Sense of Filial Obligation and Caregiving Burdens Among Chinese Immigrants in the United States

Abstract

BACKGROUND/OBJECTIVES:

Focusing on Chinese immigrants, this study examined (1) whether filial obligation, the core social norm in the Chinese culture, is related to caregiving burdens; and (2) whether level of acculturation of the caregivers moderates the above relationships.

DESIGN:

Cross-sectional.

SETTING:

Chicago, Illinois.

PARTICIPANTS:

A purposive sample of 393 Chinese adult immigrants who were primary caregivers of parents aged 60 years or older.

MEASURES:

Sense of filial obligation was captured by felt responsibility toward parents in six domains (respect, make happy, care, greet, obey, and provide financial support). Caregiving burdens were measured by the Caregiver Burden Inventory. Acculturation was measured by 12 questions about respondents’ language preference in different settings and ethnicity of individuals they interact with.

RESULTS:

A stronger sense of filial obligation was significantly associated with lower levels of developmental (β = −.15), emotional (β = −.18), social (β = −.20), and physical (β = −.10) burdens. For subjective burdens (developmental, social burdens), such a protective effect of filial obligation was stronger among caregivers with lower acculturation levels. For more objective burdens (time-dependent, physical burdens), stronger filial obligation was actually associated with greater burdens among caregivers with higher acculturation levels.

CONCLUSION:

Programs focusing on celebrating the cultural heritage of immigrants and improving the relationship between the parents and children may be helpful to reduce caregiving burdens. Intervention programs that help Chinese immigrant caregivers to find the most appropriate way to balance traditional and new social norms are important to provide successful care to aging Chinese immigrants.

The well-being of the 4.6 million older immigrants in the United States is closely related to their families, who are often the major, if not the sole, source of support for these older adults.¹ An important aspect of such support is through caregiving. As older immigrants often have limited access to both entitlement programs and formal healthcare systems,² knowledge about caregiving behavior and experience of immigrant families is crucial to better support the rapidly increasing aging immigrant populations in the United States.

Caregiving experience is shaped by sociocultural contexts, only within which caregiving has personal meaning and social significance.³ Existing literature has documented racial differences in caregiver attributes, their objective stressors, coping process, social resources, and physical and psychological well-being.^4,5 Despite the rich information obtained from these studies, our knowledge about how cultural influence of values and norms shapes one’s caregiving experience is limited in several important ways. First, comparisons of ethnic groups make up the majority of the existing studies.⁵ By using race as an independent variable, influence of other cultural-related variables is often repressed and difficult to interpret. Relatedly, there is a lack of clear definition of culture, leading to a poor understanding of the mechanisms through which unique cultural beliefs of certain racial/ethnic groups shape diverse caregiving experience.^3,5 Lastly, immigration is barely a part of the conceptualization of cultural diversity in caregiving, a notable gap in the geriatric literature given the increasing population mobility around the world. As immigrants’ acculturation process often centers around the ongoing negotiations between one’s own culture of origin and the new culture in the receiving society,⁶ level of acculturation is a particularly pertinent concept to understand the diversity in immigrants’ caregiving experience.

To address these limitations, scholars have called for more in-depth research that focuses on single ethnic groups and specific cultural values to understand the cultural contexts of caregiving.^3,5 Responding to these calls, this study focused on Chinese immigrants in the United States to examine (1) whether a sense of filial obligation, a core social norm of the Chinese population, is associated with caregiving burden; and (2) whether the acculturation level of caregivers confounds the above relationship.

Chinese Americans as Caregivers

Asian Americans are the fastest-growing minority group in the United States, but they are least studied in their caregiving experience compared to other racial groups.^4,7 Among Asian Americans, Chinese are the largest subgroup, accounting for 24% of the Asian American populations.⁸ In 2015, 63% of the Chinese Americans were foreign born and 34% had lived in the United States for less than 10 years.^8,9 The relatively recent immigration experience of Chinese Americans makes the cultural context of caregiving particularly pertinent to this population.

Chinese American’s cultural belief of filial obligation, the sense of responsibility to respect and care for aging parents, is the most predominant cultural value relating to their caregiving experience.¹⁰ Chinese American families rely mostly on adult children and other family members as their primary source of support for aging adults.¹¹ A systematic review of dementia caregiving of Chinese Americans reported that the sense of obligation not only motivates the caregiving behaviors of adult children in the first place, but also influences caregivers’ appraisal and coping.¹² In some cases, this cultural value leads to a pervasive belief among Chinese Americans that it is unacceptable to say no to family caregiving responsibilities.¹³

However, this traditional cultural norm is reshaped upon immigration and acculturation. Qualitative studies have revealed its evolving and fluid nature, documenting a continuum of traditional, modified (eg, paid care), to nontraditional caregiving behaviors (eg, placing parents in senior housing) among Chinese Americans.^14–16 Whether and to what extent this cultural traditions affects caregiving experience of contemporary Chinese American immigrants has not been formally tested using large-scale quantitative data.¹²

Filial Obligation and Caregiving Experience: Mixed Findings

There are mixed findings regarding how filial obligation, and similar concepts such as familism,¹⁷ affects caregiving outcomes. Several studies on caregiving burden reported that maintaining high levels of filial belief was associated with lower caregiving burdens in Chinese,^14,17–20 Korean,²¹ Hispanic,^22,23 and Arab caregivers.²⁴ In contrast, research on white caregivers reported the opposite findings.²⁵ Studies on Korean and Mexican Americans further indicated lack of associations between filial obligation and caregiving burden.^3,26,27 Mixed results were also reported regarding caregivers’ well-being in relation to their filial beliefs. While two studies found that sense of filial obligation was associated with better physical and mental health of Chinese Canadian caregivers,^19,28 others reported that filial beliefs were associated with elevated levels of depression, anxiety, and emotional distress among a variety of populations, including Chinese,¹⁰ Hispanic,^29,30 African American,³¹ and white caregivers.^31,32 The positive influence of filial obligations on caregiving may occur via clearer expectation about the caregiving role and duty,^11,28 greater psychological endurance,³³ self-efficacy, positive coping and appraisal,¹⁹ and reduced negative effects of stressors.^18,34 The mechanisms linking filial obligation and poorer caregiving outcomes include increased care involvement,²⁰ avoidant coping,^31,32 maladaptive thinking,²² beliefs of not meeting the needs of the parents,^30,35 and difficulties in keeping traditional family practice in the host society.^14,26 The inconsistent findings again indicate a need to further study the influence of filial obligation on immigrants’ caregiving experience.

Acculturation and Caregiving

Immigrants are a diverse population with a different degree of acculturation, which is a fluid process between culture of origin and culture in the host society.⁶ There is insufficient and equivocal knowledge regarding how acculturation shapes immigrants’ caregiving experience. Mixed results were reported that less acculturated caregivers had fewer depressive symptoms than more acculturated caregivers,^36,37 or the opposite,^30,38 or lack of association between acculturation and caregiving burden or depression.³⁹ One would also expect that acculturation further confounds the relationship between immigrants’ filial obligation and their caregiving experience. Less acculturated caregivers may be more “responsive” to the cultural tradition of parental care as they internalize this cultural norm to a greater extent and have fewer conflicting role demands and “acculturation gap” with care recipients.^27,30 This speculation has not been formally tested, leaving a gap in the literature regarding sources of diverse caregiving experience among immigrant populations. It is important to distinguish objective burden (relating to care recipients’ symptoms or disrupted lives resulting from caregiving) from subjective burden (relating to emotional reaction to caregiving)⁴⁰ in such investigations, as the cultural motives and normative expectations for caregiving tend to have a greater impact on subjective instead of objective caregiving burden.⁴¹

Research Questions

While the majority of the studies on Chinese caregivers have used qualitative designs and were conducted mainly in China,¹² this study used a large data set of Chinese immigrants in the United States to investigate: (1) whether sense of filial obligation is associated with caregiving burden; and (2) whether caregivers’ level of acculturation moderates the above associations?

METHODS

Sample

Data were derived from the PIETY study, which aims to understand the caregiving behaviors and well-being of Chinese immigrants in Chicago. Relying on referrals from community agencies, 548 Chinese immigrants in the greater Chicago areas who were aged 21 years or older and who have a parent aged 60 years or older were recruited between 2012 and 2014. Face-to-face interviews were carried out in respondents’ homes, in the language preferred by the respondents. The working sample consists of 393 participants who self-reported as the primary caregiver of the father, the mother, or both parents in the family.

Measures

Filial obligation.

The respondents reported how much they think children should provide six types of filial care to their aging parents: (1) respect, (2) care, (3) greeting, (4) bring pleasure, (5) obedience, and (6) financial support (1 = very little, 2 = rather little, 3 = average, 4 = rather a lot, 5 = very much). Sum scores were calculated, ranging from 6 to 30, with a higher score indicating a stronger sense of filial obligation (α = .85).

Caregiving burden included five types measured by the Caregiver Burden Inventory: (1) time-dependent burden (ie, feelings of restriction on time), (2) developmental burden (ie, feelings of being “off-time” in development comparing to peers), (3) physical burden (ie, feelings of physical fatigue), (4) social burden (ie, feelings of role conflict), and (5) emotional burden (eg, negative feelings toward care receivers).⁴² All but the physical burden (four items) have five items, with all the items assessed on a Likert scale, ranging from 0 = never to 4 = always. Sum scores were created for each subscale (α ranged from .78 to .88), with a higher score indicating greater burden.

Level of acculturation was measured by 12 questions about respondents’ language preference in different settings and ethnicity of individuals they interact with (ranging from 1 = only Chinese to 5 = only English/Americans).⁴³ The sum scores ranged from 12 to 60, with a higher score indicating a higher level of acculturation (α = .92). Acculturation level was further recoded into three groups: low (ie, only spoke Chinese and had friends who were all Chinese), moderate (ie, spoke Chinese more than English and had mostly Chinese friends), and high level (spoke equally or more English than Chinese, and had equal or more American than Chinese friends). In this study, 69.72%, 21.88%, and 8.40% of the respondents were categorized as having high, moderate, and low level of acculturation, respectively. We further combined the last two groups given the small size of the last group.

Control variables included age (in years), sex (women = 1), marital status (married = 1), education (in years), personal annual income (ranging from 1 = $0-$4999 to 10 = $45,000 or more), living arrangement (1 = living with parents), and number of siblings. Caregiving input was measured by weekly hours providing assistance with activities of daily living (ADLs) and instrumental ADLs (IADLs), and the length of time providing each type of care.

Data Analysis

We first present descriptive information of sample characteristics. To address the first research question, negative binomial regressions were carried out to test the associations between filial obligations and the five types of caregiving burden, controlling for the other covariates. To address the second research question, we created interaction terms between filial obligation and level of acculturation and added them into the regression models. We performed the analysis in three steps, with all the control variables (model 1), the two study variables (filial obligation, acculturation) (model 2), and interaction terms (model 3) entered sequentially.

RESULTS

Table 1 describes sample characteristics. The mean age of the participants was about 47 years. Over half of the participants were female, and nearly four-fifths were married. On average, participants had high school education and relatively low levels of acculturation (mean = 21.6 on a scale ranging from 12 to 53). Almost half of the participants lived with their parents, and the mean number of sibling was 2.35. Regarding caregiving input, 15.9% of the participants reported helping parents with ADLs for at least 1 or more hours per week, and 64.5% helped parents with IADLs. About 16% of the respondents provided care to their parents with ADLs for 1 or more years, and 64.1% of them provided care with IADLs for 1 or more years. Overall, the respondents had high levels of filial obligation (mean = 26.23 of a possible 30). They also reported relatively low levels of caregiving burden across all the domains.

Table 1.

Sample Characteristics of the PIETY Caregivers (N = 393)

Characteristics	Range	Mean/%	SD
Age, y	22–76	46.94	10.46
Women		64.12%
Married		79.90%
Education, y	0–26	12.38	3.86
Personal annual income, $	1–10	4.57	2.68
0–9999		23.85%
10,000–19,999		34.87%
20,000–29,999		18.20%
≥30,000		23.07%
Acculturation	12–53	21.64	9.14
Low	0–12	69.72%
Moderate	12.01–24	21.88%
High	24.01–53	8.40%
Living with parents		47.95%
No. of siblings	0–11	2.35	1.72
Weekly caregiving time (ADLs), h
0		84.07%
1–5		6.23%
>5		9.70%
Weekly caregiving time (lADLs), h
0		35.53%
1–5		34.25%
>5		30.22%
Length of caregiving (ADLs), y
<1		83.72%
≥1		16.28%
Length of caregiving (lADLs), y
<1		35.88%
1–5		33.33%
>5		30.79%

Abbreviations: ADL = activity of daily living; IADL = instrumental ADL.

Table 2 reports standardized beta coefficients of negative binomial regressions. The results showed that a greater sense of filial obligation was associated with significantly lower levels of developmental (β = −.15), emotional (β = −.18), social (β = −.20), and physical (β = −.10) burdens (model 2). Other variables that were associated with greater caregiving burdens included older age (time-dependent burden), higher education (all but time-dependent burden), fewer siblings (emotional burden), more hours helping with IADLs (time-dependent burden), and higher acculturation levels (time-dependent and emotional burden). Overall, the results were consistent across different models, indicating that the associations were robust regardless of control variables.

Table 2.

Negative Binomial Regressions on Caregiving Burden of PIETY Primary Caregivers

Variable	Time dependent			Developmental			Emotional			Social			Physical
	B	B	B	B	B	B	B	B	B	B	B	B	B	B	B
Age	.02**	.02*	.02**	.03	.02	.02	.02	.01	.01	.03	.02	.02	.03	.02	.03
Women	−.13	−.13	−.13	.01	.06	.04	−.05	.18	.16	−.14	.02	.09	−.11	.04	.00
Married	−.20	−.17	−.17	−.66*	−.48	−.43	−.67*	−.50	−.50	−.19	.06	.10	−.34	−.21	−.11
Education	.03	.01	.01	.14**	.09*	.10*	.14***	.09*	.10*	.14*	.10*	.10*	.12*	.10	.13*
Income	−.02	−.03	−.03	.02	.03	.03	−.01	−.02	−.03	.04	.05	.04	.00	−.01	−.02
Living with parents	−.02	−.01	−.02	.19	.09	.06	.07	.13	.13	.12	−.01	−.01	−.38	−.34	−.38
No. of siblings	−.03	−.03	−.03	−.09	−.10	−.07	−.09	−.16*	−.17*	−.02	−.08	−.06	−.07	−.06	−.01
ADL caregiving hoursa
1–5	.52	.38	.40	1.14	.81	.79	1.03	.46	.48	2.49	2.04	1.87	2.85	2.39	2.06
>5	.73	.64	.76	1.67	1.50	1.75	.62	.22	.51	1.89	1.46	1.67	3.05	2.76	2.94
IADL caregiving hoursa
1–5	.83**	.89***	.89***	−.57	−.36	−.26	−.73	−.33	−.27	−.92	−.43	−.29	.77	.86	1.24
>5	1.16***	1.23***	−1.21***	−.40	−.22	−.19	−.73	−.45	−.44	−.53	−.23	−.25	.60	1.01	1.17
ADL caregiving yearsb
≥1	−.01	.13	.07	−.63	−.32	−.43	−.49	.13	.02	−1.63	−.93	−.81	−.93	−1.46	−1.33
IADL caregiving yearsb
1–5	.05	.01	.04	.78	.83	.84	.60	.47	.48	.67	.50	.48	.44	.44	.34
>5	.12	.05	.06	.74	.68	.59	.41	.13	.14	.76	.51	.37	.57	.22	.04
Acculturation		.33*	.33*		.38	.40		.51*	.51*		.26	.37		.41	.38
Filial obligation		−.01	−.10*		−.15***	.40***		−.18***	−.34**		−.20***	−.50***		−.10*	−.50**
Filial obligation × acculturation			.06*			.18*			.11			.20*			.27**

Abbreviations: ADL = activity of daily living; IADL = instrumental ADL.

^aReference group was 0.

^bReference group was less than a year.

^*P < .05

^**P < .01

^***P < .001.

Results from the moderation effect models further showed that acculturation level moderated the associations between filial obligation and four types of caregiving burden (time dependent, developmental, physical, and social), but in different ways. As Figure 1 illustrates, for time-dependent and physical burdens that are mainly affected by caregiving involvement and physical demands of caregiving,⁴⁴ a stronger filial obligation was associated with greater burden among caregivers with a high acculturation level, but less burdens among caregivers with low acculturation. In contrast, for developmental and social burdens that are mainly reflective of caregiver satisfaction,⁴⁴ greater filial obligation was associated with a lower burden among both groups, and such associations were overall stronger among caregivers with a low acculturation level.

Figure 1.

Association between filial obligation and different caregiving burdens by levels of acculturation among the PIETY caregivers.

DISCUSSION

Using a large sample of Chinese immigrants in the United States, the present study examined whether Chinese caregivers’ sense of filial obligation is associated with their caregiving burdens and whether their acculturation level confounds such relationships. There are two key findings from this study. First, the results showed that Chinese caregivers with a greater sense of filial obligations had overall less caregiving burdens. Similar findings were reported in two quantitative studies on Chinese Canadian caregivers.^17,18 For these caregivers who are confronted with different family norms, the sense of filial obligation may represent the ethnic identity and traditional values that many of them strive to maintain.³⁶ Embracing or adhering to this traditional norm may provide these immigrants a clear expectation and sense of acceptance about their caregiving responsibilities.²⁸ It may also sustain them with psychological endurance that is needed in daily tasks of caregiving,¹⁷ and instill a sense of reward.¹⁰ As a family heritage, strong filial obligation may also entail greater emotional and instrumental support from other families, consequently reducing caregiving burdens.^14,18 In contrast, Chinese caregivers with a lower level of filial obligation may have adopted American family norms of individualism and self-reliance to a greater extent and thus were likely “puzzled or…conflicted by both new and old filial practices” in their caregiving,^14(p783) possibly leading to greater caregiving burdens. In the study, time-dependent burden (ie, feelings of restriction on time) was not associated with filial obligation, likely due to the relatively low caregiving input of the respondents (Table 1).

The second finding of our study is that the acculturation level of the caregivers moderated the associations between filial obligation and their caregiving burden, which may in part explain the mixed findings on these associations reported in the prior research.^14,22,35 We found that for developmental and social burdens that are reflective of caregivers’ subjective appraisal of caregiving experience and caregiving satisfaction, the potential benefit of filial obligation in reducing caregiving burden is stronger among individuals with a lower level of acculturation than those with a higher level of acculturation. The finding is consistent with those of previous research.^27,30 We speculate that for caregivers with a lower level of acculturation, sense of filial obligation is internalized to a greater extent and as the things that they “ought to do”⁴⁵; thus, their caregiving experience is more “responsive” to this cultural tradition of parental care. The stronger identification they have with the traditional filial value, the greater self-affirmation²⁰ or feeling of reward they may experience, whether perceived as praise or social recognition,¹⁰ consequently leading to elevated caregiving experience in the subjective domain. In contrast, immigrant caregivers with a high level of acculturation might be less “responsive” to such cultural expectation, reflected by the relatively flat line indicating the association between sense of filial obligation and subjective caregiving burden among this subgroup.

The moderating effect of acculturation functioned in a different way for time-dependent and physical burdens, which are more objective burdens closely related to caregiving involvement and physical demands of the caregiving. For more acculturated caregivers, a greater sense of filial obligation was actually associated with greater time-dependent and physical burdens, whereas filial obligation was associated with lower levels of these burdens among less acculturated caregivers. It is likely that more acculturated caregivers performed the task mainly out of necessity (eg, no one else was available) or social demand (to satisfy an external demand or social pressure), whereas less acculturated caregivers did so based on personal belief.⁵ In other words, there might be a sense of reluctance or lack of control among acculturated caregivers when they provided care. If that is the case, the stronger these individuals endorsed the filial obligation (ie, that they need to do), the more objective burden they may have that relates to physical health and time constraints. In contrast to highly acculturated caregivers, the potential benefit of having strong filial obligations in reducing subjective burden was much stronger for caregivers with a lower level of acculturation, again indicating that these caregivers endorse such filial obligations to a greater extent and may benefit more from fulfilling them.

Caregivers’ level of acculturation did not confound the relationship between filial obligation and emotional burden, which captured negative feelings toward care receivers. The finding may speak to the overall positive and cohesive intergenerational relations among Chinese immigrant families, regardless of the level of acculturation.⁴⁶

The findings need to be interpreted with cautions. Due to the limitation of secondary data analysis, current findings were contextualized in a caregiver group with minimum caregiver burden. Although the participants self-reported as primary caregivers, the overall caregiving input and burden were low, in particular for social and physical burden. It may be because the recruitment occurred in social service agencies instead of the common approach of purposive sampling of caregivers of dementia patients or patients with chronic conditions. ⁴ As sense of filial obligation can be most challenged when caregiving situations are demanding and difficult, a greater variation in caregiving input and burden may better test the associations among filial obligation, acculturation, and caregiver experience. Second, the survey did not include care-recipient characteristics, such as functional ability and/or cognitive status. Instead, we used caregiving input as a proxy of care receivers’ functional health. Future studies should include direct measures of care-recipient characteristics to better assess their caregiving needs. Third, the secondary data analysis also limited our ability to assess the potential role of support from other family members that may explain the beneficial role of filial obligations on caregiver burden. Future research should include such measures to better understand the mechanism through which filial obligation protects immigrant caregivers’ well-being. Last but not least, the study was conducted in a metropolitan area with well-established Chinese communities. More studies are needed to understand caregiving experience of immigrants who live in smaller cities or rural areas with limited access to informal social networks.

Despite these limitations, this study is among the first to use a large quantitative data set and comprehensive measures of filial obligation and caregiving burden to study how a specific cultural norm, together with the acculturation process, shapes immigrants’ caregiving experience. The findings have important theoretical and practical insights for geriatricians, nurses, and other allied professionals. The findings revealed that filial obligation has a protective effect on the caregiving experience of Chinese family caregivers. Previous research also reported a weakening sense of filial obligation among immigrant families,⁴⁷ and that many immigrant adult children reported difficulties in meeting filial expectations of their parents.^14,26 Thus, community programs focusing on celebrating the cultural heritage of immigrants and promoting the sense of filial obligation toward parental care may help improve the well-being of Chinese immigrant caregivers. For Chinese immigrant caregivers, it is important to balance their perception of filial obligations and their available physical and psychological capacity for caregiving to reduce their caregiving burden. Thus, community programs focusing on celebrating the cultural heritage of immigrants and promoting the sense of filial obligation toward parental care may help improve the well-being of Chinese immigrant caregivers.

The results of this study show that for more acculturated caregivers, endorsing the traditional norm of parental care may have a negative effect on their objective burdens because of lower cultural justification for caregiving. Highly acculturated immigrant caregivers often struggle to find the best way to manage cultural expectations and new family norms in the host society. Intervention programs that help Chinese immigrant caregivers to find the most appropriate way to balance traditional and new social norms are important to provide successful care to aging Chinese immigrants. Ultimately, these programs will help to promote the well-being of both older adults and their adult children caregivers. Finally, for healthcare providers, it is important to understand the variance of acculturation levels among Chinese caregivers and its effect on caregiving burden. Consideration of acculturation factors of Chinese immigrant caregivers, including language usage, length of residence in the United States, and ethnic communities where they are involved, would help better assess the impact of immigration on their caregiving behaviors and experience.