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The Journals of Gerontology Series B: Psychological Sciences and Social Sciences logoLink to The Journals of Gerontology Series B: Psychological Sciences and Social Sciences
. 2022 Aug 11;78(1):136–142. doi: 10.1093/geronb/gbac106

Family Typology and 6-Year All-Cause Mortality Among U.S. Chinese Older Adults

Mengting Li 1, XinQi Dong 2,✉
Editor: Zhen Cong
PMCID: PMC9890921  PMID: 35951316

Abstract

Objectives

Previous research focused on the individual risk factors of mortality, while little is known about how family environment could influence mortality in later life. This study aims to examine mortality risks in different family types and what family type may increase mortality risk for older adults with medical comorbidities or functional impairment.

Methods

Data were derived from the Population Study of Chinese Elderly (PINE) in Chicago. The baseline interview was conducted from 2011 to 2013. The outcome was 6-year all-cause mortality. Family typology included tight-knit, unobligated-ambivalent, commanding-conflicted, and detached types. Cox proportional hazards models were used.

Results

The study sample consisted of 3,019 older adults and 372 participants passed away during 6 years follow-up. Older adults in the detached type had higher risks of mortality than those in the tight-knit type (hazard ratio: 1.45 [95% confidence interval, 1.02–2.07]). Regarding the interaction effect between family typology and functional impairment, older adults with higher levels of physical impairment (1.29 [1.07–1.56]) and cognitive impairment (1.07 [1.01–1.14]) nested in the commanding-conflicted type had higher mortality risks than their counterparts nested in the tight-knit type.

Discussion

In this longitudinal cohort study with a 6-year follow-up, older adults nested in the detached family type had higher 6-year mortality risks than those nested in the tight-knit family type. Living in the commanding-conflicted family increased the 6-year mortality risks for older adults with physical impairment or cognitive impairment compared with their counterparts residing in the tight-knit family type.

Keywords: Cognitive impairment, Family type, Physical impairment, Medical comorbidities, Mortality risk

The process of population aging results in demographic trends, most notably a shift in the timing of death to increasingly later ages and extended shared life span between aging parents and adult children. Debates raise whether the protection role of family declines due to the changing of family structure and relationships. Older immigrants face aging-related challenges that prompt them to tighten their social networks to be smaller and more kin based, such as declining health and growing need of care (Carr & Utz, 2020). Moreover, international migration and the acculturation process reshape the power dynamics between aging parents and adult children and greatly increase older immigrants’ dependency on children (Cao, 2021). To some extent, intergenerational relationships may have a long-lasting impact on older immigrants’ health and even longevity.

Existing research on family relationships and mortality mainly focuses on marital status, living arrangement, family support, and family norms (Davis et al., 1997; Li & Dong, 2020; Pizzetti et al., 2005; Shor et al., 2013). Being married provides a protective role against mortality for men (Carr & Utz, 2020; Pizzetti et al., 2005). Some research reported that living alone had a detrimental effect on survival, whereas others found no significant impact (Davis et al., 1997; Sorlie et al., 1995). A meta-analysis showed that individuals with less family support or no such support had a higher mortality rate than those with relatively high family support (Shor et al., 2013). Older adults who received less respect and greetings from children than expected were associated with higher mortality risk (Li & Dong, 2020). Previous studies that measure family relationships with a single indicator leave us with an incomplete understanding of how multidimensional family relationships affect mortality. In addition, immigration challenges and reshapes family relationships. Little is known about mortality risks in immigrant families. To address these gaps, this study aims to examine the mortality risks of older Chinese Americans in multidimensional immigrant families.

Multidimensional Family Relationships in Immigration Contexts

Family relationships are multifaced, consisting of structural, associational, functional, affectual, normative, and consensual aspects, which is outlined by the intergenerational solidarity theory (Bengtson & Roberts, 1991). Structural aspect refers to the structure of family. Associational aspect highlights contact frequency and pattern between family members. Functional aspect is defined as the support exchange and resource sharing across generations. Affectual aspect focuses on emotional relationships, encompassing both positive (intimacy) and negative (conflict) relationships. Consensual aspect refers to the degree of agreement between family members in terms of values, attitudes, and beliefs. Normative aspect is featured by norms of family obligations (Bengtson & Roberts, 1991).

Foreign-born immigrants have developed in the heritage culture and adapted to the receiving culture (Berry, 1997). Acculturation process challenges immigrants’ values and participation in family relationships and arrangements, shaping structural, associational, functional, affectual, consensual, and normative solidarities in immigration contexts (Albertini et al., 2019). Older immigrants are likely to share residence with their adult children than U.S.-born older adults due to cultural preferences or a lack of assimilation (structural solidarity; Gubernskaya & Tang, 2017). Interdependence is a key feature in Asian families and other immigrant families which value collectivism, indicating high levels of intergenerational support exchange and resource sharing (functional solidarity; Pinquart & Sörensen, 2005). Frequent intergenerational contact (associational solidarity) is common in immigrant families due to co-residence and mutual support (Chen et al., 2015). Although most older immigrants maintain emotional closeness with their adult children, such intimacy is often accompanied by conflicts (affectual solidarity). Adult children exert increasing authority over aging parents, causing a parent–child role reversal in later life (Connidis, 2015). This role reversal happens in all aging families, but in immigrant families it can start earlier as immigrant children often act as language brokers for their parents and advocate for them in healthcare settings. Conflicts could also result from the acculturation gaps in immigrant families (Ho, 2010). Family norms have different demonstrations across cultures, such as familism in Latino cultures and filial piety in Asian cultures (Diwan et al., 2010). Filial obligation (normative solidarity) is stronger in ethnic minorities than non-Hispanic whites (Pinquart & Sörensen, 2005).

Family Typology in Older Chinese Americans

Family typology is classified by applying latent class analysis with structural, associational, functional, affectual, normative, and consensual indicators (Silverstein & Bengtson, 1997; van Gaalen & Dykstra, 2006). Guo et al. (2019) identified unobligated-ambivalent, tight-knit, commanding-conflicted, and detached family types among older Chinese Americans. The unobligated-ambivalent class is characterized by high intergenerational solidarity and high conflict. The tight-knit class is characterized as a traditional family type in Chinese culture, exemplifying high intergenerational solidarity and low conflict. The commanding-conflicted class is characterized by high filial expectation and support from children, low emotional closeness, and high intergenerational conflict. The detached class is characterized by low intergenerational solidarity and low conflict. Little is known regarding mortality risks in different family types.

Interaction Between Individual Characteristics and Family Context

Bronfenbrenner’s ecological theory indicated that an individual’s ecosystem consists of micro-, meso-, exo-, and macrosystems and stressed the person-context interconnections (Bronfenbrenner, 1979). Family comprises a key setting in the microsystem where older adults participate in daily activities and maintain meaningful family relations. Empirical studies demonstrated that harmonious family context contributed to aging well (Guo et al., 2015, 2019). Thus, we assumed tight-knit family type was associated with lower mortality risk. The ecological theory provides a broad overarching framework that emphasizes person-context interactions. In our study, we considered older adults’ medical comorbidities and functional impairment as key person elements and family context as a typical microsystem and focused on the intersection between individual characteristics and family contexts.

Informed by the ecological theory, the competence– environmental press model highlights the interaction effect between social and physical environmental barriers and individual functional capacities (Lawton, 1982). It unfolds the degree to which an environment is experienced as a barrier for healthy aging depending on the underlying capacities of the person. In line with the competence– environmental press model, harmful family types may tremendously affect mortality outcome among older adults with functional impairment.

Family Relationships and Health in Older Women and Men

Evidence is mixed regarding the role of gender in the relationship between family relationships and late-life health. Higher levels of strain with adult children were associated with higher initial levels of cognitive limitations among older women but appeared to be protective against increasing cognitive limitations among older men (Thomas & Umberson, 2018). Greater family cohesion and lower family conflicts were associated with lower risk for depression among older men, but not older women (Park et al., 2013). However, little is known about the association between family relationships and mortality risks in older men and women.

Asian American is the fastest growing ethnic group in the United States. Although they are frequently lumped into one “Asian” category in research studies, there are heterogeneities within this immigrant population, each with its own cultural values, language or dialect, and traditions (Pew Research Center, 2021). Chinese Americans, as the largest Asian ethnic group in the United States, exceeded 5 million, yet present 24% of all Asian Americans (Pew Research Center, 2021). Other Asian ethnic groups include Japanese, Korean, Vietnamese, Thai, Laotian, Hmong, Cambodian, Indian, Pakistani, Bangladeshi, Sri Lankan, etc. Older Chinese Americans have low English proficiency, kin-centered social networks, and limited access to healthcare services and endorse filial piety value (Li & Dong, 2018).

The purpose of this study was to examine the mortality risks in different types among older Chinese Americans based on the family clusters developed by Guo et al. (2019) with the same data set. We hypothesized H1: older adults embedded in the tight-knit type are associated with lower 6-year all-cause mortality risks than those in other family types. Based on existing evidence that older Chinese Americans in the commanding-conflicted types had worse mental and cognitive health than their counterparts (Guo et al., 2019; Li et al., 2021), we considered commanding-conflicted family as a harmful family type. Therefore, we hypothesized that commanding-conflicted type might be associated with higher mortality risks, particularly for older adults with more medical comorbidities, worse physical function, or poorer cognitive function (H2).

Method

Study Data, Setting, and Participants

Data were derived from the Population Study of Chinese Elderly (PINE), a prospective cohort study established in 2011–2013 with a 6-year follow-up. The eligibility criteria are older adults aged 60 and older in the Greater Chicago area, and self-identified as Chinese. The baseline cohort of 3,157 community-dwelling older adults were interviewed in person in their preferred language (Simon et al., 2014). Written informed consent was obtained from all participants and the study was approved by the institutional review board at Rush University Medical Center. In this study, we only included older adults with at least one child for the purpose to study intergenerational relationships. The working sample consisted of 3,019 older adults with a follow-up of 6 years and 372 participants passed away during follow-up.

Mortality

Mortality ascertained during the 6-year follow-up. We obtained data on vital status of participants from informants and family members at regular subsequent contact. Study personnel regularly searched local newspapers and websites for obituaries.

Family Typology

Family typology has been clustered by Guo et al. (2019) with the same data set, which consisted of unobligated-ambivalent (n = 1,402), tight-knit (n = 1,175), detached (n = 315), and commanding-conflicted (n = 127) types.

Moderators

Medical comorbidities were measured by a count of diseases including heart disease, stroke, cancer, high cholesterol, diabetes, high blood pressure, fractured hip, thyroid disease, and osteoarthritis. Activities of daily living (ADL) assessed eating, dressing, bathing, walking, transferring, grooming, incontinence, and toileting, with a higher score indicating higher levels of physical impairment. The Cronbach’s α of ADL in our study was .92. Cognitive impairment was measured by mini-mental state examination (MMSE; Folstein et al., 1975). All MMSE items were reverse coded, with a higher score suggesting higher levels of cognitive impairment.

Covariates

Covariates included age, sex, education, annual personal income, acculturation, and social support. Acculturation was measured by the Short Acculturation Scale for Hispanics (Marin et al., 1987), with items evaluating language preference, ethnic social relations, and media use. The social support scale was drawn from the Health and Retirement study, which included positive support and negative strain. Social support was the total score of positive support and negative strain (reverse coded).

Statistical Analysis

In this study, Cox proportional hazards models were performed to assess the relationship between family typology and mortality. In Model A, we included demographic variables (age, sex, education, income, and acculturation). In Model B, we added medical comorbidities, ADL, and cognitive impairment. Social support was added to Model C. We further tested the interaction effect of family typology and medical comorbidities/functional impairment with respect to mortality risk. In addition, we conducted all the analyses in male and female subsamples. The models were checked for violation of the proportional hazards assumption by the Schoenfeld residual test, and no relevant violations were found. All statistical analyses were performed using STATA 17.0 (StataCorp LLC, College Station, TX).

Results

A total of 3,019 participants were included in the analysis. The baseline data showed that older adults in the study sample had a mean age of 72.9 years (SD = 8.3) and 58.0% were female. On average, they had 8.6 years (SD = 5.0) of education. Most (85.1%) had an annual income of less than U.S. $10,000. The association between family type and mortality is given in Table 1. Older adults in the detached type had higher risks of mortality compared with those in the tight-knit type (hazard ratio: 1.42 [95% confidence interval: 1.00–2.03]). The survival rates in different family types during the 6-year follow-up after adjusting for confounding variables are shown in Figure 1.

Table 1.

Association Between Family Type and 6-Year Mortality

6-year mortality
Model A Model B Model C
Hazard ratio (95% CI) p-Value Hazard ratio (95% CI) p-Value Hazard ratio (95% CI) p-Value
Age 1.13 (1.11, 1.14) <.001 1.11 (1.10, 1.13) <.001 1.11 (1.10, 1.13) <.001
Female 0.51 (0.41, 0.63) <.001 0.44 (0.34, 0.55) <.001 0.44 (0.34, 0.55) <.001
Education 0.98 (0.96, 1.00) .032 1.00 (0.97, 1.03) .97 1.00 (0.97, 1.03) .98
Income 1.01 (0.88, 1.15) .94 1.00 (0.87, 1.15) .97 1.00 (0.87, 1.15) .95
Acculturation 0.98 (0.96, 1.01) .27 0.97 (0.94, 1.01) .10 0.97 (0.94, 1.01) .10
Medical comorbidities 1.12 (1.04, 1.21) .003 1.12 (1.04, 1.21) .003
ADL 1.20 (1.12, 1.30) <.001 1.20 (1.12, 1.30) <.001
Cognitive impairment 1.03 (1.00, 1.05) .034 1.03 (1.00, 1.05) .037
Social support 1.00 (0.96, 1.03) .80
Tight-knit (reference) 1 1 1
Unobligated-ambivalent 1.15 (0.91, 1.46) .24 1.25 (0.98, 1.60) .074 1.24 (0.97, 1.60) .090
Detached 1.42 (1.02, 1.97) .039 1.46 (1.03, 2.08) .035 1.45 (1.02, 2.07) .038
Commanding-conflicted 1.43 (0.91, 2.24) .12 1.56 (0.97, 2.52) .069 1.56 (0.97, 2.52) .070
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Notes: ADL = activities of daily living; CI = confidence interval. Tight-knit is the reference category in family type.

Figure 1.

Figure 1.

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The association between family typology and 6-year mortality while controlling for age, gender, education, income, acculturation, medical comorbidities, ADL, cognitive impairment, and social support.

In terms of the interaction effect (Table 2), the interaction term of ADL and commanding-conflicted type was significant regarding mortality risk (1.29 [1.07–1.56]), suggesting that older adults with higher levels of physical impairment nested in the commanding-conflicted type had higher mortality risks than their counterparts nested in the tight-knit type. The interaction term of cognitive impairment and commanding-conflicted type (1.07 [1.01–1.14]) was also significant, indicating that older adults with higher levels of cognitive impairment in the commanding-conflicted type experienced higher mortality risks than those in the tight-knit type.

Table 2.

Family Typology and Six-Year Mortality: Medical Comorbidities, Physical Impairment, and Cognitive Impairment as Moderators

6-year mortality
Model A Model B Model C
Hazard ratio (95% CI) p-Value Hazard ratio (95% CI) p-Value Hazard ratio (95% CI) p-Value
Age 1.11 (1.10, 1.13) <.001 1.11 (1.10, 1.13) <.001 1.11 (1.10, 1.13) <.001
Female 0.44 (0.34, 0.55) <.001 0.44 (0.34, 0.56) <.001 0.44 (0.35, 0.56) <.001
Education 1.00 (0.97, 1.03) .97 1.00 (0.98, 1.03) .95 1.00 (0.98, 1.03) .61
Income 1.01 (0.88, 1.15) .94 1.00 (0.87, 1.15) .99 1.01 (0.88, 1.15) .61
Acculturation 0.97 (0.94, 1.00) .097 0.97 (0.94, 1.00) .097 0.97 (0.94, 1.00) .090
Medical comorbidities 1.11 (0.98, 1.25) .087 1.12 (1.04, 1.20) .004 1.12 (1.04, 1.20) .004
ADL 1.20 (1.12, 1.30) <.001 1.14 (1.02, 1.27) .027 1.20 (1.11, 1.29) <.001
Cognitive impairment 1.03 (1.00, 1.05) .039 1.03 (1.00, 1.05) .037 1.03 (0.99, 1.06) .11
Social support 1.00 (0.96, 1.03) .79 0.99 (0.96, 1.03) .76 0.99 (0.96, 1.03) .75
Tight-knit (reference) 1 1 1
Unobligated-ambivalent 1.23 (0.95, 1.60) .11 1.19 (0.92, 1.55) .19 1.24 (0.95, 1.63) .11
Detached 1.45 (1.01, 2.08) .041 1.42 (0.99, 2.04) .056 1.55 (1.08, 2.23) .018
Commanding-conflicted 1.52 (0.91, 2.54) .11 1.25 (0.72, 2.14) .43 1.08 (0.57, 2.03) .81
Tight-knit × medical comorbidities (reference) 1
Unobligated-ambivalent × medical comorbidities 1.02 (0.86, 1.19) .86
Detached × medical comorbidities 0.98 (0.76, 1.26) .87
Commanding-conflicted × medical comorbidities 1.05 (0.75, 1.46) .78
Tight-knit × ADL (reference) 1
Unobligated-ambivalent × ADL 1.07 (0.94, 1.23) .29
Detached × ADL 1.01 (0.81, 1.26) .90
Commanding-conflicted × ADL 1.29 (1.07, 1.56) .009
Tight-knit × cognitive impairment (reference) 1
Unobligated-ambivalent × cognitive impairment 1.00 (0.96, 1.04) .97
Detached × cognitive impairment 0.96 (0.91, 1.02) .19
Commanding-conflicted × cognitive impairment 1.07 (1.01, 1.14) .029
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Notes: ADL = activities of daily living; CI = confidence interval. Tight-knit is the reference category in family type.

Supplementary Appendixes 1 and 2 show gender differences in the relationship between family typology and mortality. Older women in the commanding-conflicted type had higher mortality risks than those in the tight-knit type (2.23 [1.09–4.55]). Older women with higher levels of physical impairment in the detached (2.95 [1.17–7.41]) and commanding-conflicted (1.66 [1.22–2.25]) types had higher mortality risks than their counterparts in the tight-knit type. Older women with higher levels of cognitive impairment in the commanding-conflicted type experienced higher mortality risks than those in the tight-knit type (1.20 [1.08–1.33]). However, the relationship between family typology and mortality was not significant among older men.

Discussion

In this prospective cohort study, older adults in the detached type were associated with higher mortality risks than those in the tight-knit type. Older adults with physical impairment or cognitive impairment in the commanding-conflicted type were associated with higher mortality risks compared with their counterparts in the tight-knit type. These findings highlight the importance of family environment in older adults’ all-cause mortality.

Evidence is mixed regarding the association between a single aspect of family relationships and mortality (Davis et al., 1997; Pizzetti et al., 2005). The controversial findings might be explained by omitting the impacts of other aspects of family relationships. Research has shown that the impact of one aspect of family relationships on mortality risk may depend on the condition of other aspect of family relationships (Takagi & Saito, 2020). Our study shed light on research in this field by examining the comprehensive impact of multifaceted family relationships on mortality risks. In addition, our study revealed that family relationships disproportionately affected mortality risks among older women and men. Commanding-conflicted type was significantly associated with higher mortality risks than the tight-knit type for older women with physical or cognitive impairment but not for older men.

Prior research focused on the individual risk factors of mortality, while little is known about the influence of aging context. Family environment is an essential upstream determinant of health in later life. The ecosystem exerts differentiate effects on individuals with different characteristics (Bronfenbrenner, 1979, 1986). This study provides empirical evidence to the ecological theory by showing that life expectancy is jointly influenced by interactive individual and interpersonal risk factors. The findings may increase the awareness of gerontological practitioners not only to the disease but also to the family setting in which older adults are embedded. Social service agencies could develop programs to educate the younger generation to realize the importance of family relationships for healthy aging and the negative impacts of detached and commanding-conflicted family relationships on the life expectancy of aging parents. Meanwhile, health promotion and disease prevention programs could consider family as an analytic unit. Social service providers could actively screen for older adults who are nested in the detached and commanding-conflicted types and connect them to healthcare and social services.

This study has several limitations. First, older adults may transfer to other family types over time. Future study could examine how transitions in family types affect mortality risks. Second, this study examined a sample of Chinese older immigrants in Chicago. These findings may not be generalizable to other immigrant cohorts or other ethnic groups. Third, medical comorbidities were measured by the number of diseases without considering the severity of illness. Fourth, this study only focused on the interaction between older adults and the microsystem. Future research could further evaluate the role of meso-, exo-, and macrosystems in older adults’ health. Fifth, there are various ethnic groups (e.g., Han, Miao) in the Chinese community. Future studies could further examine family relationships and mortality across different ethnic groups within the Chinese community.

In this prospective cohort study of 3,019 U.S. Chinese older adults in the Greater Chicago area, detached family type was associated with higher 6-year all-cause mortality than tight-knit family type. We found that commanding-conflicted family type increased mortality risks for older adults with physical or cognitive impairment, which are in line with the ecological theory and the competence–environmental press model. This study highlights the importance of family environment in older adults’ health and longevity.

Supplementary Material

gbac106_suppl_Supplementary_Appendix
Click here for additional data file. (98.4KB, pdf)

Contributor Information

Mengting Li, Department of Social Security, School of Labor and Human Resources, Renmin University of China, Beijing, China.

XinQi Dong, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA.

Funding

Dr. Li was supported by Alzheimer’s Association (AARG-NTF-20-684568). Dr. Dong was supported by National Institute on Aging (P30AG059304, R01AG042318), National Institute of Nursing Research (R01NR014846), National Institute on Minority Health and Health Disparities (R01MD006173), and National Institute of Mental Health (R34MH100443).

Author Contributions

M. Li and X. Dong planned the study, supervised the data analysis, and wrote the paper. M. Li performed statistical analyses.

Conflict of Interest

None declared.

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