based on the medium value of filial expectations and receipt. Logistic regression analyses were performed.

Results:

Older adults with greater filial receipt than expectations were more likely to have lower risk of depressive symptoms (odds ratio [OR], 0.95 [0.92–0.97]). The group with high expectations and low receipt has the highest risk of depressive symptoms among the four groups (OR, 1.51 [1.07–2.13]). Greater receipt than expectations in care (OR, 0.83 [0.76–0.92]), make happy (OR, 0.77 [0.69–0.86]), greet (OR, 0.88 [0.79–0.97]), obey (OR, 0.76 [0.68–0.86]), and financial support (OR, 0.80 [0.71–0.89]) was associated with lower risk of depressive symptoms.

Conclusions:

This study goes beyond previous research by examining the association between filial discrepancy domains and depressive symptoms. Cultural relevancy of health interventions is important in the context of Chinese communities. Health care professionals are suggested to be aware of the depressive symptoms of U.S. Chinese older adults with high filial expectations and low receipt.

Chinese family is recognized for the strong sense of filial piety (1). Early research identified filial expectations and filial receipt as the two key components of filial piety (2,3). The association between filial piety and psychological well-being has been examined in prior studies, with a particular focus on filial receipt. Higher level of filial receipt was found to be strongly associated with higher level of life satisfaction in East Asia (4,5). Lower level of filial piety receipt may be a risk factor for perceived stress (6) and suicidal ideation (7). As for filial expectations, studies have consistently shown that the older generation has even lower filial expectations for the younger generations than the latter have for themselves (8,9).

Understanding discrepancy creates another dimensional understanding to these issues. Michalos’ (10) multiple discrepancy theory suggests the gap between what one has and wants was the most influential and the strongest determinant of individuals’ psychological well-being. Chinese older adults hold strong value of filial piety, and according to the multiple discrepancy theory, the filial discrepancy may affect psychological well-being of older adults. However, the association between filial discrepancy and depressive symptoms among older adults has been understudied. To the best of our knowledge, only one study conducted in Hong Kong reported that greater filial receipt than filial expectations was significantly associated with higher level of psychological well-being among Chinese older adults (11). But this study failed to examine the association between different domains of filial discrepancy and psychological well-being.

The Chinese community represents the largest and oldest Asian population in the United States, with an estimated population of 4 million (12). Filial piety has been deeply rooted in Chinese culture (7). Studies found beliefs in filial piety continued to persist among Chinese oversea immigrants (13). High level of filial expectations and filial receipt was reported by U.S. Chinese older adults (2). However, limited research focused on the gap between filial expectations and filial receipt, we call this construction filial discrepancy, among U.S. Chinese immigrants. Considering the strong sense of filial piety in Chinese families, filial discrepancy may also be associated with the psychological well-being of U.S. Chinese older adults. Hence, it is crucial to examine the association between filial discrepancy and depressive symptoms among U.S. Chinese older adults.

The objectives of this study are to (a) examine the association between overall filial discrepancy and depressive symptoms and (b) test the association between filial discrepancy domains and depressive symptoms among U.S. Chinese older adults. Our central hypotheses were greater overall filial receipt than expectations was associated with lower risk of depressive symptoms. The group with high filial expectations and low filial receipt has the highest risk of depressive symptoms. Greater receipt than expectations in care, respect, make happy, greet, obey, and financial support was associated with lower risk of depressive symptoms.

Methods

Sample

The Population Study of Chinese Elderly in Chicago (PINE) is a population-based epidemiological study of U.S. Chinese older adults aged 60 and older in the greater Chicago area. The project was initiated by a synergistic community–academic collaboration between Rush Institute for Healthy Aging, Northwestern University, and many community-based social services agencies and organizations (14–16). Data in this article were drawn from the first-wave PINE study from 2011 to 2013.

The PINE study implemented extensive culturally and linguistically appropriate recruitment strategies guided by community-based participatory research approach (17–19). Out of 3,542 eligible participants, 3,157 agreed to participate in the study, yielding a response rate of 89.1% (20). Details of the PINE study design were published elsewhere (14,21). Face-to-face home interview was conducted by trained multicultural and multilingual interviewers. The study has been approved by the Institutional Review Board of the Rush University Medical Center (22).

Measurements

Dependent variable

Depressive symptoms

The Patient Health Questionnaire-9 (PHQ-9) was adopted to measure depressive symptoms (23). Participants were asked if they had the following symptoms in the last 2 weeks: (i) changes in sleep; (ii) changes in appetite; (iii) fatigue; (iv) feeling of sadness or irritability; (v) loss of interest in activities; (vi) inability to experience pleasure, feelings of guilt or worthlessness; (vii) inability to concentrate or making decisions; (viii) feeling restless or slowed down; and (ix) suicide thoughts. The Chinese version of PHQ-9 has been validated among Chinese Americans (24). The Cronbach’s alpha of PHQ-9 in the PINE Study was 0.82 (25,26). The presence of depressive symptoms was defined as having total PHQ-9 score of ≥10 because a score of 10 or higher had a sensitivity of 88% and a specificity of 88% for detecting major depressive disorders (27).

Independent variable

Filial piety

The six domains of filial piety include respect, happiness, care, greetings, obedience, and financial support, based on the conceptual model proposed by Gallois and colleagues (28). Participants were asked to evaluate their expectations and receipt of care, respect, greetings, happiness, obedience, and financial support from their children. Participants indicated their answers using a 5-point scale ranging from 1 (very little) to 5 (very much). The scores of each domain were then summed up and the aggregate score ranged from 6 to 30, with higher scores indicating greater filial piety expectations or filial piety receipt. The internal consistency reliability of filial piety scale in the present study was 0.88 (29,30).

Filial discrepancy

Overall filial discrepancy was assessed by total score of filial receipt minus total score of filial expectations. If the score is positive, it means receipt exceeds expectations and vice versa. Levels of overall filial discrepancy were evaluated by using the medium score of filial expectations and receipt as cutoff point to divide older adults into four groups: high filial expectations and high filial receipt, high filial expectations and low filial receipt, low filial expectations and high filial receipt, and low filial expectations and low filial receipt.

Filial discrepancy domains include care discrepancy, respect discrepancy, make happy discrepancy, greet discrepancy, obey discrepancy, and financial support discrepancy. In consistent with the construct of filial discrepancy, each filial discrepancy domain was measured by filial piety domain receipt minus filial piety domain expectations.

Covariates

Basic demographic information collected included age, sex, education, annual personal income, marital status, number of children, living arrangement, years in the United States, years in the community, and medical comorbidities. Details of the measurements for sociodemographic factors have been described elsewhere (31,32).

Data Analysis

T-test was used to compare differences in each item and overall filial piety between older adults with and without depressive symptoms. Chi-square test was used to compare different filial piety groups among older adults with and without depressive symptoms. To examine the association between filial discrepancy and depressive symptoms, multivariate logistic regression models were employed. Model A was adjusted for age and sex. Model B added additional socioeconomic variables, including education and income. Marital status, living arrangement, and number of children were added in Model C. In Model D, we added years in the United States and years in the community. Model E added the number of medical comorbidities to the previous model. We repeatedly run multivariate logistic regression models for each filial discrepancy domains. Odds ratios (ORs) and 95% confidence intervals, along with significance levels, were reported. All analyses were conducted using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).

Results

Presence of Filial Discrepancy

With respect to overall filial discrepancy, participants had a mean filial discrepancy of 1.44 (SD = 6.08, range = −23 to 24), illustrating the overall filial receipt was a little higher than filial expectations. As for levels of overall filial discrepancy, most of older adults were in the group with high expectations and high receipt (35.76%) and the group with low expectations and low receipt (36.13%). 14.74% of older adults were with low expectations and high receipt, whereas 14.76% with high expectations but low receipt.

The overall filial discrepancy by depressive symptoms presents in Table 1. The group with any depressive symptoms had lower level of filial receipt than expectations compared with the group without any depressive symptoms (M ± SD: −0.12 ± 7.95 vs 1.58 ± 5.88, p < .001). In levels of overall filial discrepancy, all four groups of older adults significantly differed by category with or without depressive symptoms (p < .001).

Table 1.

Presence of Filial Discrepancy by Depressive Symptoms

Filial Discrepancy	No Depressive Symptoms (n = 2,832)	Depressive Symptoms (n = 243)	p
Overall filial discrepancy, mean (SD)
Greater filial receipt than expectations	1.58 (5.88)	−0.12 (7.95)	<.001
Greater care receipt than expectations	0.33 (1.43)	−0.01 (1.81)	<.01
Greater respect receipt than expectations	0.18 (1.22)	0.02 (1.59)	.137
Greater make happy receipt than expectations	0.23 (1.27)	0.02 (1.66)	.060
Greater greet receipt than expectations	0.11 (1.20)	−0.26 (1.53)	<.001
Greater obey receipt than expectations	0.21 (1.22)	−0.16 (1.58)	<.001
Greater financial support receipt than expectations	0.52 (1.20)	0.25 (1.50)	<.01
Levels of overall filial discrepancy, N (%)
High expectations high receipt	1,053 (33.55)	46 (1.47)
High expectations low receipt	390 (12.42)	64 (2.04)
Low expectations high receipt	422 (13.44)	31 (0.99)
Low expectations low receipt	1,018 (32.43)	115 (3.66)	<.001

Note: Overall filial discrepancy = filial receipt − filial expectations. Levels of overall filial discrepancy include high expectations high receipt, high expectations low receipt, low expectations high receipt, and low expectations low receipt.

Association Between Filial Discrepancy and Depressive Symptoms

The association between overall filial discrepancy and depressive symptoms is shown in Table 2. In the fully adjusted model (Model E), every one point higher in filial receipt than filial expectations was associated with lower risk for depressive symptoms (OR, 0.95 [0.92–0.97]).

Table 2.

Association Between Overall Filial Discrepancy and Depressive Symptoms

Outcome: Depressive Symptoms
	Model A	Model B	Model C	Model D	Model E
Variable	OR (95% CI)
Age	1.04 (1.02, 1.05)***	1.04 (1.02, 1.06)***	1.04 (1.02, 1.06)***	1.04 (1.02, 1.06)***	1.03 (1.01, 1.06)***
Female	1.70 (1.28, 2.26)***	1.76 (1.31, 2.35)***	1.69 (1.24, 2.30)***	1.69 (1.24, 2.31)***	1.58 (1.16, 2.17)**
Education		1.01 (0.98, 1.04)	1.01 (0.98, 1.04)	1.01 (0.98, 1.04)	1.00 (0.97, 1.03)
Income		0.71 (0.58, 0.85)***	0.70 (0.58, 0.85)	0.70 (0.57, 0.86)***	0.70 (0.57, 0.86)***
Married			0.89 (0.64, 1.23)	0.89 (0.64, 1.23)	0.91 (0.66, 1.26)
Living arrangement			0.99 (0.92, 1.07)	0.99 (0.92, 1.07)	1.00 (0.92, 1.08)
Number of children			0.99 (0.90, 1.09)	0.99 (0.90, 1.09)	0.99 (0.89, 1.09)
Years in the United States				1.00 (0.99, 1.02)	1.00 (0.99, 1.02)
Years in the community				1.00 (0.98, 1.01)	1.00 (0.98, 1.01)
Medical comorbidities					1.20 (1.09, 1.31)***
Greater filial receipt than expectations	0.95 (0.93, 0.97)***	0.95 (0.92, 0.97)***	0.95 (0.92, 0.97)***	0.95 (0.92, 0.97)***	0.95 (0.92, 0.97)***

Note: CI = confidence interval; OR = odds ratio.

*p < .05, **p < .01, ***p < .001.

The association between levels of overall filial discrepancy and depressive symptoms is shown in Table 3. In the fully adjusted model (Model E), the group with high filial expectations and high filial receipt (OR, 0.34 [0.23–0.49]) and the group with low expectations and high receipt (OR, 0.61 [0.40–0.93]) were more likely to have lower risk of depressive symptoms compared with their counterparts with low expectations and low receipt. However, the group with high filial expectations and low filial receipt (OR, 1.51 [1.07–2.13]) was associated with higher risk of depressive symptoms compared with those with low expectations and low receipt.

Table 3.

Association Between Levels of Overall Filial Discrepancy and Depressive Symptoms

Outcome: Depressive Symptoms
	Model A	Model B	Model C	Model D	Model E
Variable	OR (95% CI)
Age	1.04 (1.02, 1.06)***	1.04 (1.02, 1.06)***	1.04 (1.02, 1.06)***	1.04 (1.02, 1.06)***	1.03 (1.01, 1.06)***
Female	1.84 (1.38, 2.46)***	1.86 (1.39, 2.50)***	1.77 (1.30, 2.41)***	1.77 (1.30, 2.42)***	1.64 (1.20, 2.25)**
Education		1.00 (0.97, 1.02)	1.00 (0.97, 1.03)	1.00 (0.97, 1.03)	0.99 (0.96, 1.02)
Income		0.70 (0.57, 0.84)***	0.69 (0.57, 0.84)***	0.70 (0.57, 0.85)***	0.70 (0.57, 0.86)***
Married			1.00 (0.93, 1.08)	0.84 (0.61, 1.17)	0.85 (0.61, 1.18)
Living arrangement			1.00 (0.91, 1.11)	1.00 (0.92, 1.08)	1.00 (0.93, 1.09)
Number of children			0.99 (0.90, 1.09)	1.00 (0.91, 1.11)	1.00 (0.90, 1.11)
Years in the United States				1.00 (0.99, 1.02)	1.00 (0.98, 1.01)
Years in the community				1.00 (0.98, 1.01)	1.00 (0.98, 1.01)
Medical comorbidities					1.22 (1.12, 1.34)***
Levels of overall filial discrepancy
High expectations high receipt	0.38 (0.26, 0.55)***	0.36 (0.25, 0.52)***	0.36 (0.25, 0.52)***	0.36 (0.25, 0.52)***	0.34 (0.23, 0.49)***
High expectations low receipt	1.58 (1.13, 2.22)**	1.56 (1.11, 2.20)**	1.56 (1.11, 2.20)**	1.56 (1.10, 2.20)**	1.51 (1.07, 2.13)*
Low expectations high receipt	0.66 (0.43, 1.00)*	0.62 (0.41, 0.95)*	0.62 (0.41, 0.95)*	0.62 (0.40, 0.95)*	0.61 (0.40, 0.93)*

Note: CI = confidence interval; OR = odds ratio. Reference category of levels of overall filial discrepancy is low expectations low receipt.

*p < .05, **p < .01, ***p < .001.

As for the association between different domains of filial discrepancy and depressive symptoms, except for respect, greater receipt than expectations in care (OR, 0.83 [0.76–0.92]), make happy (OR, 0.77 [0.69–0.86]), greet (OR, 0.88 [0.79–0.97]), obey (OR, 0.76 [0.68–0.86]), and financial support (OR, 0.80 [0.71–0.89]) was significantly associated with lower risk of depressive symptoms (Table 4).

Table 4.

Association Between Filial Discrepancy Domains and Depressive Symptoms

Outcome: Depressive Symptoms
	Model A	Model B	Model C	Model D	Model E
Filial Discrepancy Domain	OR (95% CI)
Greater care receipt than expectations	0.85 (0.77, 0.93)***	0.83 (0.76, 0.92)***	0.83 (0.76, 0.92)***	0.83 (0.76, 0.92)***	0.83 (0.76, 0.92)***
Greater respect receipt than expectations	0.89 (0.80, 1.00)*	0.89 (0.80, 0.99)*	0.89 (0.80, 1.00)*	0.89 (0.80, 1.00)*	0.90 (0.81, 1.00)
Greater make happy receipt than expectations	0.77 (0.68, 0.86)***	0.76 (0.68, 0.85)***	0.76 (0.68, 0.86)***	0.76 (0.68, 0.86)***	0.77 (0.69, 0.86)***
Greater greet receipt than expectations	0.87 (0.79, 0.97)*	0.87 (0.78, 0.96)**	0.87 (0.78, 0.97)**	0.87 (0.78, 0.97)**	0.88 (0.79, 0.97)*
Greater obey receipt than expectations	0.77 (0.68, 0.86)***	0.76 (0.68, 0.85)***	0.76 (0.68, 0.85)***	0.76 (0.68, 0.85)***	0.76 (0.68, 0.86)***
Greater financial support receipt than expectations	0.80 (0.72, 0.90)***	0.80 (0.71, 0.89)***	0.80 (0.71, 0.90)***	0.80 (0.71, 0.90)***	0.80 (0.71, 0.89)***

Note: CI = confidence interval; OR = odds ratio. Model A adjusted age and sex; Model B adjusted Model A + education and income; Model C adjusted Model B + marital status, living arrangement and number of children; Model D adjusted Model C + years in the United States and years in the community; Model E adjusted Model D + medical comorbidities.

*p < .05, **p < .01, ***p < .001.

Discussion

This study demonstrated the overall filial receipt, with the domain of care, respect, make happy, greet, obey, and financial support, was slightly higher than expectations among U.S. Chinese older adults. And the majority of older adults had either both high level of filial expectations and receipt or both low level of filial expectations and receipt. Older adults with greater filial receipt than filial expectations were more likely to have lower risk of depressive symptoms. The group with high expectations and low receipt has the highest risk of depressive symptoms among the four groups. Greater receipt than expectations in care, make happy, greet, obey, and financial support was associated with lower risk of depressive symptoms.

Filial receipt was found slightly higher than filial expectations in care, respect, make happy, greet, obey, and financial support among U.S. Chinese older adults. Previous research reported a great number of the U.S. Chinese older adults had expectations on respect (70.9%), happiness (60.6%), care (50.8%), greeting (63.2%), and obedience (56.2%) on a higher than average level (2). Our study further identified the majority of U.S. Chinese immigrants (71.89%) have met or exceeded their filial expectations. However, the results also showed about 15% of older adults had high filial expectations but low filial receipt.

Our study suggested greater filial receipt than filial expectations was associated with lower risk of depressive symptoms among U.S. Chinese older adults. Our finding is consistent with prior studies conducted in Chinese population. The study on filial discrepancy conducted in Hong Kong reported greater filial receipt than filial expectations was significant associated with higher level of psychological well-being among Chinese older adults (11). The present study also pointed out that the group with high filial expectations and low filial receipt has the highest risk of depressive symptoms among the four groups. The group with high expectations and high receipt and the group with low expectations and high receipt were more likely to have lower risk of depressive symptoms than those with low expectations and low receipt. The perception of intergenerational support of older adults would be different in other populations. Studies conducted in the U.S. White older adults reported high expectations and high intergenerational support were more harmful than high expectations and low intergenerational support (33,34). This could be because receiving support in amounts that were undesired may compromise independence and reinforce feelings of vulnerability and powerlessness for White older adults.

Our study goes beyond previous studies by investigating the association between different domains of filial discrepancy and depressive symptoms. We found greater receipt than expectations in care, make happy, greet, obey, and financial support was associated with lower risk of depressive symptoms. Surprisingly, the gap between expectations and receipt in respect was not significantly associated with depressive symptoms. It may be explained by the emphasis of respect in Chinese culture and Chinese adult children show great respect for their ageing parents. As for Chinese adult child immigrants, they have to spend a lot of time and efforts in work and raising the next generation. Respect is easier to achieve than care, make happy, great, obey, and financial support. Therefore, the small gap between expectations and receipt in the respect may not greatly influence the depressive symptoms of U.S. Chinese older adults.

Filial piety still plays a key role in the psychological well-being of U.S. Chinese older adults (35). Chinese older adults emphasized on the filial behaviors of their children. High levels of filial receipt, even exceeding their expectations, would not compromise independence and autonomy of older adults. In addition, depressive symptoms are common among U.S. Chinese older adults (36,37). Due to the language and culture barrier, the social network of older adults shrinks and they tend to rely more on their adult children both instrumentally and emotionally (38–43). Thus, greater filial receipt than expected can prevent U.S. Chinese older adults from depressive symptoms, and those with high filial expectations and low receipt may experience highest risk of depressive symptoms.

The findings of this study should be interpreted with limitations. First, the receipt of filial piety was measured by the perception of older adults, and thus, filial discrepancy in this study is the subjective interpretation of older adults. Chinese older adults may underreport filial discrepancy to protect family honor and save “face.” Second, this was a cross-sectional study and so the direction of causality would be strengthened by a longitudinal study. Third, quantitative data were limited in providing information on filial discrepancy experiences of older adults and how these experiences related to their depressive symptoms. Future qualitative study is needed to comprehensively understand the filial discrepancy experiences of Chinese older adults.

Despite the limitations, our study has important theoretical and policy implications. This study provides new insights into research on filial piety and psychological well-being. Filial discrepancy of older adults has rarely been examined in literature. Information on filial piety were collected by two dimensions (ie, filial expectations and filial receipt) with six domains: care, respect, make happy, greet, obey, and financial support. Overall filial discrepancy, levels of overall filial discrepancy and filial discrepancy domains were adopted in evaluation. Overall filial discrepancy enables us to focus on the gap between expectations and receipt for individual older adults, whereas levels of overall filial discrepancy provide additional information for the comparison of depressive symptoms between older adults with different levels of filial expectations and receipt. Filial discrepancy domains further elaborate how filial discrepancy affects depressive symptoms. In this way, we can investigate the association between filial discrepancy and depressive symptoms from different aspects.

This study also informs policy practice in the delivery of social services. Cultural relevancy of health interventions is important in the context of Chinese communities (44–48). Given the vital role of filial piety in the psychological well-being of U.S. Chinese older adults, more policies and services are needed to support adult children to take care of their aging parents, particular for U.S. Chinese families. Our study found there were still a notable number of U.S. Chinese older adults (14.76%) who had high filial expectations but low filial receipt, and this group was associated with the highest risk of depressive symptoms. Health care professionals are suggested to pay more attention to the depressive symptoms of U.S. Chinese older adults who do not have children nearby or with higher filial expectations than receipt. It is necessary for programs and services on supporting U.S. Chinese older adults to take into account how to improve the participation of adult children in elder care.

Conclusion

Greater overall filial receipt than filial expectations can prevent U.S. Chinese older adults from depressive symptoms. Older adults with high filial expectations and low filial receipt had the highest risk of depressive symptoms. Future qualitative study is expected to understand the interpretation of filial discrepancy among Chinese older adults.

Funding

Dr. Dong has been supported by National Institute on Aging grant (R01 NR014846, R01 AG042318, R01 MD006173, R01 CA163830, P20 CA165592, R34 MH 100393A1 & R34 MH 100443A1), and Administration on Aging/ACL: 09EJIG0005-01-00.