Abstract
Face-saving represents a unique culturally salient construct among Chinese. However, our understanding regarding its relationship with psychological distress in this population remains limited. The objective of this cross-sectional study is to examine (1) the relationship between face-saving and depressive symptoms among U.S. Chinese older adults; and (2) whether face-saving mediates the relationship between acculturation and depressive symptoms. Data were from the Population Study of Chinese Elderly in Chicago (N = 3132), the largest epidemiologic study of Chinese older adults in Western countries. The relationship between face-saving and self-reported depressive symptoms was investigated by step-wise multivariable linear regression models. The Sobel test was used to test the mediating effect of face-saving. U.S. Chinese older adults with higher face-saving values experienced greater levels of depressive symptoms (B = 0.05, p < 0.001) than those with lower face-saving values, even after sociodemographic factors, health characteristics, and social support were accounted for. The mediation effect of face-saving was not statistically significant. The study findings underscore the significance of a unique cultural factor, specifically face-saving, in understanding U.S. Chinese older adults’ experience of depressive symptoms. Depression screening and treatment programs should pay attention to face-saving issues among U.S. Chinese older adults. Future studies need to incorporate cultural factors in mental health research in diverse populations.
Keywords: Face-saving, Depressive symptoms, Chinese, Cultural factors, Minority aging
Introduction
It has been well established that culture plays a significant role in individuals’ experiences of psychological distress [1–3]. Ethnic minority populations have unique culturally salient characteristics [4]. For instance, face-saving represents a key culturally relevant construct that is pervasive in interpersonal relationships among Chinese [5, 6]. Face-saving in this study refers to an individual’s aspiration to sustain positive self-image or prestige/reputation in interpersonal contexts [7, 8]. Although the concept of face applies across cultures, multiple studies suggested that face is more salient in social interactions in collectivist cultures, such as Chinese and Korean [6, 9].
According to the face-negotiation theory, saving face and losing face represent two key constructs in interpersonal interactions [10]. Face-saving is maintained by fulfilling one’s expected social roles. Failure to fulfill expectations or responsibilities of one’s social roles causes the loss of face, which can lead to negative emotions, such as humiliation, shame, guilt, and loss of self-esteem [11, 12]. Chou (1996) indicated that individuals with strong face-saving values are particularly concerned about face-losing, and thereby more prone to experience the negative emotions. Contrarily, those with low face-saving values are less likely to put pressure over themselves when experiencing stressors. Moreover, face losing in Chinese culture has a social sanction dimension due to the cultural emphasis on harmony in social relationships. Specifically, loss of face could result in rejection and condemnation from one’s social networks and communities, which can ultimately affect an individual’s social functioning [9]. The theory further posits that to prevent the aforementioned negative repercussions of losing face, individuals with strong face-saving values may engage in both preventive and restorative facework to restore face [10]. It has been recognized that facework may precipitate or exacerbate psychological distress [13]. Furthermore, compared to Western individualistic cultures that tend to attribute face-loss to factors external to one’s ability, individuals from collectivistic cultures (i.e. Chinese) may perceive face-losing as personal failure or incompetence, which may subsequently damage their self-esteem and lead to onset or worsening of psychological symptoms [10].
Despite its pertinence in social relationships in Chinese culture, face saving as a culture-specific construct has been missing in widely-used Western instruments. As a result, our understanding regarding its relationship with psychological disorders in Chinese populations remain limited. A careful review of existing literature yields only three studies conducted by Mak et al. that examined the relationship between face-saving and psychological distress in Chinese populations, including Chinese college students and community-dwelling adults in the U.S., Mainland China, and Hong Kong [13–15]. Mak et al. suggested that face-saving was a significant determinant of psychological distress among Chinese Americans, even when preexisting distress, social support and other relevant variables were accounted for [13]. However, the studies conducted by Mak et al. focused on a younger Chinese American community sample (participants’ age ranged from 18 to 65 years, mean age was 40) in California. To the best of our knowledge, the relationship between face-saving and depressive symptoms has not been examined in U.S. Chinese older adults.
A better understanding of this relationship is particularly important in U.S. Chinese older adults for two reasons. First, Chinese older adults represent one of the largest and fastest growing ethnic minority aging populations in the US [16]. Second, previous investigations reported that U.S. Chinese older adults experience higher rates of depressive symptoms compared to the general US older adult population [17]. However, our knowledge regarding sociocultural determinants of depressive symptoms in this population remain limited. Using a shortened indigenous face instrument, the present study aims to fill the knowledge gap by examining the relationship between face-saving, a unique culture-salient construct, and depressive symptoms among U.S. Chinese older adults. Additionally, because the acculturation process may change U.S. Chinese older adults’ endorsement of traditional Chinese cultural values, such as face-saving [15], which can thereby affect depressive symptoms, we further speculate that face-saving medicates the relationship between acculturation and depressive symptoms.
In summary, it was hypothesized that (1) U.S. Chinese older adults with higher levels of face-saving values would experience greater levels of depressive symptoms than those with lower levels of face-saving values; and (2) face-saving would mediate the relationship between acculturation and depressive symptoms. The findings from the present study could facilitate an improved understanding of depressive symptoms in U.S. Chinese older adults from a cultural perspective, which could ultimately inform the development of tailored depression assessment and treatment programs for this diverse aging population.
Methods
Population and Settings
The analyses used data from the Population Study of Chinese Elderly in Chicago (PINE), a population-based longitudinal study examining health and well-being of U.S. Chinese older adults. Baseline interviews were conducted with 3157 Chinese older adults between July 2011 to June 2013. A total of 2713 participants completed the follow up interviews between July 2013 and June 2015, yielding a follow-up rate of 85.9%. An additional 420 participants were recruited at the second wave to supplement those lost to follow-up. The present study used data from all participant who completed the second-wave data collection (N = 3132) because saving face was not measured in baseline interviews. Face-to-face interviews were conducted by trained multilingual and bicultural research assistants in participants’ preferred language or Chinese dialects (such as English, Mandarin, Cantonese, or Toishanese). All participants signed informed consent forms. The institutional review board of Rush University Medical Center approved the study protocol.
Measures
Dependent Variables
Depressive symptoms were measured by Chinese version of the nine-item Patient Health Questionnaire (PHQ-9), one of the most commonly used self-reporting depression instruments in clinical and research settings [18]. The items on the PHQ-9 correspond with the nine diagnostic criteria for depression disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [19]. Respondents rated the extent to which they experienced nine symptoms over a period of two weeks on a four-point scale ranging from 0 = not at all to 3 = nearly every day. The nine items included little interest in doing things, feeling down, sleep problems, feeling tired or having little energy, poor appetite or overeating, feeling bad about self, trouble concentrating on things, feeling restless, and thoughts of better off dead. Total score ranged from 0 to 27, with higher scores indicating higher levels of depressive symptoms. The Cronbach’s alpha of the scale in the present study was 0.82 [20]. To describe sample characteristics, the presence of depressive symptoms was defined as having a PHQ-9 score of 5 or greater because a cut-off point of 5 represents the threshold for mild depression [18].
Independent Variables
Face-saving was measured by a six-item scale adapted from an indigenous multidimensional personality instrument developed by psychologists in Hong Kong and mainland China [21]. The original instrument was developed to compensate for the lack of cultural validity in Chinese societies of translated Western personality instruments [4, 22]. The modified face-saving scale used in the present study consists of six items, including: (1) sometimes I pretend I understand a lot, because I do not want others to look down on me; (2) I always think about other people’s opinion of me before I do something; (3) I pay a lot of attention to how others see me; (4) sometimes when I make a mistake I am not ready to admit it in public, even though I know I am wrong; (5) I prefer not to discuss my weakness, even with my closest friends; and (6) I pay a lot of attention to what kind of attitude people have toward me. Study participants rated the extent to which they endorsed each item on a Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Total score ranged from 0 to 30, with a higher score indicating a greater level of face-saving.
To validate the applicability of the scale in the study sample, the internal consistency reliability of the scale items was examined by calculating the coefficient alpha and item-total correlation coefficients. A Cronbach’s alpha of 0.7 or above was considered as satisfactory reliability in the present study [23]. Face and content validity were assessed by a group of bilingual and bicultural community stakeholders and researchers in Chinese culture and aging related health research. Analyses show that the adapted face instrument achieved satisfactory psychometric properties in the present study. Internal consistency reliability (standardized Cronbach’s alpha) of the shortened face scale in the study sample was 0.77, which is higher than that of the original scale reported in previous studies and satisfactory [21, 24]. Standardized item-total correlations ranged from 0.43 to 0.60, which are greater than the acceptable threshold of 0.30 [25]. The bilingual and bicultural community stakeholders and researchers ascertained that the meanings of the items were culturally valid and relevant to U.S. Chinese older adults.
Covariates
Relevant sociodemographic and health characteristics that have been reported to be significant correlates of depression among older Asian immigrants in a systematic review were included as covariates in the present study [26]. Covariates included age (in years), gender (male/female), marital status (married/not married), and education (in year). Income was annual personal income from all sources reported by participants on a 10-point scale ranging from 1 ($0–$4999) to 10 ($75,000 and above). Household size was measured by asking participants the number of people in their households besides themselves. Acculturation was measured by an adapted 12-item acculturation scale [27]. The scale assessed participants’ language use and proficiency, media program preference, and ethnic preference in social relations. The participants rated the extent to which they endorsed each item on a five-point scale with 1 = only Chinese, 2 = more Chinese than English/American, 3 = both equally, 4 = more English/American than Chinese, and 5 = only English/American. A higher score indicates a greater level of acculturation. The Cronbach’s alpha of the scale for the study sample was 0.88 [28]. Perceived health was assessed by a single-item question, “In general, how would you rate your health?” on a 4-point scale ranging from 1 = poor to 4 = very good. Number of chronic conditions was the total number of chronic conditions indicated from a check-list of nine diseases, including heart disease, stroke, cancer, high cholesterol, diabetes, high blood pressure, hip fraction, thyroid, and osteoarthritis. Social support was measured by asking participants how often they could open to/ask help from spouse, family members, and friends; and how often they felt criticized/demanded too much by their spouse, family members, and friends. Participants answered on a three-point scale ranging from 1 = hardly ever to 3 = often. A higher score indicates a greater level of social support.
Data Analysis
Descriptive statistics were used to summarize the sample characteristics. Characteristics of study participants were compared by the presence of depressive symptoms (yes versus no) using t-tests or chi-square tests. Spearman correlation coefficients were calculated to describe the associations among study variables. Step-wise multivariable linear regression analyses were conducted to examine the relationship between face-saving and depressive symptoms, controlling for covariates. The Sobel test, one of the most commonly used methods to test mediation effect [29], was used to assess whether face-saving mediates the relationship between acculturation and depressive symptoms. Missing data were addressed by listwise deletion in all models. All statistical analyses were conducted using SAS Version 9.2 (SAS Institute Inc., Cary, NC).
Results
Table 1 summarizes sample characteristics by the presence of depressive symptoms. Of the 3,132 participants, 59% were female, 71% were married, and 67% rated their health to be fair or poor. On average, the participants were 74 years old, had 9 years of education, lived with 2 other people in the household, and had two chronic medical conditions. Overall, compared to those without depressive symptoms, U.S. Chinese older adults with depressive symptoms had more chronic conditions, lower levels of social support, and higher levels of face-saving. Additionally, U.S. Chinese older adults with depressive symptoms were more likely to be older, female, married, and rate their health to be fair or poor.
Table 1.
Sample characteristics by the presence of depressive symptoms
| Total | Depressive symptoms |
|||
|---|---|---|---|---|
| Yes N = 437 |
No N = 2683 |
p value | ||
|
| ||||
| Age, mean (SD) | 73.9 (8.3) | 75.5 (8.0) | 73.6 (8.3) | < .0001 |
| Gender, n (%) | ||||
| Male | 1295 (41.3) | 172 (39.4) | 1121 (41.8) | |
| Female | 1837 (58.7) | 265 (60.6) | 1563 (58.2) | 0.0006 |
| Marital status, n (%) | ||||
| Married | 2207 (70.5) | 296 (67.9) | 1903 (71.0) | |
| Not married | 922 (29.5) | 140 (32.1) | 779 (29.0) | < .0001 |
| Education, mean (SD) | 8.9 (5.0) | 9.0 (5.1) | 8.8 (5.0) | 0.477 |
| Acculturation, mean (SD) | 15.3 (4.5) | 15.3 (4.4) | 15.4 (4.6) | 0.463 |
| Household size, mean (SD) | 1.8 (1.8) | 1.5 (1.7) | 1.8 (1.8) | < .0001 |
| Income, mean (SD) | 2.0 (1.1) | 1.8 (0.7) | 2.0 (1.2) | 0.054 |
| Perceived health, n (%) | ||||
| Poor | 737 (23.5) | 133 (30.4) | 597 (22.2) | |
| Fair | 1366 (43.6) | 184 (42.1) | 1179 (43.9) | |
| Good | 900 (28.7) | 104 (23.8) | 796 (29.7) | |
| Very good | 129 (4.1) | 16 (3.7) | 112 (4.2) | < .0001 |
| Number of chronic conditions, mean (SD) | 1.9 (1.4) | 2.5 (1.5) | 1.8 (1.3) | < .0001 |
| Social support, mean (SD) | 29.8 (3.1) | 29.0 (3.2) | 30.0 (3.0) | < .0001 |
| Face saving, mean (SD) | 14.2 (4.4) | 15.2 (4.6) | 14.1 (4.3) | < .0001 |
Table 2 shows the correlation coefficients between study variables. Table 3 presents the association between face-saving and depressive symptoms using step-wise multivariable linear regression analyses. In the full model (Model E), U.S. Chinese older adults with higher face-saving values had greater levels of depressive symptoms than those with lower face-saving values (B = 0.05, p < 0.001), even after sociodemographic, health characteristics, and social support were controlled for. Results from the Sobel test suggested that the mediating effect of face-saving on the relationship between acculturation and depressive symptoms was not statistically significant (Sobel test score z = − 0.42, p = 0.67).
Table 2.
Correlation coefficients among study variables
| Age | Gender | Marital status | Education | Acculturation | Household size | Income | Perceived health | Chronic conditions | Social support | Face-saving | |
|---|---|---|---|---|---|---|---|---|---|---|---|
|
| |||||||||||
| Age | 1 | ||||||||||
| Gender | −0.028 | 1 | |||||||||
| Marital status | −0.312*** | −0.325*** | 1 | ||||||||
| Education | −0.074*** | −0.184*** | 0.174*** | 1 | |||||||
| Acculturation | −0.057** | −0.010 | 0.022 | 0.328*** | 1 | ||||||
| Household size | −0.355*** | −0.132*** | 0.383*** | 0.034 | −0.101*** | 1 | |||||
| Income | −0.00005 | −0.0009 | −0.072*** | 0.046* | 0.188*** | 1 | |||||
| Perceived health | −0.113*** | −0.065*** | 0.041* | 0.062*** | 0.077*** | 0.028 | 0.047** | 1 | |||
| Chronic conditions | 0.225*** | 0.120*** | −0.114*** | 0.052** | 0.059** | −0.150*** | 0.025 | −0.324*** | 1 | ||
| Social support | −0.221*** | −0.038* | 0.390*** | 0.099*** | −0.019 | 0.199*** | −0.050** | 0.115*** | −0.094*** | 1 | |
| Face-saving | −0.044* | −0.036* | 0.046* | 0.214*** | 0.083*** | 0.030 | 0.004 | −0.011 | 0.066*** | −0.011 | 1 |
| Depressive symptoms | 0.086*** | 0.105*** | −0.082*** | −0.017 | 0.021 | −0.077*** | −0.016 | −0.318*** | 0.205*** | −0.153*** | 0.113*** |
p<0.05
p<0.01
p<0.001
Table 3.
Multivariable associations between face-saving and depressive symptoms
| Model A | Model B | Model C | Model D | Model E | |
|---|---|---|---|---|---|
|
| |||||
| Outcome: Depressive symptoms | B (Standard Error), p value | ||||
| Age | 0.020 (0.01) | 0.020 (0.01)** | 0.017 (0.01)** | 0.009 (0.01) | 0.006 (0.01) |
| Female | 0.297 (0.10)** | 0.297 (0.10)** | 0.296 (0.10)** | 0.102 (0.10) | 0.142 (0.10) |
| Marital status (ref: married) | −0.220 (0.11) | −0.218 (0.11)* | −0.223 (0.11)* | −0.212 (0.11)* | −0.079 (0.11) |
| Education | −0.004 (0.01) | −0.005 (0.01) | −0.005 (0.01) | −0.010 (0.01) | −0.010 (0.01) |
| Acculturation | 0.004 (0.01) | 0.012 (0.01) | 0.015 (0.01) | 0.013 (0.01) | |
| Household size | −0.035 (0.03) | −0.028 (0.03) | −0.028 (0.03) | ||
| Income | −0.183 (0.05)*** | −0.122 (0.05)* | −0.120 (0.05)* | ||
| Perceived health (ref: poor) | −0.680 (0.06)*** | −0.669 (0.05)*** | |||
| Number of chronic conditions | 0.150 (0.03)*** | 0.141 (0.03)*** | |||
| Social support | −0.061 (0.01)*** | ||||
| Face-saving | 0.056 (0.01)*** | 0.056 (0.01)*** | 0.057 (0.01)*** | 0.054 (0.01)*** | 0.052 (0.01)*** |
p < 0.05
p < 0.01
p < 0.001
Sobel test (results not shown) suggests that face-saving does not mediate the effect of acculturation (Sobel test score z = −0.42, p = 0.67)
Discussion
The present study contributes to the existing literature by using a large, representative, population-based dataset to investigate the relationship between a culturally salient construct, namely face-saving, and depressive symptoms among U.S. Chinese older adults. The findings provide evidence that face-saving is positively associated with U.S. Chinese older adults’ experiences of depressive symptoms. More generally, the results underscore the importance of sociocultural factors in understanding depressive symptoms in diverse populations.
Consistent with previous studies, the findings suggest that U.S. Chinese older adults with higher levels of face-saving values experienced greater levels of depressive symptoms than those with lower levels of face-saving values, even after controlling for related sociodemographic and health factors [13]. There are several potential explanations for the relationship. It is possible that Chinese older adults with strong face-saving values may feel the urge to maintain sociocultural norms and fulfill the expectations of their social roles due to their heightened consciousness of self-image [10, 13]. Such face-saving activities could consume psychological well-being over time [10]. Additionally, when one’s face is challenged or lost, Chinese older adults with strong face-saving values may be more likely to experience negative emotions, such as humiliation, shame, embarrassment, and guilt, the accumulation of which could erode psychological well-being [11, 12, 30]. To summarize, U.S. Chinese older adults with stronger face-saving values may be more susceptible to negative emotions in case of face-losing, which could exacerbate or precipitate depressive symptoms over time.
It is also likely that U.S. Chinese older adults with higher levels of face-saving may be more prone to experience perceived stigma associated with mental illness, which could subsequently cause or intensify psychological distress [30–32]. Face and stigma are closely intertwined [12]. It has been well documented that stigma is associated with psychological disorders, such as depressive symptoms and anxiety [33]. More specifically, previous studies concluded that stigma mediates the relationship between face and psychological distress [31, 34]. Unfortunately, this mediating hypothesis could not be tested in the present study since stigma was not measured in the PINE study. Future longitudinal studies should be conducted to empirically test the relationship between face, stigma, and depressive symptoms to elucidate potential underlying mechanisms.
Furthermore, the mediation effect of face-saving on the relationship between acculturation and depressive symptoms was not supported. Longitudinal studies need to be conducted to elucidate the causal mechanisms underlying the relationship between acculturation, face-saving, and depressive symptoms.
Taken together, findings from the present study contribute to an improved understanding of the sociocultural determinants of depressive symptoms among U.S. Chinese older adults. Additionally, the study findings provide preliminary evidence that a shortened indigenous face instrument that could be easily included in population-based epidemiological studies, has satisfactory psychometric properties in U.S. Chinese older adults. Consistent with previous studies, the study findings further indicate that culturally specific characteristics that are commonly missing in the mainstream Western instruments have the potential to provide critical cultural insights in mental health research in diverse populations [4].
Strengths and Limitations
The primary strength of the present study is that it expands our understanding of the relationship between sociocultural factors and psychological distress by focusing on a culture-salient construct that has been neglected in previous research. The study findings underscore the significant relationship between face-saving and depressive symptoms among U.S. Chinese older adults.
Several limitations warrant consideration in interpreting the findings. First, depressive symptoms were self-reported, which may be subject to reporting bias due to stigma associated with mental illnesses in Chinese culture. Furthermore, self-reporting of depressive symptoms was not validated by psychiatric diagnostic instrument. Therefore, it remains unclear whether the study findings can be applicable to clinical diagnoses of depression. Second, the present study focused on Chinese older adults in the Greater Chicago area. It is uncertain whether the findings can be generalizable to Chinese older adults in other geographic areas or other ethnic minority populations. For instance, it is not clear whether the positive relationship between face-saving and depressive symptoms is applicable to other cultures with similar face values, such as Korean and Japanese. Lastly, the cross-sectional design precludes our ability to determine causal relationships between face-saving and depressive symptoms.
Implication
The results have significant clinical and research implications. First, the study findings demonstrate that research on psychological disorders in diverse populations should incorporate culturally salient factors. Moreover, more rigorous measurement studies should be conducted to further validate the applicability of the modified face scale in other diverse populations. Second, mental health professionals serving Chinese older adults need to be cognizant of face-saving values in identifying those who are at a greater risk for depressive symptoms and developing tailored depression prevention strategies. In the meantime, mental health clinicians need to be aware of face issues, particularly in self-disclosure of mental illness, to formulate culturally appropriate strategies in approaching such culturally-sensitive topics among U.S. Chinese older adults [35]. Moreover, psychoeducational intervention programs on depression should consider addressing face-saving issues to facilitate timely disclosure and mitigate the associated potential negative emotional influences.
Directions for Future Research
Future studies need to investigate other culturally salient constructs, such as harmony and Ren Qing (also known as relationship orientation), to develop a more comprehensive understanding of how sociocultural factors influence depressive symptoms in diverse populations. Examining the extent to which face-saving influences depression health help-seeking and treatment outcomes in Chinese populations is essential [6]. More broadly, the applicability of indigenous instruments in cross-cultural mental health research needs further investigation considering the increasing diversities in the aging U.S. population. Lastly, mental health implications of face-saving in other populations need to be investigated.
Conclusions
The findings indicate that higher levels of face-saving values are significantly associated with greater levels of depressive symptoms among U.S. Chinese older adults. The present study expands existing literature by highlighting the importance of culturally salient factors in understanding depressive symptoms in diverse populations. Depression screening and treatment programs need to pay attention to face-saving issues among U.S. Chinese older adults. Considering the potential negative influences of face-saving, culturally appropriate strategies need to be developed to facilitate disclosure and discussion of depressive symptoms and other psychological disorders in this population.
Funding
Dr. Dong was supported by National Institute on Aging Grants R01AG042318, R01MD006173, R01CA163830, R34MH100443, R34MH100393, and RC4AG039085; a Paul B. Beeson Award in Aging; the Starr Foundation; the American Federation for Aging Research; the John A. Hart-ford Foundation; and the Atlantic Philanthropies.
Footnotes
Compliance with Ethical Standards
Conflict of interest None.
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