Elderly Chinese in Pacific Rim Countries: Social Support and Integration

Elderly Chinese in Pacific Rim Countries Social Support and Integration

The contributors

to this book are:

Sophia Siu-chee Chan Neena L. Chappell Y.H. Cheng Iris Chi Nelson W.S. Chow Douglas Durst Lan Gien Shixun Gui John P. Hirdes Alex Yui-huen Kwan David C.Y. Lai Alex Lee Shyh-dye Lee Edward Leung Ho-hon Leung Joe C.B. Leung Meng-fan Li Ben C.P. Liu Weiqun Lou James Lubben Marian E. MacKinnon S.M. McGhee Raymond Ngan May-lin Poon Morris Saldov Xingming Song Erin Y. Tjam Shengming Yan

Elderly Chinese in Pacific Rim Countries Social Support and Integration

Edited by Iris Chi, Neena L. Chappell and James Lubben

# m *» # it m *t H O N G KONG UNIVERSITY PRESS

Hong Kong University Press 14/F Hing Wai Centre 7 Tin Wan Praya Road Aberdeen Hong Kong

© Hong Kong University Press 2001 ISBN 962 209 532 1

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Contents

Preface Contributors 1

Silent Pain: Social Isolation of the Elderly Chinese in Canada

ix xv 1

Marian E. MacKinnon, Lan Gien and Douglas Durst

2

Long-term Care in Hong Kong: The Myth of Social Support and Integration

17

Raymond Ngan and Edward Leung

3

The Lives of Elderly Bird-keepers: A Case Study of Hong Kong

35

Ho-hon Leung

4 « Social Support Networks among Elderly Chinese Americans in Los Angeles

53

James Lubben and Alex Lee

5

Social Support of the Elderly Chinese: Comparisons between China and Canada Neena L. Chappell and David C.Y. Lai

67

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CONTENTS

6

Social Support and Integration: An Illustration of the Golden Guides Uniform Group in Hong Kong

81

Alex Yui-huen Kwan and Sophia Siu-chee Chan

7

Health-related Quality of Life of the Elderly in Hong Kong: Impact of Social Support

97

Weiqun Lou and Iris Chi

8

Care of the Elderly in One-child Families in China: Issues and Measures

115

Shixun Gui

9

The Practice of Filial Piety among the Chinese in Hong Kong

125

Nelson 1/1/. S. Chow

10

Social Support and Integration of Long-term Care for the Elderly: Current Status and Perspectives in Taiwan

137

Shyh-dye Lee and Meng-fan Li

11

Social Support and Medication Use: A Cross-cultural Comparison

151

Erin Y. Tjam and John P. Hirdes

12

Family Support and Community-based Services in China

171

Joe C.B. Leung

13

The Role of Social Support in the Relationship between Physical Health Strain and Depression of Elderly Chinese

189

Xingming Song and Iris Chi

14

Living Arrangements and Adult Children's Support for the Elderly in the New Urban Areas of Mainland China

201

Shengming Yan and Iris Chi

15

Elderly Chinese in Public Housing: Social Integration and Support in Metro Toronto Housing Company Morris Saldov and May-lin Poon

221

CONTENTS

16

Health and Care Utilization Patterns of the Community-dwelling Elderly Persons in Hong Kong

vii

241

Ben C.P. Liu, Y.H. Cheng and S M McGhee

Index

257

Preface

This book considers the experience of Chinese ageing within different social contexts with contrasting social beliefs and values. A particular focus of this study is on social support and social integration. Social support is one of the most important factors in determining an older person's quality of life. Social support networks have gained increased respect from a diverse group of scholars inspired by a growing body of social science and epidemiological evidence suggesting that social support networks effect a broad spectrum of psychosocial and health phenomena (House, Landis and Umberson 1988; Stuck et al. 1999). In a Chinese context, social support is usually described as guanxi, which refers to social ties or connections among people that result in mutual benefit. Guanxi also includes instrumental resources, generally based upon self-interest, and interpersonal resources that are considered both natural and necessary for one's emotional life (Yang 1994). Guanxi is egocentric extending to others based on a hierarchical structure. The shorter the distance to the centre, the stronger the guanxi connection. Usually, kinship guanxi is the strongest guanxi for Chinese individuals, followed by extended families and consanguineous relations, neighbours, friends, co-workers, and eventually some weak connections such as those between service providers and customers. Guanxi regulates expected behaviours of people belonging to a particular network. Chances of social interaction, level of self-disclosure, and willingness to seek

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PREFACE

or provide help are some of the factors that contribute to the strength of guanxi. Guanxi also provides individuals with a sense of belonging and security. Moreover, it provides a framework of reference that assists in an individual's construction of social identity through a process of social comparison and self-evaluation. Accordingly, social support and social integration are central to understanding ageing within a Chinese context. Conversely, there has been a tendency for policy-makers and health professionals in many well-developed nations to propose highly technical medical approaches for ageing societies while disregarding less technical social interventions. Unfortunately, these highly technical medical approaches often are contrary to the preferences of elderly persons in part because their sideeffects lower the quality of life. Furthermore, such medical models tend to be very expensive and so they cannot be considered a viable option for less developed nations. Generally, the highly technical approaches have not been able to respond to the needs of ageing populations, but instead have generally created a set of new problems. Thus, a more balanced approach is preferred. More specifically, all ageing societies will need to consider medical approaches when necessary, but they must also safeguard the social support and cultivate the social integration of their older citizens. Unfortunately, social support and social integration are factors that have often been neglected by practitioners and policy-makers, even though such factors have increasingly been shown to be the essence of healthy ageing. Accordingly, a healthy ageing society must treat its older citizens as normal persons with an array of particular needs just as other citizens have other particular needs. In order to facilitate normal and healthy ageing, a society must not marginalize its senior citizens, but must fully integrate them into society and guarantee that they have adequate social support. Elderly Chinese persons living in many different parts of the world also prefer to be treated as normal citizens of the society. How to ensure that elderly Chinese persons continue to receive social support needed in their old age and how to better integrate elderly citizens into society are meaningful research topics for scholars, policy-makers and practitioners in the many countries with ageing Chinese populations. Accordingly, the focus of this book is on social support and social integration for elderly Chinese in ageing societies in many different parts of the world. The overall population of China is still relatively young, and its aged population is not evenly distributed. Most of the major cities in China can already be classified as ageing societies whereas the population in rural areas contains relatively few older persons. Nonetheless, in terms of absolute numbers, China has one of the largest numbers of older persons in the world. Although Hong Kong and Taiwan share the same ethnic and cultural background with mainland China, there are substantial differences among

PREFACE

XI

these communities as a result of social and economic development. Hong Kong was returned to China in 1997 and made a Special Administrative Region of the People's Republic of China. Before its reunion with China, Hong Kong had been a British colony for over 150 years. The social and economic development in Hong Kong surpassed that of many developed countries in the world. In order to have a smooth transition, the 'one country, two systems' policy was adopted by recognizing the cultural differences between Hong Kong and mainland China due to the long separation and ruling under different political and economic ideologies. Taiwan's current situation is quite similar to that of Hong Kong. Taiwan was a colony of Japan for many years and subsequently benefited from many years of foreign investment. Within a relatively short period of time, it has become one of the more economically developed places in the world. Historically, Chinese people have migrated to other countries seeking better living conditions. The Chinese diaspora, although never halted, has experienced varied motivations and patterns over the years. There are four overlapping types of migration (Wilson 2000). One is the conventional lifestyle Chinese migrants who choose to move in order to improve their quality of life. This group largely moves to more prosperous Western societies. Secondly, there are the economic migrants who grow old after a lifetime working in a foreign country. Thirdly, there is the small group of older Chinese whose increasing frailty requires that they move to be near their far-away children. Fourthly, there are the refugees fleeing war, famine or human rights abuse. For various reasons, Chinese populations, regardless of their final destination, have tended to maintain their distinctive identity over many years or even centuries. Chinese migrants in many parts of the world remain in enclaves separate from the communities into which they have migrated. Both internal and external social forces have enforced this tendency. A certain amount of economic success and strong sanctions against marrying outside the community were deemed important attributes for long-term community survival and so the Chinese immigrants often enforced de facto segregation policies upon themselves in whatever community they settled. In other cases, the forces were external to the Chinese immigrant community, and Chinese were restricted access to the wider community. Within most destination countries, including pluralistic and heterogeneous nations like Australia, United States and Canada, large enclaves of Chinese populations can be found. As a consequence, elderly Chinese persons living in a Western country confront different social beliefs and values that in turn may affect their later life experiences. The inability to integrate into the mainstream signifies an abnormal ageing experience for many elderly Chinese migrants. There appear to be different views on ageing emerging between developed nations and less developed ones. In the developed nations, the 'burdens' of

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pensions, care-giving burdens and intergenerational equity dominate much of the discussion on the challenges of an ageing world. In contrast, in the developing world, there is very little such debate, but rather a basic assumption that older people will work unless pension schemes become viable, and that family members will provide elderly care when it becomes necessary. At the extremes, the choice appears to be between whether the family or the individual is the central unit of society. In many Western societies, individualism is the dominant ideology. Families are often perceived to be an economic unit involving a collection of related individuals but still primarily seeking individual fulfilment. In contrast, Chinese culture assumes that the family or lineage is the basic unit of society. The individual is a relatively weak and undeveloped concept in Chinese societies. Older Chinese persons living in Western societies are caught between these two extremes. Traditionally, family care is supported by very strong social and religious sanctions in Chinese communities. Confucianism contains norms of filial piety requiring children to honour their parents and look after them. Therefore, how Chinese people think and feel about their families has far-reaching consequences for their older lives. Such traditions are officially upheld in mainland China and Singapore where the governments have stipulated very clear policy or legal statements to regulate the practice of filial piety. Nonetheless, norms appear to be rapidly changing in some Chinese communities. For example, in Hong Kong, Taiwan and Chinatowns in North America, there are increasing exceptions to these norms, which may or may not be usable by potential carers. For instance, having children and having a full-time job could be a socially acceptable excuse for not assuming a heavy parental caretaking role. Also, it is quite acceptable to employ others to care for ageing parents. Nevertheless, Chinese traditions do exist in different Chinese communities in the world and have their impacts on the lives of older persons living in these communities. Nevertheless, each society also has its own interpretations of these traditions. Structural changes appear to be affecting caring relationships in later life worldwide (Kendig, Hashimoto and Coppard 1991). It is also becoming clear that the interpretations of traditions and expectations of filial piety are different among generations within the same Chinese society. Whether globalization, post-modernization or other social forces will change the nature of social support in ageing societies, and how these social phenomena may influence long-standing Chinese traditions are interesting and important research questions for cross-cultural gerontology studies. Further, despite differing cultural traditions, all societies are facing rapidly ageing populations that will challenge the way in which care is delivered and supported. It is easier to be filial when families are large and life expectancy short. It is a bigger challenge

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XIII

when offspring are few and one's parents require long-term care that may persist for many years. Also, differences between Confucian-based societies and those of the West may be less than sometimes thought. For example, even though Western societies lack norms of filial piety and formalized policies specifying an adult child's responsibility for ageing parents, there is strong evidence that children in Western societies remain the primary caretakers of ageing parents (Stone, Cafferata and Sangl 1987). Accordingly, a comparative analysis of how various cultures will adjust to rapid demographic changes in society is an additional set of interesting questions for cross-cultural and crossnational gerontologists. The strength of a cross-cultural approach is that it contrasts dominant ideologies in different cultures, makes power relations involved more visible and so allows us to question what appears to be 'natural' in any society. Comparison among cultures also highlights the diversity within cultures by showing that ideologies that are dominant in one culture are present in others, but very often in muted form, or in ways that are modified to suit the different cultural and environmental constraints. The presence of older adults from different cultures is a challenge to mainstream gerontology. Firstly, migration is a process that emphasizes the importance of a life course perspective. Secondly, the idea of old age as ethnically homogeneous and culture-free is challenged by the presence of minority ethnic groups among the aged population. It is clear that diversity in later life cannot be ignored, and culture or ethnicity needs to be understood as one of the factors that shapes the lives of older adults (Wilson 2000). The collection of scholarship in this edited book demonstrates the rich potential for increased understanding of the ageing phenomenon that is attainable through cross-cultural and cross-national study.

§ References House, J.S., K.R. Landis and D. Umberson. 1988. Social relationships and health. Science 241: 540-5. Kendig, H.L., A. Hashimoto and L.C. Coppard, eds. 1992. Family support for the elderly: The international experience. Oxford: Oxford University Press. Stone, R., G.L. Cafferata and J. Sangl. 1987. Caregivers of the frail elderly: A national profile. Gerontologist 27: 616-26. Stuck, A.E., J.M. Walthert, T. Nikolaus et al. 1999. Risk factors for the functional status decline in community-living elderly people: A systematic literature review. Social Science and Medicine 48: 445-69. Wilson, G. 2000. Understanding old age: Critical and global perspectives. London: Sage Publications. Yang, M. 1994. Gifts, favors, and banquets: The art of social relationships in China. Ithaca, New York: Cornell University Press.

Contributors

Sophia Siu-chee Chan, Ph.D. Assistant Professor and Acting Head Department of Nursing Studies The University of Hong Kong Neena L. Chappell, Ph.D. Director, Centre on Aging; Professor, Department of Sociology University of Victoria British Columbia Canada Y.H. Cheng, Ph.D. Assistant Professor Department of Community Medicine and Unit for Behavioural Sciences The University of Hong Kong Iris Chi, DSW Director, Centre on Ageing; Professor, Department of Social Work and Social Administration The University of Hong Kong

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Nelson W.S. Chow, Ph D Chair Professor Department of Social Work and Social Administration The University of Hong Kong Douglas Durst, M S W , Ph D Professor Faculty of Social Work University of Regma Lan Gien, RN, Ph D Professor School of Nursing Memorial University of Newfoundland Shixun Gui Director of Population Research Institute East China Normal University Shanghai John P. Hirdes, Ph D Associate Professor Providence Centre University of Waterloo Alex Yui-huen Kwan, Ph D Professor Department of Applied Social Studies City University of Hong Kong David C.Y. Lai, Ph D Department of Geography and Centre on Agmg University of Victoria British Columbia Canada Alex Lee, Ph D Assistant Professor Department of Social Work and Psychology National University of Singapore

CONTRIBUTORS

xvu

Shyh-dye Lee, M.D., M.P.H. Associate Professor and Director, Graduate Institute of Long-term Care National Taipei Nursing College Edward Leung, M.D. Chief of Service (Geriatric and Medicine), United Christian Hospital, Hong Kong; President, Hong Kong Association of Gerontology Ho-hon Leung, Ph.D., McGill University Joe C.B. Leung, Ph.D. Associate Professor Department of Social Work and Social Administration The University of Hong Kong Meng-fan Li, M.S.G. Secretary General Professional Association of Long-term Care Taiwan Ben C.P. Liu, Ph.D. Deputy Director Aged Care Research Unit Haven of Hope Hospital Hong Kong Weiqun Lou, Ph.D. Department of Social Work and Social Administration The University of Hong Kong James Lubben, DSW, MPH Professor Departments of Social Welfare and Urban Planning School of Public Policy and Social Research University of California, Los Angeles Marian E. MacKinnon, RN, MN Associate Professor School of Nursing University of Prince Edward Island

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S.M. McGhee, Ph.D. Department of Community Medicine and Unit for Behavioural Sciences The University of Hong Kong Raymond Ngan, Ph.D. Convenor, Elderly Policy Research Team, Centre for Comparative Public Management and Social Policy (RCPM); Associate Head, Department of Applied Social Studies City University of Hong Kong May-lin Poon, M.S.W. Seniors Care Co-ordinator Toronto Ontario Community Access Council Canada Morris Saldov, M.S.W., Ph.D. Associate Professor of Social Work Monmouth University, West Long Branch, New Jersey Xingming Song, Ph.D. Postdoctoral Fellow Institute of Population Research Peking University Erin Y. Tjam, Ph.D., MHSc, SLP (reg) Researcher St. Mary's General Hospital Father Sean O'Sullivan Research Centre Kitchener, ON Canada Shengming Yan Lecturer Department of Sociology Peking University

1 Silent Pain: Social Isolation of the Elderly Chinese in Canada Marian E. MacKinnon, Lan Gien and Douglas

Durst

'A journey of a thousand miles begins with a single step.' This study explores the perceptions of elderly Chinese people in a small urban area in one of the Atlantic provinces in Canada, who, for reasons such as health or finance, find themselves living with and dependent on their adult children. It explores their perceptions of how the care-receiving situation affects their health and adjustment to Canada. Current knowledge about the effects of socio-economic factors, the need to feel useful and productive, to have a sense of control over ones life, and the positive effect of social connections and other determinants of health (Premier's Council on Health Strategy 1994), indicate the significance of knowing what the stresses and strains of being a care-receiver might be. Given this knowledge, it seems important to discover how the sometimes sudden transition from living an independent life to becoming a care-receiver might affect the health outcomes for the elderly. For Canadian-born elderly, the transition from independent living often follows an unexpected and sudden illness. For others, such as the respondents in this study, becoming a carereceiver seems to follow immigration and all the threats to security and independence that it brings.

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MARIAN E. MACKINNON, LAN GIEN AND DOUGLAS DURST

I Literature Review Respect for the elderly has been a guiding principle in the Chinese culture for several thousand years (Wu 1975). Because of the prominent and venerated position of the elderly in the culture, the Chinese are said to look forward to old age as a time when they can sit back and enjoy the fruits of their labour while family members seek their advice on important issues and decisions (Tsai and Lopez 1997; Cheung 1989). Traditional behaviour and social interaction in China have been strongly influenced by Confucianism. Filial piety, a central concept of Confucianism, was defined as 'loyalty, respect, and devotion to parents' (Wu 1975, p. 273) and was considered the 'root of all virtue' (Lang 1968, p. 24). Considerable significance was also placed on 'reciprocity and loyalty' (Lee 1986). Yang (1957) described reciprocity and loyalty as the foundation of the closely knit Chinese family structure, and indicated that the venerated position held by the elderly Chinese was based not only on love and respect, but also on the elderly having some control of power resources. Arising out of this long tradition of filial piety is the expectation that parents in their old age live with their adult children. However, the results of recent research suggest that because of different experiences and changing values, support from Asian families for their elders may be changing (Chan 1983; Tsai and Lopez 1997). When one considers that elderly Chinese immigrants come to Canada often having left behind their families, friends, neighbours and colleagues, as well as their homeland, properties and lifework, it is reasonable to assume that loneliness and isolation may be a problem for them (Lee 1994). RathboneMcCuan and Hashimi (1982) identified four causes of isolation: (1) physical isolators, such as language barriers and transport; (2) psychological isolators, such as uncertainty, timidity and depression; (3) lack of financial ability; and (4) change in roles of family work. With the move to a foreign country, many elderly Chinese suffer the loss of their means of livelihood and hence their economic independence. With the loss of friends, neighbours and colleagues as well as the changes in values and customs, their world may become limited to their immediate family. The stress of the move as well as the burden of being totally dependent on their families may have physical and psychological health outcomes for the elderly Chinese. Equity theory may explain some of the difficulties that occur in such a situation. A basic proposition of equity theory is that people who find themselves participating in unequal relationships become distressed (Walster, Walster and Bercheid 1978). They experience greater stress as inequality in the relationship increases. Tilden and Gaylen (1987) found that the inability to reciprocate had a greater impact on the morale of an elderly individual

SILENT PAIN! SOCIAL ISOLATION OF THE ELDERLY CHINESE IN CANADA

than the need for physical assistance with activities of daily living. Reciprocity was found to be 'fundamental to the social integrative process of the older generation' in three immigrant groups, Chinese, Malay and Indian (Mehta 1997). Mehta also noted that if elderly people could not reciprocate or did not wish to, the level of social integration within the family was low. Dowd (1975) proposed that unequal exchanges in relationships between parents and adult children reflect a decline in resources associated with ageing which leads to increasing difficulty in maintaining balanced exchange relationships. Power resources as perceived by Blau (1964) were money, approval, respect and compliance. Other authors perceived power resources to include such things as love, self-esteem, energy, knowledge and good health (Tilden and Gaylen 1987). Older people frequently have less of these resources. As an aged person's power resources decline, they are left with nothing to offer in return for the care they are given. In an effort to reciprocate, the elderly give up their status and authority in the family and are forced to offer their most 'costly commodities' and esteem (Blau 1964). In order to have a sense of personal independence, one must have a feeling of being in control of their life, and be able to make choices over affairs affecting their life. A considerable body of literature confirms the adverse effects of an absence of control on health and well-being. Fuller (1978), in a study of nursing home residents, found that perceived choice and the opportunity to be involved in decision-making were important to increased morale and was predictive of well-being in elderly people. Ziegler and Reid (1979) found that having control was significantly correlated with life satisfaction and self-concept. Seligman's work (1975) further illustrated that serious health consequences, even death, may result from extreme feelings of loss of control. Although Seligman's research was not done with Chinese people, one can speculate that similar findings may be true for the elderly Chinese as well. Much of the literature in the area under discussion is based on white populations and on related concepts such as reciprocity and the desire for independent living. This paucity of direct investigation into the perceptions and health needs of the elderly Chinese who live with their offspring indicates a need for qualitative exploration of the meaning and health outcomes associated with the experience of care-receiving.

D Design of the Study This is a qualitative, descriptive and exploratory study. The purpose of the study was to document the self-reported experiences of some elderly Chinese who were being cared for and supported by their families, and to explore the

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MARIAN E. MACKINNON, LAN GIEN AND DOUGLAS DURST

potential physical and mental health outcomes associated with being dependent on adult children for psychological, financial, social and, in some cases, physical care and support. The elderly Chinese participating in this study were first-generation (i.e. born in China), and were living with and dependent on their family. Although being 'old' is a subjective concept, defined by both culture and health (Clark and Anderson 1967; Coombs 1986), age 60 or above was chosen as a criterion for inclusion in the study. Chinese were chosen because they were one of the most populous visible minority groups in the Atlantic urban area where the study was conducted (Statistics Canada 1996). Care-receiver, for the purposes of this study, is defined as 'an elderly person who is dependent on the family for psychological, social, financial and/or physical support and care'. A non-probability, convenience sample was drawn, consisting of ten elderly Chinese (two men and eight women) whose age ranged from 69 to 81 (M = 74.8 years). The sample size was determined mainly by data saturation and accessibility.

Data collection Data collection involved audiotaped interviews with the elderly Chinese at their home. Each interview was approximately two to three hours in length with the purpose of obtaining in-depth information in the respondent's own words. Open-ended questions, guided by a semi-structured interview guide, were asked. A Personal Data Questionnaire was designed to collect demographic and other background data. The respondents were interviewed with the assistance of an interpreter.

Data analysis The constant comparative method of data analysis as described by Glaser and Strauss (1967) was used to analyse the data. Four major categories were identified, with one or two themes emerging within each category. These categories and themes will be discussed in the following section.

1 Findings and Discussion Demographic data The length of time for which this group of elderly Chinese had lived in Canada

SILENT PAIN! SOCIAL ISOLATION OF THE ELDERLY CHINESE IN CANADA

spanned a range of 6 months to 62 years. The mean number of years spent in Canada was 17.4 years. All of the respondents considered themselves to be Chinese even after as many as 40 years in Canada. One male respondent demonstrated this feeling of being Chinese after having lived in Canada for many years, when he said: You might be Canadian citizen, but you can't forget China. You never get clear of that anyway . . . . you born there, you everything there . . . . If I say I am Canadian, that is a lie. You can't just say you are not, because you are! You Canadian citizen just the same, but you can't feel no Chinese. I can't forget China. That's because I born there . . . Two of the respondents were married, seven were widowed and one was divorced. Cultural traditions can provide important stability for the elderly in the face of the multitude of changes that occur with immigration (Tsai and Lopez 1997; Coombs 1986). In the case of the women in this study, however, traditional values seemed to have increased the difficulties they faced. For example, seven of them had been widowed for many years but had not remarried, because in the Chinese culture, at least for women in this age group, it was felt to be socially unacceptable, especially for women, to remarry. All ten respondents had at least one child, and four had more than three children. This is consistent with the literature which confirms that very few Chinese are childless and that most in this age group have three or more children (Driedger and Chappell 1987). Nine of the respondents lived with a son while one lived with a daughter who was an only child. This was again in keeping with tradition. One of the most embedded traditions in Chinese culture is the role of the son in caring for his parents (Tsai and Lopez 1997; Cho 1990; Hsu 1967). This appears to be changing and becoming more Westernized, where the daughter is the main care-provider, usually for her own parents (Tsai and Lopez 1997). Eight of the respondents spoke only Chinese. Two, one male and one female, were able to speak and read both Chinese and English. Four were able to read only Chinese. Four of the female respondents were unable to read or write in either language. All respondents described how their lack of fluency in the English language limited their activity and involvement in the broader community. Only three (two male and one female) in the group had more than primary school education. None were employed, as might be expected at their age. Two had virtually no money, not even for things such as bus fare or postage stamps. Four received money from adult children who lived in another city or province. The amount and time of receipt were unpredictable. Two received only old-

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age pension, and two received old-age pension plus some income from their savings. They all tended to be very private about their finances. The following sections present the findings under the four categories identified. In order to capture the perspectives of the elderly as fully as possible, direct quotations are used.

1 Thematic Findings and Discussion During analysis, four major categories emerged: loneliness and isolation, meaningful roles and relationships, diminishing power resources, and independence/dependence.

Loneliness and isolation In this category, loneliness and isolation, two themes emerged: emotional isolation and physical health consequences. For six of these elderly Chinese, loneliness seemed to be pervasive in their lives. They seemed to long for old friends, familiar places, absent family members, and familiar activities and routines. The loneliness also seemed to be related to the enormous loss in their lives and to the inability to build a new life because of difficulties in communicating in English, transport problems, lack of money, and inability to get together with friends. The remaining four in the group also felt lonely, but their loneliness did not seem to be as wearing. They were able to fill their time with activities such as reading the Bible in winter or gardening in summer, drinking tea or coffee, and calling friends on the telephone. All four, however, indicated that these activities were time-fillers and not necessarily activities of choice. The first theme under the category of loneliness and isolation was emotional isolation. Six of this group of elderly Chinese seemed to feel emotionally isolated. Emotional isolation appeared to occur in families where respondents reported they could not talk to family members about concerns and problems and where there was a perceived absence of warmth and affection from family members. For adult children and young grandchildren, work and school commitments mean that there is little time to spend with the elderly and no time to drive them to visit friends or to church. Going to church seemed to be very important for this group, at least partially because it provided the opportunity of an outing and potential contact with friends. Lack of contact with friends was an important part of feeling emotionally isolated. All

SILENT PAIN: SOCIAL ISOLATION OF THE ELDERLY CHINESE IN CANADA

expressed the desire to maintain regular contact with friends, but none were able to do so. Maintaining contact with other Chinese people in their own age group helps the elderly Chinese to maintain their values and customs and to establish support networks, thus reducing feelings of emotional isolation (Chen 1980; Tsai and Lopez 1997). McKenna (1995) noted that those elderly immigrants who experienced high morale in the absence of strong interactions with the family, tended to be those who had been able to maintain social interactions with peers. Emotional isolation also seemed to have been increased by the changes to more Western ways in values and lifestyles of their children and grandchildren (Tsai and Lopez 1997). Bond and Hwang (1992) noted that the greater the disparities between the adult children's views and the elderly's views, the more apparent conflict became in the intergenerational family, thus the greater feeling of emotional isolation and loneliness. Although the Bond and Harvey study was not done with the Chinese, similar findings were discovered in this study with the elderly Chinese. Many adult Chinese children stated that they believed in supporting and taking care of ageing parents, however, their behaviour did not always support their claims (Yu 1983). Feelings of isolation seemed to be expressed in the following quotes: 'When 1 tell somebody something, nobody will listen' and 'You don't know if he love me, you don't know'. The second theme that became evident under the category of loneliness and isolation was physical health. Five of the respondents indicated a problem with either sleep, appetite, or strength or energy, or all three of these. One respondent expressed the need to exercise in order to maintain her health: T don't get enough exercise here, so after a long time my body won't do it, even if I can.' Five were afraid to leave the house because they felt too frail to walk alone, and there was seldom anyone home or anyone who had the time to walk with them. They also were afraid to leave the house on their own because they feared getting lost as they were unable to ask for directions or to read English street signs. The elderly in this group were very aware of their lack of opportunity for exercise, and all indicated how much they missed the tai chi exercise groups that are held in the streets and squares of cities in China. Since physical and mental health is influenced by the social environment, one's productivity and ability to control one's own affairs, and physical exercise, it is possible that the physical health of this group of elderly Chinese may be adversely affected by their way of life (Premier's Council on Health Strategy 1994).

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Meaningful roles and relationships The next major category was meaningful roles and relationships. The themes that emerged under this category were emotional needs and disagreements. All respondents described long days with little to do. Their efforts to help around the house or with the family business were usually declined. A study by Hsu (1967) in China indicated that it was normal for elderly Chinese to withdraw in later life. All the five young Chinese interpreters used for this study also believed that elderly Chinese people just wanted to 'sit around and do nothing'. The findings of this study seem to refute Hsu's, as well as the beliefs of the interpreters about the elderly of their own race. Describing the desire to be out and involved, one respondent said she was much happier when she was helping out at a friend's business. She described how, regardless of the weather, she went to work every day. Under more favourable circumstances when she had something meaningful to do, she felt more 'able'. All respondents wanted to have some meaningful role within the family, even if it were simply to cook the meals or care for grandchildren. Another respondent demonstrated this desire when she tried to help out with her son's business, but was told to 'just rest'. The first theme under meaningful roles and relationships was denial of emotional needs. As indicated by the following quotes, this group of elderly Chinese seemed to deny their emotional needs. The words T don't feel anything' came up in six of the ten interviews. Three respondents refused to answer questions about feelings and explained that if they were not happy, they just 'changed their thinking'. Alternatively, these responses may reflect the belief by some Chinese that the present reflects eternity and that individuals are expected to adjust to the present and seek a harmonious relationship with their surroundings (Kim 1988). Even though they seemed to deny their own emotional needs, they appeared to want more overt expressions of love and affection from their adult children. In Chinese culture, affection from child to parent is often expressed in instrumental ways. However, Seelbach and Sauer (1977) found that elderly parents differentiate between the kinds of support received and tend to prefer more social and affective support than instrumental support. Furthermore, Lee, Crittenden and Yu (1996) found that emotional support had a positive impact on the mental health of the elderly Korean immigrants in their study, while instrumental support had little effect. The second theme under meaningful roles and relationships was disagreements. In this group, few disagreements were reported. One woman said that this was because 'Chinese people believe you shouldn't make a racket.' In some families, when disagreements occurred, the silent treatment was used where members of the family did not speak to each other for a few days,

SILENT PAIN SOCIAL ISOLATION OF THE ELDERLY CHINESE IN CANADA

then everything returned to normal The absence of disagreements may also have been a reflection of the traditional Chinese family orientation, where family loyalty comes before personal interests A major strategy used by the older Chinese respondents in Mehta's study (1997) was avoidance of confrontation, and they were convinced that it led to a harmonious atmosphere

Diminishing power resources The third category was diminishing power resources or the desire to reciprocate care received The themes that emerged under this third category were decision-making m the family and the fear of being a burden Power resources were defined as anything that one partner m a relationship perceives as rewarding and which consequently renders him or her susceptible to social influence (Dowd 1975) Examples of power resources include money, prestige, position, property, self-esteem, good health, and knowledge All of the elderly Chinese respondents m this study reported the desire to reciprocate the care they received from their adult children All also felt they had few, if any, means to do so — no power resources They had no money and their contribution to household chores and frequently for child care was not required, especially once the children had reached a certain age In fact, they themselves needed financial, emotional and physical help In addition, they could not play the role of a wise elderly person because their life experience was from another culture and another era, and therefore their advice and opinions were not deemed relevant Equity theory (Walster, Walster and Bercheid 1978) suggests that people who find themselves m unequal relationships become distressed This seems to be true of the elderly Chinese in this study The adult children may not have expected anything in return, but the elderly respondents m this study struggled with feelings of indebtedness and seemed to want to give something m return for the care received In the absence of other resources, the elderly Chinese respondents seemed to try to please their children, or to comply with their children s wishes They made few demands For example, they did not ask for a midnight snack if they felt they wanted one, or for a drive to visit a friend, or to have favourite groceries added to the family grocery list The first theme under the category of diminishing power resources was decision-making Seven respondents did not feel free to take part m decisionmaking even though they were affected by the decision They felt they could not have any part m decision-making because they were unable to contribute to the household either financially or through participation m household chores Three respondents felt free to participate m decision-making, but felt

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MARIAN E. MACKINNON, LAN GIEN AND DOUGLAS DURST

that their knowledge and experience was irrelevant to the decisions their adult children had to make. The feelings of this group of elderly Chinese about decision-making seemed to be reflected in the following statements: 'They can do everything, they can read, they can write, I can give them no advice', 'I have no money, what can I say?' and 'Nobody will hear what the elderly say'. The second theme under the category of power resources was the fear of being a burden. This was common in all of the respondents in this study. The fear of being a burden was expressed when one woman said she felt like she was a burden to her family. Even though children may treat their dependent parents well, the subjective sense of being a burden weighs heavily on the elderly person (Mehta 1997). This group of elderly avoided making any demands on their adult children in order to avoid being a burden. One respondent said she felt her children would love her and respect her more if she had her own place, because she would not be living with them and creating problems for them. This particular respondent was seriously emotionally distressed by the feeling that she was a burden to her family. The respondents in this study chose several ways to avoid being a burden to their families. Even though it was winter and they were living in a very cold climate, they chose to wear several layers of clothing rather than turn up the heat during the day when the family was at work or at school. One elderly man, along with many layers of sweaters and a jacket, was wearing gloves in the house. In addition, to avoid raising the electricity bill, they did not watch television during the day when they were home alone. Some refused to ask for money to buy medication, even when it was critically important, for example, for diabetic treatment. They went without or asked the church for money. They would not ask for a drive to a doctor's appointment or to church or anywhere they wanted to go. They seemed to deny their own needs in order to avoid being a burden to their families. Many of the elderly in this study appeared to have low morale. This may be related to their inability to reciprocate assistance provided by their adult children. The adult children may not have expected anything in return, but the elderly felt they wanted to give something in return for the care received. This may be because, while the filial obligation of the child to the parent was strong, it was also important that the relationship be reciprocal (Mehta 1997).

Independence/dependence The fourth and final category was independence/dependence. The theme in this category was helplessness/hopelessness. All ten respondents indicated that their independence had been curtailed

SILENT PAIN! SOCIAL ISOLATION OF THE ELDERLY CHINESE IN CANADA

since arriving in Canada. Lack of English language skills, lack of familiarity with physical surroundings, societal structures and the bureaucracy of the new culture, lack of transport means, greater distances, along with loss of income, reduced their ability to be independent. All seemed to prefer greater independence, as indicated in the following statement: 'If I can I will take care of myself, if I can't there is no choice.' Another respondent expressed his preference for independence when he described his distaste for having to ask for assistance from others: 'I feel like a beggar going everywhere for meals.' Five respondents indicated they would like to live on their own. The remaining five expressed some reservation about living on their own, either because they feared they would be too lonely or because their children would not take them back if they became ill and could no longer live alone. Some had never lived alone before and did not know if they would be able to manage on their own in a new country with coincident problems. Their fears of living alone may be well grounded. Mui (1998) found that the 'mental health status of living alone Chinese elderly respondents was much worse than that of respondents who lived with someone in their household' (p. 157). The fact that as many as half of the sample expressed a desire to live on their own reflects a current trend. Many elderly Chinese immigrants, rather than face escalating cultural conflicts and intergenerational difficulties, are showing a growing preference for independent living (Tsai and Lopez 1997; National Advisory Council on Aging 1993; Chan 1983). Five respondents actively wanted to return home to China or Hong Kong. Among them, some had health complaints. Health complaints may save face for the elderly Chinese and their families, should the elderly decide to return to China. If they were to return without an apparent reason, it would bring shame and loss of face to the family, but if they were able to relate the need to return home to aches and pains brought on by the change in diet or the cold weather, then they would have an acceptable reason to leave (Leong 1976; Mui 1998). The theme that emerged under i n d e p e n d e n c e / d e p e n d e n c e was helplessness/hopelessness. The elderly in this study experienced a number of situations that have been identified in the literature as contributing to feelings of helplessness. They had a lack of knowledge (Fuchs 1987) about the new country, they were in an unfamiliar environment, and they voiced feelings of a lack of control over their personal routines. They experienced social displacement, change in personal territory and, in some cases, lack of consultation regarding decisions. Feelings of helplessness were expressed by one respondent as he said, 'If there is a fire and the water is far away, how are you going to get water to put out the fire?' Another expressed what seemed to be hopelessness when she said she hoped she would 'go to heaven soon' The elderly in this study did not seem to allow themselves to think of

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MARIAN E. MACKINNON, LAN GIEN AND DOUGLAS DURST

possibilities. When asked if there was anything they would like to change, they replied with comments like 'I don't think of that, I just go day by day'. Such statements may imply a lack of choice and control. These findings seem to indicate low life satisfaction and less than optimal mental health. This may, at least in part, be a result of the elders' perception that they had little influence and few alternatives in their lives. The importance of choice and control to the health of the elderly is emphasized in the current literature on the determinants of health and in the literature indicating that physical and psychological decline may be inhibited or reversed by providing options and allowing individuals to take charge of events that affect their lives (Fuchs 1987; Reich and Zautra 1990).

I Implications for Health-care Providers This study may contribute to the health of elderly Chinese in the Atlantic region by: • providing a better understanding of factors affecting their psychological and physical well-being; • providing further understanding of the complexity of factors in the home that may influence the response of an elderly Chinese immigrant to health care; • raising the awareness of the ethnic community that some elderly people are lonely and isolated and that this is affecting their health; and • raising awareness among health-care providers that there is a need for support groups and/or social groups for elderly Chinese. This study also indicates a need for English as a Second Language (ESL) classes for elderly Chinese immigrants, more available transport with drivers who speak their language, and tai chi groups for elderly Chinese as they were accustomed to joining them in the mornings in China.

1 Future Research Caution must be applied regarding generalization of these findings to issues concerning populations outside the group studied. Further studies need to be carried out to determine whether elderly Chinese living in metropolitan areas in Canada, such as Montreal or Vancouver where there are larger Chinese communities, feel the same way. The study must be duplicated with a larger

SILENT PAIN! SOCIAL ISOLATION OF THE ELDERLY CHINESE IN CANADA

13

group of elderly Chinese in several different settings. Comparative studies need to be carried out with Canadian-born elderly and elderly people from other ethnic populations to determine if similar problems exist.

0 Conclusion Care-receiving appeared to be associated with some physical and psychological consequences for these elderly Chinese men and women who had immigrated to small urban areas in Canada. These consequences included a concern that they might be a burden to their care-givers, the feeling that they had little that was valued to offer in return for care received from their adult children, and the perception that they must withhold their opinions and avoid talking about both their physical and emotional concerns in order to avoid being a burden to their families. The consequences also included physical ones such as insomnia, loss of appetite, and loss of energy and strength. Feelings of a lack of freedom and an inability to make independent choices and make and/ or maintain friendship were also some of the potential consequences. The Chinese cultural tradition of suppressing emotions may have prevented these elderly Chinese from communicating their needs and desires, with the possibility of both their adult children and health-care providers remaining unaware of their needs.

D References Blau, P.M. 1964. Exchange and power in social life. New York: John Wiley & Sons. Bond, M.H. and K.K. Hwang. 1992. The social psychology of Chinese people. In The psychology of the Chinese people, ed. Bond, M.H. 213-66. Hong Kong: Oxford University Press. Chan, K.B. 1983. Coping with aging and managing self-identity: The social world of the elderly Chinese women. Canadian Ethnic Studies 15 (3): 36-50. Chen, J. 1980. The Chinese of America. Cambridge: Harper & Row. Cheung, E. 1989. The elder Chinese. San Diego, CA: San Diego State University Centre on Aging. Cho, P J. 1990. Family care of the Asian American elderly: Myth or reality? In Aging and old age in diverse populations: Research papers presented at minority affairs initiative empowerment conferences, American Association of Retired Persons. 5588. Washington, DC: Minority Affairs Initiative, American Association of Retired Persons. Clark, M. and B. Anderson. 1967. Culture and aging. Springfield, IL: Charles C. Thomas.

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Coombs, S. 1986. Understanding seniors and culture: Multicultural guide 3. Edmonton, Canada: Alberta Culture, Cultural Heritage Division. Dowd, J J. 1975. Aging as exchange: A preface to theory, fournal of Gerontology 30 (5): 584-94. Driedger, L. and N.L. Chappell. 1987. Aging and ethnicity: Toward an interface. Toronto, ON: Butterworths. Fuchs, J. 1987. Use of decisional control to combat powerlessness. American Nephrology Nurses Association fournal 14 (1): 11-3. Fuller, S. 1978. Inhibiting helplessness in elderly people, fournal of Gerontological Nursing 4 (4): 18-22. Glaser, B.G. and A.L. Strauss. 1967. The discovery of grounded theory: Strategies for qualitative research. New York: Aldine De Gruyter. Hsu, F.L.K. 1967. Under the ancestor's shadow. Garden City, NY: Doubleday. Kim, Y.Y. 1988. Intercultural personhood: An integration of Eastern and Western perspectives. In Intercultural communication: A reader (fifth edition), eds. Samovar, L.A. and R.E. Porter. 344-51. Belmont, C.A: Wadsworth. Lang, O. 1968. Chinese family and society. New York: Archon Books. Lee, M.S., K.S. Crittenden and E. Yu. 1996. Social support and depression among elderly Korean immigrants in the United States. International fournal on Aging and Human Development 42 (4): 313-27. Lee, R.N.F. 1986. The Chinese perception of mental illness in the Canadian mosaic. Canada's Mental Health 34 (4): 2-4. . 1994. Passage from the homeland. Canadian Nurse 90 (9): 27-32. Leong, A. 1976. Mental health and the Chinese community. In Outreach for understanding: A report on the intercultural seminars, ed. Bancroft, G. 56-60. Ottawa, Canada: Ontario Ministry of Culture and Recreation. McKenna, M. 1995. Transcultural perspectives in the nursing care of the elderly. In Transcultural concepts in nursing care (second edition), eds. Andrews, M.M. and J.S. Boyle. 203-34. Philadelphia: Lippincott. Mehta, K. 1997. Cultural scripts and the social integration of older people. Aging and Society 17: 253-75. Mui, A.C. 1998. Living alone and depression among older Chinese immigrants, fournal of Gerontological Social Work 30 (3/4): 147-66. National Advisory Council on Aging. 1993. Aging vignette #3: A quick portrait of Canadian seniors. Ottawa, ON: National Advisory Council on Aging. Premier's Council on Health Strategy. 1994. Nurturing health: A framework on the determinants of health. Toronto, Canada: Premier's Council on Health Strategy. Rathbone-McCuan, E. and J. Hashimi. 1982. Isolated elders. Rockville, MD: Aspen Systems. Reich, J.W. and A.J. Zautra. 1990. Dispositional control beliefs and the consequences of a control-enhancing intervention, fournal of Gerontology: Psychological Sciences 45 (2): 46-51. Seelbach, E. and W. Sauer. 1977. Filial responsibility expectations and morale among aged parents. The Gerontologist 17 (6): 492-9. Seligman, M. 1975. Helplessness: On depression, development, and death. San Francisco: W.H. Freeman. Statistics Canada. 1996. Profile of divisions and subdivisions in Newfoundland. Catalogue

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no. 95-182-XPB. Ottawa, Canada: Statistics Canada. Tilden, V.P. and R.D. Gaylen. 1987. Cost and conflict: The darker side of social support. Western fournal of Nursing Research 9 (1): 9-18. Tsai, D.T. and R.A. Lopez. 1997. The use of social supports by elderly Chinese immigrants, fournal of Gerontological Social Work 29 (1): 77-94. Walster, E., G.W. Walster and E. Bercheid. 1978. Equity theory and research. Boston: Allyn & Bacon. Wu, F.Y.T. 1975. Mandarin-speaking aged Chinese in the Los Angeles area. The Gerontologist 15 (3): 271-5. Yang, C.K. 1957. The functional relationships between Confucian thought and Chinese religion. In Chinese thought and institutions, ed. Fairbank, J.K. 269-90. Chicago: University of Chicago Press. Yu, L.C. 1983. Patterns of filial belief and behaviour within the contemporary Chinese American family. International fournal of Sociology of the Family 13 (1): 17-35. Ziegler, M. and D. Reid. 1979. Correlates of locus of control in two samples of elderly persons: Community residents and hospitalized patients, fournal of Consulting and Clinical Psychology 47 (5): 977-9.

15

2 Long-term Care in Hong Kong: The Myth of Social Support and Integration Raymond Ngan and Edward

Leung

D Introduction: Rationalization of Community Care into Long-term Care as the Policy Objective Community care has been the major policy objective in developing services for the elderly in Hong Kong since its adoption in 1977 (Hong Kong government 1977). Not only has the notion of family care been commonly practised among the elderly Chinese, but it has also been accepted within the community as a family's responsibility to do so (Hong Kong government 1990). As community care seems to have been accepted as a culture-relevant policy for the aged, since it fits the concept of filial piety and family duty, the Working Group on Care of the Elderly recommended in 1994 that a policy of long-term care become key to the existing philosophy of providing services for elderly people in Hong Kong (Hong Kong government 1994). This policy of long-term care goes beyond the conventional community-care approach with the following new initiatives: 1. appropriate support should be provided for older persons and their families to allow elderly people to grow old in their home environment with minimal disruption. The concept of 'ageing in place', otherwise known as care in the community, has served us well in the past (as described in Hong Kong government 1994, p. viii); 2. a continuum of residential care and integration of services for those elderly whose families are not able to take care of them;

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RAYMOND NGAN AND EDWARD LEUNG

people-based approach and partnership among the public, subvented and private sectors; in Hong Kong government 1994, it was emphasized that the contribution of the subvented and private sectors must be encouraged and recognized. It seems that the Hong Kong government is following the developing trend towards 'the mixed economy of care provided by the public, subvented and private sectors' along that of the United Kingdom.

It seems clear that in Hong Kong, the hitherto policy of community care which has been accepted as the conventional wisdom approach to promote family care of the elderly, is now being further rationalized into a policy of long-term care to cater for different caring needs of the elderly Chinese. However, this chapter argues that the policy of long-term care is still largely a practising myth in Hong Kong as empirical experiences have shown that: 1. home-based support measures and programmes for family care-givers have not developed far, it being acknowledged only comparatively recently in Hong Kong government 1994; 2. at present, the continuum of residential care and integration of services are still largely fragmentary and piecemeal in nature; there exists a 'nocare' zone (Estes and Swan 1993) for those acute-illness patients who are discharged early from hospitals — family care-givers usually lack the basic nursing care techniques to handle their chronic but acute medical conditions, such as in the care of stroke patients. In the United Kingdom, stroke patients can normally stay a relatively longer time in hospitals than in Hong Kong. As hospital beds in Hong Kong are in tighter demand, patients are usually discharged early once their health conditions have only stabilized. When family care-givers cannot cope with their deteriorating conditions, such as a second or third stroke, incidents of these frail elders being sent to substandard private homes are usually heard. This is especially the case for those elderly suffering from dementia, paralegia and double incontinence (Leung 1992). 3. Research studies into the lives of elderly people living in Hong Kong's private homes have found that although there exists compulsory legislation regarding appropriate standards of care and practice, the staffing at these homes are in most cases inadequate and unqualified. Space standards are low and none of the homes have social workers. Social activities generally consist of only television-watching and little more (Kwan 1988). Furthermore, Leung (1992) has found that cases of gross neglect, if they exist, may be covered up easily, as deterioration in health and death can easily be construed as natural phenomena of old age. The obvious question one may ask is: What has gone wrong with this policy of rationalizing community care into long-term care? To answer this

I

LONG-TERM CARE IN HONG KONG: THE MYTH OF SOCIAL SUPPORT AND INTEGRATION

fundamental question in detail, the realities of long-term care in Hong Kong are discussed further in this chapter with data support from 'A Study of the Long-term Care Needs, Patterns and Impact of the Elderly in Hong Kong' (1994-96) by Ngan et al. (1996). The study has a sample of 945 elderly respondents. The myth of long-term care is then re-examined in the changing socio-economic-political contexts of Hong Kong. Can older people rely on their social support networks for care when they become frail? Empirical data from an updated study entitled 'A Study on the Effectiveness of the Home Care and Support Services for Frail Elderly People and their Caregivers' conducted by Ngan and Cheung (1999) will be studied. The remaining fundamental question to be answered is: What should be the appropriate roles of the government, the family and the elderly themselves in the provision of long-term care?

D Realities of Long-term Care Needs, Patterns and Impact of the Elderly in Hong Kong The context of long-term care in Hong Kong In Hong Kong, long-term care encompasses a spectrum of medical, personal and social services provided for elderly people because of their diminished capacity for self-care. With rising numbers of elderly people, there is an urgent need to review and evaluate existing service provisions available in the community, and the extent to which present care policies for the aged are adequate in meeting their needs. The demographic profile revealed 14.1% of the total population represented elderly people aged 60 or above in 1996, with a predicted rise of 19.7% by the year 2016 (Census and Statistics Department 1999). In 1999, the number of elderly people aged 70 or above was 482 900. This represents a 87% increase over that in 1986. By 2016, the number of those aged 70 or over is projected to reach 679 300, a 40% increase over that in 1999 (Legislative Council 2000). This is a cause for concern, particularly for the 'old-old' group (those aged 75 or above), who have more care needs and require extensive support services in the community. Earlier studies into waiting lists for residential care placements have shown that deficiencies and shortfalls of infirmary services exist as a result of an inefficient planning ratio of five beds per 1000 elderly people aged 65 or over (Chow 1988; Leung 1992; Yeung 1992). This arrangement can have adverse implications for informal carers (Kwan 1991; Ngan and Cheng 1992). The central waiting list for medical infirmaries stood at more than 4000 persons in autumn 1996. A large-scale study on the long-term care needs

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RAYMOND NGAN AND EDWARD LEUNG

J

and patterns of the elderly in Hong Kong was conducted from 1994 to 1996, so as to obtain a profile of the physical, social and mental functioning levels and care needs of elderly people in the community and in various aged-care institutions. In this study, long-term care is defined as 'a range of services that addresses the health, personal care and social needs of individuals who lack some capacity for self-care' (Kane and Kane 1987, p. 4).

Conceptual framework and sampling frame of the Long-term Care Needs study Figure 1 shows the conceptual framework underpinning the study. It was hypothesized that with the increase in the old-old population and the changing family structure in Hong Kong, a greater demand for long-term care services would be expected.

Social-political changes affecting family structures

Increase in the number of old-old elders

INCREASE IN LONG-TERM CARE NEED

Community care

Waiting list for services

nstitutional care

Home help, outreaching teams

Care and attention homes, infirmaries

Private/govemmentsubvented infirmaries, care and attention homes

Assessment of long-term care needs of elderly people (over 60) is made using:

FUNCTIONING LEVELS Physical

Barthel A.D.L. Index

Social

Network Orientation Scale (NOS) Social Support Appraisal Scale (SSAS)

Mental

Short Portable Mental Status Questionnaire (SPMSQ) Geriatric Depression Scale (GDS) Index of Self Esteem (ISE)

i

r

C D E V E L O P A LONG-TERM CARE POLICY^ Figure 1 The conceptual framework

LONG-TERM CARE IN HONG KONG' THE MYTH OF SOCIAL SUPPORT AND INTEGRATION

A total of 945 elderly people were successfully interviewed over the period from April 1995 to January 1996. Subjects were obtained from four main sources with stratified random sampling: those in need of institutional care on waiting lists of medical infirmaries and care and attention homes; those currently receiving community support services from home-help teams, community nursing service and outreaching teams; those currently staying in residential homes like infirmaries, care and attention homes, and private residential homes; and a random sample of elderly people from the community screened by the Barthel A.D.L. Scale<85 or SPMSQ<7 (Short Portable Mental Status Questionnaire) so as to locate suitable elderly respondents in need of long-term care services as detected by their frail functional disabilities or mental impairment. Table 1 shows the distribution of respondents in the four sample groups.

Table 1 The distribution of respondents in the four sample groups r, , Sample group

-r Types of services

On waiting lists

Care and attention homes, and infirmaries

39 1 %

Staying in institutions

Private and subvented aged homes, and infirmaries

23 4%

Living in the community Receiving community care

Percentage ,.. _ q.f..

20 8% Home help, community nursing and outreaching teams

16 7%

It was not the intention of this Long-term Care Needs study to assess the planning ratios of various types of community support services. Rather, the primary objective of the study was to provide an updated profile of the characteristics, needs and patterns of elderly people who were receiving different types of elderly services or waiting for some forms of residential care in Hong Kong. Thus the stratified random sampling method in selecting the four sample groups was considered suitable for the study. To reiterate, it was not a community-wide random sampling among the elderly in Hong Kong, but a stratified random study of those elderly people in need of long-term care services. In our sample of 945 elderly respondents, 33.5% were male and 66.5% were female. Regarding their age distribution, most (95.3%) of them were between 60 and 89 years old (27.5% aged 60 to 69, 38.7% aged 70 to 79 and 29.1% aged 80 to 89). Taking all types of elderly homes into consideration, they were taking care of 49% of our respondents.

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RAYMOND NGAN AND EDWARD LEUNG

Long-term care or institutional care? Although the Hong Kong government has launched the policy of long-term care in 1994 and community care since 1977, it was found in our study that the demand for admission to subvented elderly homes should not be neglected. About 30% of our respondents who were living in the community or in private aged homes had applied for such services. What was more striking was the fact that large shortfalls in the provision of infirmary beds were evident. It was found that for those respondents who were already waiting for admission to infirmaries, over 59.3% were living in private aged homes, and only as few as 17.8% of these applicants were still living in their own homes (Table 2). Perhaps this indicated the inability of family care-givers in coping with the level of nursing care required for those older people in need of infirmaries. Table 2

Place of residence of elderly people on waiting lists

Place of residence Own home Aged homes/hostels Care and attention homes Infirmaries Private homes Hospitals Others Total

Infirmary waiting list

Care and attention homes waiting list

24 5 23 0 80 1 2

(17.8%) (3.7%) (17.0%) (0.0%) (59.3%) (0.7%) (1.5%)

101 59 27 2 34 1 10

(43.2%) (25.2%) (11.5%) (0.9%) (14.5%) (0.4%) (4.3%)

135

(100.0%)

234

(100.0%)

Instead of being trapped in a 'no care' zone, these frail elderly were hastily sent to substandard private aged homes as their family care-givers found that they were unable to look after them for long periods of time. This observation has also been found in other studies (Chow 1983; Kwan 1988; Leung 1992; Ngan 1990a and b). But does this match well with the wishes of frail older people? It seems that the concept of 'ageing in place', otherwise known as care in the community, has not served this group of frail elderly well in their own residence because they were dislocated reluctantly to substandard private homes. In this Long-term Care Needs study, it was found that the group who had applied for residential care had a significantly lower Barthel A.D.L. Index score than those who had not (73.5 versus 85). This indicates that functional ability is an important determinant on the need for long-term care. The main reasons for their application were: deteriorating health (51.9%), becoming less mobile (51.9%), living alone (44.4%), and family cannot look after them (33.3%). For those who had chosen not to apply for residential care, the major reasons were: no such need (35.1%), availability of family support

1

LONG-TERM CARE IN HONG KONG! THE MYTH OF SOCIAL SUPPORT AND INTEGRATION

(35.1%), and fear of living in institutions (21.6%). These findings show that the existence or absence of family support is crucial in determining the need for long-term care in the community. Appropriate support and strategies should be developed to enhance the ability of the family in looking after elderly people with physical, functional and mental disabilities in Hong Kong. In 1999, it took at least five to eight years for admission to an infirmary, and four to six years for admission to a care and attention home. What is unique in our study is the finding that more than half of those on the infirmary waiting list were already residing in private aged homes. In the case of those waitlisted for admission to a care and attention home, only 14.5% were living in private homes with another 25.2% in subvented aged homes. This implies that the need for infirmary placement was more urgent, acute and serious than that for placement for care and attention homes. However, during the long waiting period in their own residences, the majority of those awaiting admission to an infirmary would need to find some other places for care as their family care-givers were unable to cope with their deteriorating frail conditions. Hence, it was not unexpected that the majority of them would find the solution in substandard private aged homes. However, as the majority of private aged homes in Hong Kong were below the prescribed standards of practice, it is recommended that more stringent control on the medical and nursing care standards be applied in the regulation of private aged homes, or some form of home-based family support services be available to facilitate family care of these frail elderly people.

Physical and mental health status of older people in need of long-term care In this Long-term Care Needs study, it has been found that respondents who were waitlisted for infirmary placement did show a significantly higher prevalence of stroke (43.1%), dementia (24.8%) and Parkinsonism (7.5%) than other sample groups (Table 3). This indicates that stroke, dementia and Parkinsonism are the main factors among various medical conditions that determine the need for residential care, especially infirmary care. On comparing with those from the community sample, it shows that their prevalence of stroke (6.8%) and Parkinsonism (0.5%) was much lower than those waitlisted for placement for infirmaries and care and attention homes. The functional abilities of the various samples were studied using the Barthel A.D.L. Index. Table 4 gives a clear pattern on this. It was shown that over half of those respondents from the infirmary waiting list (54.1%) were in a status of total dependency, with a Barthel Index score of less than 35, whereas the corresponding Index scores for the care and attention homes

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Table 3

Prevalence of chronic illnesses among different sample sources Infirmary Care and attention waiting list homes waiting list

Diagnosis Hypertension Stroke Diabetes Arthritis Dementia Fracture femur Other fractures Parkinsonism Blindness Amputation

Table 4

Community nursing Community service and home help sample

(%)

(%)

(%)

(%)

22.5 43.1 15.0 15.7 24.8 7.5 6.8 7.5 3.0 1.5

28.4 21.5 20.1 14.1 4.3 5.2 7.0 2.6 3.4 0.4

22.6 22.4 15.9 17.6 3.7 8.3 7.4 2.8 0.0 2.8

27.8 6.8 25.1 7.1 0.0 1.6 6.1 0.5 3.6 1.0

p .4 <.05 .2 .06 <.001 .2 .6 <.001 .06 .2

Functional dependency among different sample sources

Barthel Index score 0-34 (total dependency) 35-55 (severe dependency) 56-94 (moderate dependency) 95-99 (mild dependency) 100 (total independency) Total (N=)

Infirmary waiting list

Care and attention homes waiting list

Community nursing service and home help

Community sample

73 (54.1%) 30 (22.2%) 20 (14.8%) 6 (4.4%) 6 (4.4%) 135

13 (5.6%) 22 (9.4%) 34 (14.5%) 59 (25.2%) 106 (45.3%) 234

8 (7.3%) 14 (12.8%) 17 (15.6%) 32 (29.4%) 38 (34.9%) 109

2 (1%) 5 (2.5%) 12 (6.1%) 21 (10.7%) 157 (79.7%) 197

Chi-square = 368.59, p < .001

waiting list were as low as 5.6%, for community nursing and home-help services 7.3%, and for the community sample, as low as 1%. In fact, those from the sample of community nursing service and home help had a mean Barthel Index score of 78.9, those from care and attention homes waiting list 84.3, while those from the community sample 95. The above findings show that the Barthel Index score is a reliable measurement in assessing the physical functioning level of elderly persons because it has good correlation in terms of assessing the need of various levels of institutional care for elderly people. The mental status of these 945 elderly respondents was assessed by the Chinese version of SPMSQ. It was found that the mean SPMSQ score was lowest among those living in medical infirmaries (1.52) and highest for those living in their own residence (5.99). Those living in private homes had the second lowest mean score (3.13). It shows that poor mental state is one of the determinants of the need for residential care, especially infirmary care.

L

LONG-TERM CARE IN HONG KONG: THE MYTH OF SOCIAL SUPPORT AND INTEGRATION 25

Table 5

SPMSQ scores by place of residence

Place of residence Own home Aged homes/hostels Care and attention homes Infirmaries Private homes Others

Number

Mean score

439 65 149 38 207 42

5.99 4.94 4.29 1.52 3.13 5.81

p< 001

The 15-item short version of the Geriatric Depression Scale (GDS) developed by Yesavage (1988) was adopted to measure depression among the respondents. This short version correlated considerably with the full version by Brink et al. (1983) and Chan (1996) (r = 0.66, p < .001). The present study recorded a reliability coefficient of 0.7396 (alpha) for the 15-item short version. The score range of GDS is from 0 to 15. A score of six or more on the 15-item short version indicates the presence of depression (Chan 1996). Based on this classification, Table 6 shows that close to 70% of the respondents in the present study could be considered as having a certain degree of depression which was significantly higher than the 30% prevalence rate reported by Rowe Table 6

Distribution of GDS scores among the respondents

GDS score

Frequency

Low (30%) 0 1 2 3 4 5 6

1 9 34 38 39 58 50

0.1 1.2 4.5 5.0 5.1 7.6 6.6

0.1 1.3 5.8 10.7 15.9 23.5 30.0

Middle (41%) 7 8 9 10

66 61 92 95

8.7 8.0 12.1 12.5

38.7 46.7 58.7 71.2

High (29%) 11 12 13 14 15

102 60 39 17 2

13.4 7.9 5.1 2.2 0.3

84.5 92.4 97.5 99.7 100.0

Total

763

100.0

100.0

Percentage

Cumulative percentage

valid cases = 763, mean = 8.23, median = 9 00, standard deviation = 3 26

26

RAYMOND NGAN AND EDWARD LEUNG

J

(1982) However, it needs to be pointed out that among the respondents, 41% had middle GDS scores (I e seven to ten points), suggesting at least having a certain degree of depression Perhaps it could be said that those elderly people who were m need of long-term care services were probably more easily depressed than others More importantly, mental health professionals should be more responsive to the long-term care needs of the elderly in this respect Analysis of the relationship between GDS scores and places of residence reveals that there was a higher proportion of respondents residing m their own residence who fell into the highly depressed category (p < 005) (Table 7) The question is why elderly people living m the community are relatively more depressed than those staying in institutions In the absence of an acceptable explanation, we can only leave it as a peculiar phenomenon for further investigation Nevertheless, we have found that there was a positive relationship between financial independence and one's sense of depression, as shown in Table 8 The family-dependent respondents and the publicdependent respondents (surviving on public assistance) were statistically significantly more depressed than the self-supported respondents The distribution of data m Table 8 reflects that if our concern is to lower the level of depression of the elderly, our first priority should be the provision of income security, and the universal and non-means-tested Old Age Pension

GDS scores by place of residence

Table 7 Degree of depression

Own home (private/public housing) N %

Aged homes/ hostels N %

Care and attention homes N %

Private aged homes N %

49 53 24

4 16 8

Low Middle High

116 166 143

(27 3) (39 1) (33 6)

17 24 18

(28 8) (40 7) (30 5)

Total

425 (100 0)

59

(100 0)

(38 9) (42 1) (19 0)

126 (100 0)

Infirmaries N

%

(14 3) (57 1) (28 6)

43 (35 2) 52 (42 6) 27 (22 1)

28 (100 0)

122 (99 9)

Chi square = 19 57 df = 8 p < 05

Table 8 Degree of depression

GDS scores by source of income

Self supported N %

Family dependent N %

Public dependent N %

Low Middle High

12 20 11

(27 9) (46 5) (25 6)

79 65 52

(40 3) (33 2) (26 5)

125 216 152

(41 3) (27 2) (31 5)

Total

43

(100 0)

196

(100 0)

493

(100 0)

Chi square = 15 962 df = 4 p < 01

I

LONG-TERM CARE IN HONG KONG! THE MYTH OF SOCIAL SUPPORT AND INTEGRATION

Scheme seems to be a reasonable approach. It was unfortunate, however, that the scheme was withdrawn by the Hong-Kong government who had originally proposed it to the Legislative Council in 1994.

D The Myth of Long-term Care Revisited The above Long-term Care Needs study seems to show that the policy of long-term care is still largely a beautiful practising myth and slogan in Hong Kong. To begin with, there exists a number of gaps and 'no-care zones' in providing long-term care for elderly people. First of all, formal care services through the provision of medical infirmaries and care and attention homes are still grossly inadequate. Private nursing homes appear to be the only option for those frail but 'no-care' elderly concerned. However, these homes' nursing care and staffing requirements are often below the standards of practice, and incidents of elders being abused or left unattended are not uncommon. It seems that they are the poor victims of these service gaps. Ideally, a comprehensive long-term care policy should encompass both adequate institutional and community care services, and a continuum of such services should be made readily accessible in line with the frail conditions of different elderly people. However, data from our Long-term Care Needs study shows that the provision of community support services for elderly people is grossly inadequate. A majority of elderly people have no knowledge of most of these services. This could also be resulted from a lack of facilities or lack of access. To further support elderly people in need of long-term care in the community, more innovative home support programmes with flexible time should be developed to cater for the needs of elderly people and their carers. There is a need for an overall revamp of the planning, provision and financing of longterm care services for elderly Chinese people in Hong Kong. Secondly, the hitherto policy of community care has neglected the longterm home-based caring needs of frail older Chinese people, especially the old-old group. The community support services developed in the 1970s and 1980s were largely geared to minor meals-on-wheels home help needs of disabled or weak elderly people. They were not of much use in lessening the mounting pressure for 'tending care' (Parker 1981), especially for family caregivers looking after their senior dependents with double incontinence or dementia. Training programmes in better equipping the home-care management of these family care-givers have been rare. Home-based training and support programmes for long-term care management of frail elderly people have not been started until having been acknowledged only comparatively

27

28

RAYMOND NGAN AND EDWARD LEUNG

recently in the 1994 Report of the Working Group on Care of the Elderly (Hong Kong government 1994). Thirdly, under the policy of long-term care, the limited development of institutional services seems understandable, as care of the elderly is a family duty and responsibility. However, our study has found that the demand for admission to a government-subvented elderly home should not be neglected. About 30% of our respondents who were living in their own residence or in private aged homes had applied for admission to such homes. In Hong Kong, there is a very long waiting period for admission to both medical infirmaries and care and attention homes, and it is a pity to note that some older people do pass away during the long waiting period. It seems unfair that their rights and entitlement to long-term care services have not been properly catered for. Fourthly, the so-called 'mixed economy of care' (care provided by the public, subvented and private sectors) sounds good on paper but difficult in practice. To those frail and disabled elderly, the public and subvented sectors are already in acute shortage with long waiting lists, whereas the private sector is mostly made up of private aged homes which are substandard in terms of their staffing, space and quality of care. What choices do these frail elders have? To make the situation worse, many family care-givers find that they are increasingly unable to cope with the technical complexities of family care for their elderly dependents whose health conditions have deteriorated over time (MacKenzie and Beck 1991). Indeed, in cases of senile dementia and paraplegic strokes, the advice of specialized health-care professionals, for example, physicians, home-care nurses, physiotherapists and occupational therapists, on how to care for such elderly at home is required. However, handicapped by a lack of such support and technical information, more and more care-givers tend to find that basic care patterns which have been previously provided are inadequate. As a result, they begin to feel helpless and 'all alone' with escalating levels of anxiety (Kwan 1991; Leung 1991; Ngan and Cheng 1992). This increasing sense of helplessness, if not properly handled, may cause them to seek unavoidable institutional care for their elderly dependents, even though care-givers know that this is against their wishes. Who is to be blamed for this 'caring dilemma' (Ngan 1993)?

Q The Myth of Social Support in Long-term Care Can older people in Hong Kong rely on their social support networks for care when they become frail and disabled? It is commonly assumed that the Chinese normally have an extensive network of informal care-givers for aid

I

LONG-TERM CARE IN HONG KONG! THE MYTH OF SOCIAL SUPPORT AND INTEGRATION

at times of contingencies. This is because apart from their family members, kin, friends and neighbours, the Chinese usually have a network of clansmen for help (Wong 1972). However, the study by Ngan (1990b) of 540 families in Hong Kong found that the number of reliable social support network confidants who could help them over difficulties was not large — 81% of them had a network size of not more than four persons. The mean was 2.9 and the standard deviation was 2.1. Furthermore, it was found that elderly respondents (those aged 60 or above) tended to have a smaller network than the other age groups. Worse still, 13.6% of them did not have any confidants for solving their difficulties (Ngan 1990a and b). The above findings are supported by Chi and Lee's study in 1989 on the informal support networks of the elderly in Hong Kong. Over 60% of their elderly respondents did not have any relatives or friends to whom they felt close, and in fact, most of them had an average of fewer than three persons whom they felt 'close to' or were willing to visit (Chi and Lee 1989). What are the patterns of social support networks of those older people in need of long-term care services? In the Long-term Care Needs study by Ngan et al. (1996), the following patterns of those older people's social support networks were found: 1. Those elderly respondents on the waiting lists of infirmaries and care and attention homes tended to have a relatively lower social network orientation and a lower level of social support when compared with respondents living in institutions or receiving community care services, notably, home help, community nursing and outreaching services (see Table 9). Table 9

Social support by sample source

Community care (CNS/HH/OR)* N %

On waiting lists (1, C&A)** N %

Elderly in the community (HKU)*** N %

SSAS*

Institutional care N %

Good Moderate Poor

70 48 47

(42.4) (29.1) (28.5)

52 39 30

(43.0) (32.2) (24.8)

64 104 96

(24.2) (39.4) (36.4)

49 101 41

(25.7) (52.9) (21.4)

165

(100.0)

121

(100.0)

264

(100.0)

191

(100.0)

Total

Chi-square = 42.0, df = 6, p < .001 t Social Support Appraisal Scale * Community Nursing Service/Home Help/Outreaching Services ** Infirmaries, care and attention homes * * * Sample provided by the University of Hong Kong Source: Ngan et al. (1996)

2.

Those elderly respondents whose mental functioning level was low also had a lower degree of social support (37.5% in such category having

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30

RAYMOND NGAN AND EDWARD LEUNG

poor social support compared to 20.1% having good social support — see Table 10). On the other hand, those respondents who had a higher degree of social support happened to have a higher level of mental functioning (37.5% of such higher level elderly had good support compared to 27.2% of such persons who had low support — see Table 10).

Table 10 Social support by mental status SPMSO Severely impaired N %

SSAS Good Moderate Poor Total

Mildly impaired N %

Cognitively intact N %

37 78 69

(20.1) (42.4) (37.5)

11 100 57

(32.9) (42.7) (24.4)

121 114 88

(37.5) (35.3) (27.2)

184

(100.0)

234

(100.0)

323

(100.0)

Chi-square = 20.4, df = 4, p < 001 Source- Ngan et al. (1996)

3.

Multiple regression analysis shows that the higher the elderly respondents' Barthel A.D.L. scores, the higher their network orientation (Table 11).

Table 11

Network orientation by health status Barthel A.D.L. score

0-34

NOS*

56-84

35-55

85-99 %

N

%

N

%

N

%

N

Good Moderate Poor

11 25 10

(23.9) (54.3) (21.8)

20 28 19

(29.9) (41.8) (28.3)

40 26 30

(41.7) (27.1) (31.2)

64 45 76

Total

46 (100.0)

67 (100.0)

96 (100.0)

(34.6) (24.3) (41.1)

185 (100.0)

N 104 172 81

100 % (29.1) (48.2) (22.7)

357 (100.0)

* Network Orientation Scale Chi-square = 44.6, df = 8, p < .001 Source: Ngan et al. (1996)

The above findings denote an overriding concern: those older people who had poor Barthel A.D.L. scores and poor SPMSQ scores were also suffering from poor social network orientation and social support appraisals. Despite their strong need for social support, help from their informal networks appeared little and insufficient. Data from a recent evaluative study on the effectiveness of the home care and support services for frail elderly people and their care-givers by Ngan and Cheung (1999) also found that relatives and friends did not appear to

1

LONG-TERM CARE IN HONG KONG! THE MYTH OF SOCIAL SUPPORT AND INTEGRATION

have visited the frail elderly respondents more frequently over time. Analysis of the data from 116 frail old people showed that despite the common belief that friends and relatives tended to visit them more frequently in subsequent visits, the survey data from these elderly respondents found that their friends and relatives had not visited them more in visits 2 and 3 (each with an interval of three months). Data from Table 13 even showed that the time effect was negative, meaning that elders tended to report that they had fewer relatives and friends to visit them in subsequent visits (an average drop of 7.3 persons for the visit in the last three months), nor did they perceive that their friends and relatives cared them more in the last three months.

Table 12

Mean of the elder's social relationship measured by frequency of visits by relatives or friends over quarterly recorded periods

Variable 1 2

Elder having more relatives or friends visit you in the last three months (0-100) Elder recognizing that relatives or friends care about the elder more in the last three months (0-100)

Visit 1

Visit 2

Visit 3

20.7

12.5

11.1

20.7

18.8

13.9

Source : Ngan and Cheung 1999

Table 13

Effects of visits 2 and 3 on the elder's social relationship, each visit at an interval of three months

Variable 3 4

Elder having more relatives or friends visit you in the last three months (0-100) Elder recognizing that relatives or friends care about the elder more in the last three months (0-100)

Visit 2

Visit 3

Average

Every , , ten days

-12.2

14.8

-7.3

-0.65*

-7.8

-11.2

-5.6

-0.56

*p< .5 Source: Ngan and Cheung 1999

i Conclusion: The Myth of Integration In addition to adopting the attractive slogan of long-term care for the elderly, resources should be identified to develop long-term care services and home support programmes to assist family carers to care for their elderly dependents in their home environment with minimal disruption. A continuum of integrative community support programmes and long-term institutional care services needs to be formulated early with up-to-date planning ratios in accordance with the changing needs of the ageing population in Hong Kong.

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RAYMOND NGAN AND EDWARD LEUNG

New and innovative home support programmes need to be devised to provide timely help and training to family care-givers. There is a need for an overall revamp of the planning, provision and financing of long-term care services for elderly people in Hong Kong. Having simply raised the eligibility age of these services from 60 to 65, as proposed in the 1994 Report of the Working Group on Care of the Elderly (Hong Kong government 1994), has not solved the plight of family carers of effectively looking after their elderly dependents at home. Filial piety is a good noble spirit among the Chinese, but it needs to be backed up by appropriate home support care programmes to assist filial sons and daughters to care for their frail and aged parents for long periods of time in their own residence. The size and structure of the Chinese family are very different from what we used to have in Confucius China in the old days. The notion of family duty in caring for ageing parents should be realistically assessed in the light of these changes and of the enlarging 'care gap' (Walker and Walker 1985) between the demand for family care and supply of unpaid female care-givers. These changes ought to be fundamentally examined in formulating a successful long-term care policy for the elderly, especially with due regard to the long-term care needs of frail older people and their family care-givers. Attempts should be made to widen and strengthen the social support networks of frail elderly people. Simply relying on a cultural myth of family obligations without a continuum of long-term care services as a backup would only result in lonely and unhappy integration of frail elderly in the community, building on the mounting care-giving strain of family carers.

i References Brink, T.L., J.A. Yesavage, O. Lurn, P.H. Heersema, M. Adey and T.T. Rose. 1983. Screening test for geriatric depression. Clinical Gerontology 10: 37-48. Census and Statistics Department. 1999. Hong Kong annual digest of statistics. Hong Kong: Hong Kong Government Printer. Chan, A. 1996. Clinical validation of the geriatric depression scale. Journal of Aging and Health 8 (2): 238-53. Chi, I. and J.J. Lee. 1989. A health survey of the elderly in Hong Kong. (Resource paper series no. 14.) Hong Kong: Department of Social Work and Social Administration, the University of Hong Kong. Chow, N. 1983. The Chinese family and support of the elderly in Hong Kong. The Gerontologist 23 (6): 584-8. . 1988. Caregiving for the elderly awaiting admission into care and attention homes. (Research report.) Hong Kong: Department of Social Work and Social Administration, the University of Hong Kong.

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LONG-TERM CARE IN HONG KONG: THE MYTH OF SOCIAL SUPPORT AND INTEGRATION

Estes, C.L. and J.H. Swan. 1993. The long term care crisis. Newbury Park, Calif.: SAGE Publications. Ho, S.C. and J. Woo. 1994. Social and health profile of the Hong Kong old-old population. (Research report.) Hong Kong: The Chinese University of Hong Kong. Hong Kong government. 1977. Green paper on services for the elderly. Hong Kong: Government Printer. . 1990. Social welfare into the 1990s and beyond. (White paper.) Hong Kong: Government Printer. . 1994. Report of the Working Group on Care of the Elderly. Hong Kong: Government Printer. Kane, R.A. and R.L. Kane. 1987. Long term care: Principles, Programme and Policies. New York: Springer. Kwan, A. 1988. A study on the residential life of the elderly in the private elderly homes in Hong Kong. (Research report.) Hong Kong: Writers' and Publishers' Cooperative. . 1991. A study of the coping behaviour of caregivers in Hong Kong. (Research report.) Hong Kong: Writers' and Publishers' Cooperative. . 1995. Meeting the needs of the elderly population in Hong Kong: Burden or challenge? In Contemporary trend of social service, ed. Chan, Alfred. Hong Kong: Hong Kong Social Sciences Centre. Legislative Council, Hong Kong. 2000. Panel on welfare services meeting on 10 January 2000. Leung, E. 1991. An inquiry into the problem of elderly abuse in Hong Kong. Hong Kong Journal of Gerontology 3 (1): 6-9. Leung, E.M.F. 1992. The problem of residential nursing care for the elderly in Hong Kong. Hong Kong Journal of Gerontology 6 (2): 13-9. MacKenzie, P.A. and I. Beck. 1991. Social work practice with dementia patients in adult day care. In Social work practice with the elderly, eds. Holosko, M.J. and M.D. Feit. 191-217. Toronto: Canadian Scholars' Press. Ngan, R. 1990a. The availability of informal support networks to the Chinese elderly in Hong Kong and its implications for practice. Hong Kong Journal of Gerontology 4 (2): 19-27. . 1990b. Informal caring networks among Chinese families in Hong Kong. (Unpublished Ph.D. thesis.) Hong Kong: Department of Social Work, the University of Hong Kong. . 1993. The caring dilemma: Towards effective counselling for caregivers of Chinese frail elderly. Asian Journal of Counselling 2 (1): 7-16. and I. Cheng. 1992. The caring dilemma: Stress and needs of caregivers for the Chinese frail elderly. Hong Kong Journal of Gerontology 6 (2): 34-41. , E.M.F. Leung, A. Kwan, D. Yeung and A. Chong. 1996. A study of the longterm care needs, patterns and impact of the elderly in Hong Kong. (Research report.) Hong Kong: Department of Applied Social Studies, City University of Hong Kong. and J. Cheung. 1999. A study on the effectiveness of the home care and support services for frail elderly people and their caregivers. (Research report.) Hong Kong: Haven of Hope Christian Service and Department of Applied Social Studies, City University of Hong Kong.

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Parker, R. 1981. Tending and social policy. In A new look at the personal social services, eds. Goldberg, E.M. and S. Hatch. 17-32. London: Policy Study Institute. Rowe, C.J. 1982. An outline of psychiatry. Iowa, USA: Win C. Brown Company Publisher. Walker, A. and C. Walker. 1985. The care gap. London: Local government. Wong, A.K. 1972. The kaifong association and the society of Hong Kong. Taiwan: the Orient Cultural Service. Yesavage, J.A. 1988. Geriatric depression scale. Psychopharmacology Bulletin 24 (4): 709-11. Yeung, S. 1992. The community care policy of services for the elderly in Hong Kong: A critique. Hong Kong Journal of Gerontology 6 (2): 8-12.

I Authors' Note Members of the 1994-96 Long-term Care Research Team are Raymond Ngan, Edward Leung, Alex Yui-huen Kwan, David Yeung and Alice M.L. Chong.

I Acknowledgements The authors would like to thank the City University of Hong Kong for the granting of a Strategic Research Grant, and the 945 elderly people who had participated in the community-wide survey on long-term care needs. This study was awarded the Outstanding Research in Gerontology by the Hong Kong Association of Gerontology in 1997.

3 The Lives of Elderly Bird-keepers: A Case Study of Hong Kong Ho-hon Leung

Bird-keeping is extremely popular in Hong Kong. A newspaper columnist once reported that bird-shop owners estimated there were about 200 000 birdkeepers in Hong Kong. Although the number may not be accurate, we can see that people keep birds everywhere. If we look into the windows of any residential buildings, it is not difficult to find cages hung against windows or in the balcony. Taxi or mini-van (a public transport) drivers take their birds to work. The popularity of bird-keeping is unquestionable. Who are these bird-keepers? They are children, women and men of all ages. However, those who are 'visible' (seen walking their birds wherever they go or gathering at parks) are almost exclusively men. And a great number of these men are older people. From conversations with several bird-shop owners and some old bird-keepers, we learnt that many older people find life boring and lonely after they have retired; keeping birds is one way of fighting boredom. Why are they bored? Why are they lonely? What do they do in retirement other than keeping birds? Do they have families? Do they have adequate social support? A series of questions such as these eventually led to this structured inquiry. This study attempts to explore the lives of these elderly and, in particular, the role that bird-keeping plays in their lives. In recent years, students of gerontology have spent much effort in exploring the question of whether the quality of life of both institutionalized and non-institutionalized older persons has been enhanced after they have

36

HO-HON LEUNG

interacted with pets, usually dogs and cats. These researches are usually carried out in two ways: (1) experimental — introducing a pet into the life of the subjects for a period of time and measuring any change of degree in their emotional state and behaviour (e.g. Banziger and Roush 1983; Hendy 1987; Mayhew 1988; Winkler et al. 1989; Chinner and Dalziel 1991); (2) nonexperimental — studying those elderly who keep pets at home (e.g. Ory and Goldberg 1983; Mahalski et al. 1988; Robins et al. 1991; Miller et al. 1992). In general, the findings have produced mixed results. Although the results are not always consistent that pets enhance the morale of the elderly and benefit their well-being, no studies have suggested that pets have any negative impacts on the elderly. This case study on elderly bird-keepers in Hong Kong intends to explore beyond whether keeping birds enhances the quality of life of the elderly, but also to their bird-keeping behaviour in relation to their lives, and social and cultural environment, which is often overlooked in the study of gerontology. Modernization theory may shed some light on the life of the elderly. Many studies suggest that modernization has a negative impact on the life of the elderly (Burgess 1960; Cowgill and Holmes 1972). Cowgill (1974) argues that modernization weakens the compatibility of the elderly, the notion of the family and intergenerational cohesion; consequently, the elderly are forced to depend on their children financially. Although Palmore and Manton (1974) find a J-shape relationship between education, occupation and employment status to modernization, the elderly who were born before World War II are less likely to enjoy such progress. Cohn's study (1982) also supports the modernization theory. He finds that when economic development of a society advances, professional and technical people are in great demand. Older workers are less competitive in the market because younger workers are more likely to have had more job-specific schooling to meet those requirements. Furthermore, modernization is so widespread that no part in the world is left unaffected. Goldstein and Beall (1981 and 1982) find that adult Sherpa children in Nepal who could not find work there are forced to engage in wage-labour work in Darjeeling, India. This outward migration upsets the traditional family structure. And they cannot fulfil their family duties of looking after their elders. Therefore, the elderly Sherpas, though living in a rural area in Nepal, also suffer from emotional and psychological adjustment. But Goldstein and Beall also find that these elders, at the same time, are still healthy, productive and financially dependent. They further argue that the lives of the elderly should not be examined in a single dimension, but in a multidimensional fashion. In sum, studies suggest that the elderly in both industrial and nonindustrial societies are suffering one way or the other. In most cases, older people have lost their power in economic competition to younger and better-

THE LIVES OF ELDERLY BIRD-KEEPERS! A CASE STUDY OF HONG KONG

educated groups. However, some studies (Cool 1980; Palmore 1980) also point out that some elders may maintain a high status in other social aspects because of different cultures of different ethnic groups. This study attempts to explore the lives of these 'visible' bird-keepers in relation to their bird-keeping behaviour. Furthermore, this is an excellent opportunity to examine what role this very unique culture of bird-keeping plays in their lives in an ever-changing city like Hong Kong. Therefore, the social and cultural environment will be taken into account as a variable of their behaviour. The multidimensional concepts of status developed by Goldstein and Beall (1981) will be adopted to explore the lives of these elderly.

D Methodology Data was collected by two different methods, one by an open-ended questionnaire and the other by qualitative interviews and observations. Both of the methods will be discussed in the following sections. Since the size of the population of bird-keepers was unknown, it was impossible to get a random sample. Although we had approached the Agriculture and Fisheries Department to inquire about the volume of sales of birds, with the hope of making an estimate of the population of bird-keepers, the attempt was not successful. We had also tried the Society for the Prevention of Cruelty to Animals of Hong Kong, but had no luck there either. Our strategy then was to interview as many people in as many areas as possible where bird-keepers frequently gathered. Eighty-nine questionnaires were sufficiently completed to be usable. Because bird-keepers who walk their birds are almost exclusively male, of the 89 interviewees, 85 were men and only 4 were women. 1 Those who were 50 or over were interviewed. In the open-ended questionnaire, there were two sections. The first section explored the lives of these elderly people. A set of variables were used. Adapting the multidimensional concepts of status developed by Goldstein and Beall (1981), we explored their lives in several areas: their family structure and family life, socio-economic status, activity status (the work and activities actually performed by the elderly), and psychological status (the degree to which the elderly were satisfied with their current situation). The second section explored the relationship between the elderly and their birds. We asked some general questions about their bird-keeping behaviour. More specifically, we asked: 'How is your present life with birds different from life without birds?' and 'What kind of satisfaction can you get from bird-keeping?' In-depth interviews and observations were also conducted. In order to

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understand the culture of bird-keeping in Hong Kong, we interviewed two birdshop owners in the Bird Street2 which was the busiest and biggest area in this business; there were about 50 different shops that sold birds, cages, bird food and other accessories. We also conducted interviews with and observations on four bird-keepers whom we followed wherever they went with their birds and observed for a period of time how they interacted with their birds. Other observations were conducted in different places where bird-keepers gathered: parks, the Bird Street and a tea-house that was most popular with bird-keepers. The total hours spent on interviews were 14 and on observations about 20. It should be noted that since most of our questions were open-ended, not all the interviewees responded to all the questions. That is why when the findings were reported, not all numbers could be summed up to 89. Since much data was generated through open-ended questions, some data required recoding in order to create meaningful variables for discussion. The ways of recoding these data are reported wherever appropriate in the form of endnotes.

I Findings The findings are reported in two sections. The first one is on the lives of the elderly. The second is about their practice of bird-keeping. Table 1 summarizes the demographic characteristics of the interviewees. As we can see, most of these elderly bird-keepers were male, over 60 years of age, married, born in China and retired. Table 1 Demographic characteristics of interviewees Age

50-59 60-69 70 or older

21.3% (19)41.6% (37) 37.1% (33)

Sex

Male Female

95.5% (85) 4.5% (4)

Marital status3

Married Single Divorced/widowed

79.8% (71) 10.1% (9) 10.1% (9)

China Hong Kong Other Asian countries

86.5% (77) 9.0% (8) 4.5% (4)

Retired Full-time Part-time Unemployed/never worked

68.5% 22.5% 2.3% 6.7%

Place of birth

Work status

(61) (20) (2) (6)

THE LIVES OF ELDERLY BIRD-KEEPERS: A CASE STUDY OF HONG KONG

Family structure and family life To find out what kind of life the elderly were living in this ever-changing city, we asked the interviewees questions related to their family structure and family life. Although the nuclear family is the dominant family structure (Chi and Chow 1998, p. 50), this does not mean that the majority of the elderly live alone. The reason is that elderly people who are now in their 60s or 70s usually have three or more children. Even when all the children have grown up and married, they could still live with at least one of them. Therefore, physical segregation does not pose a problem for the elderly. Our findings support this argument. Our data show that 21.3% (19/89) of the interviewees had six to ten children, 44.9% (40/89) had three to five children, and 25.8% (23/89) had only one or two. A small percentage, 7.9% (7/89), reported that they had no children. The majority of those who had children, 71.9% (64/89), lived with at least one of their children; only 27.0% (24/89) lived with only their spouse or alone. The next question we asked was 'whether their children were filial4 to them'. Filial piety is one of the most salient virtues in the Chinese family. One aspect of filial piety demands that the family be the centre of loyalty. This reinforces the obligation and duty that adult children are expected to take care of their elderly parents (Leung and Nann 1995, p. 2). Of those who answered the question, a great majority of the elderly, 77.6% (59/76), reported that their children were filial to them; only 10.5% (8/76) complained that their children were unfilial to them. The rest, 11.8% (9/76), thought their children were acceptable. Furthermore, we were interested in knowing in what ways the elderly felt their children were or were not filial to them. Of the most frequently praised merits, 23.9% (27/113) related to financial support. Next, 19.5% (22/ 113) related to whether their children were concerned about them. The third merit (13.3%; 15/113) was that their children were obedient. Other virtues, such as paying them regular visits and taking care of them, 12.4% (14/113) and 11.5% (13/113) respectively, were also frequently mentioned. On the opposite side, when their children failed to support them financially or were not obedient, they thought they were unfilial. Each of these two variables takes up 23.8% (5/21). In short, most of the elderly in this study perceived their children as filial to them. Financial support and concern about the parents were the most important factors determining whether a child was perceived as filial, while lack of financial support and being disobedient were construed as the opposite. The next question we were interested in was how frequently they had family activities with their children. Of the 80 elderly who had children and responded to this question, 37.5% (30/80) had family activities with their

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children occasionally; 38.8% (31/80) reported that they had no family activities at all; 22.5% (18/80) said they had regular (weekly or biweekly) family activities; only 1.3% (1/80) claimed having frequent family activities. For those elderly persons whose children had moved out, if they had family activities, weekly visits and going to a tea-house on Sundays were their major activities. For those who still lived with their children, the usual family activities were having meals, watching television and sometimes going to a tea-house together on Sundays. It seems that they had very little communication with one another. When we asked, 'Are your children usually home after they finish work or classes?' 58.2% (32/55) of the elderly reported that their children were usually home, and the rest, 41.8 % (23/55), reported otherwise. In the case of those who claimed that their children were usually home, it does not mean that the children would keep their parents company. The young usually attended to their own activities. Only 13.3% (4/30) of the elderly mentioned that the activities of the children involved them, such as chatting with them. The majority, 86.7% (26/30), of the children were busy with their studies, their computers (games or work), watching TV or going to sleep early after long hours of work. Half, 50% (12/24), of the elderly who reported that their children were not usually home after work or classes said that their children always enjoyed their own world outside with their friends or took part in activities held by the clubs they joined; 16.7% (4/24) did not know where their children were in the evenings. A quarter, 25% (6/24), reported that their children were constantly at work or studying. For example, one elderly man said, 'My son works very hard. He has a regular job during the day, and works as a taxi driver at night and on weekends. We seldom see each other.' A small percentage, 8.3% (2/24), of the interviewees said that their adult children spent most of their time with their own families. Since there was little interaction between the interviewees and their children, what about with their spouses? We asked: 'Is your spouse usually home?' The majority, 68.8% (44/64), answered yes; 21.9% (14/64) answered no; and a small percentage, 9.4% (6/64), gave the answer 'sometimes'. When their spouses, here mostly wives, were home, what did they usually do? The majority, 87.0% (40/46), reported that they spent their time doing household chores and taking care of grandchildren. The rest, 13.0% (6/46), said that their spouses played mah-jong, a Chinese tile game, and attended to their own business. Slightly over one-third, 36.8% (7/19), who replied that their spouses were not usually home, said their spouses were at work; the same percentage reported that they attended to their own business such as playing mah-jong, travelling, spending time with their friends; the rest, 26.3% (5/ 19), said that their spouses were absent from home: they either were in China or stayed with their daughters taking care of the grandchildren. Contrasting

THE LIVES OF ELDERLY BIRD-KEEPERS! A CASE STUDY OF HONG KONG

with the question asked about their children, no respondents mentioned chatting with their spouses as part of the family activities. Contact with their relatives was also limited. The majority, 69.7% (23/ 33), said that they rarely contacted their relatives. A small percentage, 9.1% (3/33), replied that they had no contact with them; and 21.2% (7/33) said that they had no relatives in Hong Kong. In sum, although most of the elderly bird-keepers in the sample did not live alone, it seemed there was very little interaction with their family members. For those whose adult children were married and had moved out, the only family activities were mainly weekly or biweekly visits or going to a tea-house together.

Psychological status The elderly in Hong Kong live in a highly urbanized city characterized by rapid social change and uncertainty. An environment with such characteristics is disadvantageous to the elderly. Thus, theoretically, one would expect the elderly in Hong Kong to be dissatisfied with their lives. However, our findings do not support this. The majority of the interviewees, 67.9% (55/81), reported they were very satisfied or satisfied with their lives; 26 people, 32.1%, said they were not satisfied with their lives. In order to check whether the high percentage of the elderly expressing life satisfaction was out of conventionality, we further asked: 'What changes would you like to make if you were able to?' Sixty percent (21/35) of the interviewees felt content with their current situation, keeping their lives as they were. A little more than one-tenth, 11.4% (4/35), wished that they could have more contact with their family members; 5.7% (2/35) wished they could have the following: better health, a bigger flat and other miscellanies; slightly more than one-third, 34.3% (12/35), claimed that nothing could be changed. Overall, these elderly bird-keepers were satisfied with their current lives.

Life satisfaction and the family What contributed to their life satisfaction? According to Goldstein and Beall (1981), the various dimensions of status can vary independently. For example, a rich person (high economic status) may not necessarily be a happy person (psychological status). It is worth probing into the correlation between the perception of a child's level of filial piety and the psychological status of the elderly parents, since the virtue of filial piety is a vital element in the Chinese society. However, since the number of cases in which the elderly parents

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found their children's level of filial piety acceptable was less than five, it was recoded as not filial. The findings are shown in Table 2. When they felt their children treated them with filial respect, they felt satisfaction in life. Table 2

Perceptions of children's level of filial piety and psychological status of the elderly parents

„, ., , . , XX, , . Children s level of filial M piety Filial Not filial

Psychology ' + , *\ Satisfied

79 3% 35 3%

status of the elderly parents .. ^ v , , Not satisfied

20 7% 64 7%

., N

58 17 Total = 75

Chi-square = 17 979, df = 1, p < 000

Socio-economic status5 Most of the respondents, 86.5% (77/89), were refugees or immigrants from China during World War II or the Civil War. That period of time was their golden age for school, but was interrupted by the wars. Since the majority of them, 65% (52/80), came to Hong Kong alone, they had to work to support themselves. Therefore, most of them had a very low level of education. The distribution of their education levels is as follows: no schooling at all, 7.4% (5/68); primary education, 67.6% (46/68); secondary education, 20.6% (14/ 68); technical training, 2.9% (2/68); university education, 1.5% (1/68). As a result, only a few, 4.5% (4/89), were engaged in professional occupations such as engineering. A small percentage, 18.0% (16/89), were proprietors who owned family businesses, such as a small retail store or a small garage. Slightly less than one-fifth, 19.1% (17/89), were skilled workers such as construction workers. A little more than a quarter, 27.0% (24/89), were semiskilled workers such as sewers, low-level white-collar workers and so on; the majority of them, 31.5% (28/89), were either labourers, including the unemployed, or housewives. Using the composite scale for socio-economic status created for this case study, most of the interviewees belonged to the lower socio-economic status. More than one-third, 69.7% (62/89), scored 11 or lower; only 30.3% (27/89) scored 12 or higher.

Activity status The elderly in this study can be divided into three categories in terms of their activities: those who had a job, those who had never worked outside

THE LIVES OF ELDERLY BIRD-KEEPERS! A CASE STUDY OF HONG KONG

home, and those who were retired or unemployed. The main activity for the first group was related to their workplace. For the second group, all of whom were women, their lives had not changed much: they were engaged in housework all the time. Since the majority of the elderly people in this study were retired, it would be interesting to probe into their lives after retirement. There were a variety of reasons for them to retire. Less than one-third, 29.2% (14/48), said that their retirement was due to poor health. Age took up 18.8% (9/48). Mandatory retirement, 12.5% (6/48), was another reason. The majority, 39.6% (19/48), had various other reasons, such as being laid off and so on, or a combination of the above reasons. Obviously, their main hobby was keeping birds. They usually got up very early, went to a park or took a morning walk with their birds. Some practised tai chi or other exercises. Then they went to a tea-house. In the afternoon, they took a nap and was out again with their birds until dinner time. After they finished dinner, watching TV or listening to the radio were their activities before bedtime. Furthermore, when asked, 'How do you feel about life after retirement?' a large percentage, 39.1% (25/64), reported that they felt good about it; 9.4% (6/64) felt the same; 12.5% (8/64) felt bored; 29.7% (19/64) felt they were financially deprived; the rest, 9.4% (6/64), felt a combination of the above.

D The Elderly and Their Birds In this section, two sets of data will be reported. The first set is about the general bird-keeping culture in Hong Kong. The data was drawn mainly from our in-depth interviews and observations. This will give the reader a general idea of what these bird-keepers were like. The second set will report the findings on these 89 elderly bird-keepers. This will focus on the specific relationship between them and their birds.

The bird-keeping culture in Hong Kong The bird-keeping culture in Hong Kong is very different from that in Western countries where birds are kept at home. Nobody takes them out for a walk. But Hong Kong bird-keepers do walk with them, when kept in a cage of course. This is a very common practice. Garisto (1992) describes the history of bird-keeping in the Chinese culture: birds and bird cages have been 'an essential element of Chinese domestic life' (p. 46). She further observes, 'By

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Ch'ien-lung [a Chinese emperor from 1735 to 1-796] reign, no family of station was without a caged songbird, and the cages of the era reflect not just a reverence for birds but a perfect melding of aesthetics and function' (p. 46). Keeping a bird can be a simple matter, just feeding them well and keeping them warm, but making a bird sing well does require some knowledge and experience. Choosing a bird to buy also requires good knowledge. Even the charisma of a bird matters. Some buy chicks to raise so that everything is in their control. They make sure that the chicks are well fed with a good diet, and that they learn from good birds to sing in the 'right' way. This may require a lot of work. No wonder many bird-keepers we interviewed and observed felt a sense of achievement if their birds sang well. A 53-year-old retired civil servant commented, T like their singing. I can get a sense of success if 1 can keep them healthy and beautiful.' When bird-keepers are with their birds, they interact with each other. Like people who keep dogs or cats, bird-keepers stroke and talk to their birds. When we interviewed a bird-shop owner, a woman in her early 50s, a male customer chatted with her. The man played with his bird while chatting. He moved his fingers rhythmically, attracting it and playing with it. The bird, a Black and White (a small black bird with white feathers on its wings which can sing beautifully) dashed to his fingers and tried to peck his fingers while it spread its wings wide. No doubt, bird-keeping is a part of Chinese culture; however, there might be other reasons why bird-keeping is popular in Hong Kong. Of all other reasons, space is one of them. Hong Kong people live in a highly dense environment. In the 1950s and 1960s, the government launched a long-term public housing programme to accommodate the huge influx of refugees. Since then, housing estates have been built where tens of thousands of people reside. More than 50% of the population live in public housing (Hong Kong government 1991, p. 192). For sanitary reasons, there are strict regulations prohibiting the keeping of dogs and cats in these buildings. Furthermore, space in a living quarter is very limited when judged by North American standards. It might be too crowded to keep a dog or a cat. In our sample, 56.2% (50/89) of the elderly lived in public housing; 34.8% (31/89) lived in privately owned flats; the rest, 9.0% (8/89), lived in various kinds of quarters. A 67-year-old retired shoemaker who used to live in a 1000 square foot flat, considered large in Hong Kong, with his family of five people, explained, 'After all my daughters moved out, that flat was too big for us. So we moved into this 300 square foot unit. I used to keep a dog and a cat, but here is too small for them.' Plants, fish and birds become many people's options. A bird-shop owner echoed, 'Cats and dogs are very difficult for older people. They don't provide the same interests. What can you talk about your dogs when you walk them? But birds, they can compare, study and show off,

THE LIVES OF ELDERLY BIRD-KEEPERS! A CASE STUDY OF HONG KONG

show off their cages and cups [referring to those fancy ones and the antiques]. If one keeps a good bird, one is proud. This is what makes people keep birds. They don't need to spend a lot of money on them, and birds don't take up a lot of space. Living in a flat of 200-300 square feet, they are able to keep birds but not dogs or cats. Having a bird is not demanding or difficult for them. Every morning and night, doing very simple work on them is alright. But dogs, even you don't eat, and before you go to bed, you must take the dogs out for nature's calls.' Perhaps this is the reason why another bird-shop keeper had the following comment:'. . . most people who keep birds are older people.'

The elderly, their birds and the fun How did these elderly interviewees pick up this hobby? The majority, 57.3% (47/82), said it was spontaneous; 37.8% (31/82) of the elderly said it was introduced by friends, colleagues or neighbours. A few, 4.9% (4/82), were encouraged by their family members. When asked to compare their lives with and without birds, 6 many of them gave more than one answer, so the percentage does not add up to 100. Only 10.6% (9/85) claimed that there was no difference. Close to half, 45.9% (39/85), thought 'now they have something to do', felt that 'before, life was boring' or claimed that 'it is easier to pass the time'. A 64-year-old man who had been laid off for three years started to keep a bird two months previously. His wife was still working, and all his adult children had moved out. He complained that '[a]fter retiring, life was so boring. I am less active now. I don't play mah-jong. All I face is the walls at home. My wife has to work. I am the only one at home. When I feel like it, I do some household chores or grocery shopping. My friend thought I was bored and gave a bird to me. Now I go to the park with my bird. I can chat with somebody [other bird-keepers]'. Some elderly interviewees, 10.6% (9/85), felt happier after they started keeping birds. A 75-year-old housewife lived with only her retired husband; her children had either emigrated to other countries or moved out. She said, T am much happier when I am with my birds [four of them]. Before, I was busy with housework. Now I am more relaxed. Something to attach to.' Another common response, 8.2% (7/85), was that they could make friends more easily when they kept birds. One of the purposes for keeping birds is to make them sing. An experienced bird-keeper and a bird-shop owner told us how they made their birds sing, 'We always say "walk the birds". This means that staying at one place is not good for them, so we carry them around wherever we go.' Another way of making them sing is to let them learn from each other. This is why many bird-keepers take their birds to parks. Besides

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listening to the birds sing, chatting with other bird-keepers is one of their activities. A retired welder who lived with his wife, an adult child and seven birds thought life after retirement was better. Now he did not have to work to make a living. Chatting with other bird-keepers became one of his major daily activities. He said, T got acquainted with some new friends after keeping birds. I met them when I took my birds out.' Other responses suggested that the elderly now had more chance to have a walk. In turn, they were more energetic and felt healthier. A few thought their income was very limited; they did not have much money to spend. Since bird-keeping could be very economical, in that way, they were able to be entertained for only very little money. The last question was about the kind of satisfaction they could get from their birds. 7 More than half, 56.3% (49/87), claimed that the singing of their birds satisfied them. Fifteen (17.2%) of the bird-keepers felt that now they had something to do that satisfied them. Thirteen (14.9%) reported that chatting with other bird-keepers was satisfying. Ten, 11.5%, related to their mental and physical well-being: they were less bored and got to exercise while walking the birds. Obviously, some of the positive changes brought about by their birds were the kind of satisfaction they got from them.

i Discussion and Conclusion Our findings suggest that, in general, these elderly bird-keepers fared quite well. It seems that the family system in Chinese culture reinforces a support system on which the elderly can rely. Most of the elderly in our sample had relatively low education levels and labour skills, because of the interruption brought by two wars in China, and they tended to be less competitive in the market, findings similar to those of other studies (Cowgill 1974; Palmore and Manton 1974; Cohn 1982). The socio-economic status of most of the respondents was low; therefore, many of them were financially dependent on their adult children. However, the elderly people's perception of their children's level of filial piety was positively related to their level of life satisfaction. The findings seem to indicate that their subjective views about objective conditions (low socio-economic status and dependency on their children) were far more important to their life satisfaction. Traditionally, in China, one of the purposes of having children was for protection in old age. While to be dependent on one's children in old age may be considered undesirable in North American societies, this generation of elderly Chinese in Hong Kong, due to their cultural upbringing, would feel that it was only natural, to the extent that they

THE LIVES OF ELDERLY BIRD-KEEPERS! A CASE STUDY OF HONG KONG

perceived that as long as their children provided for them, they would feel content (Palmore 1980; Keith, Fry and Ikies 1990). Furthermore, although the nuclear family has become the dominant form of social units, physical segregation is not a problem for the elderly here. About three-quarters of the interviewees lived with at least one child. Moreover, contrary to Chow's (1990) and Ikels' (1980) argument, most of them felt that their children did fulfil their filial duties by providing for them to satisfy their material needs, personal care needs and housing needs. However, regarding other aspects of their family life, this study has revealed a different picture. Chappell (1992, p. 4) argues that '[b]eing isolated from others does not in itself . . . necessarily lower psychological well-being. Conversely, individuals may have relatives and friends and yet feel isolated.' Our findings seem to reflect the latter phenomenon. Although the majority of our respondents lived with their family members, and their material and physical needs were satisfied, they could not find companions to talk to or spend time with. Many of their adult children were busy with their work and life in this fast-paced city, while their wives still played a very much traditional role, attending to household chores and taking care of grandchildren. They had very little time to enjoy family activities together. How do we explain the findings that while almost half of the respondents expressed that life after retirement was good, but only a few complained about being bored? Perhaps now their lives were more relaxing and they need not worry about making a living, and their adult children did take care of them. However, those who felt good about life after retirement may also feel bored. When the elderly were asked to compare their lives with and without birds, almost half of them came up with answers such as 'now I have something to do', 'before, life was boring' or 'it is easier to pass the time'. It is then safe to interpret that many of them found life after retirement boring, although good in general. And this is why these elderly people found a way to alleviate this problem — by keeping birds. While this study by no means suggests that bird-keeping is the only solution to boredom, we did find that bird-keeping has its appeal in many ways for older people in Hong Kong. First of all, studies on pets, almost exclusively on dogs and cats, indicate that pets have the functions of uplifting people and enhancing human interaction. This study finds that birds also have the same effects. The elderly bird-keepers in Hong Kong walk, play with and talk to their birds the way people in the West treat their dogs. This is also supported by the fact that many bird-keepers reported they felt uplifted after they started to keep birds. Furthermore, birds, like dogs (Robins et al. 1991; Rogers, Hart and Boltz 1993), are able to facilitate interaction among other bird-keepers in the parks and resting areas of housing estates. This suggests that the bird-keepers in our sample found that keeping birds could

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be a substitute for the missed human contact at home (cf. Mahalski et al. 1988). Secondly, because of the crowded living environment and strict regulations on pets in public housing, birds are much more preferable than dogs and cats. Thirdly, the elderly are motivated to take a walk, if they want their birds to sing well. This, in turn, leads the elderly to do some mild exercise which many need. It may improve their health. Finally, bird-keeping is generally cost-effective, except for those who opt for artistic cages and accessories, and expensive birds. Rastogi (1994, p. 110) finds that people's use of leisure and the types of leisure activities in which they participate are strongly associated with social class. More specifically, he finds that '. . . leisure time activities of the respondents of upper class were quite expensive from the economic point of view, while the leisure time activities of the lower class were mostly of inexpensive nature' (p. 110). Since the majority of our respondents came from the lower social stratum, birdkeeping was one of their within-reach options. In terms of successful ageing, bird-keeping is one of the accepted channels for elderly Chinese to age in Hong Kong. Riley, Foner and Waring (1988) argue that as one ages, one is normatively expected to take up or leave certain social roles. A retired elder walking his or her bird(s) and chatting with other bird-keepers in public is a 'normal' thing to do in Hong Kong. They have their fun, their social circle and their 'retired' role to play. No wonder almost 40% of our interviewees were encouraged to keep a bird by their friends, colleagues or family members. To conclude, it seems that the family played a supportive role in the lives of these 'visible' elderly bird-keepers. Their adult children, in general, took good care of their material and physical needs. In turn, their life satisfaction was high. However, due to the lifestyle of their adult children and gender roles of their wives, the lives of these bird-keepers, especially the retired, were quite 'empty', in the sense that they could not find companionship from their family members. Bird-keeping seemed to satisfy this specific need for them. Given the cultural and social environment, bird-keeping is encouraged, and is an 'accepted' role for the retired elderly to play. The activities that involve in birdkeeping allow these elderly bird-keepers to widen their social circle, and provide them with entertainment and a sense of achievement. In brief, this study suggests that it is fruitful to study the life of the elderly by adopting a multidimensional perspective. Furthermore, different peoples age differently in different cultural and social backgrounds. When studying the well-being of the elderly, their cultural and social backgrounds must be taken into consideration. Finally, this study also suggests that it is beneficial to explore under what cultural and social circumstances the elderly can benefit from keeping pets.

THE LIVES OF ELDERLY BIRD-KEEPERS! A CASE STUDY OF HONG KONG

D References Banziger, George and Sharon Roush. 1983. Nursing homes for the birds: A controlrelevant intervention with bird feeders. The Gerontologist 23 (5): 527-31. Blishen, B.R. and H.A. McRoberts. 1976. A revised socio-economic index for occupations in Canada. Canadian Review of Sociology and Anthropology 13 (February): 71-9. Burgess, Ernest W. 1960. Aging in Western societies. Chicago: University of Chicago Press. Chappell, Neena. 1992. Social support and aging. Toronto: Butterworths. Chi, Iris and Nelson Chow. 1998. Housing and family care for the elderly in Hong Kong. In Housing older people: An international perspective, ed. Brink, Satya. London: Transaction Publishers. Chinner, Tracy L. and Frank R. Dalziel. 1991. An exploratory study on the viability and efficacy of a pet-facilitated therapy project within a hospice. Journal of Palliative Care 7 (4): 13-20. Chow, Nelson. 1990. Ageing in Hong Kong. In Social issues in Hong Kong, ed. Leung, Benjamin K.P. 164-77. Hong Kong: Oxford University Press. Cohn, Richard M. 1982. Economic development and status change of the aged. American Journal of Sociology 87 (5): 1150-61. Cool, Linda Evers. 1980. Ethnicity and aging: Continuity through change for elderly Corsicans. In Aging in culture and society: Comparative viewpoints and strategies, eds. Fry, Christine L. et al. New York: Bergin & Garvey Publishes, Inc. Cowgill, Donald O. 1974. Aging and modernization: A revision of the theory. In Late life communities and environmental policy, ed. Gubrium, Jaber F. Springfield, 111.: Charles C. Thomas. and Lowell Holmes, eds. 1972. Aging and modernization. New York: AppletonCentury-Crofts. Garisto, Keslie. 1992. The birdcage hook: Antique birdcages for the contemporary collector. New York: Simon & Schuster. Goldstein, Melvyn C. 1982. Indirect modernization and the status of the elderly in a rural third world setting. Journal of Gerontology 37: 743-8. and Cynthia M. Beall. 1981. Modernization and aging in the third and fourth world: Views from the rural hinterland m Nepal. Human Organization 40 (1): 48-55. Hendy, Helen. 1987. Effects of pet and/or people visits on nursing home residents. Journal of Aging and Human Development 25 (4): 279-91. Hong Kong government. 1991. Hong Kong 1991. Hong Kong: Government Printer. Ikels, Charlotte. 1980. The coming of age in Chinese society: Traditional patterns and contemporary Hong Kong. In Aging in culture and society: Comparative viewpoints and strategies, eds. Fry, Christine L. et al. New York: Praeger. Keith, J., Christine L. Fry and Charlotte Ikies. 1990. Community as context for successful aging. In The cultural context of aging: Worldwide perspectives, ed. Sokolovsky, Jay. New York: Bergin & Garvey Publishers. Mahalski, P.A. et al. 1988. The value of cat ownership to elderly women living alone. International Journal of Aging and Human Development 27 (4): 249-60. Mayhew, Pamela B. 1988. No place for a dog? The Canadian Nurse 84 (5): 28-9.

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Miller, D. et al. 1992. Discriminating positive and negative aspects of pet interaction: Sex differences in the older population. Social Indicators Research 27: 363-74. Ory, Marcia G. and Evelyn L. Goldberg. 1983. Pet possession and well-being in elderly women. Research on Aging 5 (3): 389-409. Palmore, Erdman. 1980. The status and integration of the aged in Japanese society. In Aging the individual and society: Readings in social gerontology, ed. Quadagno, Jill. New York: St. Martin's Press. and Kenneth Manton. 1974. Modernization and status of the aged: International correlations. Journal of Gerontology 29: 205-10. Rastogi, K.M. 1994. Leisure: A study in social class perspective. Delhi: Renaissance Publishing House. Riley, Matilda White, Marilyn Johnson and Anne Foner. 1972. Aging and society, volume three: A sociology of age stratification. New York: Russel Sage Foundation. , A. Foner and J. Waring. 1988. Sociology of age. In Handbook of sociology, ed. Smelser, N.J. 243-90. London: Sage Publication. Robins, D.M. et al. 1991. Dogs and their people: Pet-facilitated interaction in a public setting. Journal of Contemporary Ethnography 20 (1): 3-25. Rogers, John, Lynette A. Hart and Ronald P. Boltz. 1993. The role of pet dogs in casual conversations of elderly adults. The Journal of Social Psychology 133 (3): 265-77. Winkler, Anne et al. 1989. The impact of a resident dog on an institution for the elderly: Effects on perceptions and social interactions. The Gerontologist 29 (2): 216-23.

1 Notes 1. 2.

3.

4.

We found no female bird-keepers who walked their birds. These women enjoyed their birds at home and had never walked their birds. In the process of writing this chapter, a Hong Kong magazine reported that the Bird Street had moved to a nearby site in March 1997 due to redevelopment of the area. We had some interviewees who were married but the spouse was in China. Since the number was very small, only three, we have included them in the 'single' category for convenience. Some of the elders whose spouses lived in China had children living with them or with the spouses. In the latter group, the spouses in Hong Kong maintained some form of connection and communication with the children in China. Therefore, their answers were also used when we asked them whether their children were filial to them. Furthermore, since this was an open-ended question, a wide range of expressions were used by the interviewees to describe their children. In order to recode them into clear and meaningful categories, we read the elderly respondents' answers in their contexts and divided the attributes they used to describe their children into three groups: if the elderly described their children as having all positive attributes, we recoded their answers into the

THE LIVES OF ELDERLY BIRD-KEEPERS! A CASE STUDY OF HONG KONG

5.

category of 'filial'; if the elderly described their children as having all negative attributes, we recoded those answers into the category of 'not filial; if their answers were mixed with both positive and negative values, we recoded them into 'acceptable'. Since a socio-economic index for Hong Kong, like the one constructed by Blishen (Blishen and McRoberts 1976) for Canada, was not available at the time, we created a composite score consisting of four parts: education, occupation, income and type of housing. We created five ranks for each of these variables. The highest was 5 and the lowest was 1. Education: interviewees who had received university education scored 5; those who had received technical or other types of post-secondary education, 4; secondary education, 3; primary education, 2; and no schooling at all, 1. Since research on occupational ranking in Hong Kong was not available, we had to use the best of our knowledge about the culture of Hong Kong to rank the interviewees' occupational status. We ranked the status according to the level of prestige that a particular occupation enjoys. Government officers and professionals were ranked the highest, proprietors of small family businesses, managers and supervisors next, then skilled workers such as general clerks and bookkeepers followed. The lowest ranking went to messengers, labourers and the unemployed. When we ranked the housewives, we confronted methodological difficulties. So far, there has been no single agreed-upon method to decide on the occupational ranking of a housewife. Since education, income and occupation are the three major measurements a person's socio-economic status, our solution was to use education as the sole measurement if the interviewee did not have the last two. This principle was equally applied to widows who had never been employed outside of the home. Since all men, including widowers, were either working or had worked before, we ranked their status according to the normal method discussed above. We divided income into five groups according to the categories presented in the Hong Kong 1991 Population Census. People whose monthly income was not more than $1999 scored the lowest. Next was $2000-$5999; then $6000$9999; the second highest was $10 000-$ 19 999; the highest was $20 000 or up. However, this was applicable only to those working elderly. For the retired elderly, both male and female, and the housewives, income meant all sources of money that they received, not earnings from working. These sources included their pensions, the Old Age Supplement from the government and money given by their children. Finally, we divided the types of housing into five ranks according to their market values. Privately owned flats scored 5; flats under the Home Ownership Scheme scored 4; public housing and a rented flat in a private building scored 3; a rented room in a private flat scored 2; private temporary housing, a 'rented bed' scored the lowest. The term 'rented bed' requires some explanation. In Hong Kong, there are poor people who can afford to rent only a bed in a flat in which there are multi-level beds. A person occupies a bed and shares washroom and kitchen facilities with some 20 other occupants. The lowest score which an interviewee could receive was 4 and the highest,

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HO-HON LEUNG

20. Within this range, the scores were divided into five groups. We determined the level of socio-economic status according to the scores. The following shows the ranking: Socio-economic status Upper Upper-middle Middle Lower-middle Lower

6. 7.

= = = = =

Composite scores 19-20 16-18 12-15 8-11 4-7

Finally, for the analysis, we divided the interviewees into two broader levels of socio-economic status. The ones who scored 4 to 11 would be classified as in the rank of 'lower socio-economic status'. The ones who scored 12 or higher would be classified as in the rank of 'higher socio-economic status'. Like the questions on filial piety, a wide range of expressions were given. They were recoded into clearer and more meaningful categories. Again, since a wide range of responses were given, they were recoded for analysis.

4 Social Support Networks among Elderly Chinese Americans in Los Angeles James Lubben and Alex Lee

D Introduction The study of elderly Chinese American populations is of increasing importance. Between 1980 and 1990, the total Chinese American population grew eight times faster than the total US population (Barringer, Gardner and Levin 1993). Largely, it was immigration rather than new births that drove this surge because Chinese American women have one of the lowest fertility rates among American women. Given these low birth rates and the advanced age of many of the recent immigrants, it is not surprising that the Chinese American population is one of the most rapidly ageing subgroups in the US. US immigration policies partially account for the rapid growth of the elderly Chinese American population. The 1965 Immigration Act abolished strict quotas, allowing persons to enter the US on the basis of a person's job skills or a desire to reunite with family. The decades following the enactment of this new immigration policy have been called the 'golden years' for Chinese immigration to the US, during which time the Chinese American population more than tripled (Huang 1991). In 1965, the US accepted fewer than 300 000 immigrants from all countries. By 1989, over one million immigrants were being accepted each year (Shinagawa 1996). This rising tide of new immigrants, many with limited chances of gainful employment, generated considerable debate. Many

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JAMES LUBBEN AND ALEX LEE

politicians came to question the appropriateness of the family reunification feature of US immigration policy that had become the dominant rationale for legal entry into the US. Particularly in times of economic downturn, the debate became quite viperous. However, the 1990 Immigration Act essentially reaffirmed family reunification as a legitimate basis for entry into the US. However, as a compromise, the new legislation increased the allotment of slots reserved for those with job skills deemed to be needed to further the US economy (Barringer, Gardner and Levin 1993). For various reasons, including its location on the Pacific Rim, California has been the favourite destination for Chinese immigrants (Shinagawa 1996). Chinese ranks only behind Spanish as a language other than English spoken in Californian homes (Clark 1998). Many Chinese immigrants, once they gained US citizenship, sponsored other relatives, including parents, thus fuelling the tremendous increase in the elderly Chinese American population. By way of example, Ong (1989) estimated that the number of elderly Chinese in California would grow by 800% in the 30-year period from 1970 to 2000. He also estimated that in the year 2000, more than 80% of the elderly Chinese American population in California would be foreign-born. This phenomenal growth of the elderly Chinese American population has increasingly captured the attention of health and social science researchers. However, much of our current knowledge as to elderly Chinese Americans remains largely confined to information derived from studies of questionable value, due to inadequate research designs or unsubstantiated inferences made from studies of other elderly Asian American or minority subgroups. Relatively few studies of any type have explored patterns of social support networks specially among elderly Chinese American populations, or made comparisons with other elderly American ethnic groups. Such comparisons should prove insightful because cultures differ in the emphases placed on obligations of adult children towards parents and on the nature of these relationships (Ikels 1980). Compared to other American ethnic groups, elderly Chinese and other Asian Americans are often thought to have greater social support networks because of traditional cultural values such as filial piety (Kamo and Zhou 1994). Accordingly, society at large presupposes that elderly Chinese Americans enjoy higher levels of co-residence, family interaction and filial responsibility than those experienced by other ethnic groups (Himes, Hogan and Eggebeen 1996). Some Asian American scholars posit that the similarity in Confucian-based values among certain Asian American groups may by implication suggest minimal differences in intergenerational relationships found in elderly Chinese Americans as compared to these other Asian American groups (Ishii-Kuntz 1997; Kao and Lam 1997). It has been theorized that greater differences in social support networks may be found between Chinese and white non-Hispanic Americans,

I

SOCIAL SUPPORT NETWORKS AMONG ELDERLY CHINESE AMERICANS IN LOS ANGELES

the ethnic group that constitutes the majority of America's elderly population. For example, a recent study reported great similarity in living arrangements among various subgroups of elderly Asian Americans (Himes, Hogan and Eggebeen 1996). However, many elderly Chinese Americans possess characteristics that have been associated with more limited social support networks. For example, elderly Chinese American populations include a much higher percentage of immigrants than other subgroups of elderly American populations do. Although recent immigration has been shown to reduce the likelihood of an elderly Chinese American living alone (Burr and Mutchler 1993), immigration can also negatively affect social integration. For example, immigration in late life often severs social ties with long-term friends in the country of origin. It may also reduce the elder's traditional familial role or status (Kao and Lam 1997). Furthermore, language barriers among elderly Chinese Americans, including unfamiliarity with the dominant Chinese dialect in the new community, may inhibit making new friends. The relatively limited comparative research of elderly Chinese American and other ethnic groups in America also suggests that there may be a comparative disadvantage in social support networks among Chinese Americans. For example, a study of low-income elderly in California reported that elderly Chinese Americans had more limited social contacts than their Mexican, African and white non-Hispanic American counterparts (Lubben and Becerra 1987). Ishii-Kuntz (1997) also reported that elderly Chinese Americans received less support from their children than their Korean American counterparts did. Ishii-Kuntz argues that structural and economic factors as well as cultural values determine intergenerational relationships among Asian Americans. Yamada and Lubben (1996) reported that elderly Chinese Americans were more apt to report depressive symptoms than their Japanese American counterparts, suggesting that strains associated with immigration may account for this difference. Whereas a majority of elderly Chinese Americans are immigrants, virtually all Japanese Americans are USborn. Generally, there is insufficient empirical evidence to support either the advantaged or the disadvantaged hypothesis with respect to social support networks among elderly Chinese Americans. The present study addresses this deficiency. It describes the social support networks of elderly Chinese Americans, and compares them with two other groups of elderly Asian American counterparts. One group, Japanese Americans, is largely US-born, whereas the other group, Korean Americans, is exclusively made up of immigrants. All three groups of Asian Americans are compared and contrasted with a sample of elderly white non-Hispanic Americans.

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1 Methodology Data for this study was taken from three separate but linked studies. One was a cross-national study of elderly Chinese and elderly Chinese Americans. That study was subsequently augmented with a study of elderly Japanese Americans. These studies were funded by the University of California Pacific Rim Research Program (Kitano et al. 1994). The third study was entitled 'Older Korean Americans: Social Support Study of Long Term Care'. This study was funded by the US National Institute on Aging (Lubben et al. 1992). The studies of Chinese and Japanese Americans drew random samples of persons who were aged 60 or above. The study of Korean Americans drew a random stratified sample of elderly Korean and white non-Hispanic Americans aged 65 or above. For comparability, only those Chinese and Japanese American respondents aged 65 or above were used in the present analyses. Specific details on sampling methodologies are published elsewhere (Lubben et al. 1992; Kitano et al. 1994; Yamada and Lubben 1996; Villa et al. 1997; Moon, Lubben and Villa 1998). Since all three studies were conducted in Los Angeles within a three-year time span employing similar items in their questionnaires, compatible data from these studies was merged into a single data set. The combined data set has a total sample of 712 persons (Chinese n = 151; Korean n = 223; Japanese n = 137; white non-Hispanic n = 201). Samples of white non-Hispanics are often used in the US as a comparison group representing traditional American culture and values.

§ Results Approximately one-third of the Chinese Americans in this sample were aged 75 or above. This proportion was similar to the Korean Americans while only about a quarter of the Japanese Americans were aged 75 or above. By contrast, over half of the white non-Hispanics in this sample were aged 75 or above. Whereas a majority of elderly Korean (60%), Japanese (51%) and white non-Hispanic (65%) Americans were female, the reverse was true for Chinese Americans. Elderly Chinese Americans (62%), like the Japanese Americans (62%), were more apt to be married than their Korean (47%) or white nonHispanic (40%) American counterparts. Elderly Chinese Americans (68%) were less likely to report themselves to be in good health, compared to elderly Japanese (83%) and white non-Hispanic (77%) Americans. However, elderly Korean Americans (49%) were the least likely to report themselves to be in good health.

SOCIAL SUPPORT NETWORKS AMONG ELDERLY CHINESE AMERICANS IN LOS ANGELES

Table 1 Characteristics of Los Angeles sample (%)*

Aged 75+ Female Married Good health High school Some English US-born

Chinese (n = 151)

Korean (n = 223)

Japanese (n = 137)

White (n = 201)

37.8 43.7 61.6 67.5 63.6 20.6 4.6

37.2 59.6 46.6 48.9 53.8 4.0 0

27.8 51.1 61.8 82.4 100.0 88.9 92.0

54.2 64.7 39.8 77.1 97.0 100.0 86.1

*AII distributions are significant at p < 05 level

Elderly Chinese Americans ranked third (64%) behind elderly Japanese (100%) and white non-Hispanic (97%) Americans, when it comes to high school education. Only a fifth of the elderly Chinese American sample reported an ability to speak some English. However, elderly Chinese Americans were better off in this regard than their Korean American counterparts, of whom only 4% spoke some English. Elderly Japanese (89%) and white non-Hispanic (100%) Americans reported the highest level of English-speaking ability. The similarity between elderly Chinese and Korean Americans' English-speaking ability is undoubtedly related to birth origin. Almost all (96%) of the elderly Chinese Americans in the present sample and all of the elderly Korean Americans were born outside the US. In contrast, all of the elderly Japanese Americans and a vast majority (86%) of the elderly white non-Hispanic Americans were born in the US.

Living arrangements When it comes to living arrangements, elderly Chinese Americans were more apt to live with their family and to live in multigenerational households than the other three subgroups of elderly Americans. Very few (17%) elderly Chinese Americans lived alone. About half (49%) lived with a child and almost a third (31%) lived with their grandchildren. Elderly Chinese Americans were comparable to the other two elderly Asian American subgroups in terms of low rates of living alone. Whereas about one-fifth of the elderly Korean (21%) and Japanese (23%) Americans lived alone, almost one-half of elderly white non-Hispanic Americans lived alone. A slightly different pattern was noted with respect to living with offspring. Only the elderly Korean Americans were similar to the elderly Chinese Americans in terms of the percentages of living with a child (42%) and grandchild (26%). With regards to sharing households, elderly Japanese Americans were quite similar to their white non-Hispanic counterparts.

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Elderly Chinese were much more likely than their elderly counterparts to live in a household with three or more people. The difference between elderly Chinese Americans and their Japanese and white non-Hispanic counterparts was particularly dramatic in this regard. Elderly Chinese were five times more likely to live in households with three or more people than elderly white non-Hispanic and Japanese Americans.

Table 2

Living alone With a child With a grandchild Household size (3+)

Living arrangements (%)* Chinese

Japanese

Korean

White

16.6 49.0 30.5 37.1

22.8 28.4 4.4 6.6

21.1 41.6 25.1 29.6

49.8 16.4 5.0 7.5

* All distributions are significant at p.05 < level

Social support networks The social support networks of the elderly Chinese Americans were examined from the perspective of three domains: family networks, friend-and-neighbour networks, and confidant relationships. Elderly Chinese Americans were most apt to have three or more close family members (81%) compared with other ethnic groups. Elderly Japanese Americans ranked second, with three-quarters having three or more close family members. Korean and white non-Hispanic Americans had similar responses to this item, each reporting that about 60% had three or more close family members. When it came to family contact, 80% of elderly Chinese Americans reported weekly contacts, which was about the same proportion as that of white non-Hispanic Americans. This proportion was slightly less than those of their Korean and Japanese American counterparts (87% and 85% respectively). When it came to friends and neighbours, elderly Chinese Americans were quite similar to their white non-Hispanic counterparts, with about two-thirds of both groups reporting having three or more close friends. Only about half of the elderly Japanese and Korean Americans reported having that many close friends (51% and 56% respectively). Although more elderly Chinese Americans reported having three or more close friends, only half of the elderly Chinese Americans maintained weekly contacts with their friends. All the other ethnic groups had larger proportions that maintained weekly contacts with their friends (64%, 69% and 56% for elderly Japanese, Korean and white non-Hispanic Americans respectively).

SOCIAL SUPPORT NETWORKS AMONG ELDERLY CHINESE AMERICANS IN LOS ANGELES

Table 3

Social support networks (%)* Chinese

Japanese

Korean

White

80.7 80.1

75.1 85.2

64.6 86.6

60.3 77.8

65.3 50.0

50.7 63.8

56.0 69.1

64.2 56.2

72.7 59.4

79.5 52.6

77.2 64.1

95.6 80.6

Family Close family members (3+) Weekly contact with family Friends Close friends (3+) Weekly contact with friends Confidant Has confidant Is a confidant

* All distributions are significant at p < .05 level.

About three-quarters of the elderly Chinese Americans reported having a confidant relationship. This figure was smaller but approximate to those of the elderly Korean and Japanese Americans. However, it was much smaller than that of the elderly white non-Hispanic Americans. When asked whether they served as a confidant to others, slightly more than half of the elderly Chinese Americans replied affirmatively. This proportion was again quite similar to those of the elderly Japanese and Korean Americans. However, it was much lower than that of the elderly white non-Hispanic Americans. More than 80% of them described themselves as a confidant to someone.

Table 4

Multiple regression for social support networks

(Standardized regression coefficients)

Total networks ***

Family networks***

Friend-and-neighbour networks***

Age Female Education levels Self-rated health Korean Japanese White non-Hispanic

-.13*** .01 .10* 24*** .15*** -.12** .07

-.10** .01 -.01 .13*** -.10 # -.09 #

-.02 .07# .09*

#p<.10

*p<.05

**p<.01

_ oo*#*

-1 " 7 * * *

.28*** -.16*** .26***

***p<.001

Multiple regression analyses were carried out for social support networks. The Lubben Social Network Scale (LSNS) (Lubben 1988; Rubinstein, Lubben and Mintzer 1994; Lubben and Gironda 1997) was used as a measure of social support networks. This scale was designed specifically for communityliving elderly persons and has been translated into several languages, including Chinese, Korean and Japanese. Sub-scales constructed from the LSNS were also employed to examine how the various ethnic groups differed with respect to their family networks and their friend-and-neighbour networks.

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The results show that better self-rated health was the most important determinant of stronger social support networks as measured by the LSNS. More education also enhanced the likelihood of stronger social support networks whereas advanced age was associated with weaker social support networks. Gender had no apparent effect on the strength of social support networks after controlling for the other determinants. However, significant differences among ethnic groups still remained after controlling for these other determinants. Elderly Chinese Americans had stronger social support networks than their Japanese American counterparts, but more limited networks than the elderly Korean Americans. Somewhat surprisingly, there were no significant differences between elderly Chinese and white non-Hispanic Americans in terms of overall social support networks. Analysis of LSNS sub-scales clarified these findings. Only age, self-rated health and ethnic group were significant predictors of family support networks, but their relative importance differed from what existed in the overall social support network model. In the family sub-scale model, ethnic group became the most important determinant. Elderly Chinese Americans had significantly stronger family networks than their white non-Hispanic counterparts after controlling for the other possible determinants. There was also a tendency for elderly Japanese and Korean Americans to have weaker family networks than elderly Chinese Americans, but the differences were not significant. The pattern was quite different when considering friend-and-neighbour social support networks. Ethnic group remained the major determinant of this dimension of social support networks, but with these networks, elderly Chinese Americans were at a disadvantage compared to their Korean and white non-Hispanic counterparts. However, elderly Chinese Americans had stronger friend-and-neighbour social support networks than elderly Japanese Americans. With respect to the other determinants, education levels and better self-rated health enhanced stronger friend-and-neighbour social support networks, whereas age and gender were not significant predictors.

Functional status Functional status was measured by whether the respondents had difficulty performing the following advanced activities of daily living (AADLs): shopping for personal items; climbing a flight of stairs; walking two blocks; taking a bus; doing heavy housework; and lifting a heavy (251bs.) object. Approximately 45% of the elderly Chinese Americans reported more than one difficulty with these AADLs. Another 10% had only one difficulty and close to half reported having no AADL difficulties. The elderly Chinese Americans were similar to the Japanese and white non-Hispanic Americans

SOCIAL SUPPORT NETWORKS AMONG ELDERLY CHINESE AMERICANS IN LOS ANGELES

in this respect, but were quite different from their Korean American counterparts. Only one-fifth of the elderly Korean Americans had no functional difficulty. About a quarter of them had one AADL limitation, and more than one-half of the elderly Korean Americans had two or more AADL functional difficulties.

Table 5

Difficulties 0 1 2 3+

AADL functional difficulties {%)*

Chinese

Korean

Japanese

White

47.0 9.9 16.6 26.5

19.7 25.6 23.8 30.9

54.7 17.5 10.9 16.8

47.3 14.4 12.4 25.9

* Distribution is significant at p < .05 level

Multiple regression analyses were conducted to examine determinants of the number of AADL functional difficulties. The data indicated that age, being female, lower education levels and poor self-rated health were all strong predictors of the amount of an elder's functional difficulties. No significant differences in functional status among elderly Chinese, Japanese and white non-Hispanic Americans were noted after age, gender, education and selfrated health as determinants were controlled for. The only ethnic group that stood out from the Chinese Americans was the Korean American group who had more AADL functional difficulties.

Table 6

Variable Age Female Education levels Self-rated health Korean Japanese White non-Hispanic (Constant)

Multiple regression for functional difficulties

B

Beta

t

p value

.05 .50 -.04 -.62 .44 .09 .15 -.10

.14 .11 -.08 -.36 .09 .02 .03

4.00 3.24 -1.97 -10.35 2.11 .37 .67 -.10

.0001 .0013 .0490 .0000 .0353 .7150 .5051 .9187

Model statistics F = 30 46, df = 7, r2 = .23, p < 0000

Whereas the number of AADL functional difficulties is a gross indicator of need, a measure of unmet social support can be constructed by counting the number of these AADL functional difficulties for which an elderly person did not receive assistance. Elderly Chinese and Japanese Americans appeared to do especially well in this area. Neither group had many AADL difficulties

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for which they did not receive some help. Elderly Korean Americans reported larger proportions having unmet AADL needs when compared to the other two Asian American subgroups. Elderly white non-Hispanic Americans had the greatest amount of AADL difficulties for which they did not receive assistance. Almost one-third of the elderly white non-Hispanic Americans reported having three or more unmet AADL needs.

Table 7

Unmet needs {%)*

Unmet needs

Chinese

Korean

Japanese

White

0 1 2 3+

79.5 9.3 5.3 6.0

26.5 43.5 12.1 17.9

79.6 9.5 5.1 5.8

52.7 12.4 14.9 29.9

* Distribution is significant at p < .05 level.

Another multiple regression analysis was conducted for unmet AADL needs. This time, older age and poor self-rated health remained significant predictors. Although gender and education levels were relevant to a number of AADL difficulties, the analysis showed that they had no bearing on unmet needs. Even after controlling for age, gender, education levels and self-rated health, there remained essentially no differences between elderly Chinese and Japanese Americans in terms of the number of unmet AADL needs. However, significant differences persisted between elderly Chinese Americans and their Korean and white non-Hispanic counterparts. Both of these latter groups had more unmet AADL needs than the elderly Chinese Americans.

Table 8 Variable Age Female Education levels Health Korean Japanese White non-Hispanic (Constant)

Multiple regression for unmet needs B

.03 .06 -.02 -.31 .82 .18 .81 -1.05

Model statistics: F = 30.91, df = 7,R2 = .24, p < .001

Beta

t

p value

.16 .02 -.06 -.29 .28 .05 .27

4.77 .68 -1.43 -8.45 6.44 1.19 5.95 -1.76

.0000 .4993 .1527 .0000 .0000 .2334 .0000 .0782

I

SOCIAL SUPPORT NETWORKS AMONG ELDERLY CHINESE AMERICANS IN LOS ANGELES

D Discussion The results showed that the functional status of the elderly Chinese Americans was similar to that of the elderly Japanese and white non-Hispanic Americans, whereas elderly Korean Americans appeared to have significantly more functional difficulties. Although elderly Chinese and white non-Hispanic Americans had similar levels of functional difficulty, the former were more apt to have these needs addressed than the latter. Perhaps because the elderly Korean Americans had so many more functional difficulties, they also endured significantly more unmet needs than their Chinese American counterparts. One reason for these differences might be explained by variations in their respective social support network patterns. Although elderly Chinese Americans were similar to their white non-Hispanic counterparts in the strength of their overall social support networks, important differences appeared when family support networks were analysed separately from friendand-neighbour networks. Elderly Chinese had stronger family support networks than the elderly white non-Hispanic group. Among the elderly US population, family members are generally reported to be the primary source of care at times of disability (Stone, Cafferata and Sangl 1987). Thus, the stronger family networks observed among elderly Chinese Americans probably explained why they had fewer unmet functional difficulties than elderly white non-Hispanic Americans, although both groups had similar AADL limitations. It would appear that family networks are especially important to meeting elderly persons' functional needs. Although elderly Korean Americans had more interactions with friends than their Chinese counterparts, this advantage did not appear to help meet their functional needs. There is some evidence to support Asian American scholars who suggest that Confucian-based values might explain some of the family social support differences observed. The elderly Chinese Americans, who probably retained stronger Confucian-based values than any of the other groups, had the strongest family ties. The elderly Korean and Japanese Americans were somewhat in between the elderly Chinese and white non-Hispanic groups in this regard. Although elderly Korean Americans were even less assimilated into mainstream American culture than elderly Chinese Americans, as evaluated by language and country of origin, many Korean Americans were Christian. The elderly Japanese Americans were largely nisei or sansei (secondor third-generation Americans). The present study also suggests that social scientists in the US may have to reconsider their use of white non-Hispanic Americans as a reference group for traditional American culture. The increased diversity of the American population, partially driven by immigration and low fertility rates among white non-Hispanics, will likely challenge the notion that white non-Hispanics are

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more American than other groups. On the basis of being born in the US, the elderly Japanese American sample was more American than the white nonHispanic comparison group. Finally, the present study is only a partial response to requests for more research on elderly Chinese American populations (e.g., Lee 1987; Cheung 1989; Mui 1996). There remains a pressing need for more studies comparing various Asian American groups with one another as well as with other ethnic groups in America. Given the surge of elderly immigrants to the US, it would seem especially appropriate for more studies of the immigrant experience in old age. Also, cross-national comparisons provide opportunities to compare and contrast cultural changes and adaptation among elderly populations. The goal of such research should be to identify positive aspects in various subgroups so that all ageing societies may learn of the unique strengths that might be transferred from one group to another. Further, such research should also identify specific needs of ethnic groups so that culturally sensitive policies and programmes can be developed to enhance the health and well-being of all elderly persons.

I References Barringer, H.R., R.W. Gardner and MJ. Levin. 1993. Asians and Pacific islanders in the United States. New York: Russell Sage Foundation. Burr, J.A. and J.E. Mutchler. 1993. Nativity, acculturation, and economic status: Explanations of Asian Americans living arrangements in later life. Journal of Gerontology: Social Sciences 48 (2): 53-63. Chan, S. 1991. Asian Americans. 167-71. Boston: Twaine. Cheung, M. 1989. Elderly Chinese living in the United States. Social Work 34 (5): 457-61. Clark, W.A.V. 1998. The California cauldron: Immigration and the fortunes of local communities. New York: Guilford Press. Himes, C.L., D.P. Hogan and D.J. Eggebeen. 1996. Living arrangements of minority elders. Journal of Gerontology 51B (1): 542-8. Huang, K. 1991. Chinese Americans. In Handbook of social services for Asian and Pacific islanders, ed. Mokuau, N. N.Y.: Greenwood. Ikels, Charlotte. 1980. The coming of age in Chinese society: Traditional patterns and contemporary Hong Kong. In Aging in culture and society: Comparative viewpoints and strategies, eds. Fry, Christine L. et al. New York: Praeger. Ishii-Kuntz, M. 1997. Intergenerational relationships among Chinese, Japanese, and Korean Americans. Family Relations 46: 23-32. Kamo, Y. and M. Zhou. 1994. Living arrangements of elderly Chinese and Japanese in the United States. Journal of Marriage and the Family 56: 554-8. Kao, S.K.R. and M.L. Lam. 1997. Asian American elderly. Working with Asian Americans: A guide for clinicians, ed. Lee, E. 122-39. New York: Guilford Press.

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Kitano, H., J.E. Lubben, E. Berkanovic, I. Chi, C.Z. Chen and X.Y. Zhu. 1994. A cross-national study of elderly Chinese and Chinese Americans. In International perspectives on healthcare for the elderly, ed. Stopp, G. Harry, Jr. New York: Peter Lang Publishing, Inc. Lee, J.J. 1987. Asian American elderly: A neglected minority group. Journal of Gerontological Social Work 9: 103-16. Lubben, J.E. 1988. Assessing networks among the elderly population. Family Community Health 11 (3): 42-52. and R.M. Becerra. 1987. Social support among Black, Mexican and Chinese elderly. In Ethnic dimensions of aging, eds. Gelfand, D.E. and C M . Barresi. 13044. New York: Springer Publishing Co. et al. 1992. Elderly Korean Americans: Social support and long term care. US National Institute on Aging (R01-AG111182). (Funded research project to UCLA for period from 30 September 1992 to 30 June 1996.) and M. Gironda. 1997. Social support networks among elderly people in the United States. In The social networks of elderly people, ed. Litwin, H. 143-61. Wesport, CT: Praeger. Moon, A., J.E. Lubben and V. Villa. 1998. Awareness and utilization of community long-term care services by elderly Korean and non-Hispanic white Americans. Gerontologist 38 (3): 309-16. Mui, A. 1996. Depression among elderly Chinese immigrants: An exploratory study. Social Work 41 (6): 633-45. Ong, P. 1989. California's Asian population: Past trends, projections for the year 2000. Los Angeles: UCLA Graduate School of Architecture and Urban Planning. (Research monograph.) Rubinstein, Robert L., James E. Lubben and J. Mintzer. 1994. Social isolation and social support: An applied perspective. The Journal of Applied Gerontology 13: 58-72. Shinagawa, L.H. 1996. The impact of immigration on the demography of Asian Pacific Americans. In The state of Asian Pacific America: Reframing the immigration debate, eds. Hing, O. and R. Lee. 59-126. Los Angeles: Leadership Education for Asian Pacifies (LEAP) and the UCLA Asian American Studies Center. Stone, R., G.L. Cafferata and J. Sangl. 1987. Caregivers of the frail elderly: A national profile. Gerontologist 27: 616-26. Tsai, D.T. and R.A. Lopez. 1997. The use of social supports by elderly Chinese immigrants. Journal of Gerontological Social Work 29 (1): 77-94. Villa, V.M., S.P. Wallace, A. Moon and J.E. Lubben. 1997. A comparative analysis of chronic disease prevalence among elderly Koreans and non-Hispanic whites. Family and Community Health 20 (2): 1-12. Wong, M.G 1988. The Chinese American family. In Ethnic families in America: Patterns and validations (third edition), eds. Mindel, C.H., R.W. Habenstein and R. Wright Jr. N.Y.: Elsevier. Yamada, H. and J.E. Lubben. 1996. Social support and mental health among Chinese and Japanese American elders. Hong Kong Journal of Gerontology 10 (supplement): 386-9. (Proceedings of the 5th Asia/Oceania Regional Congress of Gerontology.)

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5 Social Support of the Elderly Chinese: Comparisons between China and Canada Neena L. Chappell and David C.Y. Lai

0 Introduction While studies of life satisfaction and quality of life abound in gerontology, only recently has attention focussed on the elderly Asians, specifically Chinese, in this area. Understandably, most of the research on the elderly Chinese discusses those living in one location, for example, in Hong Kong or in Calgary. Research examining the quality of life among the elderly Asians, specifically Chinese, has to date not incorporated cross-national comparisons. Rather, studies of the elderly Chinese in North America frequently assume that their difference from the host society is attributable to their foreign 'culture', despite the fact that Chinese culture is also evolving. However, as Ikels (1990) notes in relation to living arrangements in China, these usually reflect a child living in the parents' home, dictated through scarcity of available accommodation and resources, rather than necessarily preference. Yet, these living arrangements, noted by Kitano et al. (1991) to be more common among the elderly Chinese in North America than for whites, are usually interpreted as indicative of Chinese cultural norms about the value of elderly persons. Comparisons of the elderly Chinese living in China and in North America are important for assessing differences and similarities between the two. In this chapter, seniors living in Victoria, British Columbia (B.C.), Canada, and those living in Suzhou, China, are compared. The significance of location

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(Victoria versus Suzhou) for their quality of life is assessed, and the predictors of quality of life for those living in each location are also assessed.

§ Suzhou and Victoria These two cities were chosen because they are twin cities and share several characteristics, although they differ in important ways as well. Victoria City Council approved the twinning of Suzhou and Victoria in July 1980. In October, the mayor of Victoria and the vice-chairman of the Suzhou Municipal Revolutionary Committee signed a proclamation in Suzhou, declaring Victoria and Suzhou 'Sister Cities'. In celebration, the city of Victoria gave its sister city 5000 daffodil bulbs, two cluster light standards and an Indian totem pole. The bulbs were planted and the light standards and totem pole installed in the Eastern Garden in Suzhou. In return, the city of Suzhou gave Victoria a pair of sculptured stone lions, a Chinese painting and a piece of reversible Suzhou embroidery. The stone lions were placed in front of the Gate of Harmonious Interest at the entrance to Victoria's Chinatown, the oldest Chinatown in Canada. Both cities are known for their scenic beauty and tranquillity. Suzhou is referred to as the City of Gardens in China and Victoria is Canada's Garden City. Both cities are linked with water: Suzhou is criss-crossed by a maze of small canals whereas Victoria is located on an island in the Pacific Ocean. Both are retirement centres and tourist centres. In the nineteenth century, Suzhou was a prosperous cultural, financial and commercial centre, whereas Victoria was an important seaport on the Pacific Coast of Canada. Today, they are both located near large metropolitan centres: Victoria to Vancouver and Suzhou to Shanghai. In addition to these similarities, there are significant differences between the two. Suzhou, founded in 514 B.C., has a much longer history than Victoria, incorporated in 1862. In 1992, Metropolitan Suzhou had a population of 5.6 million, of whom 850 000 lived in the City of Suzhou. On the other hand, in 1996, Metropolitan Victoria had a population of only 313 000, of whom about 75 000 lived in the City of Victoria. In other words, the City of Suzhou's population was about 11 times of the population of the City of Victoria. Unlike Victoria, whose major activities include tourism, as well as being the seat of the provincial government, Suzhou is highly industrialized. Its High-Tech Development Zone, Economic and Technological Development Zone, and Free Trade Zone have attracted investments from several transnational corporations, such as Philips of the Netherlands, DuPont Corporation of the United States, and Mitsubishi Corporation of Japan.

1 SOCIAL SUPPORT OF THE ELDERLY CHINESE' COMPARISONS BETWEEN CHINA AND CANADA

Victoria is close to Metropolitan Vancouver with a population of 1.0 million, but it has few or no economic ties with its large neighbour. On the other hand, Suzhou is close to and integrated economically with Shanghai with a population of over 13 million. The ultimate result of this integration became known as Larger Shanghai, which covers a total area of nearly 322 000 square kilometres and has over 220 million inhabitants, including Suzhou. Finally, Victoria and Suzhou have very different governmental systems. The former has a democratic system of government within a capitalist society, while the latter has a socialist system within a communist society.

D Quality of Life in Old Age Quality of life among the elderly Chinese has previously been studied in terms of life satisfaction, subjective well-being, psychosocial concerns, mental health status and depression. Some studies of the elderly in China have been reported in English. Li (1995) analysed Old Age Security data from Guangzhou and found that, in multivariate analyses, income was the only significant predictor of subjective well-being. Li noted that economic well-being was a major concern for the urban elderly in China, since urban workers' pensions were set at 70% of their salaries before retirement with no opportunities for raises, regardless of inflation or increases in living standards. The transition towards nuclear families, it was argued, made the young less reliant on their parents and the parents more independent of their children. Living with children was not related to subjective well-being. Krause, Liang and Gu (1998) found that financial difficulty was related to increased distress when financial assistance was received from family members. It was, however, associated with less distress when anticipated in the future. In Beijing, Meng and Xiang (1997) reported that family environment and health were related to wellbeing; Zhang et al. (1997) found these factors plus financial strain and unhealthy lifestyles predictive of depression. Both Chi (1995) and Ho et al. (1995) studied the quality of life among the elderly Chinese in Hong Kong. Chi found that women who had higher education levels and who were married had a better mental health status; those with adequate financial resources, fewer chronic diseases, fewer psychosomatic complaints and more social support were less likely to be depressed. Ho et al. reported that having two or more relatives, more education and more income, being satisfied with living arrangements, and participating in religious activities were significantly correlated with life satisfaction. These researchers conclude that the determinants of quality of life are,

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by and large, similar among the elderly Chinese in China as have been reported for elderly North Americans. Research into the elderly Chinese in North America includes studies from both Canada and the US. Lai (1995), for example, found that, among senior housing-facility residents, psychological health, sense of personal control and social support were the strongest predictors of life satisfaction. For men, financial adequacy was a significant determinant while for women, social support, self-esteem and perceived health were more important. Gee (1998) found that living with someone, health status and city (Victoria rather than Vancouver in Canada) were related to well-being. Mui (1996) reported that in the US, perceived health, living with others, and satisfaction with help from family members were related to depression. Noticeably, studies to date have not included comparisons of elderly Chinese living in China with those living in North America. Rather, the focus of previous studies has tended to be on other seniors in the host society, either explicitly or implicitly. In general, these studies have concluded that the predictors of quality of life of these seniors, variously operationalized, tended to be similar to the predictors of quality of life found in studies of white seniors, usually in North America. Without comparable groups of elderly Chinese in China and in North America, no comparisons about the levels of life satisfaction or quality of life have been attempted.

1 Methodology The sample for Victoria, British Columbia, Canada, was obtained through a unique strategy that listed as many Chinese surnames as possible, then the Vital Statistics of the provincial government drew a random sample of all persons aged 65 or over living in the greater Victoria area. There was little concern that this strategy would underestimate Chinese women married to non-Chinese in this population of elders. Furthermore, the strategy is selfevidently superior to the use of local telephone directories, typical in studies of minority group elders in North America. The sample was purposely overdrawn, and telephone screening ensured accuracy by identifying the appropriate individual, who self-identified himself/herself as of Chinese origin being aged 65 or over. In Suzhou, 500 elderly people aged 60 or over were randomly drawn as subjects. A staged random sample was used: a new urban area (defined as an area that was a suburb before 1992 and that was urbanized between 1992 and 1994) in Suzhou, a township (Lou Feng), was chosen, with a population of 35 305, of whom 14.8% were elderly persons in 1994. This township consisted of 24 subdivisions. Nine subdivisions were drawn,

j SOCIAL SUPPORT OFjmELDERLY

CHINESE'. COMPARISONS BETWEEN CHINA AND CANADA

using a simple random sample. Within each subdivision, a simple random sample was drawn of all households. One subject aged 60 or over, living within the household, was selected randomly from among those eligible. Only those aged 65 or over are included here for comparability with the Victoria sample (n = 359). Data was collected in face-to-face interviews during the summer and autumn of 1995. In Victoria, they lasted on average one hour and fifteen minutes. The interview schedules for the two sites were devised through a co-operative effort using faxes and emails between the Canadian researchers and researchers in China (who were preparing for a four-city study there). We agreed to use many comparable items for comparative purposes, and our researchers in China agreed to collect data in Suzhou for comparisons with Victoria. Each site pretested their data with a variety of instruments. In Victoria, of an original 2158 names drawn, 35.9% were ineligible because they were not Chinese, they had passed away, they were away for an extended period, or were too frail or ill. Another 13.7% could not be contacted after ten attempts. With the use of call backs and the involvement of a project steering committee from the local Chinese community, an overall refusal rate of 22.5% of those eligible was obtained. This refusal rate is similar to (or lower than) that of community surveys of this type with the general population of seniors in North America. In Suzhou, the survey was co-organized by the Suzhou Statistical Bureau. In China, co-operation with the government in survey studies is mandatory. Accordingly, everyone who was contacted participated in the study (less than 1% could not be contacted after three attempts). Interviews were conducted in the language of the elder. In Victoria, 77.2% of the interviews were conducted in Cantonese. An additional 11.1% were conducted in Taishan, 5.8% in Putonghua (Mandarin), 5.2% in English, and less than 1% each in Shantou, Hakka, and Chaozhou dialects. In total, 250 interviews were conducted. In Suzhou, Putonghua was used. In Victoria, all questions were worded first with the assistance of an expert steering committee, consisting of individuals from the Chinese community. The questions were piloted with several Chinese elders individually, revised, piloted again, and revised again. They were translated into Chinese, then back-translated into English. They were revised and pilot-tested in Chinese two more times. For the purposes of this chapter, analyses were restricted to those variables available in both data sets. The dependent variable, life satisfaction (a cognitive rather than affective component of quality of life) (Myers and Diener 1995; Sirgy 1998) was measured using an adaptation of the Terrible-Delightful Scale. Devised by Andrews and Withey (1976), the scale has good psychometric properties. Respondents are asked to rate their feelings about different areas

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of their lives and living conditions in several areas (health, finance, family relations, family responsibilities, friendship, housing, recreation activity, how they feel about themselves). They rate each area on a scale from one (very dissatisfying) to five (very satisfying). Items were aggregated to form the scale. Cronbach's alpha equalled .80 for the Suzhou sample, .77 for the Victoria sample, and .85 for the combined total sample, indicating high internal reliability. In addition, a single indicator question was also asked: 'How do you feel about your life as a whole right now?' The same scale was used. Predictor variables included a number of indicators of health. Subjects were asked about chronic conditions from which they were suffering: 'For each condition I will now list, please indicate whether or not you currently have it, and whether or not you are being treated for it.' Conditions included: allergy; problems with joints, back, etc.; heart disease/troubles; anaemia or other blood diseases; high blood pressure (hardening of the arteries); problems due to stroke; cancer; mental health problems (including Alzheimer's/ dementia, nerves/emotional problems); recurrent stomach ache or other gastrointestinal problems excluding incontinence; problems with the urinary tract including kidney and bladder troubles (not incontinence); dental problems (teeth need care, dentures do not fit); diabetes; chronic obstructive/ lung diseases including chronic bronchitis, asthma, emphysema; Parkinson's disease; foot trouble; skin problems; and others (to be specified). These items were aggregated to give an indication of the number of chronic conditions individuals had. Functional ability was measured in terms of the individual's ability to do both basic (ADL) and instrumental activities of daily living (IADL). The items included: washing, bathing, grooming; eating, feeding; personal mobility; using the toilet; heavy household chores; transport; shopping; food preparation; and personal business affairs such as paying bills. Response categories included: no help needed, minimal help required, much help required, completely dependent. These items were aggregated. Cronbach's alpha equalled .85 for the Victoria sample, .65 for the Suzhou sample and .78 for the total sample. Subjects were also asked about a number of symptoms: fainting, breathing difficulties, tiredness, headaches, and bowel problems. The numbers of symptoms experienced were aggregated. Cronbach's alpha for the Victoria sample equalled .72, for the Suzhou sample equalled .47 and for the total sample equalled .61. A number of social support variables were also included. Marital status measured whether or not the subjects were married. To capture a different distinction, a separate analysis included a different marital status variable: whether the person was married and not living alone versus others; and

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1 SOCIAL SUPPORT OF THE ELDERLY CHINESE! COMPARISONS BETWEEN CHINA AND CANADA

whether they were not married and living alone versus others. Another variable captured whether or not they were living with their daughters; and another whether or not they were living with their sons. They were also asked as to the number of close friends they had and whether they had anyone they could talk to and confide in about their problems and of other things that were important to them. Sources of income were classified into the following categories, each constituting a separate variable in the analyses: sons or daughters (including sons-in-law and daughters-in-law) in the house; sons or daughters (including sons-in-law and daughters-in-law) not in the house; work; pension; stocks; rent; savings, etc. Education was recorded as two separate variables: as number of years taught in English and as number of years taught in Chinese. Other variables included current employment status (yes/no), gender (male/female), age, and location (Victoria/Suzhou). Analyses began with cross-tabulations using Chi square analyses to assess the differences in levels of life satisfaction between seniors living in Victoria and those living in Suzhou, for the single indicator question, for the total scale, and for each of the domains that constituted the scale. Multiple regression analyses were then used to examine the predictors of life satisfaction among the total sample (with place — Victoria or Suzhou — as an independent variable); and the predictors of life satisfaction among those living in Victoria and Suzhou separately. Multiple regression analysis was chosen because it could assess the independent contributions of a number of predictors simultaneously, i.e., while controlling for all others. Appropriate diagnostics were used to assess for the presence of multicollinearity and lack of linearity. When multicollinearity was found, the relevant variables were entered into separate analyses.

D Findings Sample characteristics are shown in Table 1. There were more old elderly (aged 75 or over) in the Victoria sample than in the Suzhou sample (44.0% vs. 20.4%). There were, however, approximately the same proportion of men (53.6% in Victoria and 46.7% in Suzhou) and women in each sample and approximately the same proportion who were married (62.8% in Victoria and 58.5% in Suzhou). Slightly more in Suzhou were employed (9.7% vs. 3.2%) than in Victoria, but fewer lived alone (8.0% vs. 16.8%). More in Victoria lived with daughters (15.6% in Victoria vs. 10.3% in Suzhou), but many more in Suzhou lived with sons (61.6% in Victoria vs. 32.4% in Suzhou). The two samples differed significantly from one another.

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J

Table 1 Sample characteristics Percentages Victoria (n = 250)

Suzhou (n = 359)

33.2 22.8 17.6 26.4 100.0

42.1 37.5 15.2 5.2 100.0

53.6 46.4 100.0

46.7 53.3 100.0

62.8 37.2 100.0

58.5 41.5 100.0

3.2 96.8 100.0

9.7 90.3 100.0

16.8 83.2 100.0

8.0 92.0 100.0

Live with daughter — yes Live with daughter — no X2= 3.71; df = 1 ; p < .05

15.6 84.4 100.0

10.3 89.7 100.0

Live with son — yes Live with son — no X2= 49.70; df = 1; p <.000

32.4 67.6 100.0

61.6 38.4 100.0

Age 65-69 70-74 75-79 80+ %2= 60.49; df = 3 ; p < . 0 0 0 Gender Male Female not significant Marital status Married Not married not significant Employment Employed Not employed %2= 9.56; df = 1; p < .01 Living arrangements Live alone Live with others X2= 10.87; df = 1; p < .001

Table 2 shows levels of life satisfaction of the elderly in each of the sites. For both the single indicator and the scale, the elderly living in Suzhou were much more likely to express dissatisfaction with life than were the elderly living in Victoria. Fully 40.7% of Suzhou elderly expressed dissatisfaction with life compared with only 15.6% of Victoria elderly when asked the single question. The figure was even higher (over half, at 55.3%) when Suzhou elderly were asked about the several domains on the Life Satisfaction Index. Among the Victoria elderly, fewer (4.8%) showed low life satisfaction on the

1 SOCIAL SUPPORT OF THE ELDERLY CHINESE.' COMPARISONS BETWEEN CHINA AND CANADA

index. That is, the discrepancy between the elderly in the two sites was larger when examining the index than the single indicator. Only 6.3% of elders in Suzhou said they were very satisfied with life, whether asked the single question or the index. For Victoria elders, the figures were 36.0% and 73.2% respectively. These differences are dramatic and are consistent with Chi's (1997) discussion of the low self-esteem and high suicide rates among the elderly in China.

Table 2

Life satisfaction by location

1. Life Satisfaction — Single Indicator Dissatisfied Somewhat satisfied Very satisfied

Suzhou 40.7 53.0 6.3 100.0

Victoria 15.6 48.4 36.0 100.0

Suzhou 55.3 38.4 6.3 100.0

Victoria 4.8 22.0 73^ 100.0

X2 = 99.64; df = 2; p < .000 2. Life Satisfaction Index Low Medium High X2= 311.42; df = 2; p < .000

Examining the single items that comprise the life satisfaction measure provides additional insight into the life satisfaction of the elderly in the two sites. It should be recalled that eight domains constituted the life satisfaction index. Table 3 shows the percentages of elderly in Suzhou and Victoria who expressed satisfaction with each of these domains. Not surprisingly, given the dramatic differences between the two sites in terms of the satisfaction scale, there were significant differences between the sites in all eight domains, and all were significant at the .000 level. Those living in Suzhou were especially dissatisfied in the areas of family relations and finance, followed closely by family responsibilities and themselves. They were most satisfied in the areas of friendship, recreation and health. The satisfaction among those who lived in Victoria was obvious (at least three-quarters expressed satisfaction in each area), but those with which people were the most dissatisfied include health, followed closely by recreation, friendship and finance. The most satisfaction was expressed in terms of housing (96% were satisfied), followed by family relations and family responsibilities. In terms of relative rank, elders in the two different cities agreed only in terms of relative dissatisfaction with finance, compared with other domains.

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Table 3

Percentages satisfied with each domain of life*

Domain

Suzhou

Victoria

53.6 29.2 20.6 34.8 63.1 45.0 54.5 34.8

75.2 78.2 89.6 88.6 77.7 96.0 77.1 84.2

Health** Finance** Family relations** Family responsibilities* Friendship** Housing** Recreation** Yourself** * combines satisfied and very satisfied responses ** p < .000

The multiple regression analyses with the Life Satisfaction Index as the dependent variable are shown in Table 4. Site not only remained statistically significant when controlling for other factors, it emerged unquestionably as the strongest predictor. Indeed, it explained an impressive 59% of the variance, followed by marital status and living arrangements (the combined variable) lagging far behind and explaining only 4% of the variance. Other variables were also significant but did not explain much of the variance. They included the number of chronic conditions the elder had, the number of symptoms they experienced, the number of close friends they had, whether they had income from work earnings, and whether they had income from stocks and properties. Marital status and living alone were also significant, but were multicollinear with the combined marital status/living arrangements variable, so were entered into separate analyses. (The same variables minus income from work earnings were significant predictors when the single indicator was

Table 4

Multiple regression analyses for Life Satisfaction Index

Total sample Victoria Married and living with others (Married)* (Live alone) No. of chronic conditions No. of symptoms No. of close friends Confidante Income from work earnings Income from stocks/properties

b

Beta

t

P

10.03 2.62 (2.51) (-2.51) -.62 -.75 .25 2.10 1.12 3.12

11 .20 (.19) (-.12) -.09 -.11 .15 .14 .06 .06

25.70 7.62 (7.23) (-4.76) -3.11 -4.14 5.17 5.51 2.23 2.56

<.000 <.000 (<.000) (<.000) <.01 <.000 <.000 <.000 <.05 <.01

F = 128.20; df = 8 and 589; p < .000 Adjusted R2 = .63 * Variables in brackets were multicollinear with those appearing immediately above and were included in separate analyses.

j SOCIAL SUPPORT OF THE ELDERLY CHINESE! COMPARISONS BETWEEN CHINA AND CANADA

the dependent variable, and 27% of the total variance was explained — not shown here.) Other than site, it was social support, health and socio-economic variables that were related to life satisfaction — all consistent with past research on life satisfaction among the elderly, in both China and North America. Given that site was such a powerful predictor of life satisfaction, it became relevant to ask whether the same predictors of life satisfaction were operative in the different sites. The multiple regression analyses for Victoria and Suzhou are shown separately in Table 5. Among the Suzhou elderly, those who were married and living with others in addition to their spouse, or those who were not married but living with others, had more close friends and had someone with whom they could discuss important decisions (a confidante) revealed higher life satisfaction than others, when the index was used as the dependent variable. Being married and living with others was clearly the strongest predictor. When the single question was used, only the number of close friends and having someone for important decisions emerged as significant, and only 11% of the variance was explained (not shown here). That is, among the Suzhou elderly, social support was the only predictor of life satisfaction. Neither health nor socio-economic status was significant. Table 5

Multiple regression analyses for Life Satisfaction Index

Suzhou Married and living with others (Marital status)* Not married and living with others (Live alone) No. of close friends Somebody for important decisions

Beta

t

5.51 (3.71) 2.67 (-4.11) .33 1.88

.59 (.40) .23 (-.24) .25 .18

6.99 (8.63) 2.76 (-5.10) 5.53 4.06

b

Beta

f

.15 (.13) -.19 -.18 -.17 .11 .19 .13

2.59 (2.37) -3.33 -3.13 -2.91 2.09 3.51 2.36

b

P < < < < < <

.000 .000 .01 .000 .000 .000

F = 39.49; df = 4 and 343; p < .000 Adjusted R2= .31 Victoria Married and living with others (Married) No. of chronic conditions No. of symptoms Disability No. of close friends Confidante Income from stocks/properties

1.40 (1.27) -.82 -.83 -.13 .17 2.31 2.90

p < (< < < < < < <

.01 .05) .001 .01 .01 .05 .001 .05

F = 15.58; df = 7 and 242; p < .000 Adjusted R2 = .29 * Variables in brackets were multicollinear with those appearing immediately above and were included in separate analyses.

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In Victoria, those who were married and living with others, those with fewer chronic conditions, with fewer symptoms, with less disability, with more close friends, with a confidante, and with income from stocks and properties reported higher life satisfaction than others. Although both the number of chronic conditions and having a confidante were the strongest predictors, neither explained much of the variance (4% each), and each was similar to the other predictors. In total, 29% of the variance was explained. When the single question was used as the dependent variable, 28% of the variance was explained, and all the same variables except the number of close friends emerged as significant. That is, among the Victoria elderly, social support, health and socio-economic status all emerged as significant predictors. Health was clearly important, with three measures emerging as significant. Variables not relevant for the elderly in Suzhou (number of years living in Canada, place of origin — China, Hong Kong or others, being a naturalized Canadian, and ability to speak English) could be important for life satisfaction among the elderly in Victoria. A separate multiple regression analysis with these variables added was conducted. All of the variables shown in Table 5 remained significant. In addition, the number of years in Canada, and that alone of the variables added, was statistically significant (Beta = .22; t = 3.59; p < .001). Those who had been in Canada longer revealed greater life satisfaction. The fact that the number of years in Canada, but not the place from which they migrated, was significant suggests that cultural rather than immigrant differences explained the findings.

1 Summary and Conclusion Unlike previous research on the quality of life among the elderly Chinese, this study compared both the level of life satisfaction and the predictors of life satisfaction among those living in Suzhou, China, and Victoria, Canada. The data revealed large differences in both the levels of and predictors of life satisfaction among the elderly in the two cities. The elderly living in Victoria showed much greater levels of life satisfaction than those living in Suzhou. Furthermore, location was overwhelmingly the strongest predictor of life satisfaction. However, among those living in Suzhou, the level of life satisfaction was determined by a variety of social support factors in their lives. Unlike the elderly Chinese living in Canada, neither their economic status nor their health was significantly related to their life satisfaction. The overriding importance of social support for the elderly Chinese in Suzhou suggests a very different culture from the one in North America, one without an emphasis on materialism and capital. At the same time, their levels of life

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satisfaction were low so that even though economic factors were not salient, the social support in their lives was far from optimal. However, changes in this area could improve their quality of life. The emergence of social support as the major factor affecting the quality of life for the elderly in Suzhou suggests that research should be paying far more attention to the details of the social fabric of life when examining the overall well-being of the elderly in China. Unlike existing studies on wellbeing among the elderly in China, the data from this study does not suggest similarity in the predictors of life satisfaction when compared with the elderly in North America, but rather suggests major differences in the experience of life that relates to quality of life. Furthermore, it would appear that the findings reflected cultural rather than immigrant differences.

1 References Andrews, F.M. and S.R. Withey. 1976. Social indicators of well-being. New York: Plenum Press. Chi, I. 1995. Mental health of the old-old in Hong Kong. Clinical Gerontologist 15: 31-44. . 1997. Aging in Hong Kong. (Presented at Aging in Pacific Rim Countries', first international conference, Vancouver, B.C., March.) Gee, E.M. 1998. Well-being among Chinese Canadian elders. International Sociological Association Paper. Ho, S.C., J. Woo, U. Lau, S.G. Chan, Y.K. Yuen, Y.K. Chan and I. Chi. 1995. Life satisfaction and associated factors in older Hong Kong Chinese. Journal of the American Geriatrics Society 43: 252-5. Ikels, C. 1990. The resolution of intergenerational conflict: Perspectives of elders and their family members. Modern China 16: 379-406. Kitano, H.H.L., J.E. Lubben, E. Berkanovic, I. Chi, C.C. Zhang and Z.X. Ying. 1991. A cross national study of elderly Chinese and Chinese Americans. Hong Kong. Krause, N., J. Liang and S. Gu. 1998. Financial strain, received support, anticipated support, and depressive symptoms in the People's Republic of China. Psychology and Aging 13: 58-68. Lai, D.W. 1995. Life satisfaction of Chinese elderly immigrants in Calgary. Canadian Journal on Aging 14: 536-52. Li, L. 1995. Subjective well-being of Chinese urban elderly. International Review of Modern Sociology 25: 17-26. Meng, C. and M. Xiang. 1997. Factors influencing the psychological well-being of elderly people: A 2 year follow-up study. Chinese Medical Health Journal 11: 2735. Mui, A.C. 1996. Depression among elderly Chinese immigrants: An exploratory study. Social Work 41: 633-45. Myers, D.C. and E. Diener. 1995. Who is happy? Psychological Science 6: 10-9.

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Sirgy, M.J. 1998. Materialism and quality of life. Social Indicators Research 43: 2 2 7 60. Zhang, A.Y., Lucy C. Yu, J. Yuan, Z. Tong, C. Yang and S.E. Foreman. 1997. Family and cultural correlates of depression among Chinese elderly. International Journal of Social Psychiatry 43: 199-212.

6 Social Support and Integration: An Illustration of the Golden Guides Uniform Group in Hong Kong Alex Yui-huen Kvrnn and SojMa Siu-chee

Chan

0 Introduction The effects of population ageing are felt today in many Asian nations (Lee 1995). In Hong Kong, the population passed the six million figure for the first time in 1996 and reached 6 860 000 in 2000, comprising 3 462 500 men and 3 397 500 women (Hong Kong Census and Statistics Department 1997, p. 7, Table 1). Life expectancy, which was estimated to be 75.1 for men and 80.8 for women in 1991, is expected to rise to 78 for men and 83 for women by the year 2016. These changes will increase the proportion of the population aged 65 or over from 11.1% (748 300) in mid-1999 to about 11.3% (759 200) by mid-2000 (Hong Kong Census and Statistics Department 2000, p. 4, Table 1.3). Increasing numbers of older persons will result in a corresponding increase in the demand for a greater number, variety and duration of services for the elderly. This chapter presents the findings as to the physical, psychological and social well-being of the Golden Guides (Kwan and Chan 1997a, b and c) of the Hong Kong Girl Guides Association, in comparison to the elderly care centre members and community elderly in Hong Kong.

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I Senior Volunteerism In the Western world, the phrase 'productive ageing' is often associated with the older members of the population either participating in the labour force or contributing to the community (Caro, Bass and Chen 1993, pp. 4-8). The importance of respecting the old, of appreciating and utilizing their wisdom and experience, and of acknowledging the importance of the elderly in the community, is a given in most societies. However, the notion of older people providing help or support to others beyond one's family is not a general practice in many countries, particularly in less developed countries (Kerschner and Butler 1994, p. 210). Elderly people are eager to be useful and to spend their time in meaningful activities (Ward 1979). They like to feel that they have something of value — usually in the form of a service — to offer to someone else. One study found that older persons were much more likely than younger persons to agree strongly that retired people should contribute through community service and that 'life is not worth living if you can't contribute to the wellbeing of others' (Herzog and House 1991, p. 53). There is growing evidence that the manner in which individuals spend their free or voluntary time is strongly associated with their physical and mental well-being (e.g. Holahan 1988; Baltes, Wahl and Schmid-Furstoss 1990). Older people are potentially very important to act as volunteers (Fisher, Mueller and Cooper 1991). With the extension of life, the improvement of general health among the young elderly, and the trend towards early retirement, the healthy non-working elderly represent an enormous pool of people that could make major contributions as volunteers. In the last decade or so, volunteer programmes for seniors, both public and private, have developed and flourished. Thousands of senior volunteer programmes exist, many arising from church and interfaith groups, health-care institutions, and a broad range of cultural and social service organizations. These programmes are mostly of recent vintage (Tout 1993). The development of these programmes has meant a substantial increase in opportunities for older persons to be volunteers. For example, in the US, the Older Americans Act has increased volunteer opportunities by providing administrative support for the development of several national programmes and transport services to facilitate local participation. The Retired Senior Volunteer Program (RSVP) offers people aged 60 or over the opportunity of participating in volunteer service to meet community needs. RSVP agencies place volunteers in schools, hospitals, libraries, courts, day care centres, nursing homes, and a host of other organizations. RSVP programmes provide transport to and from the place of service. The Service Corps of Retired Executives (SCORE) offers retired business people an opportunity to help owners of small business and

SOCIAL SUPPORT AND INTEGRATION IN HONG KONG

managers of community organizations who are having management problems. Since 1965, over 200 000 businesses have received help from SCORE. Volunteers receive no pay, but are reimbursed for out-of-pocket expenses. The Senior Companion Program offers a small stipend to older people who help adults with special needs, such as the handicapped and the disabled. A programme called Green Thumb, sponsored by the National Farmers Union in 24 states, provides part-time employment in conservation, beautification and community improvement in rural areas, as well as in existing community service agencies. The US Department of Labor also has three programmes that offer older people part-time employment as aides in a variety of community agencies, including child care centres, vocational training programmes, building security, clerical service, and homemaker services. The Senior Aides programme is administered by the National Council of Senior Citizens, Senior Community Services Aides is sponsored by the National Council on Aging, and Senior Community Aides is sponsored by the American Association of Retired Persons. The success of these programmes illustrates that older people can be quite effective in both volunteer and paid positions (Atchley 1994, pp. 329-30). Even so, many successful programmes are found in only a few local areas, while elsewhere older persons with comparable interests and skills have no such volunteer opportunities. Moreover, many fine programmes have very small budgets, which restrict their services and limit their ability to recruit and work with older volunteers. Despite the fact that significant proportions of elders report having done volunteer work (Herzog and Morgan 1993), relatively little systematic research has been conducted on the outcome of volunteer activity. The Golden Guides programme upon which we report in this chapter is the first of its kind initiated in Hong Kong.

D The Golden Guides Programme In early July 1990, a staff member (who was also a Guider at the Girl Guides) of SKH Wong Tai Sin Elderly Centre approached the Kowloon Region Office of the Hong Kong Girl Guides Association that they would like to organize a 'Guide Group' for the elderly in their centre because they felt that the Girl Guides programme might suit their female members. After consultation with the Girl Guides Commissioners and some experts (including the investigator) in the field, an experimental project was started, and the first group was organized at SKH Wong Tai Sin Elderly Centre in November 1990. Up to the present, there are 28 groups established with about 1300 Golden Guides, and more groups are being organized.

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J

In Hong Kong, there are three elderly uniform groups in existence, being the Golden Guides, the Tuen Mun Road Safety Brigade operated by Yan Oi Tong Multi-service Centre for the Elderly (with over 40 members), and the Red Cross Elderly Group managed by the Hong Kong Baptist Hospital's Au Shue Hung Health Centre (with over 30 members). Their group natures are quite similar to self-help groups (Katz and Bender 1976). Since the movement of Golden Guides in Hong Kong is the only one implemented within the Girl Guides Association, its experiences are extremely useful for other regions as reference. Also, its uniqueness among the three uniform groups and its remarkable receptiveness by the elderly population might illustrate its worthiness as a model programme for other regions to initiate and replicate.

§ The Golden Guides Study Subjects In order to have a comprehensive sample of the Golden Guides, we took a full sample of all the 16 teams (about 18 members per team) in early 1995. We also selected 160 subjects from various social centres for elderly or community centres for elderly, being members who had not joined any uniform group before, as they were used as a control group in the study. We also randomly selected 100 elderly people from the community as another control group, being subjects who had not joined any Centre as members. With the assistance of the Golden Guides' team leaders, a total of 264 successful interviews were obtained from the Golden Guides, with a return rate of 91.7%. As to the elderly centre sample, a total of 120 successful interviews were obtained, with a return rate of 75%. Finally, a total of 57 community elderly were successfully interviewed, with a return rate of 57%. The average time of an interview was 90 minutes.

Measurements Ten measurements were used in the interview questionnaire in order to obtain the necessary information from the respondents: the Health Perception Questionnaire, adopted from Davis and Ware (1981); the Activity Difficulties; Physical Emotion and Health Status, both adopted from Anderson, Sullivan and Usherwood (1990); the Life Satisfaction Index, adopted from Neugarten, Havighurst and Tobin (1961); the Social Activity, adopted from Donald et al.

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85

(1978); the Golden Guides Satisfaction, adopted from Attkisson et al. (1979); the Self Concept, adopted from Rosenberg (1965); and the Emotional Feelings and Family Support, both developed by the researchers. Nearly all the measurements used were modified from original scales or from relevant local studies. Most of the questions were in the Likert Scale format. In the calculation of the well-being of the respondents, we obtained the total score by summation of each item score, then categorized the respondents into three groups (high, moderate and low) for further analysis. In order to test the reliability of the ten measurements (Health Perception, Activity Difficulties, Health Status, Life Satisfaction, Social Activity, Family Support, Self Concept, Emotional Feelings, Physical Emotion, and Golden Guides Satisfaction), Guttman's split-half method was used, and reliability coefficients were calculated. The results are presented in Table 1.

Table 1 Guttman's split-half reliability coefficients of measurements by samples Reliability coefficients

No. of items

Golden Guides Elderly centre Community Health Perception Questionnaire (HPQ) Activity Difficulties (AD) Health Status (HS) Life Satisfaction Index (LSI) Social Activity (SA) Family Support (FS) Self Concept (SC) Emotional Feelings (EF) Physical Emotion (PE) Golden Guides Satisfaction (GS)

26 6 4 13 5 5 6 10 6 18

.72 .78 .67 .38 .82 .76 .75 .43 .80 .66

.80 .83 .72 .48 .80 .76 .75 .49 .69 .67

.86 .76 .66 .50 .80 .73 .75 .63 .67 .67

D Results Characteristics of the sample Before we go into the analysis of the general well-being of the Golden Guides in comparison to the elderly centre respondents and the community respondents, a brief description of the general characteristics of the respondents will be helpful in obtaining a better understanding of their background. According to the findings, members of the Golden Guides were relatively younger, nearly half (48.5%) were aged between 65 and 74. As to their educational background, 66.2% reached at least primary level, which was much better than the average elderly population. Buddism was the major

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ALEX YUI-HUEN KWAN AND SOPHIA SIU-CHEE CHAN

religious belief of the Golden Guides. Nearly half of the respondents stayed at private tenements, as compared to 34% at public housing estates. Only 28.8% of the respondents had joined the Golden Guides within the previous six months, the rest joined the programme for more than a year. About onequarter (23.5%) of the respondents were living alone, while the rest were living with their family members. Comparing the Golden Guides to elderly centre respondents and community respondents, the Golden Guides received more emotional support from their family members (an average of 2.13 members vs. 2.03 and 2.09 respectively). As to the number of family members providing financial support, respondents from elderly centres and the community obtained more financial support than the Golden Guides (an average of 1.88, 2.21 and 1.72 members respectively). The Golden Guides were the most active group in volunteer services (76.1% in comparison to 60.8% and 31.6% accordingly). About 41.3% of Golden Guides were widowed, and nearly half (49.6%) were still married. Most of the respondents were introduced to Golden Guides by friends (33.3%) and social workers (37.9%). Regarding individual contribution to society, the majority (89%) considered the issue positively, as they did in considering the elderly's contribution to society. The Golden Guides group had a higher degree of family support (45.8% in comparison to 31.7% for the elderly centre group and 22.8% for the community group).

Relationships of independent and dependent variables Data analysis was conducted to examine the bivariate relationships among the ten dependent variables (Activity Difficulties, Health Status, Health Perception, Family Support, Life Satisfaction, Social Activity, Self Concept, Emotional Feelings, Physical Emotion, and Golden Guides Satisfaction) and the background variables. A total of 180 Chi-square tests were conducted for the Golden Guides sample, and the results are presented in Table 2. Due to the limitation of space, we have not presented the specific cross-tabulation tables. Instead, we have summarized the findings of all the significant correlations as below. Furthermore, the bivariate relationships among the ten dependent variables were examined, and the results of the Pearson Correlation Coefficients analysis are presented in Table 3. Analysis of inter-item correlations was c o n d u c t e d for the ten measurements in order to assess their internal consistency. The findings confirmed that all the measuring scales were generally consistent internally. The majority of the inter-item correlations were statistically significant at the .05 level.

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L Table 2

87

Inter-variable association matrix (X2 test) of Golden Guides respondents HS HPQ

Variables

AD

Duration of joining Number of family members stay with Family emotional support Family financial support Voluntary services Individual contribution Contribution to society Join Girl Guides before Girl Guide relatives Girl Guide friends Know Girl Guides Impression of Girl Guides Girl Guide neighbours Girl Guide identity Current health Pain Health constraint Work constraint

n.s.

22.5

17.4 43.9 32.7* 21.0 35.9 20.4 15.1 19.7 17.4 10.6* 19.5* n.s. 21.6 26.1 19.9* 32.2 25.9

n.s. n.s. n.s. n.s. 20.0 13.0 20.3 22.4 33.0 n.s. 45.3 13.3 44.1 26.0 20.2* 50.4 42.5

EF

FS

LSI

SA

n.s.

36.8

n.s.

22.5

n.s.

23.6

n.s.

n.s.

n.s. n.s. n.s. n.s. 24.3 18.7 47.2 39.2 26.6 n.s. 57.3 50.0 56.0 77.1 53.7 45.7 47.5

39.0 70.7 56.5 n.s. 28.7 20.4 18.4 31.6 25.6 11.3* 27.3 16.1 24.9 31.1 19.2* 23.1 24.6

38.1 n.s. n.s. n.s. 12.3* 11.1* 21.4 13.2 13.0 n.s. 39.2 16.1 28.8 26.1 21.9* 26.6 20.2

26.6* n.s. n.s. n.s. n.s. n.s. 15.6 12.1* 17.5 n.s. 37.3 19.1 26.9 n.s. 41.4 51.4 33.5

23.5* 50.7 46.7 12.2* n.s. n.s. n.s. n.s. 11.8* n.s. 21.7* 33.6 n.s. 23.5 n.s. 25.0 19.3

n.s. 42.0 31.5* 18.4 13.7 16.9 9.6* 17.8 12.5 19.9 30.4 29.2 19.4* n.s. 21.7* 22.8 34.3

n.s. 31.3 n.s. 13.4 n.s. n.s. 26.1 28.3 22.4 25.4 50.9 27.8 26.2 18.3* 19.3* 33.2 29.1

n.s. n.s. n.s. n.s. 20.8 16.6 23.3 17.5 26.0 n.s. 37.1 23.7 28.8 18.2* n.s. 42.4 34.8

SC

PE

GS

* significant at the .05 level n.s.: not significant; all the rest are significant at the .01 level

Table 3 Variables AD HS HPQ FS LSI SA SC EF PE GS

Inter-scale Pearson correlation (r) matrix of Golden Guides respondents AD

HS

HPQ

FS

LSI

SA

SC

EF

PE

GS

X

33.5

21.0 32.3

27.0 28.2 26.2

n.s. 16.6 14.5 33.4

11.5* 36.4 29.6 31.2 27.5

19.7 11.9* 10.5* 16.9 15.8 12.5

31.9 37.2 25.4 31.8 31.0 31.0 28.3

27.2 33.8 13.0 11.4* 15.0 16.9 45.5 60.4

16.6 18.3 14.2 21.0 17.6 18.9 n.s. 29.0 n.s.

X

X

X

X

X

X

X

X

X

* significant at the .05 level n.s.: not significant; all the rest are significant at the .01 level

As to the ten measuring scales' reliability, the split-half method was used, and reliability coefficients were calculated. It was found that all the scales had an acceptable reliability level. When we ran 180 cross-tabulations between the ten scales and the background variables, we obtained 132 statistically significant X2 associations at the minimum .05 level. This suggested that various measurements which had different significant and meaningful relationships, existed in the study. When we further ran the bivariate correlations among the ten measuring scales, we obtained 42 significant

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correlations from the 45 correlation coefficients. This indicated that there were a lot of meaningful relationships among the measuring variables.

Summary The present study sample comprised 306 non-Golden Guides respondents in the Part I survey, and 264 Golden Guides, 120 elderly centre members, and 57 community elderly respondents in the Part II survey, during the spring of 1995. Besides opinions towards Golden Guides, activity difficulties, family support, physical emotion, health status, life satisfaction index, self concept, health perception, emotional feelings, social activity, and Golden Guides satisfaction, consideration was also given to the relationship with the Girl Guides, years of knowing the Golden Guides, medical and health aspects, social satisfaction, health views, economic satisfaction, and other sociodemographic variables. The findings derived from analytical procedures may be summarized as follows: 1. In the Part I opinion survey, the majority of the Golden Guides participants were positively and highly regarded by others. 2. The top five positive items regarding the Golden Guides participants were: kind, easy to get along with, happy, clean and honest. It indicated that the Golden Guides participants did present a very positive and healthy image to others in the community. 3. In the Part II survey, it was found that members of Golden Guides were relatively younger, with nearly half being aged between 65 and 74. 4. As to their educational background, 66.2% reached at least primary level, which was much better than the average elderly population. 5. Buddism was the major religious belief of the Golden Guides. 6. Nearly half of the respondents stayed at private tenements, as compared to 34% at public housing estates. 7. Only about one-third of them had joined the Golden Guides within the previous six months, the rest had joined the programme for more than a year. 8. One-quarter of the respondents were living alone, while the rest were living with their family members. 9. In comparison to the elderly centre respondents and community respondents, the Golden Guides received more emotional support from their family members. 10. Golden Guides received less financial support from family members compared to the elderly centre respondents and community respondents. 11. Among the three groups, the Golden Guides were the most active group in volunteer services.

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12. About 40% of Golden Guides were widowed, and nearly half were married. 13. Most of the respondents were introduced to join the Golden Guides programme by friends and social workers. 14. Regarding individual and the elderly's contribution to society, the majority of the respondents considered the issue positively. 15. Comparing the three groups, the Golden Guides group received the highest degree of family support. 16. As to their relationships with the Girl Guides, most of them had had some kind of connection with the Girl Guides previously, and a majority had a good impression towards the Girl Guides. 17. Over half of the respondents had a fair identification with the Girl Guides, while 40% had a rather strong identification. 18. Regarding their medical and health status, on average the respondents had a good current health situation. Only one-tenth said that their health might hinder their activities. Less than 2% experienced pain in the previous month. The majority never experienced any health limitation or work constraints. More than 80% considered their health status satisfactory. 19. The Golden Guides respondents enjoyed a higher degree of life satisfaction in comparison to the elderly centre respondents and community respondents. 20. The Golden Guides respondents had more frequent visits with their family members, had one or two neighbours to visit, and considered that they had enough contacts with their relatives and friends. 21. More than half of the respondents had an average degree of self concept. 22. A majority of the respondents perceived their health generally to be good. 23. In general, the respondents had positive emotional feelings. 24. Regarding their pattern of social activity, on average about 40% of the respondents had more than three families with whom they could closely interact. About half of them had more than three very close friends, and had outings with others two or three times per month. 25. When they were asked to compare their general interaction with others, one-third of the Golden Guides said that it was better than the norm. 26. In the economic aspect, most of the respondents accounted for their own daily expenses, and more than half received help from their relatives. 27. Most of them did not have any salary or business income. Ten percent of Golden Guides respondents received public assistance money, about onethird received an old age allowance, and only 4% received a pension. One-third wished to have more income. 28. Regarding their overall satisfaction with Golden Guides, only about 10% were not satisfied.

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I Social Support and Integration of the Elderly in the Community Social contacts and leisure activities, crucial to an individual's well-being and quality of life, are pursued by most of the population through a wide variety of social networks and cultural, sports, educational, entertainment and travel activities. Although many older people continue or increase such activities on retirement, social opportunities are reduced for some people in later life through loss of work contacts, bereavement, disabilities or lack of financial resources. Women are still the foundation of informal care, an army of unpaid labour whose position is assiduously justified by the familial discourse. Yet, women caring in the community are hampered by inhospitable community environments, plus their own poverty and poor health which may arise from years of intensive caring (Cowen 1999, p. 207). There has also been a shift of emphasis from providing social activities for older people to promoting their active participation in the social life and organization of their community or in their residential homes, and empowering them to make decisions, improve their living conditions and develop their own potential (Kwan and Chan 1999a and b). Thus self-help, volunteering and community-based initiatives have been encouraged for older people in the US, France, Germany, Italy and United Kingdom (Tester 1996, Chapter 6). The Golden Guides movement is one of these initiatives attempted in the Hong Kong community. Thus, for pragmatic, economic, social, psychological and political reasons, as well as in recognition of the value bases upon which such pragmatic reasons rest, policy-makers have refocussed on the informal support system of kin, friends, neighbours and community-based volunteer groups as resources essential to providing support to the elderly (Social Welfare Department 1998; IYOP Organizing Committee 1999; Tarn 1999). The central notion behind the concept of informal social support networks includes giving emotional support, providing specific information, filling in when a close relationship is severed by death, illness, divorce or separation, helping identify arenas of good professional help, and serving in place of professionals when they are not trusted or not available (Warren 1981). The fundamental conclusion common to most of the social support and wellbeing studies undertaken is that a breakdown in the social support system of an individual greatly increases the likelihood of stress factors having serious detrimental effects on health and well-being. Stated more positively, the availability of a supportive social network seems to significantly enhance the ability of an individual to cope with both physical and psychological stress factors (McCubbin, Sussman and Patterson 1983). Sauer and Coward (1985) have presented a good discussion on the role of social support networks in

SOCIAL SUPPORT AND INTEGRATION IN HONG KONG

the care of the elderly. The Golden Guides programme in Hong Kong plays exactly that kind of role for the female ageing population. There are numerous opportunities available to older people who wish to serve as volunteers. The emphasis on older persons as volunteers has increased as the pool of women outside the paid labour force has shrunk. For older people, the volunteer role is a potential source of meaningful activity and status which can counteract the marginality and demoralization of old age (Ward 1979, p. 258). Friendship and neighbour relations in old age can provide an important mechanism for social integration in the community and in broader society (Peters and Kaiser 1985). Volunteering and self-help groups offer opportunities for older people to contribute to, and benefit from, support and social interaction (Kwan and Chan 1998a and b, 2000). Undertaking unpaid work as a volunteer can provide job satisfaction for people who have retired from employment or no longer have child-rearing responsibilities. There are various structures for the organization of such work, often within or coordinated by the voluntary non-profit sector. Activities which benefit other older people comprise only part of a very extensive range of volunteering opportunities. Similarly, the voluntary organizations and self-help groups in which older people participate include not only those which are exclusively for the older age groups, but also those catering for many other interests. Our major question therefore is how the near old and the young old who are retired and economically secure can be more effectively engaged in community services (Morris and Caro 1997, pp. 96-7). These groups are already making a useful contribution, but the potential for greater contribution is substantial. The fact that many are already engaged in formal and informal help to their families and communities is encouraging, but invites the question of whether substantially more productive activity is possible. We propose that organizations assign greater responsibilities to volunteers. We also predict that capable older people can be found who would welcome the challenge.

1 Discussion and Conclusion If we think of non-working time as free time or leisure, it is apparent that the technological revolution in industry that has occurred over time is making possible an ever-increasing amount of free time. On the other hand, virtually any activity that one engages in could be considered a leisure activity. Leisure is something that is important to each of us, and is something we intuitively understand. Leisure activities represent a major aspect of old people's lives. Leisure is an important source of well-being across adulthood and offers ways

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of meeting new people. At the same time, we need to learn much more about how old people spend their non-working time. Our present study on Golden Guides has offered some partial answers in this regard. The prevalence of chronic conditions, including psychopathological conditions, and the relatively high levels of limitation of activity of some elderly, may give the impression that elderly people view themselves as being in poor health and unable to function. This is not the case. According to our findings, the majority of older people assessed themselves as being in excellent or good health when compared to other people of their own age. Ageing changes activities in many ways. Changes in physical functioning can impose limits on what we are able to do physically and may eventually become serious enough to restrict our activities to an institutional environment. Regular social activity may, however, lead to improvements in body image as well as in attitude towards life. When activity is done as part of a group, the social aspect of group activity may help overcome loneliness as well as give a sense of belonging and worth. It would appear from the research evidence that uniform group programmes for the elderly can be useful in improving social support and integration in the community. Group activities can be satisfying for persons of any age, but membership in voluntary associations can offer important benefits for older people particularly. Such group activities may be a source of social integration to fill the vacuum created by role losses such as retirement or widowhood. Also, any type of group participation offers opportunities for self-expression and personal involvement. Within this study, the findings revealed that Golden Guides participants were in a much better position all round in comparison to elderly centre members or the community elderly. Voluntary activities can be a source of personal identity, personal development, sensory experience, prestige or status, new experience, peace and quiet, fun and joy, feelings of accomplishment, or something to look forward to. Activities can also meet goals such as being with people, getting the 'vital juices' flowing, serving others, passing time, exercising competence, or finding escape. Time spent in service to others is time well spent, regardless of one's age. Few other activities can rival volunteer work as a source of 'good feelings' about oneself. As stated previously, the volunteer role is a potential source of meaningful activity and status which can counteract the marginality and demoralization of old age. Within this study, we can see that the Golden Guides' service role offers both meaningful activity for many older people and benefits to society. Unfortunately, however, other elderly persons have not been effectively tapped as a resource. We need greater understanding of what makes different volunteer activities appealing and successful. There is also a need to develop ways of encouraging older people to participate in such activities, particularly those who have been relatively uninvolved.

SOCIAL SUPPORT AND INTEGRATION IN HONG KONG

The increasing size of the older population and growing awareness of their shared problems and interests heighten the likelihood that groups specifically designed for older people will become increasingly prevalent. With the worldwide trend of population ageing in recent decades and the consequent increased emphasis on the issue, it has become increasingly within our power to intervene directly in the processes of ageing, with prevention, treatment and rehabilitation. It is also within our power to intervene in social, cultural, economic and personal environments, influencing individual lives as well as those of older persons en masse. However, as warned by Butler (1994, p. 3), if we fail to alter present negative imagery, stereotypes, myths and distortions concerning ageing and the aged in society, our ability to exercise any new possibilities will remain sharply curtailed. Activity theory promotes the value of active living. It contends that people experience high life satisfaction if they stay active (Neugarten 1987). Therefore, it would prove extremely valuable if the following steps were taken to create the conditions for a truly productive ageing society (Morris 1993, p. 291): 1. Developing a consensus in society that the aged can and should be considered as assets, with opportunities for those over 55, 60 or 65 to continue, or to create, their own roles in society. 2. Changing public and anti-age discrimination. 3. Opening the doors of all institutions, whether proprietary, non-profit, voluntary or governmental, for significant opportunities for interested and capable elders. 4. Placing a value on many activities that are voluntary, private or unreported and thus fail to be reflected in our national accounts, even though these activities may concretely improve social and economic conditions. Institutions and organizations in other countries have already begun to expand opportunities to adults in their Third Age (Laslett 1991). We only hope that in the new millennium, the Hong Kong Special Administrative Region will do the same. The Hong Kong Girl Guides Association reported a tenfold increase in the number of people aged over 60 who had joined Golden Guides, from 144 people in 1991 to 1300 in 1996 (Lee 1996, p. 4). The Golden Guides initiative has proved to be a very successful and valuable programme for older persons in Hong Kong. We hope that Girl Guides associations in other regions will likewise prove successful for their female members.

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I References Anderson, J . C , F. Sullivan and T.P. Usherwood. 1990. The medical outcomes study instrument (MOSI) — Use of a new health status measure in Britain. Family Practice 7 (1): 205-18. Atchley, R.C. 1994. Social forces and aging (seventh edition). Belmont, California: Wads worth. Attkisson, C.C, D.L. Larsen, W.A. Hargreaves and T.D. Nguyen. 1979. Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning 2 (1): 197-207. Baltes, M.M., H. Wahl and U. Schmid-Furstoss. 1990. The daily life of elderly Germans: Activity patterns, personal control and functional health. Journal of Gerontology 45 (4): 173-9. Butler, R.N. 1994. Dispelling ageism: The cross-cutting intervention. In Perspectives in social gerontology, ed. Enright, R.B., Jr. 3-10. Boston: Allyn and Bacon. Caro, F.G., S.A. Bass and Y.P. Chen. 1993. Introduction: Achieving a productive aging society. In Achieving a productive aging society, eds. Bass, S.A., F.G. Caro and Y.P. Chen. 3-25. Westport, Connecticut: Auburn House. Cowen, H. 1999. Community care, ideology and social policy. London: Prentice Hall Europe. Danigelis, L. 1985. Social support for elders through community ties: The role of voluntary associations. In Social support networks and the care of the elderly — Theory, research, and practice, eds. Sauer, William J. and Raymond T. Coward. 159-77. New York: Springer Publishing Company. Davis, A.R. andJ.E. Ware, Jr. 1981. Measuring health perceptions in the health insurance experiment (Rand: Publication no. R-2711-HHS.) Santa Monica, California: Rand Corporation. Donald, C.A., J.E. Ware, R.H. Brook and A. Davies-Avery. 1978. Conceptualization and measurement of health for adults in the health insurance study: vol. IV Social health. (Rand: Publication no. R-1987/4-JEW.) Santa Monica, CA: Rand Corporation. Fisher, L., D.P. Mueller and P.W. Cooper. 1991. Older volunteers: A discussion of the Minnesota senior study. The Gerontologist 31 (1): 183-94. Gelfand, D.E. 1999. The aging network: Programs and services. 116-9. New York: Springer Publishing Company. Herzog, A.R. and J.S. House. 1991. Productive activities and aging well. Generations 15 (1): 49-54. and J.N. Morgan. 1993. Formal volunteer work among older Americans. In Achieving a productive aging society, eds. Bass, S., F. Caro and Y.P. Chen. 11942. Westport, CT: Auburn House. Holahan, C.E. 1988. Relation of life goals at age 70 to activity participation and health and psychological well-being among Terman's gifted men and women. Psychology and Aging 3 (3): 286-91. Hong Kong Census and Statistics Department. 1997. Hong Kong population projections 1997-2016. Hong Kong: Government Printer. . 2000. Hong Kong monthly digest of statistics. Hong Kong: Government Printer. IYOP Organizing Committee. 1999. Programs for the international year of older persons

SOCIAL SUPPORT AND INTEGRATION IN HONG KONG

in Hong Kong. Hong Kong: Hong Kong Council of Social Service and Social Welfare Department. Katz, A.H. and E.I. Bender. 1976. The strength in us: Self-help groups in the modern world. New York: New Viewpoint. Kerschner, H.K. and F.F. Bulter. 1994. Productive aging and senior volunteerism: Is the U.S. experience relevant? In Perspectives in social gerontology, ed. Enright, R.B., Jr. 210-6. Boston: Allyn and Bacon. Kwan, Y.H. and S.C. Chan. 1997a. Golden Guides movement in Hong Kong — A pioneer gerontological social work attempt. Soochow Journal of Social Work 3 (1): 213-30. (In Chinese.) and S.C. Chan. 1997b. A new service for elderly work in Hong Kong — The Golden Guides Program. Quanguo Laoling Gongzuo (National Old Age Work) 7: 26-7. (In Chinese.) and S.C. Chan. 1997c. The new model of the very old women to continue to work — The movement of 'Old Age Girl Scouts' in Hong Kong. Research on Aging 7: 16-8. (In Chinese.) and S.C. Chan. 1998a. A comparison on the psychological well-being of the Golden Guides, elderly centre members, and community elderly in Hong Kong. (Paper presented at the 2nd International Conference on Social Work in Health and Mental health, organized by the University of Melbourne, 12-15 January 1998 at World Congress Centre, Melbourne, Australia.) and S.C. Chan. 1998b. A comparison on the social well-being of the Golden Guides, elderly centre members, and community elderly in Hong Kong. In A reader on aging into the 21st century, ed. Fung, Q.S. 522-42. Shanghai: Shanghai Scientific Technology Books Publisher. (In Chinese.) and S.C. Chan. 1999a. Empowerment of older women through Golden Guides — A successful program in Hong Kong. (Paper presented at the International Conference with a Special Focus on Older Women in Asia, organized by Tsao Foundation, 5-7 July at Fort Canning Lodge, YWCA, Singapore.) and S.C. Chan. 1999b. From passive to active — A new social movement in empowerment of older women in Hong Kong. (Paper presented at the International Conference on Citizen Action and Community Development, organized by International Association for Community Development, 8-12 April at University of Edinburgh, Scotland, United Kingdom.) and S.C. Chan. 2000. A comparison on the physical well-being of the Golden Guides, elderly centre members, and community elderly in Hong Kong. In All about elderly welfare, ed. Kwan, Y.H. 1-13. Hong Kong: Cosmos Books Ltd. (In Chinese.) Laslett, P. 1991. Afresh map of life: The emergence of the third age. Cambridge, MA: Harvard University Press. Lee, M. 1995. Going grey. Asia Magazine (18-20 August): 8-11. Lee, N. 1996. Golden Guides on march. South China Morning Post (27 October): 4. McCubbin, H.I., M.B. Sussman and J.M. Patterson. 1983. Social stress and the family: Advances and developments in family stress theory and research. New York: Haworth Press. Morris, R. 1993. Conclusion: Defining the place of the elderly in the twenty-first century. In Achieving a productive aging society, eds. Bass, S.A., F.G. Caro and Y.P. Chen. 287-93. Westport, Connecticut: Auburn House.

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and F.G. Caro. 1997. The young-old, productive aging, and public policy. In The future of age-based public policy, ed. Hudson, Robert B. 91-103. Baltimore, Maryland: the John Hopkins University Press. Neugarten, B.L. 1987. Kansas City studies of adult life. In The encyclopedia of aging, ed. Maddox, G.L. 372-3. New York: Springer. , R.J. Havighurst and S.S. Tobin. 1961. The measurement of life satisfaction. Journal of Gerontology 16 (1): 134-43. Peters, G.R. and M.A. Kaiser. 1985. The role of friends and neighbors in providing social support. In Social support networks and the care of the elderly — Theory, research, and practice, eds. Sauer, William J. and Raymond T. Coward. 123-58. New York: Springer Publishing Company. Rosenberg, M. 1965. Society and the adolescent self image. Princeton, New Jersey: Princeton University Press. Sauer, W.J. and R.T. Coward. 1985. The role of social support networks in the care of the elderly. In Social support networks and the care of the elderly — Theory, research, and practice, eds. Sauer, William J. and Raymond T. Coward. 3-20. New York: Springer Publishing Company. Social Welfare Department. 1998. Hong Kong elderly services guide. Hong Kong: Government Printer. (In Chinese.) Tam, Y.C. 1999. A brief discussion on elderly service direction in SAR. Social Service Quarterly 149: 3-5. (In Chinese.) Tester, S. 1996. Community care for older people. London: Macmillan Press Ltd. Tout, K, ed. 1993. Elderly care: A world perspective. London: Chapman and Hall. Ward, R.A. 1979. The aging experience: An introduction to social gerontology. New York: J.B. Lippincott. Warren, D.L 1981. Helping networks: How people cope with problems in the urban community. Notre Dame, IN: University of Indiana Press.

7 Health-related Quality of Life of the Elderly in Hong Kong: Impact of Social Support Weiqun Lou and Iris Chi

1 Introduction The ageing of society presents challenges to social and economic development all over the world. A strategic aim of the World Health Organization is to promote healthy ageing so as to: (1) maximize independent living of older persons and promote their further contributions to society; and (2) minimize the demands for family and social care for older persons. The quality of life of the elderly population would be greatly improved if these goals could be achieved. As a financial and economic centre in the Asia-Pacific region, Hong Kong has become more and more urbanized since 1980. More than 95% of the territory is urban. The major strategy of the Hong Kong government to cope with this urbanization is the development of so-called new towns in outlying areas. These new towns were initially built in the boundary area between the main central urban districts and the suburbs, and eventually in more remote locations. Many people who lived in the densely-populated urban parts of Hong Kong have moved to the new towns because of urban redevelopment or to take advantage of better housing standards there. However, relocation is not always a positive experience. Poor public transport, lack of community services and few job opportunities are some of the major complaints. There has been no consensus on the impact of urbanization and relocation

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on the quality of life of older persons. Hugo (1991) summarized three major hypotheses that could apply to different levels of social and economic development. The first hypothesis argues that the quality of life of older persons decreases with the process of urbanization and socio-economic development. In this view, elderly people lose their control of resources, and their ability to function in society is weakened. This results in society losing its traditional respect for its senior members for their wisdom and experience. Elderly people are forced into low-income jobs or are forced to rely on their children or the government for support (Cowgill 1974; Hermalin 1995). The second hypothesis proposes a TJ'-shaped pattern for the quality of life of older persons as society becomes more urbanized (Palmore and Manton 1974). The quality of life of older persons decreases at the beginning of the urbanization process, but after the society has developed formal support systems, the quality of life of older persons increases again. The third hypothesis challenges these pessimistic views of the relationship between the quality of life of older persons and urbanization (Evandrou et al. 1986). It argues that living independently does not necessarily result in isolation from others, but instead can represent an achievement of freedom. Therefore, older persons could maintain a certain level of quality of life if they were able to accumulate adequate resources during their working lives (Michael, Fuchs and Scott 1980). Local cultural traditions and the level of socio-economic development have a great effect on the ability of elderly people to live well, and differences in local conditions are reflected in the various hypotheses on development and the elderly. However, no matter how different the hypotheses are, one basic assumption behind each model is the recognition of the contribution of resource control and social support to the quality of life of the elderly. Older persons who move to Hong Kong's new towns are required to adjust to a new environment. This chapter examines how this affects their health status and how financial and social support can contribute to the health and quality of life of elderly people in these new environments. Implications for community service in the new towns will also be discussed.

1 Methodology Procedure A survey study was conducted from 1995 to 1996 in Tin Shui Wai, one of Hong Kong's new towns with medium economic development. Trained researchers carried out face-to-face interviews in respondents' homes. Each interview lasted for about half an hour to 45 minutes.

HEALTH-RELATED QUALITY OF LIFE OF THE ELDERLY IN HONG KONG

Sampling Stratified random sampling was adopted in this study. The building of residence and the individual unit were the two strata in the sampling process. Five or six households were selected randomly from each of 66 buildings in Tin Shui Wai. A random replacement was conducted if there was no elderly person in a selected household. A random selection was carried out if there were more than one elderly person in a selected household.

Subjects A total of 334 elderly people were interviewed. Of the subjects, 41.6% were men and 58.4% were women. The average age of the respondents was 68.8, and 80% t)f the respondents were below 75. According to 1996 census figures, in Hong Kong, the sex ratio of people aged 60 or above was 0.89 (male vs. female), and 25% of the elderly population were 75 years old or above (Hong Kong Census and Statistics Department 1997). Therefore, the sample in this study differed slightly from the total population. The majority of the respondents were either married or widowed — 57.5% and 39.8% respectively. The gender differences in marital status were significant: the percentage of female widowhood was 2.7 times of that of male widowhood. Table 1 Sample characteristics Male Female Total Frequency Percentage Frequency Percentage Frequency Percentage Total Age < 75 ^75 Marital status*** Married Widowed Others Work status*** Full-time Part-time Unemployed Retired Never worked Education level*** No formal education Primary school Secondary school or above ***p< 001

139

41.6

195

58.4

334

100.

113 25

81.9 18.1

151 43

77.8 22.2

264 68

79. 20.

107 28 4

77.0 20.1 2.9

84 104 5

43.5 53.9 2.6

191 132 9

57. 39. 2.

13 6 3 114 3

9.4 4.3 2.2 82.0 2.2

5 2 3 134 51

2.6 1.0 1.5 68.7 26.2

18 8 6 248 54

5. 2. 1. 74. 16.

62 35 42

44.6 25.2 30.2

154 30 11

79.0 15.4 5.6

216 65 53

64. 19. 15.

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WEIQUN LOU AND IRIS CHI

Regarding the employment status of the respondents, 74.3% were retired and 16.2% had never worked. The employment rate of the respondents was 7.8%, while 1.8% were unemployed. The gender difference in work status was significant, with the percentage of women who had never worked 11.8 times greater than the percentage of men who had never worked. The average number of years of formal education received by the respondents was 2.6. The men received an average of 4.6 years, while the women received an average of only 1.4 years. The gender difference among those who had received no formal education was significant — 79.0% of women vs. 44.6% of men. In sum, the socio-economic characteristics of the respondents in Tin Shui Wai were somewhat different from those of the general elderly population in Hong Kong. Compared to the general elderly population, the female respondents were over-represented, fewer respondents were married, more respondents were still employed, and more respondents had never received any formal education. Whether these characteristics can apply to the elderly population in other new towns needs further investigation.

Instruments The questionnaire used in this study consisted of three major parts: background indicators, social support, and health status and health-related quality of life. Background indicators Indicators of status, material resources and financial resources were used to measure the resource situation of the respondents. These included age, sex, marital status, work status, education level, living arrangement, and self-perceived financial adequacy. Social support The Lubben Social Network Scale (LSNS) (1988) was used to measure the social support networks of the respondents. Based on a social network index, the LSNS was developed to assess the social support networks of older persons. This ten-item scale covers support networks from family members, friends and neighbours. The reliability and validity of the LSNS were found to be satisfactory among the elderly population in Hong Kong (ChiandBoey 1994). Measures of health-related quality of life Health-related quality of life was measured in three aspects: physical health, functional health and affective health. Self-rated health and the presence of somatic symptoms or chronic diseases were used to measure the physical health of the respondents. The

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101

functional health of the respondents was assessed by activities of daily living. The activity level of older persons is related to their social functioning and their self-care ability. First proposed by Sideny Katz in 1963, daily activity functioning is generally represented by three aspects of activity: physical activities, instrumental activities and gross mobility (Katz et al. 1963). The 16-item scale used in this study covered all the above three aspects. The Center of Epidemiological Study's Depression Scale (CES-D) was used to measure the depressive symptoms of the respondents (Radloff 1977). This is a 20item scale with a range of scores from 0 to 60. All these indices have shown satisfactory reliability and validity among the elderly population in Hong Kong (Chi and Boey 1994).

D Results Financial support The majority of the respondents (67.5%) received financial support from their children (see Table 2). Of the respondents, 40% received financial support from their sons living together and 15% from their daughters living together. Children who did not live with their parents played a comparatively unimportant role in providing financial support for their elderly parents. Less than 21% of the respondents relied on their own financial resources such as savings, salaries or pensions.

Table 2 Source Son living together Daughter living together Son not living together Savings / interest / rental income Salary Pension / disability allowance Daughter not living together Others

Major sources of financial support Frequency (N = 326) 130 49 31 29 20 19 10 38

Percentage (%) 39.9 15.0 9.5 8.9 6.1 5.8 3.1 11.7

Since there had been no mandatory pension system in Hong Kong until very recently, the financial support received by the elderly in this study varied according to their socio-demographic background. Children supported 77.6% of the female respondents and only 53% of the male respondents. About 80%

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of the widowed elderly were supported by their children, and almost 90% of the respondents who had never worked were supported by their children. The major financial source of the elderly respondents was not the only source of income for them. The respondents usually had a few different sources, with an average of 2.63 (SD = 1.02) sources of income (see Table 3). The significant socio-demographic factors affecting the differences in the number of sources of income were marital status, education level and living arrangements. Respondents who were married or had a higher level of education had more financial sources than others. Respondents who were living alone had the least number of financial sources. Table 3

Number of sources of income by socio-demographic factors

Total Sex Male Female Age <75 ^75 Marital status* Married Others Education level* No formal education Primary school Secondary school Work status Employed Unemployed Retired Never worked Living arrangement* Alone With spouse only With children With others f

Frequency

Mean

SD

334

2.63

1.02

139 195

2.76 2.53

1.06 0.98

264 68

2.61 2.75

1.05 0.87

191 143

2.74 2.48

1.06 0.94

216 65 53

2.53 2.67 2.96

0.99 1.07 1.00

26 6 248 54

2.69 2.17 2.70 2.33

1.23 1.17 1.00 0.95

18 48 253 15

2.00 2.75 2.66 2.40

0.91 0.96 1.02 1.06

p < .05

Further analysis indicated that there was no significant relationship between perceived financial adequacy and the number of sources of income. The differences in financial adequacy among respondents with various sociodemographic backgrounds were also not significant. Almost all of the respondents perceived that their sources of income were sufficient or could just make ends meet, and very few respondents perceived themselves as lacking adequate income or as having more than sufficient income (see

HEALTH-RELATED QUALITY OF LIFE OF THE ELDERLY IN HONG KONG

103

Table 4). In line with the results on perceived financial adequacy, more than 70% of the respondents were a little or never worried about extra expenses. They would seek help from their children or spouses if necessary, and only a few respondents expressed the intention of seeking help from the government. Table 4

Perceived financial adequacy and help-seeking behaviour

Worried about extra expenses (N = 334) Never Little Much Very much Help-seeking (first priority) (N = 332) Children Self / spouse Government Relatives Friends / neighbours Others Perceived financial adequacy (N = 334) Severely inadequate Inadequate Just make ends meet Sufficient Sufficient with surplus

Frequency

Percentage (%)

8 230 88 8

2.4 68.9 26.3 2.4

272 48 4 2 2 4

81.9 14.5 1.2 0.6 0.6 1.2

1 11 153 167 2

0.3 3.3 45.8 50.0 0.6

Family and social support The living arrangement of the respondents was one of the indicators that reflected family support in a Chinese context. Most of the respondents lived with their children, and only one out of seven respondents lived with only their spouses. About 5% of the respondents lived alone, and very few lived with others who were not related to themselves (see Table 5). Table 5 shows that the living arrangement of the respondents was also correlated with their socio-demographic backgrounds, especially sex, marital status and education level. More male than female respondents lived alone or with only their spouses, while more female than male respondents lived with their children. Respondents who were widowed, divorced, separated or never married were more likely to live alone or with unrelated people. The percentage of respondents who lived with their children decreased as the education level of the respondents increased. No significant differences in living arrangements were found within each of the following sociodemographic categories: age, work status and perceived financial adequacy.

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Table 5

Living arrangements of the respondents

Frequency

With children

(%) Sex** Male Female Marital status*** Married Others Education level*** No formal education Primary school Secondary school ** p< .01

With spouse only (%)

Alone

(%)

With others (%)

139 195

67.6 81.5

22.3 8.7

7.2 4.1

2.9 5.6

191 143

70.2 83.2

25.1

-

2.6 9.1

2.1 7.7

216 65 53

81.0 78.5 50.9

9.7 12.3 35.8

6.0 1.5 7.5

3.2 7.7 5.7

*** p< 001

Besides their living arrangements, social support received by the respondents was also indicated by their social relationship with relatives and friends/neighbours (see Table 6). For the majority of the respondents, relatives served as an important source of support. The average number of relatives contacted at least once a month was 4.68. This number was correlated to the respondents' marital status and education level. Married respondents or respondents with higher levels of education reported larger numbers of contact relatives compared to other respondents in the respective socio-demographic categories. Divorced respondents reported the least number of contact relatives, with only 2.4 persons on average (not shown here). Regarding the number of contact relatives with whom the respondents could communicate intimately, the average was 4.5. It was thus clear that the network was closely related to whether they had people with whom to communicate intimately. The network was closely related to the perceived availability of emotional support for the elderly respondents. Besides relatives, friends/neighbours served as another important source of support. The average number of friends/neighbours contacted at least once a month was 3.5. This number was correlated to the respondents' levels of education and perceived financial adequacy. The higher the level of education or the higher the level of perceived financial adequacy of the respondents, the larger the number of contact friends/neighbours. This result seems to suggest that contact with friends/neighbours had resource implications — the more resources a person has, the greater the chance that the person has contact with friends/neighbours.

HEALTH-RELATED QUALITY OF LIFE OF THE ELDERLY IN HONG KONG

L Table 6

105

Social relationships with relatives and friends/neighbours by sociodemographic factors Relatives

Friends/neighbours

Number of relatives contacted at least once a month

Number of intimate relatives

Number of friends/neighbours contacted at least once a month

Number of intimate friends/ neighbours

4.68

4.50

3.50

4.10

4.83 4.57

4.71 4.33

3.48 3.51

4.05 4.14

4.69 4.57

4.47 4.53

3.31 4.21

4.00 4.50

5.03 4.20

4.83 4.05

3.59 3.38

4.20 3.97

4.37 5.34 5.13

4.24 5.08 4.85

3.07 3.69 5.02

3.73 4.34 5.36

4.80 5.33 4.81 3.93

4.50 5.50 4.71 3.41

3.73 1.33 3.66 2.90

4.38 3.17 4.07 4.22

3.67 5.41 4.60 4.87

3.72 5.38 4.42 3.87

3.67 3.56 3.48 3.53

4.22 4.02 4.12 3.93

3.92 4.88 4.55

3.83 4.61 4.44

1.92 2.98 4.08

2.67 3.65 4.61

Total Sex Male Female Age < 75 ^75 Marital status Married Others Education level No formal education Primary school Secondary school Work status Employed Unemployed Retired Never worked Living arrangement Alone With spouse only With children With others Perceived financial adequacy Inadequate Just make ends meet Sufficient

Social support network The mean score of LSNS was 28, with a standard deviation of 7.5. The scores ranged from 5 to 43. Using a score of 20 as the cut-off point, 10.8% of the respondents had insufficient support networks. Further analysis showed that the LSNS scores were correlated to the respondents' marital status, employment status and living arrangements (see Table 7). Married respondents had better social support networks than other respondents, with only 7.3% of them having insufficient support networks, as compared to 15.4% for others. Unemployed respondents had worse social support networks compared to others. Regarding living arrangements,

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J

respondents living alone were most prone to having insufficient social networks. Some 44.4% of the respondents who were living alone were categorized as insufficient in support networks.

Tabie 7

Marital status** Married Others Work status* Employed Unemployed Retired Never worked Living arrangement*** Alone With spouse only With children With others * p < .05

** p < 01

Social support networks of the respondents Mean

SD

Insufficient support networks (%)

28.9 26.7

6.9 8.0

7.3 15.4

27.7 22.3 28.5 26.1

7.5 9.9 7.5 7.1

11.5 33.3 9.3 14.8

20.6 29.9 28.2 26.7

9.6 6.7 7.2 7.6

44.4 6.3 9.1 13.3

*** p < .001

Health-related quality of life (see Table 8) Self-rated health The majority of the respondents (54%) rated their health as good, 12.3% rated their health as very good, 28% rated their health as normal, and only less than 6% rated their health as poor. Chronic diseases and somatic symptoms The most frequently reported disease among the respondents was rheumatoid arthritis, followed by hypertension, heart disease, diabetes, chronic pneumonia, and stroke. About 80% of the respondents had one or more chronic diseases, and about 30% of the respondents had two or more chronic diseases concurrently. The average number of chronic diseases reported by the respondents was 1.2. Rheumatoid arthritis and cardiac-related diseases were the most commonly mentioned chronic diseases among the sample. Regarding rheumatoid arthritis, more female than male respondents reported that ailment, with a 16% difference. However, more male than female respondents had chronic pneumonia, with a 5.5% difference. About 20% of the respondents reported no chronic diseases at the time of the survey, and only 18% of the respondents reported no somatic symptoms. As to the types of somatic symptoms, the most frequently reported symptom was joint enlargement, followed by sleep disturbances, headaches, syncope,

HEALTH-RELATED QUALITY OF LIFE OF THE ELDERLY IN HONG KONG

Table 8

Health-related quality of life of the respondents

Physical health Self-rated health Poor Normal Good Very good Number of chronic diseases 0 1 2 3 4+ Number of symptoms 0 1 2 3 4 5+ Functional health3 Lifting or carrying something as heavy as 10 kg Doing heavy work Climbing 2 to 3 flights of stairs Walking 200 to 300 metres Squatting down Taking transport Affective health (CES-D scoreb) 0 1-15 16-20 21-25 above 25 3 b

Frequency

Percentage (%)

19 94 180 41

5.7 28.0 54.0 12.3

69 167 72 16 10

20.2 50.0 21.6 4.8 3.0

60 66 34 71 79 24

18.0 19.8 10.2 21.3 23.7 7.2

215 212 153 137 101 48

64.4 63.5 45.8 41.0 30.2 14.4

12 284 26 9 3

3.6 84.9 7.9 2.7 0.9

the percentage indicates lost ability of a particular daily activity CES-D scores ranged from 0 to 60

poor appetite, and fatigue. The average number of somatic symptoms reported was 2.4. Female respondents reported more somatic symptoms than did male respondents, averaging 2.7 and 2.0 respectively. Some 61.5% of female respondents reported three or more somatic symptoms, compared to 38.8% of male respondents. Functioned health Table 8 shows that lost ability of daily activities was mostly reported in general physical activities or activities demanding high physical strength. Almost all of the respondents could handle self-care activities such as brushing teeth, dressing, getting out of bed, and shopping for necessities. The loss-ability rate of these activities was only about 1%. However, almost

107

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WEIQUN LOU AND IRIS CHI

half the respondents had difficulties in climbing two to three flights of stairs, and more than 60% of the respondents could not lift or carry something as heavy as 10 kg. Depression Using a score of 16 on the CES-D as the cut-off point, the incidence rate of depression among the respondents was 11.5%. Less than 4% of the respondents (3.6%) reported no symptoms of depression, with more than 80% of the respondents scoring between 1 and 15, while about 1% of the respondents scored over 25.

Affective health and support indicators Levels of depression were correlated to the respondents' support indicators: marital status, work status and perceived financial adequacy (see Table 9). As expected, married respondents were less likely to have depressive symptoms than others were. Respondents who were still employed were less likely to have depressive symptoms than others were. On the other hand, respondents who indicated that they were unemployed were more likely to have depressive symptoms than others were. Perceived financial inadequacy was also correlated to depressive symptoms.

Table 9

Marital status* Married Others Work status* Employed Unemployed Retired Never worked Perceived financial adequacy* Inadequate Just make ends meet Sufficient

CES-D by support indicators Frequency

Mean

SD

189 141

8.74 9.89

5.08 5.31

26 6 245 53

8.81 15.33 9.04 9.66

5.11 5.16 5.43 3.64

12 151 167

12.92 9.56 8.68

7.54 5.23 4.88

* p < .05

Social support network and health-related quality of life Table 10 shows the correlation coefficients between social support network scores and indices of health-related quality of life. Social support network

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109

scores were significantly related to somatic symptoms, functional health and depression. The more social support networks the respondents had, the lower the number of somatic symptoms they reported, the higher the level of functional health they reported, and the lower the level of depressive mood they experienced.

Table 10 Correlation coefficients between LSNS and indices of health-related quality of life Self-rated health .01 .07 -.17** .26*** -.33***

Self-rated health Chronic diseases Somatic symptoms ADL CES-D * * p < 01

-.32*** -.20*** -.26*** _

QO***

Chronic diseases

Somatic symptoms

.37*** .17*** .17**

.24*** 0-7***

.35***

*** p < .001

Further analyses were conducted by using multiple regression in order to explore the contribution of perceived financial adequacy and social support to indices of health-related quality of life. Table 11 illustrates the results of multiple regression analyses using somatic symptoms, functional health and CES-D scores as dependent variables respectively. Only significant beta figures are shown in the table.

Table 11

Multiple regression on indices of health-related quality of life Dependent variables (Beta)

Independent variables

Somatic symptoms Male Age Education level Financial adequacy LSNS Self-rated health Chronic diseases Somatic symptoms ADL CES-D 2

R

Functional health

CES-D

.18 .29 .22 -.17 -.12 .36

-.14 -.19 .12

.20

.22

.30

.28

.14 -.11 -.19 -.15 .24 .26 .25

Note: All beta figures are statistically significant at .001 level.

The results of the multiple regression analyses indicated that the contribution of social support networks to health-related quality of life was

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consistent across the three indices — somatic symptoms, functional health and depression. Higher levels of perceived social support network were associated with increasing levels of health-related quality of life. However, the contribution of perceived financial adequacy was inconsistent across the three indices. Higher levels of perceived financial adequacy were associated with lower levels of depressive mood, but higher levels of somatic symptoms.

B Discussion The finding that about three-quarters of the respondents lived with their children suggests that older persons usually move to the new towns in Hong Kong together with their children. The higher support reported by older persons who lived with their children shows that living with children is still a very viable arrangement for older persons in Hong Kong to receive family support. The family usually plays the most significant role in providing emotional and instrumental support for the elderly. It serves as the primary caretaker of the elderly and provides financial support in emergencies. Regarding the health-related quality of life, it was found that the respondents perceived themselves as comparatively physically healthy, and most of them were able to take care of themselves. However, depression was quite common among the respondents. Results showed that particular characteristics of the respondents, like gender, age, education level and perceived financial adequacy, were correlated to the level of health-related quality of life. Women, those over 80 years of age, those living alone, those who never worked, and those with low incomes comprised the 'high risk' group in terms of the health-related quality of life. It is worth noting that the social support networks of these new-town elderly residents were limited. Relocating older persons away from their familiar networks forces them to break their connections with friends and neighbours because of the physical distance. In older urban districts, public areas near public or private housing estates, neighbourhood restaurants, and gathering places for morning exercise are the most popular places for older persons to maintain a network outside the family. Many older people spend much of their time in these places, chatting with each other. Moving to the new towns obviously can disrupt their previous lifestyle. Regarding the significant impact of social support on the respondents' health-related quality of life, the findings showed that social support had a significant impact across all measures of health-related quality of life. In sum, the findings of this study support the third hypothesis summarized by Hugo (1991), which argues that older persons can maintain a certain level

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111

of quality of life despite urbanization of the local society. The health-related quality of life of older persons moving to the new towns is comparatively higher in terms of their physical status, but a little lower in the psychological aspect. The majority of the respondents in this study lived with their family members, which provided a supportive network for the relocated older persons.

0 Implications for Social Services There are two main implications of the findings for the provision of social services. Firstly, preventive services should be provided for older persons before they relocate to the new towns. The new physical and social environment of the new towns could be introduced to the older persons before they move, so that they can psychologically prepare for the new surroundings and changes of lifestyle. Moreover, difficulties that might be experienced by the older persons after relocation could be another focus of such services. This kind of services could be integrated into the urban planning programmes organized by community service centres. Secondly, community-based services should consider the particular needs of older persons moving to the new towns. For example, community tours could help older persons to familiarize themselves with amenities available nearby, such as supermarkets, shops, laundries, parks and libraries. This simple service could go a long way to easing the anxieties of older persons when facing life in a new environment. The formation of neighbourhoodbased network groups should be facilitated in new estates. Although it appears that most of the older persons relocated to the new towns move together with their children, their children need to go to work during the day. And long daily commute costs their children a great deal of time every day, limiting the time they have available to accompany their elderly parents in outings. Moreover, previous networks of the older persons are broken because of relocation. Based on these observations, a neighbourhood-based network group might be a good way for elderly people to receive and provide support among each other. We also suggest the establishment of community-based mobile clinics to provide medical and psychological services because of the great costs old people incur in going outside the new towns for health consultation. Generally, by integrating a few simple, proactive information and treatment services based on the needs of relocated older persons, the senior members of our society will be able to enjoy a significantly better quality of life in the newly developed urban environment of Hong Kong.

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J

Q References Chi, I. and J.J. Lee. 1989. A health survey of elderly persons in Hong Kong. Hong Kong: Department of Social Work and Social Administration, the University of Hong Kong. and K.W. Boey. 1994. Mental health and social support of the old-old in Hong Kong. Hong Kong: Department of Social Work and Social Administration, the University of Hong Kong. Cowgill, D.O. 1974. Aging and modernization: A review of theory. In Late life, communities and environment policy, ed. Gubrium, J.F. Illinois: Charles C. Thomas. Evandrou, M., S. Arbor, A. Dale and G. Gillbert. 1986. Who cares for the elderly? Family care provision and receipt of statutory services. In Dependency and inter dependency in old age, eds. Phillipson, C , M. Bernard and P. Strong. Bedkeham: Croom Helm. Hermalin, A.I. 1995. Aging in Asia: Setting the research foundation. (Asia-Pacific research report no. 4.) Honolulu: East-West Center. Hong Kong Census and Statistics Department. 1997. 1996 by-census report. Hong Kong: Government Printer. Hugo, G.J. 1991. The changing urban situation in Southeast Asia and Australia: Some implications for the elderly in the United Nations. In Aging and urbanization: proceedings oj the United Nations International Conference on Ageing Population in the Context of Urbanization, Sendai (Japan), 12-16 September 1988, ed. Department of International Economic and Social Affairs. 203-37. New York: United Nations. Katz, S. et al. 1963. Studies of illness in the aged: The index of ADL: A standard measure of biological and psychological function. JAMA 185: 914-9. Lubben, J.E. 1988. Assessing social network among elderly populations. Family and Community Health 11 (3): 42-52. Michael, R., V. Fuchs and S. Scott. 1980. Changes in propensity to live more. Demography 17: 39-53. Palmore, E. and K. Manton. 1974. Modernization and the status of the aged: International correlations. Journal of Gerontology 29: 205-10. Radloff, L.S. 1977. The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement 1: 385-401.

C Acknowledgements The authors would like to thank the Committee on Education and Conference Grant, the University of H o n g Kong, a n d the National Health Research Development Program of Health, Canada, for their research grants. The a u t h o r s are grateful to all w h o helped in carrying out the fieldwork. T h e y are p r o f e s s o r s F a n g Y u a n , S h e n g m i n g Yan a n d Aiyu Lui at t h e D e p a r t m e n t of Sociology, Peking University; Professor Shixun Gui at the

HEALTH-RELATED QUALITY OF LIFE OF THE ELDERLY IN HONG KONG

Population Research Institute, East China Normal University; Professor Zhongru Zhang at Shanghai University; Professor Chengzhang Chen at Zhongshan Medical University; officials from the Statistical Bureau in Suzhou Municipality; and all the students who helped to conduct the survey in the five cities.

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8 Care of the Elderly in One-child Families in China: Issues and Measures Shixun Gui

The mainland of China has the largest number of elderly of Chinese origin than anywhere else in the world. It was estimated that, at the end of 1999, the population aged 65 or above reached 92 510 000 and accounted for 7.6% of the total population (State Statistical Bureau 2000). There will be extremely prominent social issues in China in the future — how to take good care of a large number of elderly people in one-child families. In September 1980, the Central Committee of the Communist Party of China pointed out to all its members and the Communist Youth League, in an open letter regarding the control of China's population, that the one-child policy would lead to care problems for older persons in 40 years' time — a problem which already existed in many countries and needed solving, for maybe no one would be available to care for many of the elderly at that time. This chapter mainly studies the influences of the one-child policy in relation to the care of the elderly in China in the future, and discusses the policies and measures necessary for an appropriate solution. It is well known that the government of China has implemented a onechild policy around the whole country, except for some less-populated minority regions, since 1980, in order to control the phenomenal growth of the population and harmonize the development of population, the economy, society and environment. The total number of persons applying for one-child certificates was 28 170 000 in 1984 (Centre of China Population Information

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1985) and 53 370 000 (excluding those children above 16 in 1997) (National Family Planning Commission 1998). The author estimates that, by the year 2010, the accumulative total of children for whom one-child certificates were applied approaches 100 million while that of their parents will reach 200 million. In Shanghai, the number of children for whom one-child certificates were applied was only 366 700 in 1980; this number increased to 1 665 700 (excluding those above 16) in 1997 (Shanghai Statistical Bureau 1998) and, by the author's estimation, will be 2 700 000 by the year 2010. What will be the proportion of 'one-child elderly' in society in the first half of the twenty-first century? Table 1 indicates that the percentage of women aged from 22 to 33 with only one living child was more than 30% of the total of the same age group, according to the 1990 population census. Providing those one-child women above 30 years old will keep the number of their children in their whole lifetime within the current birth-control policy, 30% of 60-year-old women in 2017 or 75-year-old women in 2032 will be onechild elderly in China. Because of its relatively high levels of economic and social development, high urbanization level, and the universally advocated one-child policy with exception for those families with special difficulties, the percentage of one-child elderly in a same age cohort will be much higher in Shanghai than in the whole country. According to the 1990 population census, in Shanghai, women aged from 29 to 35 with only one living child formed more than 80% of the total population in the respective age group. These percentages were 83.2%, 86.6%, 87.6%, 88.1%, 87.2%, 86.2% and 83.2% respectively (Office of Population Census of Shanghai, Shanghai Statistical Bureau 1992). Providing those one-child women above 30 years old will keep the number of their children in their whole lifetime within the current birthcontrol policy, at least 80% of 60-year-old women in 2015 or 75-year-old women in 2030 will be one-child elderly in Shanghai. It is obvious that how to care for the aged will become a great social problem in China when the one-child elderly reach the age of 75 by the thousands in 2030, because at that time, not only will their self-care ability become increasingly weak, but their 'spouse-bereft' rate will be about 50% high (China Aging Scientific Research Center 1994), and most of their only adult-children will be living away from them, or at least, not close to them. What is remarkable is that large numbers of one-child parents reach their octogenarian years just when China will have a high percentage of aged and very aged within the total population, in the twenty-first century. According to the 1990 population census, the given total fertility rate will decline from 2.3 in 1990 to 2.1 in 2000 and to 1.8 in 2010, then will remain at the same level until 2050. The life expectancy of men will increase from 67.58 in 1990 to 76.0 in 2050, and that of women from 70.91 in 1990 to 80.0 in 2050. Some scholars conclude that the total number of persons aged 65 or above

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Table 1

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Percentage of one-child older w o m e n within the same age group

1990

2030

%

22 23 24 25 26 27 28 29 30 31 32 33

62 63 64 65 66 67 68 69 70 71 72 73

32.0 41.0 46.5 48.5 48.1 45.1 39.8 42.2 39.4 35.5 33.0 30.0

Source calculated from Population Census Office of China State Department, Population Division of State Statistical Bureau 1992

will go beyond the 100 million mark in 2007, will reach 200 million in 2028, and 300 million in 2041. It will reach the 307 million mark, that is, 20.4% of the total population, in 2050 — 4.9 times and 3.6 times the figures in 1990 (63.14 million and 5.6%) respectively. The total number of persons aged 75 or above will reach 152 million in 2050, that is, 7.1 times more than the number in 1990 (18.66 million). They also conclude that, as Table 2 shows, the total number of 75-year-olds or above will be 36.9% of that of 60-yearolds or above in 2050, that is, 0.9 times more than the figure in 1990 (19.2%) (Du 1994). Table 2

Ageing trend in China, 1990-2050

60 or above

65 or above

75 or above

Year

million

% of the total population

million

% of the total population

million

% of the 60-orabove population

1990 2000 2010 2020 2030 2040 2050

97.2 128.3 164.8 230.6 335.4 383.6 411.9

8.6 9.8 11.8 15.6 21.9 25.1 27.4

63.1 87.4 107.9 160.8 223.9 298.9 306.8

5.6 6.7 7.7 10.9 14.6 19.6 20.4

18.7 28.1 38.9 48.3 80.8 112.7 152.0

19.2 21.9 23 6 20.9 23.9 29.4 36.9

Source Du 1994

Since the early 1980s, the author has been studying these problems, appealing for recognition of them by the government and society, and has made many suggestions, which are listed as follows.

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Firstly, develop lifelong health education and health care in order to effectively shorten the average 'un-self-care' period (the period when the elderly can no longer care for themselves) of the elderly. According to the 1990 population census and survey on support systems for the elderly in 12 provinces, autonomous regions and municipalities in China, conducted by China Aging Scientific Research Center, it was estimated (as shown in Table 3) that the average un-self-care duration was 1.4 years for older men and 2.5 years for older women in urban areas, 1.0 year for older men and 1.5 years for older women in rural areas, within their residual lifetime of above 65, in China, in 1992 (Wang 1993). As the un-self-care period of the elderly is remarkably negative in relation to their health, a lot of chronic diseases being interrelated with smoking, drinking, high sugar and high salt intake, and irrational nutrition and living habits, we should strengthen health education not only to adults, including the aged, to enhance their awareness of selfprotection in the matter of health, but also to children, to help them foster good eating habits and lifestyles early in their childhood (Gui 1990).

Table 3

Average expectancy of self-care duration of the elderly in China, 1992

Age

Region

Sex

Average expectancy of self-care duration (years)

Average residual life-span (years)

60

Urban

Male Female

14.90 16.78

16.30 19.26

Rural

Male Female

14.76 16.79

15.77 18.36

Urban

Male Female

11.45 12.97

12.85 15.44

Rural

Male Female

11.44 13.19

12.44 14.70

65

Source. Wang, April 1993

Secondly, strengthen the teaching of respecting, loving and supporting older parents in the whole of society, especially among only children in their teens. According to the experiences of foreign countries and practices in China, home care by families is the primary pattern of care for the elderly and rest-home care by society is secondary, and this will still be the main pattern of care for the elderly in both rural and urban China in the twentyfirst century. However, now, quite a few only children are treated as 'young emperors' or 'small suns' by their families; these children always want to be taken good care of, but hardly want to care for others. This is particularly apparent in Shanghai. This will greatly endanger the care of elderly one-child parents in China in the future, if this situation persists.

CARE OF THE ELDERLY IN ONE-CHILD FAMILIES IN CHINA! ISSUES AND MEASURES

According to the cooperative project conducted by the author in 1989, which focussed on the situation and desire of the elderly needing care at home, 22.4% of 994 rural and urban older persons aged 65 or above thought that, regarding measures needed to be taken by society for the care of the elderly, the first goal should be to strengthen education and propaganda programmes, stressing the need to show respect for the elderly. In particular, among the 232 of them who were without children or were away from their children, 24.6% hoped the government would instruct their children to attend regularly to their elders, 7.3% hoped a grandchild would live with and care for them, and 4.3% hoped that their children would pay more for their care. A recent study conducted by the author (1998) on the needs of 3000 elderly people in urban and rural Shanghai showed similar concerns. Older people still concerned that the government and society should strengthen the ideology of respecting the older people and the education programme. Therefore, the author suggests that the Ministry of Education should make respect for the elderly an important part of moral education at all school levels, from infants schools to universities, when they draft education outlines and compile new books for all levels of students. Moreover, all enterprises and institutions should consider respect for the elderly an important element when selecting those for promotion and when checking the behaviour of cadres and employees (Gui 1992). Thirdly, allow and advocate that couples, where both partners are only children, should bear two children, and encourage the grandchildren to help their parents in the care of the elderly. In the survey by the author referred to above, when 196 older persons who were living away from their adult children were asked what they would consider the perfect way of being cared for, if they could not stay with their children, either then or in the future, 53.7% of them replied that they would like to stay with and be cared for by their grandchildren. Fifteen persons in the survey could not reply for health reasons and four refused to reply (Gui 1994a). In 1983, the author argued in an article that couples where both partners are only children should be permitted to bear two children after their marriage. Thus, when the grandchildren reach the age of 15, they could help their parents with the care of their grandparents, that is, the present one-child parents, who will by then be approaching 70 years old or above (Gui 1983). At present, couples where both partners are only children are permitted to have two children under the family planning programmes in many provinces, autonomous regions and municipalities in China. In fact, from many investigations in Shanghai, it appears that more than half of the couples of child-bearing age there would like to have two children, if that were permitted. The author predicts that there will be quite a large number of

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two-children families after 2005, and in the future, the intergenerational structure will be 'four-two-two' in about half of the families in urban areas. Fourthly, introduce to young parents who have fewer children than in earlier times, the idea of saving for their old age, and inform them of the necessity to save part of their surplus allowance for the cost of care when they grow old. In China, most fees for care, whether in a rest-home or at home, are paid by the elderly themselves or their families, except in the cases of a very few older persons who depend on social relief paid by the government or by a collective economic organization. When the mass of one-child parents in China can no longer care for themselves in the 2030s, it will be a heavy economic burden on the adult children to support their four elderly parents. So, young couples, especially those who are only children, should be aware of the need to protect themselves and prepare themselves for old age. As they have fewer children than their parents did and therefore have more income for themselves, they need to invest in deposit pension insurance schemes, life insurance, properties or bonds and so on, to save for the cost of their care in their old age. According to the 1992 sampling survey by the author on the life cycle of the aged in Shanghai and Zhejiang Province, the mean first-marriage age of older women was 19.7 and the mean first-birth age was 22.0. The average number of children was 4.6, their average age when their last child ended their schooling was 49.9, and the average period of time bringing up children was 27.9 years (Gui 1994b). In contrast, the present younger generation not only postpones their marriage and childbearing, but also have fewer children, therefore experiencing a shorter period of time bringing up children. It is estimated that, in cases of couples having only one child, the period of time bringing up children will now be seven years less than before, although the schooling period for children has increased from 8.1 years previously to 14 years now. There must be a 100% possibility that young couples today can save something for their old age. Fifthly, improve the community service network for the elderly based on their practices and needs at home. The fact that home care is now the primary method of care for the elderly is not to deny that social care may be important regarding the care problems of the elderly in one-child families during the twenty-first century. Among China's current social services for the elderly, the community service for the aged is most welcomed by older people. The service fully relies on society, also supports the elderly at home, eases the social welfare burden, and, at the same time, provides a network of grassroots services for the aged. The community service is convenient for the elderly and their families; not only is it inexpensive, it enables older persons

CARE OF THE ELDERLY IN ONE-CHILD FAMILIES IN CHINA! ISSUES AND MEASURES

to continue living in familiar surroundings, keep continual contact with their families and neighbours, and get better spiritual comfort. The service not only allows adult children to put more time and vigour into their work, it also improves interrelationships, and enhances a civilized spirit within the community. In the aforementioned investigation into the situation and desire of 994 rural and urban elderly people cared for at home, regarding the question of whether the sub-districts or townships should provide services for the aged, 22.9% of the families there caring for an elderly person wanted home visits for check-ups or injections, 11.3% wanted the service for laundry, 9.6% for meals, 8.5% for bathing, and 6.5% wanted rehabilitative exercises. Regarding nursing service for the aged, 2.9% of 863 older persons who were able to answer questions wanted it, while 7.0% of the 855 main supporters of the programme were keen to utilize it (Gui 1992). Sixthly, develop nursing facilities for the aged at an appropriate fee to absorb more bedridden elderly people and those who are difficult for their families to care for. At present, the main facilities for the aged in mainland China include social welfare houses, geriatric hospitals, rest-homes and apartment blocks for the aged. It is very difficult for 'only-child couples' to provide round-the-clock care for a permanently bedridden parent, especially if the other parent is too old or too ill to help, or even, has passed away. Most of these couples would find it very difficult to afford to pay for nursing care from their incomes. So it is essential to develop nursing facilities for aged people, at an appropriate, affordable rate, especially for those in need of full care. According to the investigation referred to above, when asked whether they wanted to utilize residential homes that would take full care of their elderly relatives, 8.1% of the 855 main supporters needed this service very much; especially keen were the 13.2% of those whose parents were bedridden and suffered from encopresis. Another 8.0% wanted to use the service, to a relatively high degree (Gui 1992). As the number of beds for facilities for the aged is only about 0.5% of the total population of 60-year-olds or above in China, the government at every level and society should adopt drastic measures to greatly increase their investment in residential nursing facilities for the aged and to cope with the rapid increase of the aged population in the first half of the twenty-first century, even though the percentage of beds per aged population may rise to 1.5% to 2.0%. Meanwhile, they should speed up the development of geriatric hospitals in rural and urban areas, convert social welfare houses and resthomes into facilities catering to the needs of the elderly who require rnediurnor high-degree care, enhance the level of management and the quality of

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nursing, and reduce the cost of service and standard payment as much as possible. Lastly, organize the younger, healthy elderly to help each other, and to care for those elderly people who are not capable of self-care, either voluntarily or for payment. The 1990 population census showed that the working-age population (15 to 59 years old) stood at 723 400 000 in the middle of that year. According to the projection of China's population from 1990 to 2050 as mentioned above, the population aged from 15 to 59 will exceed 800 million in 1998 and 900 million from 2007 to 2037, with a peak of 973 600 000 in 2021, and then reach 849 400 000 by 2050 (Du 1994). The trend of a continually increasing working-age population will bring a heavy employment burden on China in the first half of the twenty-first century, causing the impossibility of extending the retirement age (60 for men, 55 for female cadres and 50 for other women) in urban, town or township enterprises nationwide over a long period. If those retirees who are in good health and are willing to care for the elderly are organized and trained as an important social service group for the elderly, it will not only utilize human resources, but will also have a meaningful effect on social care of the aged in the future. These retired persons are about to reach or already have reached their own later years. Therefore, they can understand more easily the suffering of the elderly who are unable to care for themselves than the young do, and will be more enthusiastic and patient when facing the elderly. Because they are drawing pensions, they can also be paid less than the young when employed by social service institutions, which are in favour of cutting down salary levels within the service. Of course, the retirees would be unfit for some management positions and services in those institutions. Thus, we should have a combination of young, full-time staff and older service workers, based on practice needs (Gui 1995). The purpose of this chapter, in discussing the issues and measures concerning care for the elderly in one-child families in the future, is to stimulate the interest and concern of scholars both at home and abroad. The author would like to have more opportunities to cooperate with all friends and to strive for enhancing the quality of life for the elderly Chinese in the Pacific Region.

D References Centre of China Population Information. 1985. Handbook of China's population data. Beijing: Unpublished materials.

CARE OF THE ELDERLY IN ONE-CHILD FAMILIES IN CHINA! ISSUES AND MEASURES

China Aging Scientific Research Center. 1994. Collection oj data of survey on Chinese older persons' supporting system. Beijing: Hua Ling Press. Du, Peng. 1994. Study on the aging process of China's population. Beijing: China People's University Press. Gui, Shixun. 1983. Future natural changes should be benefit to the development of the society. Society 4. . 1990. China's population and education in the turning of century. Journal of East China Normal University (Education Science) 3. . 1992. The elderly needing home care in Shanghai: Situation and policy suggestions. In The elderly and family, ed. Li, D.H. Shanghai: Shanghai Scientific Popularization Press. . 1994a. Investigation and study on life circle of the elderly in China. China Population Science 4. . 1994b. The problems and suggestions for counter-measures regarding care of the elderly with only one child. In International perspectives on healthcare for the elderly, ed. Stopp, G. Harry, Jr. New York: Peter Lang Publishing Inc. . 1995. Study on the family of the elderly and caring pattern of community in future China. South Population 2. . 1998. A survey on needs of the Shanghai elderly. Shanghai: Unpublished materials. National Family Planning Commission. 1998. China family planning program. Beijing: China Population Press. Office of Population Census of Shanghai, Shanghai Statistical Bureau. 1992. Data of Shanghai fourth population census. Beijing: China Statistic Press. Population and Employment Division of State Statistical Bureau. 1995. China population statistical yearbook 1995. Beijing: China Statistic Press. Population Census Office of China State Department, Population Division of State Statistical Bureau. 1992. Data of China's 1990 population census. Beijing: China Statistic Press. Population Census Office of Shanghai. 1992. Data of Shanghai's 1990 population census. Beijing: China Statistic Press. Shanghai Statistical Bureau. 1991. 1991 Shanghai statistical yearbook. Beijing: China Statistic Press. . 1998. 1998 Shanghai statistical yearbook. Beijing: China Statistic Press. State Statistical Bureau. 2000. China statistical yearbook 2000. Beijing: China Statistic Press. . 1996. 1996 Shanghai statistical yearbook. Beijing: China Statistic Press. Wang, Mei. April 1993. Health of the aged population and medical security. Beijing: China Economic Press.

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9 The Practice of Filial Piety among the Chinese in Hong Kong Nelson W.S. Chow

D Filial Piety in Chinese Societies As a society made up predominantly of the Chinese race, it is only natural for the Chinese culture to exert an influence on how elderly people are being treated in the Hong Kong Special Administrative Region of China. For thousands of years, the Chinese culture has been described as one of respecting the old, or xiao, as known in the old classics. Although some people have found this value too oppressive and inapplicable in the modern society, it is, however, still very much treasured and upheld by Chinese people all over the world (Chow 1991). Article 49 of the 1982 Constitution of the People's Republic of China states that 'parents have the duty to rear and educate their minor children and children who have come of age have the duty to support and assist their parents.' The Singapore Parliament passed a law a few years ago making it an offence for children with means to refuse to support their elderly parents requiring assistance (Singapore Ministry of Community Development 1996). Similar legislation expecting grown-up children to fulfil their filial duties can also be found in Taiwan, another predominantly Chinese society (Lee, Netzer and Coward 1994). Although Hong Kong has yet to adopt such legislation, the tradition of respecting the old has always been included as part of moral education and

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taught to the younger generations. The Chief Executive, Mr Tung Chee-hwa, in his Policy Address in 1997, pointed out that '[i]t is only right that we reciprocate the love of our parents and take care of them when they are old' (Tung 1997, paragraph 117). He further emphasized in his 1998 Policy Address that 'Hong Kong's elderly have contributed much to our success over the years. It is only right that we should help them to enjoy a sense of security, a sense of belonging, good health and a feeling of personal worth' (Tung 1998, paragraph 129). It can thus be concluded that the Chinese culture still governs to a large extent how young people in Hong Kong should behave towards their elders, both within the family and in society. It should further be pointed out that the tradition of respecting the old can persist in Chinese societies because it is closely linked up with the kind of family system valued by the Chinese. The traditional Chinese family system was once described as one that 'had a leading part in economic life, in social control, in moral education, and in government' (Latourette 1964, p. 565). Today, it is still widely believed by the Chinese that an orderly family system forms the starting point of a harmonious society, and a family can be orderly only when its members behave properly towards each other. As for the proper behaviour of children towards their parents, it is epitomized in the word xiao, the scope of which ranges from supporting one's parents to fulfilling their wishes (Chow 1996). What has been discussed so far has ignored the changes of the modern era, especially the modifications that the Chinese family system has undergone in recent times. Xiaotong Fei, a well-known Chinese anthropologist, once observed that with modernization, the significance of xiao as well as the family system in China had gradually been watered down (Fei 1985). However, he believed that since the practice of xiao was so closely linked up with the family system, as long as the Chinese family system remained to be the most fundamental unit in society, xiao would continue to exert its influence as a regulator of behaviour. He believed that it would be unlikely for the practice of xiao to disappear and become a phenomenon of the past; the value would only take on a different meaning as the role and status of the elders changed.

1 The Practice of Filial Piety in Hong Kong There is no doubt that the role and status of the elders in Hong Kong have undergone immense changes since the early 1970s. Traditionally, old age in Hong Kong had been recognized as a symbol of honour and power. This was so because older people were seen as persons possessing valuable experiences. Hence, they also would not have difficulties in commanding the obedience

THE PRACTICE OF FILIAL PIETY AMONG THE CHINESE IN HONG KONG

127

of their children and enjoying the latter's support and care (Finch and Mason 1990). There were of course children who, for one reason or another, failed to fulfil their filial responsibilities, as well as elders occupying low positions, but this had not made void the tradition of respecting the old. Older people in Hong Kong began to find themselves in a less revered position when their experiences became less valuable. Since the early 1970s, with the progress of compulsory education, the younger generations often found themselves better educated than their parents and possessing skills more suited to the demands of a modern society. Children coming out to work soon caught up with or even surpassed their parents in terms of income levels; as a result, the status of the elders as someone holding power and resources quickly declined. Older people have thus increasingly found themselves playing a less significant role in the making of important decisions, both within the family and in society. The role and status of the older people in Hong Kong have changed so much that one wonders whether the tradition of respecting old age is still relevant and applicable. The questions needed to be asked are: Can the elders still maintain their traditional position as someone commanding respect and reverence (Koyano et al. 1994)? How do people in Hong Kong perceive xiaol Is respecting old age a value worthy of preservation (Pak 1996)? Can xiao carry a new meaning in present-day Hong Kong? The above questions are asked because they can help to provide a guide for the kind of public policies that should be formulated for the older people. However, before one can answer the above questions, a clearer understanding of the meaning of xiao is necessary.

D The Meaning of Xiao and Its Application Once, a disciple of Confucius asked him about the meaning of xiao. Confucius was disappointed that people of his day often interpreted xiao as no more than providing one's elderly parents with food and other basic necessities. He said that such behaviour was no different from that of the animals, as no respect was shown. In other occasions, Confucius pointed out that children must treat their parents with reverence and obedience. According to his teachings, the practice can be differentiated into three levels: The first level of practising xiao includes providing parents with the necessary materials for the satisfaction of their physical needs and comforts, including attending to them when they are ill. The second level of practising xiao includes paying attention to parents' wishes and obeying their preferences.

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The third level of practising xiao includes behaving in such a way as to make parents happy and to bring them honour and the respect of the community. In order to understand how people in Hong Kong perceive xiao and put it into practice, a telephone survey was conducted in the summer of 1998. Over 1000 people aged 18 or over were successfully interviewed. Other than a few questions on personal characteristics, respondents were asked to respond to nine questions, with seven focussing on the three levels of practising xiao. The seven questions on the practice of xiao were all devised in such a way that they would reflect the daily activities or the behaviour of the respondents. The seven questions are: For the first level: 1. Do you regularly give money to your parents? 2. Did you assist your parents in their accommodation? 3. Did you financially support them when they were ill? For the second level: 4. Did you consult your parents when choosing a job? 5. Did you pay attention to your parents' advice when considering marriage? For the third level: 6. Have you done anything to satisfy your parents' wishes? 7. Have you performed anything to make them feel happy and honoured?

8. 9.

In addition to the above seven questions, two others were asked: Would you consider that you are pious to your parents? Would you consider that people in Hong Kong are pious to their parents?

1 Survey Results on the Practice of Xiao Characteristics of the respondents Of the 1027 people who were successfully interviewed, 440, or 42.8%, were male and 587, or 57.2%, female. The median age of the respondents was 35, with around 70% of the respondents being aged 30 or over. One can safely say that the majority of the respondents had parents aged 60 or over. In terms of housing, 34.4% of the respondents lived in rental public housing, with another 13.0% in home-ownership-scheme flats and 48.1% in private housing. The distribution was very close to that of the general population. As for the educational attainment of the respondents, 14.9% studied up to primary level, 65.3% secondary level and 19.8% post-secondary level.

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129

Generally speaking, except for the over-representation of female respondents, the other characteristics of the sample indicate that they were very similar to the general population and can be regarded as representative.

The practice of xiao at the first level

Table 1 The practice of xiao at the first level 1. Do you regularly give money to your parents? No. Yes 846 No 172 No answer 8 Total 1026

% 82.5 16.8 0.8 100.1

2. Did you assist your parents in their accommodation? No. Yes 445 No 567 No answer 15 Total 1027

% 43.3 55.2 1.5 100

3. Did you financially support your parents when they were ill? No. Yes 716 No 283 No answer 28 Total 1027

% 69.7 27.6 2.7 100

As far as the first level of practising xiao is concerned, the majority of the respondents could be described as pious. A total of 82.5% of the respondents said that they regularly gave money to their parents, and 69.7% of the respondents financially supported their parents when they were ill. It should be pointed out that it is still expected by most parents in Hong Kong that their children should regularly contribute money to the family when they start working. The act itself is taken as a sign of their gratitude for their parents and usually has little to do with the latter's financial needs. Financially supporting one's parents in illness carries the same meaning, though the latter's need for financial support may be greater when they are not well. However, only 445, or 43.3%, of the respondents answered that they had helped their parents in their accommodation. The survey further found that only 414, or 40.4%, of the respondents were living with their parents. The relatively low percentage of respondents providing help in this area was possibly due to the fact that their parents either owned their units or lived on public housing estates where rents were low. If perceived in this light, it

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NELSON W.S. CHOW

appears that children in Hong Kong are still conscious of their responsibilities to help their parents when the latter have difficulties in housing. It can be concluded from the above that children in Hong Kong still believe that they have a responsibility to meet the physical needs of their parents and consider it as their way of showing them respect and reverence.

The practice of xiao at the second level Table 2 The practice of xiao at the second level 4. Did you consult your parents when choosing a job? No. Yes 216 No 791 No answer 19 Total 1026 5. Did you pay attention to your parents' advice when considering marriage? No. Very important 104 Quite important 232 Half-half 395 Not important 183 Never consult 75 No answer 36 Total 1025

% 21.1 77.1 1.9 100.1 % 10.1 22.6 38.5 17.9 7.3 3.5 99.9

Two questions were asked about respondents' readiness to consult their parents when making important decisions. In the old days, it was a must for children to first obtain the consent of their parents in making such decisions as choosing a job or considering marriage. In today's world, as circumstances have changed, it is thought that the most the children would be expected to do is to seek the opinions of their parents, instead of following unreservedly their advice. In terms of marriage, the majority of the respondents still thought it important to pay attention to parents' preferences. Those who considered it unimportant or had never consulted their parents accounted for 25.2%. The reverse was true for job-seeking as 77.1% of the respondents did not think it important to consult their parents in deciding on a job. The differences in the distribution of answers between marriage and job-seeking perhaps lie in the belief of the children that their parents have already lost touch with the job market and might not be able to offer any useful advice. The opinions of parents were valued more in marriage because children understand that their future partners would have a greater chance to be in contact with their parents

L

THE PRACTICE OF FILIAL PIETY AMONG THE CHINESE IN HONG KONG

131

and the latter's acceptance would result in a more harmonious relationship in the future. In other words, it can no longer be assumed that children nowadays must seek the opinions of their parents when making important decisions. The social situation has, in fact, changed so much that it has often made the advice of parents irrelevant and inapplicable. Parents, on the other hand, might also be unable to offer advice, and this would make the children hesitant further to seek their opinions. In summary, so far as the second level is concerned, it appears that children nowadays are not as keen to consult their parents as in the past. The decision to consult or not appears to depend more on some practical issues, like the knowledge of their parents about the job market. It is not to be taken as a sign of filial or unfilial behaviour of the children.

The practice of xiao at the third level

Table 3 The practice of xiao at the third level 6. Have you done anything to satisfy your parents' wishes? No. Yes 444 No 508 No answer 73 Total 1025

% 43.3 49.6 7.1 100

7. Have you performed anything to make them feel happy and honoured? No. Yes 544 No 420 No answer 60 Total 1024

% 53.1 41 5.9 100

At the third level of practising xiao, only 43.3% of the respondents said that they had considered the wishes of their parents and made an effort to satisfy them. A slightly higher percentage of respondents, 53.1%, reported that they had done things to make their parents happy. Notwithstanding the fact that about half of the respondents still thought it important to please one's parents and satisfy their wishes, it is quite obvious that bringing honour and esteem to their parents is no longer a strong motivator in their behaviour.

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Opinions on self and other people Table 4 8. Would you consider that you are pious to your parents?

Yes No No answer Total

No

%

774 142 110 1026

75 4 138 107 99 9

Table 5 9. Would you consider that people in Hong Kong are pious to their parents?

Yes No No answer Total

No

%

382 264 380 1026

37 2 25 7 37 99 9

In addition to the questions on the three levels of practising filial piety, respondents were also asked to evaluate themselves and other people in regard to putting xiao into practice. It is interesting to find that 75.4% of the respondents answered in the affirmative about themselves, indicating at least that they were upholding the tradition of respecting old age. However, when they were asked to evaluate other people, only 37.2% of the respondents said that people in Hong Kong were pious. The discrepancies in the evaluation between self and others are not difficult to understand. As long as respondents still held dear the tradition of respecting old age, they would probably think that they had already made the effort and would therefore regard themselves as pious. On the other hand, their evaluation of other people would be based on the latter's actual performance, and there is a tendency for them to be less favourable in their judgements. It should be noted that over a third of the respondents did not want to comment on the behaviour of other people, suggesting that they might regard filial piety as an individual matter and not a concern of other people.

Differences in age, gender and educational attainment In the telephone survey, we asked the age, gender and educational attainment of our respondents. Cross-tabulating these characteristics with the answers that they gave on the practice of filial piety, a number of interesting findings have appeared. By dividing the respondents into two groups, one of those

THE PRACTICE OF FILIAL PIETY AMONG THE CHINESE IN HONG KONG

133

aged 40 or over and the other of those aged under 40, we found that the younger group, on the whole, showed greater respect for their parents. It is even more gratifying to find that respondents aged under 40 indicated a greater wish to satisfy their parents' wishes and to make them happy, suggesting that they still held dear the tradition of respecting old age. When gender was considered, we found that the male respondents were generally more concerned about their responsibilities towards their parents than the female respondents. However, in choosing future marriage partners, female children were more prepared to pay attention to the preferences of their parents than their male counterparts. Compared with age and gender, the educational attainment of the respondents appeared to be more determining in influencing the filial Table 6 Age, gender, educationai attainment and the practice of filial piety A. Age and the practice of filial piety Under 40 Item Give money to parents Assist in their accomodation Support when ill Choosing a job Considering marriage Satisfy wishes Make parents happy

40 or over

Yes (%)

No(%)

Yes (%)

No(%)

84 45.3 68.8 23.5 74.3 46.1 55.3

15.5 53.1 28.5 75.5 22.9 48.2 40.6

80.2 38.4 71.4 16.2 65.7 37.2 48

18.6 60.1 26.4 81.1 30.7 52.3 42.9

Sig. ie\ n.s.

* n.s.

# * * *

B. Gender and the practice of filial piety Male Item Give money to parents Assist in their accomodation Support when ill Choosing a job Considering marriage Satisfy wishes Make parents happy

Female

Yes (%)

No(%)

Yes (%)

No (%)

Sig. level

85.4 51.3 73.6 20.2 63.2 46.6 52.8

13.9 47.7 24.1 78.9 33.5 46.1 42.1

80.2 37.6 66.8 21.7 77.5 40.9 53.3

18.9 60.8 30.2 75.8 18.9 52.1 40.2

n.s.

C. Educational attainment and the practice of filial piety Primary Secondary Item

n.s.

** n.s. n.s.

Tertiary

Yes (%) No (%) Yes (%) No (%) Yes (%) No (%) Sig. level

Give money to parents Assist in their accomodation Support when ill Choosing a job Considering marriage Satisfy wishes Make parents happy * < .01

#* *

** < 001

75 29 69.1 11.3 69.1 26.3 43.7

n.s. = not significant

23.7 69.7 29.6 85.4 26.3 65.1 47

83.9 45.7 71.2 22.1 74.2 42.9 49.5

15.4 52.6 26.3 75.9 22.7 51.2 44.8

84.2 46.5 66.3 25.7 64.5 58.7 73.5

15.3 52.5 29.7 73.8 32.5 31.3 23

n.s.

# n.s.

* n.s.

#* *#

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NELSON W.S. CHOW

behaviour of the respondents. It is clear from the comparisons that the higher the educational attainment of the respondents, the keener they were in upholding the tradition of showing respect for their parents. No attempts have been made to account for the differences in the filial behaviour of the respondents, but the findings do suggest that some of the common beliefs that the young, the male and the educated are often not so pious are not necessarily correct. The fact that the young and the educated still find filial piety a value to be upheld indicates that the younger generations are as conscious as, if not more so than, the older ones to reciprocate the love and care of their parents.

D A New Interpretation of the Practice of Filial Piety There is no doubt that people in Hong Kong have a different interpretation of how the value of filial piety should be practised in today's world than what was perceived traditionally. Our survey findings indicate that the majority of the respondents still found it their responsibility to satisfy the material needs of their parents. We have not compared this sense of responsibility with the welfare role of the government, but as long as children are aware of their duty to support their parents, filial piety is certainly not a value that should be easily discarded. However, as suggested by the survey findings, we probably have to accept that children nowadays are quite reluctant to seek the opinions of their parents, even in such important matters as choosing a job or considering marriage. There may be obvious reasons for children not to follow the traditional way of consulting their parents and submitting to their advice, as children nowadays are generally more educated and knowledgeable than their parents. They may also regard marriage as a personal matter for which they themselves must finally be responsible and not their parents. In other words, the relatively low percentages of respondents consulting their parents in important matters may simply reflect a change in societal circumstances and not necessarily a disrespect for their parents. Some parents would no doubt find the attitude of their children offensive and would still expect the latter to seek their opinions in important matters. While it may be helpful to encourage children to discuss with their parents, parents, on the other hand, should not take it as a sign of disrespect when children do not consult them in everything they do. As mentioned previously, it is gratifying to find that more than half of the respondents were conscious of their duties to fulfil the expectations of their parents and to make them happy. Of course, one should not

THE PRACTICE OF FILIAL PIETY AMONG THE CHINESE IN HONG KONG

135

overemphasize this way of showing respect, as children may regard their parents' wishes as important only when they are not in conflict with theirs. Furthermore, the survey findings told us nothing about the expectations that children had to meet and also whether parents felt happier as a result of the acts of their children. These are some of the limitations that we have to accept in a telephone survey when too many questions cannot be asked. In conclusion, what one can say is that the value of filial piety is not totally forgotten in present-day Hong Kong. It is still upheld by most Hong Kong people as a value that they should treasure and also practise in ways that they find suitable and appropriate. However, how Hong Kong people practise filial piety is certainly different from that traditionally upheld as proper. Looking at the present-day behaviour of Hong Kong people, Confucius would certainly denounce it as improper and far-away from the true spirit of xiao. However, he would accept that since circumstances have changed, putting parents' wishes over and above one's own may no longer be applicable. He would be happy to find that Hong Kong people today have not forgotten what he had taught more than 2000 years ago and that they still find xiao an appropriate value to regulate their behaviour. He would agree that what is important is not the ways in which xiao should be shown, but the upholding of the spirit of respecting one's parents.

D References Chow, N. 1991. Does filial piety exist under Chinese communists? Journal of Aging and Social Policy 3 (1/2): 209-25. . 1996. Filial piety in Asian Chinese communities. Hong Kong Journal of Gerontology 10 (supplement): 115-7. Fei, X. 1985. The caring of the old in families undergoing structural changes. In Proceedings of the conference on modernization and Chinese culture, ed. Chia, C. 121-32. Hong Kong: Faculty of Social Sciences and Institute of Social Studies, The Chinese University of Hong Kong. Finch, J. and J. Mason. 1990. Filial obligations and kin support of elderly people. Ageing and Society 10: 151-75. Koyano, W., M. Hashimoto, T. Fukawa, T. Shibata and A. Gunji. 1994. The social support system of the Japanese elderly. Journal of Cross-Cultural Gerontology 9: 323-33. Latourette, K.S. 1964. The Chinese, their history and culture. New York: Macmillan. Lee, G.R., J.K. Netzer and R.T. Coward. 1994. Filial responsibility, experiences, and patterns of inter-generational assistance. Journal of Marriage and the Family 56: 559-65. Pak, J.P. 1996. The ideal of filial piety in modern times. Hong Kong Journal of Gerontology 10 (supplement): 130-2.

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Singapore Ministry of Community Development. 1996. Singaporeans — Maturing with age. Singapore: Ministry of Community Development. Tung, C.H. 1997. Building Hong Kong for a new era. Hong Kong: Printing Department of the HKSAR. . 1998. From adversity to opportunity. Hong Kong: Printing Department of the HKSAR.

10 Social Support and Integration of Long-term Care for the Elderly: Current Status and Perspectives in Taiwan Shyh-dye Lee and Meng-fan Li

D Introduction: Social and Cultural Background in Taiwan Population ageing is a worldwide phenomenon. It has become a major challenge in most regions/countries as to the provision of support and care for their elderly citizens. Taiwan is projected to be second fastest in 'population ageing speed' in the next 30 years compared to comparable ageing countries, just following Japan (Table 1). That is, according to official prediction, the period for the doubling of the aged population in Taiwan, from 7% to 14%, will be less than 30 years, compared to 25 years in Japan, 70 years in the US, and 125 years in France. The shorter the doubling time of the elderly percentage, the greater the pressure that impacts the whole society/ country. Problems of long-term care accompanied with the increasing ageing population have become one of the toughest social issues in all developed countries. The major components of long-term care delivery include life care, medical care (including nursing, rehabilitation, prevention), personal care and social support. However, non-medical care seems predominant (Lee, Kuo et al. 1995; Lee 1996; Wu et al. 1999; Wu, Lue and Lu 1998). Selfevidently, there are lots of components and determinants in the long-term care delivery system, including, at least, need/demand estimation, resource

138

Table 1

SHYH-DYE LEE AND MENG-FAN LI

International comparison of population ageing among several elderly countries Year of elderly population

Country

Japan Taiwan Germany United Kingdom

US Sweden France

/ % #

/ 4 % #

1970 1993 1930 1930 1945 1890 1865

1995 2021 1975 1980 2015 1975 1991

Time (years) passed

'Population ageing speed'ranking

25 28 45 50 70 85 126

1 2 3 4 5 6 7

* ageing rate Source Department/Ministry of Health, Taiwan 1998b

provision, financial and economic s u p p o r t , organizing, p l a n n i n g , administration, policy, and service delivery, etc. In Taiwan, the long-term care issue will be no less important than social security in the twenty-first century. This chapter reviews Taiwan's long-term care services with reference to societal background, policies and programmes, delivery systems, especially in social support and integration programmes, and future trends.

D Background of Long-term Care in Taiwan The demographic domain Due to developments in public health and advanced medical services, improved living standards and nutrition levels, and upgraded quality of health and medical care, life expectancy in Taiwan has greatly increased for men from 53.4 years in 1951 to 72.0 years in 1998, and for women, from 56.3 years to 77.9 years respectively (Department/Ministry of Health, Taiwan 1998a). Life expectancy after 65 years of age has been prolonged from 1.53 years in 1951 to 16.0 years in 1998. The proportion of persons aged 65 or over amounted to only 2.4% of the population in the 1950s, but had tripled by the end of 1990s, to around 8.3% in 1999. The aged population had increased to 7.02% by 1993, just crossing the threshold of a 7% standard laid down by the World Health Organization (WHO), from which time Taiwan joined the group of 'elderly countries' (Economic Progression Council, Taiwan 1996; World Health Organization 1997 and 1999). It is apparent that the number of the oldest among the elderly population will grow more quickly than any other age group (Table 2). By the year 2020, there will be around 20 000 elders aged above 100 (National

1

SOCIAL SUPPORT AND INTEGRATION OF LONG-TERM CARE FOR THE ELDERLY IN TAIWAN

Health Insurance Bureau, Taiwan 1998). Therefore, in the future, the ageing population, not only the number but also the component, will be a major challenge to the nation in the provision of support and care. Table 2

The increasing rate of the population by age groups in Taiwan

Total Year population 1990 1996 2000 2020

20 230 21 634 22 249 25 025

%*

204 124 168 753

<15

15-64

5 518 224 4 948 412 4 803 325 4 639 114

13 481 259 14 963 880 14 884 693 16 927 419

-15.9

25.6

23.7

65+

65-69

1 230 721 529 359 1 721 831 672 202 1 895 629 664 841 3 458 559 1 396 657 181.0

163.8

70-74 336 502 571 831

618 270 883 220

146.9

75-79 217 640 303 845 376 322 568 015 161.0

80+ 147 243 283 663

104 514 270 874

351.2

* rate of increase, based on figures in 1990 Source: Ministry of Interior Affairs, Taiwan 1998

The epidemiological domain Shift in the ten leading causes of death With the prolongation of life expectancy, chronic diseases/conditions have become predominant as the major causes of death. Table 3 shows the shift in the ten leading causes of death from acute diseases/conditions in 1952 to chronic diseases/conditions in recent years. There has been an obvious changing trend in the ten leading causes of death from acute pandemics to chronic, acquired man-made infirmities, and delayed degenerative disease. Table 3

Change in ten leading causes of death, 1952 and 1998

1952 Gastritis, duodenitis, colitis Pneumonia Tuberculosis Heart disease Vascular lesions, affecting central nervous system Causes of perinatal mortality Nephritis and nephrosis Malignant neoplasms Bronchitis Malaria

Death /oer 100 000 135.01 131.47 91.56 49.03 48.78

1 2 3 4 5

134.0 51.8 50.5 50.3 34.5

44.06 36.31 30.74

6 7 8

22.6 20.4 15.7

28.13 27.45

9 10

10.4 10.0

1998 Malignant neoplasm Cerebrovascular disease Accidents and adverse effects Heart disease Diabetes mellitus Chronic liver diseases and cirrhosis Pneumonia Nephritis, nephrotic syndrome and nephrosis Hypertensive disease Suicide

Source: Department/Ministry of Health, Taiwan 1999b

Disability rate of the elderly There is still no consensus or official national data relating to distribution of the disabled in Taiwan. The main reason is

139

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SHYH-DYE LEE AND MENG-FAN LI

that there is no consensus in the definition and indicators of disability within the field of medical care services, or in the field of social welfare services. The Ministry of Interior Affairs only started to collect data concerning disability of the elderly in 1986. ADL (five items instance) developed by it is the major index of the disabled. Based on a national survey conducted in 1996, among the entire elderly population (aged 65 or above), less than half self-evaluated themselves as healthy (44.3%), 50.2% self-evaluating themselves as unhealthy with some chronic diseases/conditions, and 5.4% self-evaluating themselves as needing some kind of long-term care services (Table 4). This survey accordingly indicated that the disabled elderly population was around 92 000. Furthermore, in relation to the living arrangements of the disabled elderly, the survey showed 4.0% (3665) stayed in hospitals, 2.9% (2676) in health-related facilities, 3.1% (2864) in assisted living facilities, and the vast majority (89.7%, 82 340) living at home being cared for by their families (85.1%). As to their preferred living arrangements, on enquiry, 90% of the disabled elderly would rather receive care at home than stay in institutions (Ministry of Interior Affairs, Taiwan 1997). Table 4

The health and care status of the elderly in Taiwan, 1993

Unhealthy Items

Total (thou- Healthy sand)

Total Male Female

1 690 749 859 941 123 849 362 91 761 44 829 71 145 59 836 47 950 71 908 923 426 762 496 120 452 857 43 263 21 108 34 592 28 062 22 809 32 856 767 322 097 445 003 396 505 48 498 23 721 36 553 31 774 25 141 39 052

100.0 % Male % 100.0 Female % 100.0

44.3 46.2 42.0

Dependent (disabled) Subtotal

55.7 53.8 58.0

Selfhelp

50.3 49.1 51.7

SubDressFeeding Bathing ing total

5.4 4.7 6.3

2.7 2.3 3.1

4.2 3.8 4.8

3.5 3.0 4.1

Toilet- Transing ferring

2.8 2.5 3.3

4.3 3.6 5.1

Source: Executive Yuan, Taiwan 2000

With the rapid growth of the elderly population (especially the number and needs of the oldest elderly group) and the shifting health problem patterns (towards more chronic diseases/conditions), health care for the elderly will need to involve not only the medical care services, but also follow-up, postacute and long-term care services. Care services will need to include not only institutional-based services, but also community-based and home-based care services. It should also integrate both social support and health care. That type of care service is still not yet available or accessible to meet current needs, and represents the major challenge confronted as to the delivery and finance of post-acute care and long-term care for the elderly in the future in Taiwan (Executive Yuan, Taiwan 2000).

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SOCIAL SUPPORT AND INTEGRATION OF LONG-TERM CARE FOR THE ELDERLY IN TAIWAN

The change in social structure The change in living arrangements decreases family support Traditionally, in an Oriental society, as in Taiwan, families played a major role in the longterm care of the elderly through provision of services, financial support and emotional sustenance. However, the recent change in the social environment, the structure and function of families, the increasing number of double-income families and single-parent families, has dramatically decreased the capacity/ ability of the family to provide care to the elderly, especially for the disabled elderly. According to recent national surveys of the elderly and care services conducted by the Ministry of Interior Affairs, the living arrangements and care patterns for the elderly have shifted from extended families to stem families, and even to nuclear families. In Taiwan, the percentage of the elderly population living with children/siblings changed from 70.2% in 1986 to 64.3% in 1996. The elderly living in facilities for the elderly increased from 0.8% in 1986 to 0.9% in 1996 (Table 5). The percentage of the elderly living with only their spouse, increased from 14.1% in 1986 to 20.6% in 1996. These trends are important indicators concerning the elderly for society to organize care/service programmes to improve and provide community-based support services for the increasing number of old couples living alone.

Table 5

Living arrangements of the elderly in Taiwan, 1986-96

Living arrangement

1986

1987

1989

1991

1996

Increase rate

Living alone Living with spouse only Living with children Living with relatives Living in facilities Others

11.6 14.1 70.2 3.0 0.8 0.3

11.5 13.5 71.0 3.0 0.6 0.4

12.9 18.2 65.7 2.2 0.9 0.1

14.5 18.7 62.9 2.4 1.2 0.3

12.3 20.6 64.3 1.4 0.9 0.5

6.0% 46.1% -8.4% -53.3% 12.5% 66.7%

Furthermore, care patterns for the disabled elderly have changed dramatically within the last ten years. For the ten-year period from 1986 to 1996, the caring of the disabled elderly in facilities increased fivefold (Table 6). In general, the major care pattern for the disabled elderly was staying at home being cared for by families, home supporters or other relatives. Home-based supporters have taken a significant proportion of the care requirements of the disabled elderly, particularly by foreign nursing aids. In general, those living in facilities were only around 10% of the disabled elderly. Although caring for the disabled elderly shows a shifting trend in the last ten years from being cared for by families to being cared for by facilities or home supporters, there is still only a small percentage of the disabled elderly (around

141

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SHYH-DYE LEE AND MENG-FAN LI

10% to 15%) who would choose institutions/facilities as a long-term place of care in the future (Ministry of Interior Affairs, Taiwan 1997). It is clear that the preferred living arrangement of the disabled elderly is to stay in their familiar environment, such as in the perceived safety of the home. Hence, 'ageing in place' is still the basic value of long-term care for the disabled elderly in Taiwan. Table 6

Care patterns of the disabled elderly in Taiwan, 1986-96

Care patterns

1986

1987

1989

1991

1996

Increase rate

By families By home supporters By relatives By self By facilities Others

80.5 3.9 2.9 11.0 1.7 0.0

83.9 2.4 6.5 1.7 5.6 0.0

78.8 4.1 4.2 1.2 11.8 0.0

87.6 1.9 2.0 1.0 7.5 0.0

77.2 7.9 2.3 2.0 10.3 0.4

-4.1% 103.0% -13.8% -81.8% 505.9% 400.0%

Fewer children/siblings increases the dependent rate It is recognized that the family remains the backbone in providing support and care for the elderly in Taiwan society. A dramatically dropping fertility rate will decrease the self-dependent rate and increase the burden of the working age (15 to 64) stratum. It has been projected that in the year 2020, there will be only four working adults to support one elderly person. How to maintain, strengthen and protect the family's vital role in caring for the elderly will be a challenge for policy-makers and programme designers. Women9s participation in the labour force decreases caring support in the family Women are the major care-givers to the disabled elderly. According to a national survey, more than 70% of care-givers were women, including wives (30%), daughters-in-law (35%) and daughters (13%). Regarding the length of care, half of the care-givers provided more than five years of longterm care for their family, around one-fourth even longer than ten years. Needs of the care-givers included accident prevention (69.5%), transport (56%), consultation (50.3%), respite care (41.6%), home care/services (around 30%), etc. (Institute of Public Health et al. 1995). However, the female labour force increased from 39.2% in 1978 to 45.6% in 1998 which resulted in an insufficient supply of care-givers at home. Recently, hiring foreign house maids or nurse aids for taking care of family members has become quite popular, whether at homes or in institutions. The quality of care and the impact on the quality of life of the disabled as well as their care-givers, giving support to care-givers and preserving the elderly's preference for care to be given in the community and home, will all be major concerns facing makers of longterm care policies and programmes.

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Changes in living standards and value system on health Since World War II, the economy of Taiwan has developed rapidly, and living standards have greatly improved. The per capita income of Taiwan in 1998 was US$12 040, which was a ten-fold increase over US$1041 in 1976. In 1976, only 12.71% of the total population were covered by some form of social security programmes; in 1998, this figure increased to 96.08%, a sixfold increase in 22 years. In 1976, only 7.39% of the population had received higher education, and the literacy rate was 85.0%. In 1995, as estimated, 17.89% had higher education backgrounds, and the literacy rate was 94.0%, an increase of 10.5% and 8.98% respectively. The National Health Insurance Bureau was set up on 1 January 1995, while the National Health Insurance Program/System started in March 1995 (Department/Ministry of Health, Taiwan 1999a; Department/Ministry of Health and National Health Insurance Bureau, Taiwan 1994 and 1995) and soon became the major part (55.9%) of Taiwan's overall health expense in 1998. As for financial aspects, the total health and medical care expenditure of government at all levels in financial year 1998 was NT$4718 billion (or approximately US$145 billion). The proportion of health and medical expenditure in GNP was more than 5.4% of the government budget in 1998 (Directorate-General of Budget, Accounting and Statistics, Taiwan 1999; Department/Ministry of Health, Taiwan 1999c). All these improvements in living standards and health care/welfare stimulate further demands, needs and expectations for better and more delicate health care, satisfying expectations as to quality and services.

Fatal events raising further concerns Fire events in unlicensed facilities/institutions Fire events in unlicensed facilities/institutions for the aged occurred with increasing frequency around the beginning of 1998. Illegal/unlicensed facilities/institutions for the disabled elderly exist all over the island. Most of them are situated around the neighbourhood of medical centres and regional hospitals, as well as general veteran hospitals. Their bed numbers are believed to be even larger than those of their legal/licensed counterparts. According to an unofficial report, in March 1998, there were more than 700 such facilities/institutions providing around 10 000 beds for the elderly in need of long-term care, compared to 200 licensed ones providing fewer than 8000 beds. Certainly, the quality and security of the unlicensed facilities were doubtful and non-controlled. In one incident, at the beginning of 1998, there was a fire event in an unlicensed facility where 11 frail elderly died. As a result, legislators and society drove the government harder to supervise/monitor the public and personal security of the disabled

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elderly. Unlicensed facilities for the disabled elderly have been requested to cease operations, otherwise they will be sanctioned and fined in accordance with the Act for the Elderly issued on 18 June 1999. On the other hand, events of this nature inspire the government to give more financial incentives to encourage the private sector to invest in the social welfare services for the elderly in Taiwan. News reports regarding the death of the living-alone elderly Since the beginning of 1998, there have been reports of around ten elderly persons living alone who have passed away in their houses and have not been discovered until several days later. As news of this type has spread over the island, social service programmes as well as community-support programmes for living-alone elderly have been urgently reassessed and actioned. These fatal events have been an impetus to the development of long-term care programmes and services, especially community care, for the elderly in Taiwan.

1 Current Status of Long-term Care Policies and Programmes in Taiwan Current status of services The current delivery system of long-term care (mostly for the elderly) in Taiwan comes in four categories: (1) the medical care system; (2) the social welfare system; (3) the retired servicemen (veteran) system; (4) the private sector. In 1999, the medical care system, supervised by the Department/ Ministry of Health, provided care services through 15 chronic-disease hospitals, 110 nursing homes (4300 beds), home care services (250 centres), day health care centres (30), and institutionalized respite care for care-givers. The social welfare system, supervised by the Ministry of Interior Affairs, provided subsidized care services, such as homes for the elderly, assistance with living facilities, home life care, day activity centres, supportive mechanisms and finance subsidies issued through verified procedures, and other community care services (e.g. meals on wheels, life line, on-line help services for the abused, home respite care, etc.). The retired servicemen (veteran) system provides general care through 14 public-financed homes. The private sector provides care services through business mechanisms in 597 facilities, including organizations for informal, unregistered institutionalized care. The National Health Insurance Program/System started in March 1995,

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and provides universal general health care including preventive health care service for the elderly. However, most long-term care needs are not covered by the National Health Insurance Program, although professional parts of nursing care in the long-term care package are, to some extent, now placed under the coverage of the National Health Insurance Program.

Current policy status In order to provide pertinent and accessible long-term care services, the medical care and social welfare authorities have developed unified national plans, named 'Three-Year Plan for the Long-Term Care of the Elderly' and 'Project of Care Services to the Elderly' respectively, for caring for the ageing and disabled population in the forthcoming years. Up to the present time, major policies of long-term care are as follows: • integration among the three public systems: the medical care system, the social welfare system, and the retired servicemen (veteran) system; • amendment and deregulation of related laws and acts; • encouragement of resources and services, especially in community/home bases; • improvement of, and better balance between, the various facilities and resources available relating to long-term care; • development/nurturing of care-providers and manpower (including health-care professionals and volunteers) and enhancement of the multidisciplinary care model; • review of the payment system for long-term care provided by the National Health Insurance Program; • establishment of a consolidated long-term care delivery network and of a service information system; • improvement of the quality of long-term care; and • introduction of services and support systems to care-givers. In the face of the dramatic growth in the ageing population and the needs of the population for long-term care, the Executive Yuan (the Cabinet) prepared and issued in 1999 a 'Ten-Year Plan for the Establishment of LongTerm Care System for the Elderly', and started to promulgate certain aspects thereof from the beginning of 2000. The main purposes of this project are to construct a community-based long-term care system and to plan a sound and affordable long-term care financial system for the future (Wu et al. 1999).

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Social support programme Social support can be divided into formal and informal social support. As to the latter, the fundamental sociocultural value system in Taiwan, respecting and caring for parents as a 'natural obligation and responsibility' (i.e., filial piety) is of major significance. Under these traditional norms, informal social support, especially from adult children/siblings, is expected to support the elderly in terms of their basic needs including board and care, respect, emotional and financial support, and health care. According to a nationwide survey as to the status of the elderly in 1989, family members were the major givers as well as receivers in the social support system. Emotional support had a strong and positive relationship with the well-being of the elderly. Furthermore, the demographic characteristics of the elderly, including their financial security, health status and the number of children they had, correlated with the structure and function of the informal social support system and impacted on the life satisfaction of the elderly. Hence, informal social support was found to be the major resource of caring for the elderly in Taiwan, especially for the frail (Li 1991). On the other hand, formal social support performed as a backup system when family or other informal support systems were not available. Social welfare and services in earlier times only provided support for the elderly who did not have any children/siblings or other relative supporters, and such support was based on a means-test policy. Most of the subsidies and services were designed for the low-income and middle-low-income elderly, as well as the frail. Institutional care put more emphasis and greater budget resources into constructing facilities (such as homes for the aged, assisted living facilities and nursing homes) and provision of services (Wu et al. 1999). This weakness has changed since 1998 following implementation of the 'Three-Year Plan for the Long-Term Care of the Elderly' and the 'Project of Care Services to the Elderly', which were conducted by the Department/ Ministry of Health and the Ministry of Interior Affairs respectively. Several community/home formal social support services have been initiated, such as home-helper services, meals-on-wheels programmes, respite care for caregivers, lifeline services, home nursing care, day care centres, etc. Long-term care volunteers have been trained for those in need of information referral, emotional support, home management, transport, etc. Facing the increasing demands for support are the fragmented services provided by two governmental systems/agencies, the Department/Ministry of Health taking responsibility for the health-care needs of the frail and the Ministry of Interior Affairs taking responsibility for the personal/daily living care needs of the disabled and frail elderly. As a result of this dual system, both long-term care service providers and receivers frequently feel confused.

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It is also detrimental in terms of policy-making, budget/finance reallocation, programme integration, service delivery, and organization/information administration (Wu et al. 1999; Lee 2000).

Integration programme Linkage, integration and cooperation between the two related systems will be the next major step for developing long-term care policy, programme and service delivery in Taiwan. Integration should initially occur among the different tiers of central government, local government, administration agencies and the service providers. The scope will include policies, finance arrangements, programme planning, service delivery and administration, and even information collection, diffusion and issuance (Wang 1997). The ultimate purpose of integrating long-term care is to provide continuous, humanistic and comprehensive services for the benefit of the needy and their families. A single-entry system for long-term care patients is one of the important programmes in the 'Three-Year Plan for the Long-Term Care of the Elderly'. The Department/Ministry of Health subsidized local governments and related agencies to establish centres of long-term care resource and referral (CLTCRR). Up to April 2000, seven CLTCRRs have been established for providing information referral, case management, supplemental equipment exhibition and arrangement, public education, care-giver support group, and respite care referral. The long-term care case managers play a key role to integrate social, health and financial services (Yuan, Li and Chan 1999). 'Discharge planning' is the other integration programme which aims to integrate acute care and long-term care services. At least 51 regional hospitals implement discharge planning for those for whom there is a high risk of long-term stay, especially stroke/CVA patients. Currently, the CLTCRRs work with the discharge planning departments to ensure appropriate reallocation for long-term care patients. From the policy perspective, since 8 March 1999, the Ministry of Interior Affairs and the Department/Ministry of Health had formed a special council integration task force engaged in the linkage and coordination among social welfare and health-care services in regard to long-term care. The first three priorities of its agenda are: to simplify the classification of long-term care facilities, to deregulate and standardize current long-term care-related services, and to buffer the gap between needs and supplies. The long-term care policy- and programme-making in Taiwan has only sparsely achieved integration of the long-term care system, and is still insufficient. Considering the great discrepancy between community/home service needs and supplies in long-term care (Department/Ministry of Health,

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Taiwan 1999d), and the fragmented long-term care and acute care services, the policy-makers need to refocus their consideration more fundamentally on the meaning of integration, and put greater effort into building models of continuum care in the community/home setting. This reverse trend is clearly exemplified by many European governments in the 1980s (Coleman 1995) and the US federal and state governments in the 1990s (Mollica 1998).

I Conclusion In this new century, the ageing of the global population is one of the biggest challenges to face the world. However, it is also potentially a great turning point to change current attitudes and patterns of life. In 1982, the World Assembly on Aging, held in Vienna, had affirmed that 'the fundamental and inalienable rights enshrined in the Universal Declaration of Human Rights apply fully and undiminishedly to the aging', 'quality of life is no less important than longevity', and 'the aging should be enabled to enjoy in their own families and communities a life of fulfillment, health, security, contentment, appreciated as an integral part of society'. The theme of World Health Day 1999, in the International Year of Older Persons, which was 'Active Aging Makes the Difference', recognized that it is key for older people to continue playing an active part in society. Active ageing involves every dimension of our lives: physical, mental, social and spiritual (Word Health Programme, World Health Organization 1999). There is much an individual can do to remain active and healthy in later life. Hence, care-providers should recognize that service patterns need to shift from the traditional care model (based on stabilization of acute conditions on acute care and on hi-technology, physician-driven, short-term and cureoriented, and disease-based) to a model focussed on long-term care and the continuum of care (maximizing or at least maintaining the function level, long-term-oriented care, function- and resources-based, multidisciplinary collaboration, adequate utilization of resources, high-touch, residents and family involvement) (Wang 1997). The continuum of care model should aim to integrate not only health-care services, but also social welfare services, housing, transport, education, community-based services and support, finance and law support (Wang 1991). It should tend towards community-based, client-centred, policy-focussed programmes and services. To provide a high quality of care and to improve the quality of life and the dignity of the ageing population, especially the frail elderly, is, throughout the world, a fundamental goal of this new century. To accomplish this goal, an integrated health care system is the first task that needs to be accomplished.

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An integrated health system is m o r e than a collection of fragmented services; it is integrated systemic care. It is a system comprising a collection of providers organized to render coordinated c o n t i n u u m of health-care services t h r o u g h either contractual or ownership arrangements. T h e integrated delivery system m u s t be internally managed a n d organized to take financial risks a n d b e accountable for the health status and quality of life of a defined population.

D References Coleman, B J. 1995. European models of long-term care in the home and community. International Journal of Health Services 25 (3): 455-74. Department/Ministry of Health (Taiwan). 1998a. The health statistics in Taiwan. Taipei: Department/Ministry of Health. . 1998b. The major health care and medical care indices in Taiwan. (Unpublished reference.) Taipei: Department/Ministry of Health. . 1999a. Annual report of public health in Taiwan — 1997. Taipei: Department/ Ministry of Health. . 1999b. Annual report of public health in Taiwan — 1998. 12. Taipei: Department/Ministry of Health. . 1999c. General health statistics in Taiwan. Taipei: Department/Ministry of Health. . 1999d. Internal report to the Director General of Department/Ministry of Health. Taipei: Department/Ministry of Health. and National Health Insurance Bureau (Taiwan). 1994, 1995. National Health Insurance Act (with related Regulations, Rules, Standards, Criterion). Taipei: Department/Ministry of Health and National Health Insurance Bureau. Directorate-General of Budget, Accounting and Statistics (Taiwan). 1999. National income of Taiwan. Taipei: Directorate-General of Budget, Accounting and Statistics. Economic Progression Council (Taiwan). 1996. Population estimation 1995-2036. Taipei: Economic Progression Council. Executive Yuan (Taiwan). 2000. Three-year pilot project for the establishment longterm care delivery system to the elderly. Taipei: Executive Yuan. Institute of Public Health and Center for Health Policy Research, National Taiwan University and Taiwan Provincial Institute of Family Planning. 1995. Health care for the elderly in Taiwan — A fact book, 1993-1994. 60-6. National Taiwan University and Taiwan Provincial Institute of Family Planning. Lee, S.D. 1996. Health care and policy for the elderly. Journal of Rehabilitation Medicine 4 (1) (special issue): Sl-4. . 2000. Policy and finance arrangement of/for long-term care — An experience in Taiwan. Long-term care workshop for the elderly: 'Long-term Care for the Elderly at the Turn of New Century: An International Experience'. Hong Kong: the University of Hong Kong and Elderly Commission, SAR government. 10-14 January. , J.S. Kuo et al. (Planning Group of Gerontological Research, National Health

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Research Institutes (NHRI)). 1995. Planning report of gerontological research, National Health Research Institutes (NHRI). National Health Research Institutes (NHRI). Li, M.F. 1991. Informal social support and life satisfaction among the elderly in Taiwan. ii, 3, 4. (Master's thesis, University of Southern California.) Ministry of Interior Affairs (Taiwan). 1997. Surveillance report of elderly related issue in Taiwan — 1996. 10-2. Taipei: Ministry of Interior Affairs. . 1998. The population census in Taiwan. Taipei: Ministry of Interior Affairs. Mollica, R. 1998. State innovation in long-term care delivery systems. The public policy and aging report. National Academy on An Aging Society 9 (3): 10-2. National Health Insurance Bureau (Taiwan). 1998. National health insurance profile. Taipei: National Health Insurance Bureau, Department/Ministry of Health. Wang, E.F. 1991. Geriatric continuum of care. In 'Aging and long-term care' symposium, American Hospital Association (AHA). . 1997. Geriatric and long-term care: Presentation guidelines for Taiwan. (Speech handout.) Taipei: Department/Ministry of Health. World Health Organization (WHO). 1997. World health statistics annual (WHSA). Geneva: WHO. . 1999. Ageing and health: A global challenge for the 21st century. Kobe, Japan: WHO Centre for Health Development. World Health Programme, World Health Organization (WHO). 1999. Ageing: Exploding the myths. Geneva: WHO. Wu, S.C., P.C. Lue and R.F. Lu. 1998. The study on the long-term care policy — Following social welfare system in Taiwan. Taipei: Research and Accredit Council. , C. Wang, W.Y. Lin, Y.C. Wu and R.C. Wang. 1999. Ten-year plan for the establishment of long-term care system for the elderly in Taiwan. 1, 10, 19. Taipei: Executive Yuan. Yuan, Y.M., M.F. Li and C. Chan. 1999. An analysis on current status of the Center of Long-term Care Resource and Referral. The Journal of Long Term Care 3 (2) (December): 14, 27.

11 Social Support and Medication Use: A Cross-cultural Comparison Erin Y. Tjam and John P. Hirdes

D Introduction After decades of research, gerontologists have come to a clear consensus that older adults are characterized by their heterogeneity rather than their homogeneity. As people age, their life experiences contribute to their uniqueness physically, psychologically and culturally (Fry 1990). Cultural and ethnic variations in health have been known for some time, and strict medical or biological models have not been able to explain more than a fraction of these variations. The remainder must be attributed, at least in part, to environmental, social and cultural factors (Zola 1979). An examination of health across cultures, especially in the elderly population, is timely because of the rapid demographic changes in Canadian society. While the population of individuals aged 65 or above is growing quickly, both in absolute numbers and as a proportion of the whole, the Canadian population is also becoming more culturally diverse. In this study, cross-cultural variations in medication use by ChineseCanadian elderly versus mainstream Canadian elderly were examined. There are many reasons for concern about medication use by older persons, including the high prevalence of polypharmacy and adverse drug reactions. The cost of medications and consequences of adverse drug reactions are also major reasons for the concern of health care-providers and policy-makers (Hershman et al. 1995).

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In examining the determinants of medication use, various demographic (e.g., age, sex), physiological (e.g., health status), psychological (e.g., depression), social (e.g., social isolation, widowhood) and health service utilization (e.g., physician visits) factors have been reported to be associated with medication use (McKim, Stones and Kozma 1990; Simons et al. 1992). For this reason, a wide range of health-related indicators must be examined to explain medication use fully.

Pattern of medication utilization by the elderly More elderly persons use prescribed and over-the-counter medications than those in the younger age groups (Chrischilles et al. 1992). In addition, the elderly are more likely than younger people to be multiple-medication users (Bergob 1994). In the Chinese elderly population, medication use is further complicated by the combined use of Western medicines and traditional Chinese medicines (TCM). Treatment with TCM is common among Chinese people, and its use is increasing in non-Chinese countries (But and Kan 1995). On the other hand, Canadian regulations on TCM practice and the enforcement of regulations on TCM sale remain inadequate for the protection of public health. Further, individuals in the Canadian health care system are unfamiliar with TCM products, and they may not understand the pharmacological properties of TCM (Tjam et al. 1998). The concomitant use of Western medicines and TCM is of additional concern because it is known that TCM often have pharmacological effects (Chan, Chan and Critchley 1992; Homma et al. 1993; Lo et al. 1992) and these effects may lead to drug-drug interactions with Western medications (Chan et al. 1993). The use of medications without physician consultation, the use of multiple medications, and age-related changes in pharmacokinetics and pharmacodynamics can exaggerate the risk of adverse drug reactions.

Determinants of medication use Several factors have been shown to be related to increased medication use. Guttman (1978) reported that poor health and physical disability predict a higher level of medication use by the elderly, and Skelton (1985) found that age does not predict increased medication use for a healthy population. McKim, Stones and Kozma (1990) found that the presence of disease and its severity, followed by perceived health, were strong determinants of medication use. The National Alcohol and Other Medications Survey (NADS) showed

SOCIAL SUPPORT AND MEDICATION USE: A CROSS-CULTURAL COMPARISON

that reported stress and lack of family support were strong predictors of increased or multiple medication use (Health Canada 1992; Swinkels, Hirdes and Ellis-Hale 1996). Chrischilles et al. (1992) found that smoking and drinking, reported depressive symptoms, impaired physical functioning, and poor perceived health status were predictors of increased medication use. Hanlon et al. (1996) concluded that the community-based elderly with cognitive impairments were less likely to use any medications than the cognitively intact elderly, perhaps reflecting differences in the extent to which some patients demand drug-based solutions.

Assessment of health and medication use in a cross-cultural context When Western culture meets traditional ethnic culture, the treatment approach to illness is not constant. In studying medication use by the Chinese elderly, the scenario is further complicated by the expanded choices of Western medicines and TCM, and the coexistence of multiple belief systems. This chapter aims to examine the determinants of each type of medication use (Western medicines and TCM) based on data from a comprehensive geriatric assessment. Hirdes and Carpenter (1997) commented that one of the serious problems in studying health in different populations is the lack of comparable data across studies. To a degree, this is due to a lack of standardization in the data collection and definition of health variables. The health of elderly people varies widely, and their needs are multidimensional. To achieve valid and reliable c o m p a r i s o n s of health data w i t h i n - c u l t u r e and across cultures, a comprehensive assessment instrument with consistent operational definitions, standardized administration protocols, and cross-cultural applicability in the elderly population is needed. International experience with the Minimum Data Set for Home Care (MDS-HC) showed it to be a logical choice for comprehensive assessments of the elderly in the community settings. The MDS-HC was developed by interRAI, an international team of more than 30 researchers from 16 countries committed to standardized assessment to improve care of the elderly. It is a comprehensive, standardized instrument for evaluating the needs, strengths and preferences of elderly individuals living in the community, and of home care agencies (Morris et al., in press). The MDS-HC is the assessment component of a complete care planning system, the RAI-Home Care. The MDS-HC instrument enables assessors to evaluate in about an hour the function, health, social support, and service use of the community-based elderly and adults with disabilities (Morris et

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al., in press). The MDS-HC instrument uses specific combinations of questions/ items as 'triggers' for a series of 30 problem-oriented Client Assessment Protocols, known as CAPs. Each CAP uses MDS-HC assessment data in a structured manner to identify health concerns to be addressed through further evaluation and care planning.

1 Methods Sampling Two groups of elderly people were studied: Chinese-Canadians residing in Kitchener/Waterloo, Ontario, and mainstream Canadians receiving home care services from the Red Cross Homemaker Program. This study was crosssectionally designed, and the target population were cohorts of frail elderly people (predominantly 65 years old or above, with the exception of a few younger frail individuals aged 60 or above). The Chinese-Canadians were identified through local Chinese physicians and elderly Chinese clients of the Waterloo Home Care Program. Also, elderly members of the Central Ontario Chinese Cultural Centre (COCCC) and the Chinese Alliance Church were contacted. Patients are more likely to see physicians who are similar to them (McKim and Mishara 1987), so the Chinese elderly will probably be more inclined to visit Chinese physicians who share their language, culture and beliefs background. The names of Chinese physicians and Chinese patients were obtained from the telephone directory and the physicians' caseload list respectively, using a phonologically based Chinese surname identification method. This method uses phonological rules of Chinese words to distinguish Chinese surnames from non-Chinese surnames (Tjam, Hirdes and Roehrig 1996). The Chinese elderly who were unable to be identified through any of these three methods were probably individuals who had not seen a Chinese physician, had not participated in any organized Chinese activities, and had not attended the Chinese Church. This is likely a negligible number because most Chinese-Canadian elderly will maintain close relations with the Chinese culture. Any of the unidentified individuals were probably second-generation Chinese-Canadian elderly, or those who had been residents for an extended length of time, making them more similar to the mainstream Canadians than the Chinese. Potential participants were invited by post and followed up by telephone calls. Upon verbal agreement to participate in the study, written consent was obtained at the participant's home before commencing the assessment. Trained bilingual assessors telephoned each potential participant and confirmed their

SOCIAL SUPPORT AND MEDIC A TION USE: A CROSS-CUL TURAL COMPARISON

cultural/ethnic identity through self-declaration. Individuals who declared themselves as non-Chinese, moved out of the region, or were not available (moved to a nursing home, wrong address, wrong phone number, expired, etc.) were excluded from the study. Based on the 1991 census (Statistics Canada 1992), the total number of Chinese in the Kitchener/Waterloo area was 1900. Given that 7.5% of the general Chinese population in Canada was elderly (Statistics Canada 1992), there was an expected total number of 143 elderly Chinese people living in the Kitchener/Waterloo area. In this study, 154 potential Chinese-Canadian elderly participants were initially identified. Fifteen individuals were nonChinese, leaving a total of 139 Chinese-Canadian elderly in this area. Excluding 34 ineligible individuals (due to migration, death, wrong address or phone number), the study achieved an 87.2% response rate yielding 92 participants. Therefore, this was a near census and representative coverage of the total population of Chinese-Canadian elderly in the Kitchener/Waterloo area. The mainstream Canadian elderly were clients of the Red Cross Homemaker Program residing in Ontario. The Canadian Red Cross Homemaker Program is a non-profit private service offered to the frail community-based elderly and adults with disabilities. Sampling was based on a stratified random sample of clients of the Red Cross Homemaker Program in six Ontario cities: Windsor, Owen Sound, Brantford, Scarborough, Brockville and Thunder Bay. A computer-generated census list was sent to the project investigators, who in turn drew random samples of 100 individuals from each city. The selected participants were approached by Red Cross staff and were given preliminary information explaining the nature and purpose of the study. Within a few days, they were formally approached to grant consent to participate in the study. Consent was also obtained from the assessors for performance of their role in the project.

Translation of the MDS-HC The Chinese elderly in the Kitchener/Waterloo area were assessed using a translated version of the MDS-HC. The MDS-HC was translated into Chinese by two experienced translators with expert conceptual and content knowledge of the instrument. The translated version was further evaluated and modified by another group of bicultural and bilingual medical professionals. Independent back-translation was performed to assess the translation equivalence. Then, a pre-test with the target population was conducted for final modification. The MDS-2.0 for nursing homes has already been translated

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into 12 languages, with known cultural compatibility and sound psychometric properties. The MDS-HC is highly comparable with the MDS-2.0, so it should share the same cultural compatibility and psychometric properties. To further ensure cultural appropriateness, bilingual, bicultural, trained and experienced clinical practitioners were used as assessors in this study.

Assessor training Assessors were trained using a standardized training protocol involving a two full-day training session preceded by a detailed individual review of the assessment manual. On the first day, a general overview of the history and development of MDS instruments, and objectives of the research, and a comprehensive section-by-section study of the MDS-HC form were undertaken. All assessors were then given a true-case assessment to complete as practice. On the second day, the completed MDS-HC assessment was examined, followed by item-by-item, problem-solving and detailed group analysis of questions encountered in assessment. Assessors were also given training on interviewing techniques, cultural sensitivity issues and ethical considerations. The intensive and comprehensive training session, together with the qualifications of the professional assessors, produced well-trained and competent assessors.

Data collection After consent was obtained, data was collected using face-to-face assessments. The full MDS-HC instrument was administered in a standardized format using direct questioning of the elderly person and his or her informal care-givers, assessing clinical areas, observing the elderly in the home environment, and reviewing other health-related documents when available. Proxy response was permitted if the elderly person was unable to provide the information. Each assessment took approximately one hour to complete. For medication use, assessors reviewed and recorded all the TCM, prescription and over-thecounter medicines used by the participant within seven days prior to the assessment date.

Statistical analysis Dependent variables of the study were polypharmacy (using more than three medicines: TCM or Western medicines), Western medication use, TCM

SOCIAL SUPPORT AND MEDICATION USE: A CROSS-CULTURAL COMPARISON

medication use, and combined medication use (using Western medicines and TCM jointly). Independent variables were the multidimensional health indicators. Differences in health indicators and medication use were tested using Chi-square analysis and Student's t-test. Multivariate regression analysis was used to examine the independent effects of the various health indicators on different aspects of drug use.

D Results For the Chinese-Canadian sample, 18 potential Chinese physicians were identified in the Waterloo regional phone directory using the phonologically based surname search method. Two of them were non-Chinese (Korean and Vietnamese) yielding 16 eligible physicians, and the response rate was 81.3% (13/16). Based on the 1991 census (Statistics Canada 1992) of 1900 Chinese in the Kitchener/Waterloo area, and given that 7.5% of the general Chinese population in Canada was elderly (Statistics Canada 1992), an expected 143 elderly Chinese people were needed in the Kitchener/Waterloo area for the study to be a census. Combining the physicians' lists, clients of the Waterloo Home Care Program, COCCC elderly members, and elders attending the Chinese Alliance Church, a total of 176 potential Chinese-Canadian elderly individuals were initially identified. Seventeen of them were non-Chinese (mostly Southeast Asians or Koreans), leaving a total of 159 Chinese-Canadian elderly in this area, which approximated the census estimate of 143. Excluding 53 ineligible individuals (due to migration, death, wrong address or phone number), the study achieved an 89.1% response rate yielding 106 participants. For the Red Cross sample, 127 were excluded from the 600 people originally sampled because they did not meet eligibility requirements (e.g., too young, already discharged by the time they were contacted, or passed away before contact). Among the 473 individuals eligible to participate, there were 96 refusals resulting in an overall response rate of 79.7%. The response rate did vary by region with a low of 64.3% (Brockville) and a high of 100% (Scarborough). However, the present analyses were done at the provincial level rather than the regional level.

Demographics Table 1 shows that the Chinese-Canadian population was comprised of more women than men (63.2% versus 36.8%), and the majority (56.6%) of the

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Tabie 1 Percentage/frequency distributions of sociodemographic variables: the Chinese-Canadian and the Red Cross-Canadian samples Variables

Chinese-Canadian % (N) (n = 106)

RC-Canadian % (N) (n = 377)

Gender*** men women

36.8 63.2

(39) (67)

22.5 77.5

(83) (286)

Age*** below 65 65 to 74 75 or older

13.2 56.6 30.2

(14) (60) (32)

11.9 21.5 66.6

(45) (81) (251)

2.2 56.5 39.1 1.1 1.1 0.0

(2) (52) (36) (1) (1) (0) (14)

8.2 28.2 56.4 1.9 4.5 0.8

(31) (106) (212) (7) (17) (3)

2.0 0.0 84.9 46.5 38.4 13.1

(2) (0) (84) (46) (38) (13)

87.4 4.3 0.0 0.0 0.0 8.3

(327) (15) (0) (0) (0) (31)

30.4 30.4 6.5 8.7 1.1 7.6 10.9 4.3

(28) (28) (6) (8) (1) (7) (10) (4) (14)

1.1 42.0 18.4 16.0 4.3 11.2 4.0 2.9

(4) (157) (69) (60) (16) (42) (15) (11)

9.8 9.8 37.0 39.1 4.3 0.0

(9) (9) (34) (36) (4) (0)

58.1 25.5 2.9 10.9 2.7 0.0

(219) (96) (11) (41) (10) (0)

Marital Status*** never married married widowed separated divorced other missing value Language*** English French Chinese Cantonese Putonghua other Education*** no schooling grade 8 or below 9-11 grades high school technical or trade school some college bachelor's degree graduate degree missing value Living Arrangement*** lived alone lived with spouse only lived with spouse and other(s) lived with children (not spouse) lived with other(s) (not spouse or children) lived in group setting with non-relative(s) ** p < .0001 comparing among samples

respondents were between 65 and 74 years old. Similarly, the Red CrossCanadian sample also contained more women than men. Most of the respondents in the Chinese-Canadian sample were married (56.5%) or

SOCIAL SUPPORT AND MEDICATION USE! A CROSS-CULTURAL COMPARISON

widowed (39.1%), and for the Red Cross sample, the majority (56.4%) of the respondents were widowed, followed by married (28.2%). A large proportion of the Chinese-Canadians had either no schooling (30.4%) or below grade eight education (30.4%), and 23% had college or above schooling, reflecting a bimodal distribution. Almost half of the Red Cross Canadians had below grade eight education, nearly 40% had some form of high school or trade school education, and about 20% had some college or above education. A total of 39% of the Chinese-Canadian sample lived with their children and without a spouse, and 37% lived with their spouse and children. Few lived alone (9.8%) or with their spouse only (9.8%). With the Red Cross-Canadian sample, the majority (58.1%) of them lived alone, and 25.5% lived with their spouse only. Only 10.9% lived with their children.

Medication use Table 2 indicates that 67.9% of the Chinese-Canadian sample used some type of medicine, 28.3% used TCM, 21.7% combined TCM and Western medicines, 61.3% used Western medicines, 37.7% adopted polypharmacy that included TCM, and 29.2% adopted polypharmacy that excluded TCM. For the Red Cross-Canadian sample, the percentage for use of Western medicines was 95.5, and polypharmacy 83.8.

Table 2

Percentage/frequency distributions and means (standard error) of medication use: the Chinese-Canadian and the Red Cross-Canadian samples Chinese-Canadian

Variables Total Sample percentage frequency Total Sample mean standard error

RC-Canadian

Polypharmacy Any Combined Western Western TCM with without Polypharmacy medicine medicines medicines medicines TCM TCM 67 9 72

28 3 30

21 7 23

23 02

05 01

#

61 3 65 1 8 02

37 7 29 2 40 31

*

*

95 5 360

83 8 316

58 01

* not applicable

Table 2 also revealed that the Chinese-Canadian sample had a mean of 2.3 of any medicine used. The mean of TCM used was 0.5, and Western medicines 1.8. For the Red Cross-Canadian sample, the mean of Western medicines used was 5.8, a significantly higher number than that of the Chinese-Canadian sample.

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Determinants of medication use Health indicators associated with medication use in other studies were examined as potential determinants of medication use. Health indicators significant at the bivariate level were tested in multivariate regression models to examine their relative predictive effects on medication use. Age, sex, marital status, education, cognition and functional impairments were controlled for, but none was significant in the multivariate models, and no interaction effects were found.

Binary dependent variables The multivariate logistic model for use of any medicine by the ChineseCanadians included three main effects with no interaction or curvilinear terms (Table 3). Immigrants from other countries (Vietnam, Laos, Cambodia) besides Hong Kong/Taiwan and China were more likely to use some type of medicine (TCM or Western), as indicated by an odds ratio (OR) of 8.71. Coming from China compared with Hong Kong/Taiwan was not significantly associated with the use of any medicine. Living with child was found to have a protective effect on the use of any medicine (OR = 0.22). Although borderline significant (p = .06), after controlling for the living with child' variable, one's country of origin being other countries became significant. Also, the effect of number of diseases was more prominent. In light of the relatively small sample size, living with child was believed to be an important factor to consider. Higher number of diseases was associated with an increased likelihood of using any medicine. As the number of diseases increases by one, the odds of using any medicine are 17 times greater. No equivalent dependent variable was available for the Red Cross-Canadian sample.

Table 3

Independent variables Country of origin Hong Kong/Taiwan China other countries Living with child no yes Number of diseases

Multiple logistic regression for use of any medicine by the Chinese-Canadian sample Parameter estimates

Standard

95% confidence interval

0.00 0.35 2.16

0.71 0.82

1.00 1.42 8.71

0.35,5.75 1.76,43.18

0.00 -1.53

0.82

1.00 0.22

0.04,1.08

2.84

0.69

17.09

4.38,66.64

SOCIAL SUPPORT AND MEDICATION USE: A CROSS-CULTURAL COMPARISON

L

The multivariate logistic model for use of TCM contained three main effects: health beliefs, pain symptoms and hospitalization (Table 4). For those who experienced pain symptoms, there was a near six times higher likelihood of using TCM than those without pain. In addition, being hospitalized strongly predicted TCM use: the odds of using TCM by those who were hospitalized was 15 times greater than those not hospitalized.

Table 4

Multiple logistic regression for use of TCM by the Chinese-Canadian sample Parameter estimates

Standard error

-3.00

1.09

Health beliefs squared

0.25

0.09

statistical interactions

Pain symptoms no yes

0.00 1.76

0.50

1.00 5.82

Hospitalized no yes

0.00 2.71

1.32

1.00 15.10

Independent variables Health beliefs

OH

95% C.I.

(not discussed)

2.20, 15.41

1.13, 202.58

Living with child was significantly associated with a reduced likelihood of combining TCM and Western medicines, as shown in Table 5 (OR = 0.15). Similar to the use of TCM, the presence of pain symptoms (OR = 4.45) and being hospitalized (OR = 15.71) increased the odds of combined medication use. Chinese-Canadian elders who reported social isolation problems also were more likely to combine TCM with Western medicines, as indicated by an OR of 6.25.

Table 5

Multiple logistic regression for combined medicine use by the Chinese-Canadian sample

Independent variables Living with child no yes

Parameter estimates

Standard error

0.00 -1.87

OR

95% C.I.

0.77

1.00 0.15

0.03, 0.70

Pain symptoms

1.49

0.48

4.45

1.73, 11.41

Social isolation problems no yes

0.00 1.83

0.81

1.00 6.25

1.28, 30.62

Hospitalized no yes

0.00 2.75

1.30

1.00 15.71

1.23, 200.25

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ERIN Y. TJAM AND JOHN P. HIRDES

Similar to the use of any medicine and of combined medicines, living with child presented a significant protective effect towards the use of Western medicines (OR = 0.14). Those Chinese-Canadian elders not living with their children had seven times higher the likelihood (OR = 1 versus 0.14) of using Western medicines than those living with their children. Chinese-Canadian elders with physical health problems were 11.46 times more likely to use Western medicines than those without physical health problems. The number of diseases was also positively associated with the use of Western medicines: an increase of one disease led to over 15 times higher the odds of using Western medicines (Table 6).

Table 6

Multiple logistic regression for use of Western medicines by the Chinese-Canadian sample

. , , ... Independent+ variables

Parameter ^ M estimates

Standard error

0.00 -1.94

Physical health problems no yes Number of diseases

Living with child no yes

~D OR

OP-0/ r . 95% L.I.

0.82

1.00 0.14

0.03, 0.71

0.00 2.44

0.86

1.00 11.46

2.11, 62.31

2.71

0.63

15.07

4.41, 51.52

As shown in Table 7, an increase in the cognitive performance score (indicating more cognitive impairment) had a protective effect on Western medicine use (OR = 0.70) by the Red Cross-Canadian sample. This means that those who were cognitively intact were more likely to use Western medicines than the cognitively impaired. The number of diseases displayed the same determinant effect on the use of Western medicines as on the use of any medicine by the Chinese-Canadian sample, but to a smaller extent. An increase in one disease led to 2.26 times higher the likelihood of using Western medicines in the Red Cross-Canadian sample.

Table 7

Multiple logistic regression for use of Western medicines by the Red Cross-Canadian sample

, . , ... Independent+ variables Cognitive performance score Number of diseases

Parameter . estimates

Standard error

~D OR

.__, _ . 95% C.I.

-0.36

0.18

0.70

0.49,0.99

0.81

0.20

2.26

1.52,3.37

SOCIAL SUPPORT AND MEDICATION USE! A CROSS-CULTURAL COMPARISON 163

L

Those in the Chinese-Canadian sample who experienced social isolation problems had nearly four times the odds of adopting polypharmacy than those without social isolation problems (Table 8). An increase in the number of diseases also contributed to greater odds of adopting polypharmacy (OR = 4.49). Both loneliness and an increase in the number of diseases were associated with increased odds of polypharmacy by the Red Cross-Canadian sample, as indicated by odds ratios of 3.51 and 1.64 respectively (Table 9). Respondents who did not have their medications reviewed by a physician were found to be less likely to adopt polypharmacy (OR = 0.23). Those whose medication was reviewed had over four times (1 versus 0.23) the likelihood of adopting polypharmacy.

Table 8

Multiple logistic regression for polypharmacy (including TCM) by the Chinese-Canadian sample Parameter estimates

Standard error

Social isolation problems no yes

0.00 1.35

0.57

1.00 3.85

1.25, 11.85

Number of diseases

1.50

0.31

4.49

2.47, 8.19

Independent variables

Table 9

95% C.I.

Multiple logistic regression for polypharmacy by the Red Cross-Canadian sample Parameter estimates

Standard error

Feels lonely no yes

0.00 1.26

Number of diseases Medication reviewed yes no

Independent variables

OR

OR

95% C.I.

0.42

1.00 3.51

1.54, 8.02

0.50

0.09

1.64

1.36, 1.98

0.00 -1.47

0.49

1.00 0.23

0.09, 0.60

Continuous dependent variables For the continuous variable of the number of any medication used, the final multilinear regression model as presented in Table 10 includes one main effect and one interaction effect (not discussed in this chapter), and explained 61% of the variance. A higher number of diseases was significantly related to an increased number of any medication used.

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ERIN Y. TJAM AND JOHN P. HIRDES

Table 10

J

Multiple linear regression for the number of any medication used by the Chinese-Canadian sample Parameter estimates

Standard error

p-value

Pain symptoms

1.08

0.29

0.0003

Number of diseases

0.94

0.14

0.0001

Perceived poor health no yes

0.00 1.85

0.00 0.57

0.0000 0.0019

-1.81

0.70 not discussed here

0.0115

F-value 31.44

Degrees of freedom 4

p >F 0.0001

Independent variables

Pain symptoms x perceived poor health R-square 0.61

Two main effects and one interaction term were found to be significantly related to the number of TCM used (Table 11). Those Chinese-Canadian elderly who received formal services used less TCM, indicating an inverse relationship, and those with more pain symptoms used more TCM. The interaction effect between the number of diseases and social isolation problems is presented in Figure 1. An increase in the number of diseases affected most drastically the Chinese-Canadians who were socially isolated, which resulted in a much higher number of TCM used. For those who were not socially isolated, the effect of the number of diseases on the number of TCM was minimal, as only a small increase in the number of TCM used was observed. This shows that TCM use was much more prevalent for those with social

Table 11

Multiple linear regression for the number of TCM used by the Chinese-Canadian sample

Independent variables Formal services used no yes Pain symptoms

Parameter estimates

Standard error

0.00 -0.91

0.35

p-value

0.01

0.33

0.17

0.05

Social isolation problems

-0.05

0.25

0.85

Total number of diseases

0.05

0.10

0.59

Social isolation problems x number of diseases

0.44

0.14

0.003

F-value 8.88

Degrees of freedom 5

p >F 0.0001

R-square 0.32

SOCIAL SUPPORT AND MEDICATION USE! A CROSS-CULTURAL COMPARISON

L

isolation problems in an attempt to address the increasing health problems. Health care-providers need to be aware of this behaviour in order to prevent any inappropriate combined use of medications. This model accounted for 32% of the explained variance.

Z.

4

CD -Q

£

3

1

2

— «—

#

3

4

•

r

-

— «-

5 6 7 Number of diseases

-- • - - Without social isolation problems

•

8

- -...*.-- - - •

9

-••

10

—•— With social isolation probksms

Figure 1 Predicted number of TCM used by the interaction effects of social isolation problems and the number of diseases, the Chinese-Canadian sample

D Discussion Previous studies on cultural variations in medication use are almost nonexistent. A few studies looked at racial differences in the number of medications used, which suggested that 'whites' were higher users of medications than 'non-whites' (Kotzan, Carroll and Kotzan 1989; Brown et al. 1995; Hershman et al. 1995; Fillenbaum et al. 1993). This racial grouping neglected important cultural differences in medication use. Further, the gross aggregation of racial groups is of little use in understanding the medicationtaking behaviour of any particular cultural group. Cultural and social factors which are rarely examined in studies of determination of medication use were found to be significant with the ChineseCanadian sample. Country of origin from Vietnam and other South East Asian countries was positively related to increased odds of using any medicine. This is not surprising because immigrants from these countries are mostly refugees. Often disadvantaged even prior to departure, refugees endure perilous escapes, illness, deprivation and lengthy stays in overcrowded and unsanitary refugee camps before arriving in the host country. Many have deteriorated under difficult living conditions, which reduce their physical health and well-being

165

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ERIN Y. TJAM AND JOHN P. HIRDES

to its lowest level (Lai and Yue 1990). This poor health status naturally leads to an increased likelihood of using medications. Social support factors such as living with child were found to be protective factors to using any, combined, and Western medicines for the ChineseCanadians (Tables 3, 4 and 5). Although many studies suspect that intact and cohesive extended family structures providing strong social support might be diminishing, Kitano et al. (1994) reported that this strong family interaction remains for elderly immigrants, and they are more likely than general Americans to live with their children. In the Chinese immigrant community, the increasing dependency of elders is often an accepted norm (Evans and Cunningham 1996). Therefore, for those Chinese-Canadian elderly living with their children, decisions in using medications might be influenced by their children. As younger adults are often better informed about health and medication complications, their opinions might guide their elderly parents towards less medication use. Further, this readily available informal support might be helpful in preventing the use of medications as the first avenue to resolving health concerns. Comparing the determinants of medication use affecting the ChineseCanadians and the Red Cross-Canadians, it is obvious that cultural social support factors play an important role and cannot be ignored. Two variables that have distinctively different determinant roles between these two cultures are the feeling of loneliness and medication review. Feeling lonely was the strongest predictor of polypharmacy in the Red Cross-Canadian sample, but not a predictor in the Chinese-Canadian sample. Although the prevalence of loneliness was essentially the same in both samples (38.7% for Red Cross and 36.8% for Chinese), the nature of loneliness might be very different. Most Red Cross-Canadians lived alone (58.3%) at an old age. The loneliness experienced by this group might be more likely to result in depression, which has been found to correlate with high somatic complaints, hence higher medication use (Chrischilles et al. 1992; Laukkanen et al. 1992; Kroenke and Pinholt 1990). In the Chinese-Canadian sample, most of them lived with someone, so their source of loneliness might be related more to the immigration process. Also, as informal care is easily accessible, this may act as a buffer to the progression of loneliness manifesting itself in a more serious form as depression. Using medication as a method to handle loneliness is undesirable. More non-drug treatment should be explored with the Red Cross-Canadians to reduce any inappropriate medication use. Medication reviews were found to be positively related to an increased likelihood of polypharmacy (four times higher, Table 7) and an increased number of Western medication used (Table 9) for the Red Cross-Canadians, but not the Chinese-Canadians. The difference between these two cultures could be related to divergent cultural beliefs. As discussed earlier, in the

I

SOCIAL SUPPORT AND MEDICATION USE! A CROSS-CULTURAL COMPARISON

167

Chinese culture, traditional beliefs in social sensitivity and filial piety inhibit challenging an expert and increase an individual's submission to authority (Chae 1987). Therefore, Chinese-Canadian elders would be unlikely to request different or more medications from physicians, hence the pattern of increased medication use when physicians reviewing their medicines might not be present. In the general North American population, studies have shown that for those aged 65 or above, each physician visit leads to an average of two additional medications prescribed; and the mean number of prescriptions per encounter written for those aged 65 or above is much higher than for the younger population (Ferguson 1990; Knapp et al. 1984). It is not known if this increase was a result of patient requests or independent physician decisions. The present study also does not permit conclusions on whether the polypharmacy or increased medication use was justified or could be avoided. However, polypharmacy does present a potential hazard to users, especially elderly people, through adverse drug reactions, medicationmedication interactions and an elevated risk of non-compliance. Results indicating that about 25% of the community-based elderly received at least one potentially inappropriate medication (Willcox, Himmelstein and Woolhandler 1994), raise further concerns about the risks of polypharmacy. Based on the results of this study, it is obvious that medication use is not simply determined by biological factors (e.g., the number of diseases, pain, physical health problems), but also by social support and cultural factors (e.g., living with child, loneliness, social isolation, country of origin). This multidimensional nature of the causal pathway of medication use must be addressed by using a comprehensive assessment instrument in order to be sensitive to the diverse and complex patterns of medication use.

I References Bergob, M. 1994. Drug use among senior Canadians. Canadian Social Trends (summer): 25-9. Brown, S.L., M.E. Salive, J.M. Guralnik, M. Pahor, D.P. Chapman and D. Blazer. 1995. Antidepressant use in the elderly: Association with demographic characteristics, health-related factors, and health care utilization. Journal of Clinical Epidemiology 48 (3): 445-53. But, P.P.H. and W.K. Kan. 1995. Adverse reactions to Chinese medicines in Hong Kong. Abstracts of Chinese Medicines 6 (1): 104-22. Chae, M. 1987. Older Asians. Journal of Gerontological Nursing 13 (11): 10-7. Chan, T.Y.K., A.Y.W. Chan and J.AJ.H. Critchley. 1992. Hospital admissions due to adverse reactions to Chinese herbal medicines. Journal of Tropical Medicine and Hygiene 95: 296-8.

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Chan, T Y K J C N Chan, B TomlmsonandJ A J H Critchley 1993 Chinese herbal medicines revisited A Hong Kong perspective The Lancet 342 1532-4 Chnschilles, E A , D J Foley, R B Wallace, J H Lemke, T P Semla, J T Hanlon, RJ Glynn, A M Ostfeld and J M Guralnik 1992 Use of medications by persons 65 and over Data from the established populations for epidemiologic studies of the elderly Journal of Gerontology Medical Sciences 47 (5) M137-44 Evans, C A and B A Cunningham 1996 Caring for the ethnic elder Geriatric Nursing 17 (3) 105-10 Ferguson, J A 1990 Patient age as a factor in drug prescribing practices Canadian Journal on Aging 9 (3) 278-95 Fillenbaum, G G , J T Hanlon, E H Corder, T Ziqubu-Page, W E Wall and D Brock 1993 Prescription and nonprescription drug use among black and white community-residing elderly American Journal of Public Health 83 (11) 1577-82 Fry, C L 1990 Cross-cultural comparisons of aging In Gerontology Perspectives and issues, ed Ferraro, Kenneth F 129-46 New York Springer Publishing Co Guttman, D 1978 Patterns of legal drug use by older Americans Addictive Diseases 3 337-56 Hanlon, J T , L R Landerman, W E Wall, R D Horner, G G Fillenbaum, D V Dawson, K E Schmader, H J Cohen and D G Blazer 1996 Is medication use by community-dwelling elderly people influenced by cognitive function 7 Age and Ageing 25 190-6 Health Canada 1992 Alcohol and other drugs use by Canadians A national alcohol and other drugs survey (1989), Technical Report Ottawa Health Canada Hershman, D L , P A Simonoff, W H Fnshman, F Paston and M Aronson 1995 Drug utilization in the old old and how it relates to self-perceived health and allcause mortality Results from the Bronx aging study Journal of the American Geriatric Society 43 356-60 Hirdes, J P and G I Carpenter 1997 Health outcomes among the frail elderly in communities and institutions Use of the Minimum Data Set (MDS) to create effective linkage between research and policy Canadian Journal on Aging 16 (supplement) 53-69 Homma, M , K Oka, T Niitsuma and H Itoh 1993 Pharmacokinetic evaluation of traditional Chinese herbal medicmes-letter The Lancet 341 1595 Kitano, H H L , J E Lubben, E Berkanovic, I Chi, C Z Chen and X Zhu 1994 A cross-national study of elderly Chinese and Chinese Americans In International perspectives on healthcare for the elderly, ed Stopp, G H J New York Peter Lang Knapp, D A , T H Wiser, RJ Michocki, SJ Nuessle and W K Knapp 1984 Drug prescribing for ambulatory patients 85 years of age and older Journal of the American Geriatrics Society 32 (2) 138-43 Kotzan, L , N V Carroll and J A Kotzan 1989 Influence of age, sex, and race on prescription drug use among Georgia Medicaid recipients American Journal of Hospital Pharmacy 46 287-90 Kroenke, L T C K and E M Pinholt 1990 Reducing polypharmacy m the elderly A controlled trial of physician feedback Journal of the American Geriatrics Society 38 (1) 31-6 Lai, M C and K M K Yue 1990 The Chinese In Cross-cultural caring A handbook for health professionals in Western Canada, eds Waxier-Morrison, N , J M

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Anderson and E. Richardson. 68-90. Vancouver: University of British Columbia Press. Laukkanen, P., E. Heikkinen, M. Kauppinen and M. Kallinen. 1992. Use of drugs by non-institutionalized urban Finns born in 1904-1923 and the association of drug use with mood and self-rated health. Age and Ageing 21: 343-52. Lo, A.C., K. Chan, J.H. Yeung and K.S. Woo. 1992. The effects of Danshen (Salvia Miltiorrhiza) on pharmacokinetics and pharmacodynamics of warfarin in rats. European Journal of Drug Metabolism and Pharmacokinetics 17: 257-62. McKim, W.A. and B.L. Mishara. 1987. Drugs and aging. Toronto: Butterworths. , M.J. Stones and A. Kozma. 1990. Factors predicting medicine use in institutionalized and non-institutionalized elderly. Canadian Journal on Aging 9 (1): 23-34. Morris, J.N., B.E. Fries, K. Steel, N. Ikegami, R. Bernabei, G.I. Carpenter, R. Gilgen, J.P. Hirdes and E. Topinkova. (In press.) Comprehensive clinical assessment in community setting — Applicability of the MDS-HC. Journal of American Geriatrics Society. Simons, L.A., S. Tett, J. Simons, R. Lauchlan, J. McCallum, Y. Friedlander and I. Powell. 1992. Multiple medication use in the elderly — Use of prescription and non-prescription drugs in an Australian community setting. The Medical Journal of Australia 157: 242-6. Skelton, D. 1985. Drug utilization in a relatively fit elderly population. (Paper presented at the Canadian Association for Gerontology.) Statistics Canada. 1992. Profile of census divisions and subdivisions in Ontario — Part A. Ottawa: Statistics Canada. Swinkels, H., J.P. Hirdes and K. Ellis-Hale. 1996. A comparison of sleeping pill and tranquilizer use among community-based adults in Canada and the Netherlands. Hong Kong Journal of Gerontology 10 (supplement): 96-102. Tjam, E.Y., J.P. Hirdes and N. Roehrig. 1996. Identification of the Chinese population using surname searches based on phonological rules. (Presented at the 25th Annual Scientific and Educational Meeting of the Canadian Association on Gerontology, Quebec.) , K. Kan and I. Chi. 1998. A survey of proprietary traditional Chinese medicines in the Waterloo region — Labelling and regulation issues. Hong Kong Journal of Gerontology 10 (supplement): 103-7. Willcox, S.M., D.U. Himmelstein and S. Woolhandler. 1994. Inappropriate drug prescribing for the community-dwelling elderly. Journal of the American Medical Association 272 (4): 292-6. Zola, I. 1979. Oh where, oh where has ethnicity gone? In Ethnicity and aging: Theory, research, and policy, eds. Gelfand, D.E. and A.J. Kutzik. New York: Springer.

12 Family Support and Community-based Services in China Joe C.B. Leung

D Introduction Over the past two decades, the economy of China has been one of the fastest growing economies in the world. Between 1978 and 1996, China's GDP grew at an average of 10% a year, and an average of 6% to 8% is expected in the first decade of the twenty-first century. More significantly, with a GDP per capita reaching US$961 in 1998, it is now ranked as a middle-income country (Asian Wall Street Journal, 17 April 2000, p. 2). While the successes of China's economic reforms have been substantial and indisputable, they have been accompanied by a wide array of mounting social problems and needs. For centuries, it has been a cherished Chinese tradition for the elderly to be supported by their offspring; and formal social services for the aged were often regarded as not necessary (Chow 1991; Chen 1996). After the establishment of the People's Republic of China in 1949, a comprehensive employment-based social security system covering retirement and medical care was introduced. After the economic reforms beginning in 1978, however, this social security system became riddled with problems. As a consequence of the demographic shift, the issue of an ageing population has posed a formidable challenge to the Chinese government in meeting the present and impending financial and long-term care needs of the elderly. Meanwhile, modernized living has invariably eroded the capacity and willingness of the

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family to provide care for the elderly. This chapter provides a general demographic background and the profile of the needs of the elderly in China. After an appraisal of the family support capacity and formal welfare services, this chapter describes the emerging community-based support system for the elderly. Finally, it points out the urgent need to develop formal welfare services supporting family care. In the context of a globalized economy, China is now actively in search of a pluralistic social welfare system that is compatible with an emergent market economy. Under such a system, the role of the family and community in providing care for the elderly would be pivotal.

I China as an Ageing Society One of the consequences of the Draconian population control policy in China is the rapid increase in the proportion of the elderly population. With continuous low birth rates for more than two decades (16 per 1000 population in 1998), the proportion of children (aged 0-14) in the national population declined from 33.6% in 1982 to 24.3% in 1998. Coupled with low death rates (6.5 per 1000 population in 1998), the proportion of the elderly (aged 65 or over) in the national population surged from 4.9% in 1982 to 7.4% in 1998. The proportion was much higher in large cities such as Shanghai (13.1%), Beijing (9%) and Tianjin (8.9%), and lower in western provinces, such as Ningxia (4%), Xinjiang (5%) and Qinghai (5.1%) (State Statistical Bureau 1999, p. 119). The life expectancy of Chinese people reached 70.8 years in 1996 (male: 68.7 years; female: 73 years), as compared with 68.6 years in 1990 (male: 66.8 years; female: 70.5 years) (State Statistical Bureau 1998, p. 232). From 1991 to 1995, the elderly population increased at an average annual rate of 4.9%. This increase rate is five times the average annual population growth rate (natural growth rate in 1998 was 9.53 per 1000 population), and is 2.25 times higher than the growth rate in 1986-90 (Beijing Review, 10-16 March 1997, p. 23). Demographic projections show that the elderly population will reach 11.4% of the national population by the year 2020, and further increase to 20% by the year 2050. What worries the Chinese government most is the rate of increase in the proportion of elderly people. It took only 20 years for China's elderly population to increase from 5% to 7% of the national population. In the early days of other developed countries, with the exception of Japan, similar increases took at least 50 years (Tian 1990, p. 42). The elderly dependency ratio, referred to as the proportion of the elderly people (aged 65 or above) to the working population (aged 1 5 64), increased steadily from 8.3 in 1985 to 10.9 in 1998 (State Statistical

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Bureau 1999, p. 33). Being one of the fastest ageing societies in the world, China has to face all the problems of elderly care that are found in developed countries. Yet, its economy is still of a developing country.

Table 1 Changes of demographic structure of China in census years and 1998 (%) Year Age 0-14 15-64 65 or above Median age

1953

1964

1982

1990

1998

36 3 59 3

40 7 55 7

33 6 61 5

27 6 66 8

24 3 68 3

74

44

36

49

56

21 7

20 2

22 9

25 3

Source Yu 1995, p 23, State Statistical Bureau 1999, p 119

Among the elderly population in 1995, 8.4% were the old-old (aged over 80), a moderate increase over the figure in the 1990 census (7.9%). The population of this group of older people who usually have the greatest need for care will inevitably increase. Among the elderly aged between 60 and 64, the sex ratio was 100 women to 104.6 men, but the ratio dropped to 100 women to 55.8 men for those aged over 80 years old (State Statistical Bureau 1996, p. 72). A national survey in 1994 showed that 70.4% of the elderly population (aged 60 or over) were illiterate (41.2% in cities and 74.4% in villages). Some 93.4% of women in villages, where 70% of the Chinese people lived, were illiterate. On average, urban elderly people had 4.1 years of education (5.8 years for men and 2.6 years for women) whereas those in the rural areas had only 1.2 years (2.3 years for men and 0.3 year for women) (China Research Center on Aging 1994, p. 7). On the whole, differences in the level of education between elderly people in urban and rural areas and between men and women were substantial. As a developing country, both the pension system and formal social services for the elderly are largely inadequate. In a national survey in 1994 on major sources of income for the elderly, 31.8% had a comparatively stable source of income support from employment (17.1%) and pensions (14.7%). The remaining were supported mainly by their children and relatives (Beijing Review, 10-16 March 1997, p. 23). In cities, about 73.7% of the elderly received pensions. Among those receiving pensions, only 38.8% were female (China Research Center on Aging 1994, p. 10). Gender differences in the receipt of pensions and employment are significant. As such, women have to rely more than men on the family for economic support. In villages, 94.2% of the elderly had no pensions. For those over 80 years old, 86.2% had to rely solely on their families for economic support (State Statistical Bureau 1995, p. 66). Due to economic necessity, some 56% of the elderly aged

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between 60 and 64 are still working (retirement age in China is 60 for men and 55 for women) (Association of National Condition Research of China 1998, p. 364). For most peasants, the official retirement age has no real meaning at all. Another national survey in 1994 showed that 7.8% of the elderly aged over 60, or nine million people, had to depend on others to take care of them. As expected, only 3.4% of those aged between 60 and 69 were unable to take care of their daily needs themselves, while the percentage increased to 28.4% for those aged 80 or over (State Statistical Bureau 1995, p. 66). Another survey also showed that some 25% of the elderly population aged over 60 years old, or 25 to 27 million people, were in a poor health condition (Shi and Zhu 1998, p. 35). In Shanghai, a survey showed that 7% of the elderly population could not take care of their daily needs themselves, and 2.6% were bedridden (China Civil Affairs 7, 1997', p. 23). A survey by the China Research Center on Aging also found that some 93% to 98% of the elderly in fact could take care of themselves in terms of dressing, feeding, bathing and toileting. For those who could not take care of themselves, main care-givers were their spouses and adult children (China Research Center on Aging 1994, p. 15). Care provided by domestic helpers, volunteers and social services was minimal. In other words, the majority of older people in China are still living with and cared for by their children. According to a survey by the author in 1998 in Guangzhou city, the problem of elderly care and retirement was perceived as relatively less critical as other social issues such as unemployment, income disparity, drug abuse, poverty and housing provisions (Chow and Leung 2000).

I Family Support for the Elderly When the Communist Party took political power in China in 1949, an urgent task of the government was to redirect the primacy of loyalty of the individual to the state over loyalty to the family and kinship groups. During political movements, young people were encouraged to denounce their own parents as a way of demonstrating their new loyalties to the regime (Whyte 1997). Besides the nationalization of family businesses in cities and the collectivization of family farming in villages, the government introduced comprehensive social welfare coverage to urban employees. Under the centrally planned economy modelled upon the Soviet Union, each work unit functioned as a self-sufficient 'welfare society' within which an individual received employment and income protection, and enjoyed heavily subsidized benefits and services, such as housing, food, education, and social security benefits for sickness, maternity,

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work injury, invalidity and death, and old age (Walder 1986; Leung 1994; Leung and Nann 1995; Lu and Perry 1997; You 1998). As this welfare system was employment-centred, the role of the state at the macro level was to provide a stable order within which the work units could develop and fulfil the functions of political education, economic protection and welfare provision. For the few people outside a work unit, the state would provide a remedial and limited welfare programme for the 'three nos': those with no family, no source of income and no working ability. The domination of work unit-centred welfare rendered social services organized by non-governmental charities and government departments unnecessary. In rural areas, the communes developed the 'five guarantees' schemes, which guaranteed the childless elderly the provision of food, housing, clothing, medical care and burial expenses. The cooperative medical insurance also ensured that basic medical care for peasants was provided. In so doing, the government tried to ensure that the elderly could be financially independent of the family. The implementation of the Marriage Law in 1950 provided the freedom of marriages and divorces, and further undermined the traditional influence of elders over their family members' choices of careers, employment and marriages. Despite the government's intention to erode family functions, families in China, possibly with the exception of periods of radical political movements, remained stable. Restricted residential mobility was mainly due to the policy of lifelong employment and household registration. Coupled with the lack of social services, such as nurseries and housing, families were still a major source of child and elderly care. The problem of acute housing shortage meant that children, even after marriage, had to live with their parents. The replacement system, which enabled retiring parents to secure employment for their children in their work units, also reinforced family togetherness (Davis-Friedmann 1983; Whyte and Parish 1983; Unger 1993). In rural areas, despite collectivization in the form of communes, family cultivation of private plots and sideline production was possible most of the time. In addition, cadres would use administrative procedures to mediate marital disputes and enforce family obligations in providing care to children and elderly parents. Work units, with little need to consider economic efficiency, would support employees carrying out their care duties, providing, for example, family leave for employees to take care of their sick parents (Leung 1997). To many people, their parents were in fact a resource rather than a burden, providing assistance to them in terms of finance, domestic chores and child care. In living together, their relationship can be best described as mutual interdependence between the generations (Whyte 1997). A recent survey on filial obligations showed that a high percentage of both parents and grown-up children (95% to 96%) expressed the view that grown children should always be filial to their parents, no matter how their

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|

parents might have treated them when they were young. Over 60% of both parents and children expressed the view that the older generation should have the final say in important family decisions, even if the children were adults. Furthermore, about 82% to 92% of the respondents stressed the benefits of co-residence — enabling one generation to provide assistance and support for the other (Whyte 1997). Another survey carried out by the author in 1998 in Guangzhou city (Table 2) showed that there was still a strong sense of filial obligations among the Chinese. Influenced by traditional norms, a quarter of them preferred sons to be their supporters. Another one-third of them regarded sending their elderly parents to homes for the aged as a face-losing act. Nevertheless, some would consider homes for the aged as an alternative for care, and not necessarily because the children were unable to take care of their elderly parents. In the same survey, the most desirable living arrangement for the elderly was: homes for the aged, 16.8%; independent living, 6.5%; living together with children, supported by maids if necessary, 46.4%; and with children living nearby, 26.5%. In addition, only 5.7% of them expected that young people should rely on their children for support when they became old. They should rely more on pensions and savings (Chow and Leung 2000). For most families, therefore, powerful family obligations survived, but with a significant softening of the power of the senior generation (Jia 1988; Kwong and Cai 1992; Cai et al. 1994; Whyte 1995 and 1997). The majority of the elderly in China are still living with their children. According to the 1987 national survey, 82.2% of the elderly (aged over 60 years old) lived with their children. In 1997, a similar survey showed that Table 2

Public attitudes towards family responsibility (%)

Statement -

-

Grown-up children have responsibility to take care of their elderly parents. The caring responsibility should rest on the sons. Care of the elderly should start with one's own family. Elderly parents should live with their children. Elderly people live in homes for the aged because they have no children or their children are unable to take care of them. Government assistance to elderly people would erode family support responsibility. Children have no responsibility to support their parents. Children incapable of supporting their parents would lose face.

Agree

Disagree

Don't know

96.7

3.1

0.2

28.1

71.6

0.4

90.7

8.8

0.6

81.9

14.1

4.0

41.3

54.9

3.8

37.9

59.0

3.1

2.1

97.5

0.4

30.4

68.1

1.5

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the percentage had dropped to 76.7%. In addition, 11.7% lived with their spouses, 1.2% with relatives, and 0.3% with other people. More importantly, 11% of the elderly lived alone (State Statistical Bureau 1998, p. 235). A study on care-givers in the family in 1994 revealed several characteristics regarding family care in daily activities of the elderly. Firstly, women tended to be more capable of self-care than men, in both cities and villages, and spouses were the primary care-givers within the families. Urban male elderly were more dependent than urban female elderly on their spouses as caregivers, while wives often had to take care of their own needs. Secondly, elderly people in villages tended to rely more on their children than the elderly in cities did. Thirdly, there was a greater likelihood in cities than in villages for daughters to take care of the elderly, while daughters-in-law were common care-givers in villages. In all these cases, women were shown to be primary care-givers (China Research Center on Aging 1994; Leung 1997). On the whole, the majority of the elderly people still preferred to live with their married sons and receive financial assistance from them. Many of them would, at the same time, expect female members of the family to take care of their practical needs. On the other hand, some elderly people who are economically and physically more independent would prefer to live separately from their children (Hareven 1987; Sher 1984; Unger 1993). Also, living together does not necessarily mean that family obligations in providing care for the elderly are carried out automatically. Likewise, even though more elderly people prefer to live separately from their married children, it does not mean that they do not maintain close contact or that their relationships are deteriorating. Many of them do expect to live in the vicinity of their children. When their spouses pass away or when their health deteriorates, they resume living with their children. Some, in fact, choose to live in homes for the aged where their family members would visit them during weekends (China Daily, 22 February 2000). Demographic and social changes are affecting the capacity and willingness of the family to provide care for the elderly. In 1998, 76% of families were nuclear families (families with one to four persons); the average household size was 3.6 persons (3 persons in Shanghai and 5.3 persons in Tibet), down from 4.4 persons in 1982. Smaller family size means there are fewer potential care-givers. Furthermore, the number of divorces granted in 1998 reached 1.2 million, which was three times the number in 1981 (State Statistical Bureau 1998, pp. 109, 800). In addition, women, who are usually the primary caregivers in the family, have been encouraged to actively participate in the workforce. The 1990 census showed that 73% of the female population above 15 years old were economically active, compared with 70% in 1982. Some 45% of the workforce were women, and the rate of women's participation in

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the labour force reached almost 90% for those aged between 20 and 44, rather similar to that of their male counterparts (Cheng 1995, p. 72). Under the Household Registration system before 1978, it was difficult for people to move from place to place to seek jobs. With the relaxation of the restriction on peasants moving into cities and towns, and urban workers in the western and central provinces seeking jobs in coastal provinces, ruralurban and city-city migration has become more common. As more rural young people, particularly men, go to the cities for jobs, aged parents risk being 'abandoned'. Some migrants may still maintain responsibility for elderly care through sending home remittances; others just disappear (Leung 1997). Economic reforms have also led to the re-emergence of poverty and unemployment in China. In cities, conservative estimates put the number of people living in poverty at 12 million. While many of them became povertystricken because of unemployment, others fell into poverty because of low wages and pensions (Leung 1999). The official unemployment rate in 1998 was only 3.1%, representing 5.7 million people, but unofficial estimates put the figure at over 10% (State Statistical Bureau 1999, p. 133). To enhance the efficiency of state-owned enterprises, more workers are being laid off, and some 60% of the persons laid off are women (Leung 1996). In addition, the State Council has allowed persons within five years from their retirement age to have early retirement. From January to August 1998, some 35% of the two million newly retired workers were classified as early retirees (Song and Liu 1999). Rising female unemployment means more can stay at home and serve as care-givers. But, as more families are facing economic hardship and job insecurity, providing care to dependent members of the family can be a heavy burden to many families. Today's elderly people were born in or before the 1930s, and married in the 1950s, the period when there was a baby boom. Therefore, they have, on average, three to four children (3.5 in cities and 3.7 in villages) to share the responsibility of care (China Research Center on Aging 1994, p. 8). However, when their children, who married and gave birth to children in the mid1970s and the early 1980s, become elderly early in the twenty-first century, they will probably have only one child to look after them. This is one of the inevitable and daunting consequences of the one-child policy implemented in 1980. The phenomenon is described as '4-2-1': that is the responsibility of caring the two parents and the four grandparents will rest on the sole grown-up child. Linked to the economic reforms, the government became convinced that the family should have the primary responsibility for the care of the elderly. Article 183 of the Criminal Law (1979) makes it an offence, punishable by a sentence of not more than five years' criminal detention, for adult children to refuse to perform their proper duty to support an aged family member. The welfare role of adult children, including adopted children, to

L

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support their parents was reiterated in the revised Marriage Law (1980). Article 7 of the Inheritance Law (1985) provides for the disinheritance of an heir who had inter alia committed a serious act of abandonment or maltreatment of the deceased, and Article 13 also stipulates that heirs who had provided care and support for the deceased may be given larger shares of the estate, whereas those who had the ability and were in a position to maintain the deceased but failed to fulfil their duties shall be given no share or a smaller share of the estate (Palmer 1995). In 1996, the government enacted the Law on the Protection of the Rights and Interests of the Elderly. Chapter 2 of the Law (Maintenance and Support by Families) reiterated the responsibility of adult children to support their parents as well as parents-in-law. They are expected to take care of the financial, medical, housing and social needs of the elderly. Article 17 states: Supporters may conclude an agreement between themselves on their duty to provide for the elderly, subject to approval by the latter. Neighborhood committees, villagers' committees or the organizations of the supporters may supervise the fulfillment of the agreement. In addition, Chapter 5 (Legal Responsibility), Article 45 states: When the elderly have disputes with their family members over their support, or over housing or property, they may ask the organizations where their family members are employed, the neighborhood committees or the villagers' committee to mediate. They may also bring a lawsuit directly to the People's Court. If the family members are found to be in the wrong through mediation of the disputes mentioned in the preceding paragraph, they shall be educated through criticism and ordered to correct their mistakes (China National Commission on Aging 1996). To reduce the state responsibility in social welfare, the government introduced legislation prescribing family obligations for the care of the elderly. The enforcement of these family obligations rests on the mechanism of the mediation service operated at the neighbourhood level in the cities and villages, and work units. In 1998, there were almost one million people's mediation committees, with 9.2 million mediators, handling a total of 5.3 million cases, declining from 7.3 million cases in 1989 (State Statistical Bureau 1999, p. 745). On average, each committee had only 5.4 cases, and each mediator worked on 0.6 case a year. This means that these committees function only informally, and most of these mediators work on a part-time basis. About 39.1% of these cases involved family issues. The number of cases involving the care of the elderly in 1998 reached 388 352, representing 7.4%

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of the total, as compared with 409 235 cases or 5.6% of the total in 1989 (State Statistical Bureau 1990, p. 814). On the whole, there is an increasing tendency for people to resolve their social conflicts through legal means rather than through informal mediation (Leung 2000).

Q Welfare Services for the Elderly Traditionally, work units shouldered the responsibility of providing social care to their employees. They operated a wide variety of social services for their employees, such as nurseries, schools, homes for the aged, hospitals, dining halls, cultural centres and sport stadiums. In particular, they provided social care to the elderly, the disabled and the poor. As such, the function of the government had been remedial, being responsible for taking care of those elderly without work units and family support (Ikels 1992). Under the marketoriented economic reforms, work unit commitments towards welfare have been rapidly eroding, and there is a rising need for the development of a non-employment-based welfare system. Currently, social welfare services consist mainly of welfare institutions. Originally, they provided free-of-charge residential care for the 'three nos'. These included the mentally ill or the mentally disabled, orphans and the childless elderly. Since 1983, these institutions have also been open to people who can afford to pay market fees. In 1999, they provided a total of 996 401 residential places, representing a 40% increase over the places available in 1989. Given the rapidly ageing population, the increase is quite moderate. Some 90% of these places, or 900 000 places, were for the elderly. In addition, some 85% of these places were provided by the neighbourhood governments (in China, township governments in the rural areas and street offices, being an extension of the district people's government, in the urban areas are both regarded as semi-governmental organizations), and the rest were provided by the Civil Affairs Department (Ministry of Civil Affairs, www.mca.gov.cn', China Civil Affairs 1, 2000, p. 44). With an occupancy rate of only 77.5%, these homes were underutilized. This phenomenon reflects the traditional reluctance of the elderly in China to live in institutions. In addition, the low quality of care provided by these homes was another factor leading to their underutilization (China Civil Affairs 3, 2000, p. 26). With an elderly population (aged 60 or over) of 120 million in 1997, the institutionalization rate of elderly people was extremely low, representing about 0.6% of the total elderly population. The government has pledged to increase the current provision of homes for the aged to 10 beds per 1000 elderly persons living in cities, representing an institutionalization rate of 1% (China Civil Affairs 4, 2000, p. 29).

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In 1998, Guangzhou city had an elderly population (aged over 60) of 800 000. There were 175 homes for the aged, providing 8578 places. The city and district governments operated seven homes, providing 37.5% of the places. On average, there were 269 residents in each home. The rest were provided by street offices (6.3%), township governments (41.7%), and the private for-profit sector (18.2%) (China Social Work 4, 1998, p. 11). This is the only city in China where a significant proportion of homes are operated by the private for-profit sector. However, homes for the aged are operated by for-profit organizations are beginning to be found in some large cities. On average, those homes operated by non-governmental organizations are much smaller, with only 11.3 residents in those operated by street offices, 39.2 residents in those operated by township governments, and 118 residents in those operated by the for-profit sector. Government welfare services catered primarily for the 'three nos' elderly who were taken care of in homes for the aged operated by either the government or street offices. Among the 700 'three nos' elderly persons living in homes for the aged in Guangzhou, 130 lived in homes operated by street offices. Some 80% of the places in homes for the aged operated by street offices were charging fees at market rates (China Social Work 4, 1998, p. 11). According to a survey in Beijing, homes for the aged provided a total of 10 946 beds, but only 63.9% of these beds were in use, accommodating 7000 people. The number of elderly people in institutional care accounted for 0.42% of the elderly population (1.7 million people) (Beijing Review, 8-14 February 1999, p. 21). In Shanghai, the rate was only 0.3% (China Civil Affairs 7, 1997, p. 23). According to the estimates made by the Ministry of Civil Affairs, the proportion of elderly people requiring residential care had reached 11%, or 14 million people (China Civil Affairs 3, 2000, p. 26). In a survey on the need for residential care in Guangzhou, some 90% of the elderly respondents perceived no need for themselves to live in the homes for the aged. The major reason given for not living in homes for the aged was that they were satisfied with the care provided by their children (60%). For those who showed a desire to live in homes for the aged (10%), reasons given included the preference for collective living and better living environment of residential care. The same survey on residents living in homes for the aged showed that those who lived in these homes tended to be older and had difficulties in self-care. More importantly, the survey found that some 70% of elderly people, with their own incomes, could not afford to pay for the fees charged by the homes. The average monthly fees for these homes are close to the average wages in Guangzhou. Therefore, high charges are a major deterring factor for the elderly regarding admission to institutional care (Guangzhou Sociology Society and Guangzhou Civil Affairs Bureau 1999). Besides residential care, other potential forms of formal care services for the frail elderly, such as

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nursing homes, care and attention homes, home help and day care centres, are largely non-existent. As a new source of welfare, community-based welfare services for the vulnerable population in the cities have been enthusiastically promoted by the government in the 1990s. In China, an urban neighbourhood of about 50 000 residents is administered by a street office. The street office is responsible for the provision of a variety of community services, including both public and social services. Public services for general residents include fire and crime patrols, environmental management, sanitation improvement, marriage registration, household registration, family planning, family and neighbourhood mediation, household repairs, bicycle parking, and recreational and cultural activities. Welfare services include supervision of delinquents, nurseries, recreational and cultural activities, job placements for the unemployed, homes for the aged, day care centres for the disabled and the elderly, and shelter workshops for the disabled and the mentally ill. Recent emphasis has been placed on the development of volunteer services. Community services are regarded as an emergent and vital source of personal social services, particularly for the vulnerable population such as the frail and single elderly, orphans, the physically and mentally disabled, the chronically ill, former criminals, ex-servicemen, the unemployed, low-income families, and youth at risk. Under the supervision of each street office are a number of residents' committees. Each committee, administering an average of 500 to 700 households, is responsible to assist the street office in implementing government policies and operating community service programmes. Committee members, including the chairperson and vice-chairperson, are elected by local residents. As residents' committees are closely supervised by street offices, they are in effect semi-governmental organizations. In 1996, there was a total of 3400 community service centres at the street office level, 440 000 community service stations at the residents' committee level, 6300 homes for the aged, 160 000 service units for the aged (day care centres, marriage matching service and activity centres), 140 000 service units for exservicemen, and 37 000 service units for the disabled. To operate these community service programmes, some 580 000 full-time cadres and 600 000 part-time cadres as well as 5.5 million volunteers were involved (Shi and Zhu 1998, p. 48). W i t h limited financial s u p p o r t from city g o v e r n m e n t s , each neighbourhood has to rely on its own efforts to develop public and welfare services. In the case of Guangzhou city, city government allocation for community services accounts for only 30% of the total expenses. Profits derived from commercial enterprises (factories, restaurants and guest-houses) and fees charged for public and welfare services managed by street offices are

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used to finance overall operations. The principle is well described by the Chinese saying: 'to use profit-making services to support services that are free of charge'. Another major source of funds to finance community services is allocations from city welfare lottery funds. Since the introduction of welfare lotteries in 1987, the government has raised a total of 9.5 billion yuan (US$1 = 8 3 yuan) for welfare purposes (Ye 2000). Furthermore, community services can receive preferential treatment from the city government in terms of taxation and credits. As such, it is exceedingly difficult to separate the welfare and profit-making commercial functions of community services. Because the provision of welfare services is largely dependent on the ability of the street office to develop a profitable local economy, the quality and quantity of welfare services provided can vary substantially from n e i g h b o u r h o o d to neighbourhood. Generally, street offices in commercial districts and city centres tend to have much higher revenues. In some street offices, charity funds for welfare are established receiving revenue from public donations, profits from welfare enterprises and street office allocations. In general, community services are both informal and loosely structured with the quality of services not standardized. The quality of community services is also plagued by the poor staff quality of neighbourhood cadres. Particularly in residents' committees, the majority of the cadres are retirees and redundant workers laid off from ailing state enterprises (Leung 2001). The following are some of the typical services provided by the street office to elderly people.

Homes for the aged Homes for the aged operated by street offices can provide care to the elderly in need. These homes are usually small in size, with some having only several residents. Only those who are defined as being in the 'three nos' category are admitted to these homes free of charge. According to government plans, street offices with a population of less than 60 000 residents should have a home for the aged providing accommodation for 30 elderly people (China Civil Affairs 4, 2000, p. 30).

Social assistance Since 1993, the government has gradually introduced in cities the communitybased social assistance programme. According to the regulations, assistance may be provided only to those with urban household registration status, which would exclude those rural migrants living in cities. For those who still have

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connections with their work units, the work units are responsible for providing the assistance. The assistance level is calculated according to the minimum level of living standard, often based on expenditure surveys of low-income households and the financial capacity of the local government. Based on a minimum level, the assistance merely covers subsistence food and clothing costs, excluding rent, medical care and school fees. The city and district governments finance the programme, but the administration is communitybased. Street office cadres are responsible for carrying out investigations, delivering the benefits and reviewing the situation of the recipients periodically. Based on the principle of deterrence, the provision is rendered so unpleasant and harsh as to deter all save the most desperate. To facilitate 'public monitoring' of the situation of the recipients, the names of the recipients and the a m o u n t of benefits received are publicized on neighbourhood bulletin boards (Leung 1999). A breakdown of the background of recipients in Wuhan city in 1998 showed that only 0.15% of the city population received assistance from the programme, and some 71% of them were unemployed while the rest were mainly childless elderly and the disabled (Yang and Zhang 1999). Among the 36 cases receiving assistance from a Guangzhou street office, 14 cases were in the 'three nos' category, with an average age of 76 (Leung 1999). In 1999, all the 688 cities in China had implemented the programme, and 1.84 million people received assistance from it (Ministry of Civil Affairs 1999, p. 42).

Care groups For those 'three nos' elderly living alone and not in institutional care, the street office can make arrangements to establish a care group for each elderly person in need. The care group comprises cadres and volunteers. The group provides the basic need of home help, meal delivery, escort to see doctors, laundry and house-cleaning.

Family mediation According to the Law on Protection of the Rights and Interests of the Elderly, neighbourhood cadres are responsible to ensure that adult children carry out their filial obligations to provide care for their elderly parents. In practice, the mediation service has to be accepted by both parties. Education and persuasion is the basic approach, and no coercive sanction should be employed. The neighbourhood mediator should be impartial and neutral. The outcome of mediation carries no authority to force acceptance. Any person

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who does not accept the agreement can take his/her case to court for litigation (Leung 2000). A study on the needs of the elderly as regards community services in Tianjin city showed that 94% of the respondents claimed to depend on their family members for care in the event of sickness and poor health. Some 2% chose domestic helpers as care-givers. About 10% preferred the street office to take care of them (respondents were allowed to indicate two choices). Some 42% of the respondents had received care from community services and neighbours. Assistance provided included social conversation, visits during festivals, medical consultation and advice, laundry, contacting relatives, care during sickness, meal preparation, and escort service to see doctors (Tianjin Elderly Livelihood Survey Group 1998). In the study by the author in Guangzhou city, most of the elderly had used some community services. Some 42% of the respondents perceived that community services for the elderly were essential (Chow and Leung 2000). In short, community services are becoming a vital source of social support for the care of elderly people.

D Conclusion Since social welfare services for the aged in China are largely underdeveloped, the Chinese government has had to resort to the use of legislation to enforce family support. To be sure, family obligations cannot be enforced solely through the rule of law. Filial obligation values are still intact, and there is no evidence that children are becoming less willing to provide care for their elderly parents. Yet, with smaller families, more working wives and growing divorce rates, the pool of potential care-givers will shrink, affecting the capacity of the family to provide care and support to dependent elderly family members. In fact, family care has been taken for granted by Chinese policy-makers as natural, and there are very few studies in China on understanding the changing nature of family care. The most crucial question is how informal family care can be maximized. While most of the existing welfare services are targeting at the 'three nos', there is an urgent need to develop formal social services supporting the family, rather than simply relying on coercive legal action and moral appeals to enforce the responsibility of family care. With the longterm care needs of the elderly escalating, a staggering number of those elderly people, even still living with their family members, will be at risk. In particular, there is a resounding reluctance on the part of the Chinese elderly to enter into institutional care. They have a strong desire to live with their children and in the community. That is why homes for the aged in China are largely underutilized. Still, policy-makers in China are pre-occupied

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with the notion that building more homes for the aged is the solution to the problem of elderly care. Only recently in a policy document issued by the State Council entitled 'Concerning the Views on the Speeding Up of the Socialization of Social Welfare' in February 2000 were changes evident, it recommending that the basis of care should be in home services (China Civil Affairs 4, 2000, p. 30). Community-based and in-home care services supporting the elderly to continue to live within the family have become essential. Currently, in-home care services for the elderly, such as home help, community nursing, meals on wheels and day care centres, are still underdeveloped. There is an urgent need to institutionalize these communitybased services which are largely informally organized and loosely structured. In short, community service and family support should be complementary rather than mutually exclusive. There is a foremost need for a coherent and integrative policy on family care and community-based services to be developed to maintain the elderly in their own homes and neighbourhood for as long as possible.

I References Asian Wall Street Journal 17 April 2000. Association of National Condition Research of China. 1998. Report of China's national conditions 1998. Beijing: China Statistical Publishing House. Beijing Review. 10-16 March 1997, 8-14 February 1999. Cai, W.M., Y.H. Song, X.Y. Luo and L.W.Jiang. 1994. China. In International handbook on services for the elderly, ed. Kosberg, J. 87-190. Westport, CT: Greenwood Press. Chen, S.Y. 1996. Social policy of the economic state and community care in Chinese culture. Aldershot: Avebury. Cheng, X.Y. 1995. Women's population issues and development in China. Beijing: Beijing University Press. China Civil Affairs. 7, 1997; 1, 2000; 3, 2000; 4, 2000. China Daily. 22 February 2000. China National Commission on Aging. 1996. Law of the People's Republic of China on protection of the rights and interests of the elderly. Beijing: Hua Ling Press. China Research Center on Aging. 1994. A data compilation of the survey on China's support systems for the elderly. Beijing: Hua Ling Press. China Social Work. 4, 1998. Chow, N. 1991. Does filial piety exist under Chinese communism? Journal of Aging and Social Policy 3 (1/2): 209-25. and J. Leung. 2000. Report on welfare reforms in China: The case of Guangzhou City. Hong Kong: Department of Social Work and Social Administration, the University of Hong Kong. Davis-Friedmann, D. 1983. Long lives: Chinese elderly and the communist revolution. Cambridge: Harvard University Press.

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Guangzhou Sociology Society and Guangzhou Civil Affairs Bureau. 1999. The study on the elderly care in Guangzhou City. (Monograph copy.) Hareven, T. 1987. Reflections on family research in the PRC. Social Research 54: 6 6 3 89. Ikels, C. 1992. Family caregiving and the elderly in China. In Aging and caregiving: Theory and practice, eds. Biegel, D. and A. Blum. 270-84. Newbury Park, CA: Sage Publications. jia, A. 1988. New experiments with elderly care in rural China. Journal of CrossCultural Gerontology 3 (2): 139-48. Kwong, P. and G.X. Cai. 1992. Ageing in China: Trends, problems, and strategies. In Aging in East and South-east Asia, ed. Phillips, D. 105-27. London: Edward Arnold. Leung, J. 1994. Dismantling the iron rice bowl: Welfare reforms in the PRC. Journal of Social Policy 23 (3): 341-61. . 1996. The emergence of unemployment insurance in China: Problems and issues. Canadian Review of Social Policy 38: 5-17. . 1997. Family support for the elderly in China: Issues and challenges. Journal of Aging and Social Policy 9 (3): 7-101. . 1999. The emergence of a community-based social assistance program in urban China. Social Policy and Administration 33 (1): 39-54. . 2000. Enforcing family care obligations for the elderly in China through mediation. Asia Pacific Journal of Social Work. (In press.) . 2001. Community-based service for the frail elderly in China. International Social Work. (In press.) and R. Nann. 1995. Authority and benevolence: Social welfare in China. New York: St. Martins Press. Lu, X.B. and E. Perry, eds. 1997. Danwei: The changing Chinese workplace in historical and comparative perspective. Armonk, N.Y.: M.E. Sharpe. Ministry of Civil Affairs. 1999. China civil affairs yearbook 1999. Beijing: Ministry of Civil Affairs. Palmer, M. 1995. The re-emergence of family laws in post-Mao China: Marriage, divorce, and reproduction. China Quarterly 141: 110-34. Sher, A.E. 1984. Aging in post-Mao China. Boulder, CO: Westview Press. Shi, Z.X. and Y. Zhu. 1998. China social welfare and social progress report (1998). Beijing: Social Science Publishers. Song, Q.Z. and F. Liu. 1999. Early retirement and its impact on retirement insurance funds. China Social Security 6: 18-9. State Statistical Bureau. 1995. China statistical yearbook 1995. Beijing: State Statistics Publishers. . 1996. China statistical yearbook 1996. Beijing: State Statistics Publishers. . 1998. China development report 1998. Beijing: China Statistical Publishers. . 1999. China statistical yearbook 1999. Beijing: China Statistical Publishers. Tian, X.Y. 1990. China's elderly population and society. Beijing: China Economic Publishers. Tianjin Elderly Livelihood Survey Group. 1998. The dependency of the livelihood of urban elderly on family and community. China Social Work 3: 27-9. Unger, J. 1993. Urban families in the eighties. In Chinese families in the post-Mao era, eds. Davis, D. and S. Harrell. 25-49. Berkeley: University of California Press.

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Walder, A. 1986. Communist Neo-traditionalism: Work and authority in China's industry. Berkeley: University of California. White, G. 1998. Social security reforms in China: Towards an East Asian model. In The East Asian welfare model: Welfare orientalism and the state, eds. Goodman, R., G. White and HJ. Kwon. 175-97. London: Routledge. Whyte, M. 1995. The social roots of China's economic development. China Quarterly 144: 999-1019. . 1997. The fate of filial obligations in China. The China Journal 38 (7): 1-31. and W. Parish. 1983. Urban life in contemporary China. Chicago: University of Chicago Press. World Bank. 1998. World development report. New York: Oxford University Press. Yang, Z.C. and Q.L. Zhang. 1999. The analysis of the study on the implementation of the minimum living standard guarantee system in Wuhan. Economic Forum 4: 99-103. Ye, L. 2000. Lottery market booms in China. Beijing Review (March): 26-7. You, J. 1998. China's enterprise reform: Changing state/society relations after Mao. London: Routledge. Yu, XJ. 1995. The study on the economics of the aging population in China. Beijing: China Population Publishers.

13 The Role of Social Support in the Relationship between Physical Health Strain and Depression of Elderly Chinese Xingming Song and Iris Chi

The examinations of social support and of life stress are two leading approaches to contemporary social studies of depression. During the past several decades, considerable research effort has been devoted to investigating the impact of life stress on mental health. There is ample evidence which shows that stressors may play a causal role in depression. Yet the evidence is also clear in suggesting that the majority of people who are exposed to stressors do not develop significant depressive disorders. For this reason, research interest has shifted to factors like social support that may modify the impact of life stress. Thus, research of social support has proliferated, and many investigations have focussed specifically on support for elderly people. In this chapter, life stress refers to physical health problems — chronic diseases and medical symptoms. For aged persons, depression is often correlated with the decline in physical health that occurs frequently among older age groups (Blazer 1983; Himmelfarb and Murrell 1983). Using data gathered from an elderly Chinese population, this chapter examines the relationships among social support, physical health strain and depression, and it focusses on the potential role of social support in the relationship between physical health strain and depression.

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1 The Conceptual Models and Research Hypotheses Conceptually, social support may affect depression in two ways. One is the additive model, in which social support has a direct and positive influence on mental health (Williams, Ware and Donald 1981). It suggests that strong social support is beneficial to individuals independent of their exposure to stress. That is, the stronger the social support one can amass, the less likely he or she would experience depression. Furthermore, this negative relationship should remain even when individuals are confronted with significant life stress. The other way that social support can affect depression is the buffering model, which holds that social support mediates possible negative effects of life stress on mental health (Henderson 1992). This model, attracting by far the most research efforts in the social support area, represents a dominating concern of research about the impact of social support on mood disorder. It argues that life stress is potentially harmful, and if it is not buffered, it can lead to a deterioration of the individual's mental health. Based on these two models, we intend to propose four research hypotheses. 1. Physical health strain is positively related to depression. 2. Social support is negatively related to depression. 3. If an individual has physical health problems, social support will have a buffering effect on depression. That is, among people with physical health problems, those with low social support are more likely to develop depression. 4. The more physical health problems an older person has, the bigger the protective effect of social support.

I Source of Data and Measures A household survey using structured questionnaires was conducted in the Chinese cities of Beijing, Shanghai, Suzhou and Guangzhou during 1995-96 (Chi 1998). About 500 elderly aged 60 or above were randomly drawn as the subjects for each city. A total of 2002 completed interviews were available for analysis. Some 57.5% of the respondents were women and 42.5% were men. The mean age of the respondents was 69.5 years. Although a substantial and widely varying amount of data was collected in the survey, the present discussion is confined to those measurements which are related to the topic of social support, physical health strain and depression.

PHYSICAL HEALTH STRAIN AND DEPRESSION OF ELDERLY CHINESE

Social support Both objective and subjective types of social support are examined in this chapter. Objective social support was measured by the social network approach, using the Lubben Social Network Scale (LSNS). The LSNS consists of ten items addressing the extent of an individual's social connections with family and friends (Lubben 1988). Three of the items ask about the frequency of contact with family members, the number of family members with whom contact is maintained, and the number of family members to whom the elderly feel close. Three similar items provide equivalent information about friends. The four other items ask about confidants and interdependent support relationships. The LSNS score is an equally weighted sum of ten items ranging in value from 0 to 50. Higher scores indicate larger social networks. However, having a large social network does not necessarily mean that one can obtain social support from it. Furthermore, according to the stressorsupport specificity model (Cohen and Mckay 1984), the resource of support must correspond to the coping requirements elicited by a particular stressor or stress experiences in order to act as an effective buffer to life stress. Thus, subjective social support was measured by asking elderly respondents to rate the reliability of nine groups of persons (indicated by relations with elderly people such as their sons, daughters, sons-in-law, daughters-in-law, grandchildren, extended relatives and friends) on whom they could count for emotional, care and financial needs. Three separate indices of social support, that is, an index of emotional support (IES), an index of care support (1CS) and an index of financial support (IFS), were developed. IES is expressed by the number of persons who are willing to listen to the respondent's worries or problems. ICS and IFS are respectively expressed by the number of persons who can be relied upon to provide care for the respondent in times of illness and the number of persons who can be relied upon to provide financial support to the respondent in times of need.

Physical health problems Physical health problems were measured by two items: chronic diseases and chronic medical symptoms. Sixteen chronic diseases and 11 medical symptoms were listed in the questionnaire. The respondents were asked directly if they had any of the 16 chronic diseases in the past year and if they frequently had any one of the 11 medical symptoms in the past half-year. The chronic diseases selected for the study were arthritis, hypertension, heart disease, cerebrovascular disease, cancer, diabetes, chronic lung disease, chronic liver disease and chronic kidney disease. Seven medical symptoms were selected

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for the study dizziness, stiffness or swelling of joints, frequent headaches, heart pains or tightness m the chest, shortness of breath, frequent stomachaches and constipation The remaining four symptoms (e g poor appetite, tiredness) were excluded because they are depressive symptoms and could have confounded the results The variables — the number of chronic diseases and the number of medical symptoms the respondents had experienced — were based on disease-and-symptom records m the interview

Depression Depression was assessed by means of the Center for Epidemiological Studies Depressed Mood Scale (CES-D) (Radloff 1977) The CES-D scale consists of 20 items ascertaining how the respondent felt or behaved during the previous week It was developed for use in studies of epidemiology of depressive symptomatology in a general population The CES-D has frequently been used in studies of elderly populations and is judged among the best screening instruments for symptoms of depressed mood m older adults (Blazer 1983, Himmelfarb and Murrell 1983, Radloff and Ten 1986) It has high levels of reliability and validity m detecting both clinical (by the criteria of Diagnostic and Statistical Manual of Mental Disorders, DSM-III) and non-clmical depressive symptoms in older adults (Myers and Weissman 1980, Berkman et al 1986, Oxman et al 1992, Brown, Milburn and Gary 1992) The CES-D score is a sum of 20 items ranging in value from 0 to 60 A higher score denotes greater psychological distress A score of 16 or higher on the CES-D was used to classify persons as having depression The cut-off score of 16 has been validated with DSM-III criteria for clinical depression (Radloff 1977) and has been used with other populations (Myers and Weissman 1980, Brown, Milburn and Gary 1992)

i Results Prevalence of chronic diseases and medical symptoms Table 1 describes the prevalence of chronic diseases and medical symptoms among the respondents Among the nine diseases named in the table, arthritis was the most prevalent condition (23 6%), followed closely by hypertension (21 5%), with heart disease ranking third and chronic lung disease fourth About 55% of the elderly respondents had at least one of the designated diseases, and about 25% had at least two of the diseases Except constipation,

PHYSICAL HEALTH STRAIN AND DEPRESSION OF ELDERL Y CHINESE

the prevalence rates for all other six medical symptoms were over 10%, ranging from 12% to 30%. About 60% of the respondents had at least one symptom, and about 32% had at least two symptoms. Table 1 Prevalence of chronic diseases and medical symptoms Chronic diseases

%

Medical symptoms

%

Arthritis Hypertension Heart disease Chronic lung disease Cerebrovascular disease Diabetes Chronic kidney disease Chronic liver disease Cancer

23.6 21.5 15.5 8.3 2.6 2.6 1.4 1.2 0.8

Dizziness Stiffness/swelling of joints Frequent headaches Heart pains/tightness in the chest Shortness of breath Frequent stomach-aches Constipation

30.1 25.9 16.7 15.5 14.2 12.3 8.3

Number of medical symptoms 0 1 2 3 4 5+

40.2 28.2 14.9 8.3 4.3 4.1

Number of chronic diseases 0 1 2 3 4

5+

44.6 30.6 16.1 6.1 1.6 1.0

Prevalence of depression and its social and demographic differences Table 2 presents the prevalence of depression among the subgroups with different social and demographic characteristics. The prevalence of depression for the total sample was 18.2%. Table 2 also shows that there were significant differences in the prevalence of depression according to sex, marital status and economic conditions. The prevalence was higher for women than for men, and 50% of the separated or divorced respondents had symptoms of depression, a percentage much higher than that for respondents with other marital status. The prevalence rose significantly with increasing economic conditions, reaching 30.6% for respondents who said their financial resources were 'enough', which was about three times as high as that for the category 'not enough'. However, the relationships between depression and age and between depression and education were not significant.

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Table 2

Prevalence of depression by social and demographic characteristics

Characteristics

%

Total sample

182

Age <75 ^75 Sex Male Female Marital status Married Widowed Separated/divorced Never married *p < 01

%

Characteristics

Education (years) 0 1-3 4-6 ^7 Money to cover daily expenses Enough Just enough Not enough

173 21 2

* 154 20 2

* 161 21 0 50 0 23 3

197 137 152 152

** 30 6 165 108

**p < 001

Relationships among chronic diseases, medical symptoms and depression There were very strong relationships among chronic diseases, medical symptoms and depression. The prevalence of depression was 22.8% for those elderly who suffered from chronic diseases, about 1.8 times of that for those elderly who did not suffer from any of the diseases listed in Table 1. The difference in prevalence was more evident between the respondents who had and those who did not have chronic medical symptoms. Specifically, it was 23.9% for those who experienced chronic medical symptoms, about 2.5 times of that for those who did not suffer from any of the symptoms listed in Table 1. Table 3 shows that as the number of chronic diseases increases, the prevalence rises rapidly. The highest prevalence was about 58%, about 45 percentage points higher than the lowest prevalence. The same pattern can be found in the relationship between chronic medical symptoms and depression.

Table 3

Prevalence of depression by the number of chronic diseases and by the number of medical symptoms

No of chronic diseases 0 1 2 3 4 5+ *p < 001

% 124 196 23 3 29 2 35 5 57 9

No of medical symptoms 0 1 2 3 4 5+

% 95 167 25 2 28 4 36 6 47 5

PHYSICAL HEALTH STRAIN AND DEPRESSION OF ELDERLY CHINESE

L

The protective effect of social support against developing depression Tables 4 and 5 show the prevalence of depression by physical health strain and social support. In Table 4, the elderly respondents are divided by whether or not they had chronic diseases and in Table 5, by whether or not they had chronic medical symptoms. The four social support indices (LNSN, IES, ICS and IFS) are respectively split at the midpoint of the range of observed values of each index. In these two tables, PD denotes the prevalence difference between the elderly respondents who had and those who did not have physical health problems at the same level of social support. AP denotes the attributable proportion of the interaction of social support and physical health problems to depression prevalence, that is, the percentage of the effect resulting from the interaction among total effect of low social support and physical health problems. Here, the effect resulting from the interaction can be calculated by subtracting the PD for the low social support group from the PD for the high social support group; the total effect can be calculated by subtracting the depression prevalence for those elderly with low social support and physical health problems from that for those elderly with high social support and no physical health problems. The results show that there is an interactive effect of social support and physical health problems on depression. Tables 4 and 5 make it clear that, for each of the eight cases shown in the two tables, those elderly

Table 4

Prevalence of depression by life stress (chronic diseases) and social support

Social networks and types of social support

Chronic diseases Yes (%) No(%)

Social networks (LSNS Score) High*** Low*** Interaction Emotional support High Low*** Interaction Care support High*** Low*** Interaction Financial support High Low*** Interaction *p< 05

**p < .01

***p< .001

PD

(%)

# #-*

##

18.1 33.9

10.3 18.0

#*#

-

7.8 15.9 n.s.

13.7 26.1

10.6 13.1

3.1 13.0

#**

-

#*

** #

19.2 29.0

9.0 18.3

**

-

10.2 10.7 n.s.

15.2 24.9

11.8 12.6

3.4 12.3

-

-

*

195

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XINGMING SONG AND IRIS CHI

Table 5

Prevalence of depression by life stress (medical symptoms) and social support Medical symptoms No(%) Yes (%)

Social networks and types of social support

**p<.01

AP

(%)

#* *

Social networks (LSNS Score) High*** Low*** Interaction Emotional support High* Low*** Interaction Care support High*** Low*** Interaction Financial support High*** Low** Interaction *p < .05

PD

(%)

18.9 36.8

8.2 11.6

10.7 25.2

**#

-

#*

14.7 27.3

8.8 9.8

5.9 17.5

***

*

-*#

62.7

19.2 31.8

7.7 12.7

*

-

11.5 19.1 n.s.

31.5

17.9 25.5

5.9 10.3

-

-

12.0 15.2 n.s.

16.3

50.7

***p<.001

40 35 . (a) Interaction of emotional support and chronic diseases 5 30 c 25 o 2

1 °

^ > ^

low support

10

g30

o 25 8 20

high support

c 25 3 20

I 15 8 10

•

CD

Q

high support

10 5

No-disease group

i30

low support

Q. 15

•"""""

5

40 35

(b) Interaction of financial support and chronic diseases

CD

Q. 15 Q

35

0 No-disease group

Disease group

(c) Interaction of emotional support and medical symptoms

low support •

40 35 - (d) Interaction of social >• networks and / 30 medical y low support symptoms y o 25

i

§20 8 15

high support

CD

high support

5 0 No-symptom group Symptom group

Disease group

Q

• ***

No-symptom group Symptom group

Figure 1 Interaction of social support and physical health problems on depression

PHYSICAL HEALTH STRAIN AND DEPRESSION OF ELDERLY CHINESE

who had chronic diseases or medical symptoms and low social support were more likely to be depressed than those in any of the other three cells. The interaction can be tested by the contrast between the PD for the high social support group and the PD for the low social support group. If the PDs are significantly different between these two groups, we can say that the interaction exists. In all cases, the PD was higher for the high social support group than for the low social support group, and significant interaction of social support and physical health problems can be found in the four cases. For example, in Table 4, the PD was 13.0% for the low emotional support group, but significantly reduced to 3.1% for the high emotional support group; similarly, in Table 5, the PD was 17.5% for the low emotional support group but significantly reduced to 5.9% for the high emotional support group. Thus, to some extent, the interaction was confirmed, indicating that social support can buffer the negative effect of physical health on depression. The results also show that among the three types of social support listed, emotional support may be more important than care and financial support in modifying the effect of physical health problems. No matter whether chronic diseases or chronic medical symptoms were taken as an indicator of physical health problems, higher emotional support had a significant protective effect against depressive symptoms, with APs over 60%. The protective effect of financial support on the relationship between medical symptoms and depression was not significant, but higher financial support shows a protective effect when chronic diseases are present. However, no significant protective effect of care support was found in this study. If we carefully look at the results presented in Tables 4 and 5, another interesting pattern can be found. When chronic diseases or medical symptoms were absent, social support had little direct and positive effect on depression, and the significant prevalence difference between the high and low social support groups appeared in only three of the eight cases. However, when chronic diseases or medical symptoms were present, the direct and positive effect of social support increased notably, and the significant prevalence difference between the high and low social support groups appeared in all eight cases. Thus, social support had a much stronger effect on depression for the disease and symptom groups as compared to the no-disease and nosymptom groups. Furthermore, Figure 2 shows that the more chronic diseases or medical symptoms an elderly person had, the stronger the protective effect of social support on depression (taking only one as an example).

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XING MING SONG AND IRIS CHI

20 r

^

16 "

8

0

_

•

^

g 12 " °~

_

^ s ^ ^

<

T_

1

0

1

.

2

.

1

3

4 5 Number of medical symptoms

Figure 2 The relationship between social support, number of medical symptoms, and depression

D Summary This study examines the potential role of social support in relation to physical health problems and subsequent depression. The major findings are as follows: 1. The expected relationship between physical health problems and depression was observed. The depression prevalence was significantly higher in those elderly people with physical health problems than in those without. As the number of chronic diseases or the number of chronic medical symptoms increased, the depression prevalence rose rapidly. 2. Social support had a buffering effect on depression. The probability of those elderly with physical health problem developing depression was higher when social support was conspicuously deficient. Emotional support may be more important in modifying the effect of physical health problems on depression than other types of social support. 3. There was an inverse relationship between social support and depression. The relationship was very weak when physical health problems were absent, but it became stronger when physical health problems were present. Furthermore, the results showed that the more chronic diseases or medical symptoms an elderly person had, the stronger the protective effect of social support on depression. These results may support the social support mobilization perspective which assumes that social support is stress-responsive and that if an individual who experiences a stressful life event is able to mobilize a strong social support system, then the detrimental effects of life stress can be reduced.

PHYSICAL HEALTH STRAIN AND DEPRESSION OF ELDERLY CHINESE

D References Berkman, L.F., C.S. Berkman, S. Kasl et al. 1986. Depressive symptoms in relation to physical health and functioning in the elderly. American Journal of Epidemiology 124: 372-88. Blazer, D. 1983. The epidemiology of depression in later life. In Depression and Aging: Causes, Care, and Consequences, eds. Breslau, L. and M. Haug. 30-50. Berlin: Springer-Verlag. Brown, D.R., N.G. Milburn and L.E. Gary. 1992. Symptoms of depression among older African Americans: An analysis of gender differences. Gerontologist 32: 78995. Chi, I. 1998. A study on life condition and life quality of the elderly in Mainland China and Hong Kong [in Chinese]. Beijing: Peking University Press. Cohen, S. and G. McKay. 1984. Social support, stress and the buffering hypothesis: A theoretical analysis. In Handbook of psychology and health, eds. Baum, A., S.E. Taylor and J.E. Singer. Hillsdale, N.J.: Lawrence Erlbaum. Henderson, A.S. 1992. Social support and depression. In The meaning and measurement of social support, eds. Veiel, O.F. Hans and U.R.S. Baumann. New York: Hemisphere Publishing Corporation. Himmelfarb, S. and S.A. Murrell. 1983. Reliability and validity of five mental health scales in older adults. Journal of Gerontology 38: 333-9. Lubben, J.E. 1988. Assessing social networks among elderly populations. Family Community Health 11 (3): 42-52. Myers, J.K. and M.M. Weissman. 1980. Use of a self-report symptom scale to detect depression in a community sample. American Journal of Psychiatry 137: 1081-4. Oxman, T.E., L.F. Berkman, S. Kasl, D.H. Freeman and J. Barrett. 1992. Social support and depressive symptoms in the elderly. American Journal of Epidemiology 135: 356-68. Radloff, L.S. 1977. The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement 1: 385-401. and L. Teri. 1986. Uses of the Center for Epidemiological Studies — Depression Scale with older adults. In Clinical gerontology: A guide to assessment and intervention, ed. Brink, T.L. 119-35. New York: Haworth Press. Williams, A.W., J.E. Ware and C.A. Donald. 1981. A model of mental health, life events, and social supports applicable to general populations. Journal of Health and Social Behavior 22: 324-36.

0 Acknowledgements The authors w o u l d like to thank the Committee on Education and Conference Grant, the University of H o n g Kong, a n d the N a t i o n a l Health Research Development Program of Health, Canada, for their research grants. T h e a u t h o r s are grateful to all w h o helped in carrying out the fieldwork.

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They are professors Fang Yuan, Shengming Yan and Aiyu Lui at the Department of Sociology, Peking University; Professor Shixun Gui at the Population Research Institute, East China Normal University; Professor Zhongru Zhang at Shanghai University; Professor Chengzhang Chen at Zhongshan Medical University; officials from the Statistical Bureau in Suzhou Municipality; and all the students who helped to conduct the survey in the five cities.

14 Living Arrangements and Adult Children's Support for the Elderly in the New Urban Areas of Mainland China Shengming Yan and Iris Chi

In the past two decades, China has experienced rapid urbanization. Statistics show that in 1978, the urbanization rate in China was only 17.92%, whereas in 1995, the level of urbanization reached 29.04% (State Statistical Bureau 1996). In the process of this rapid urbanization, many cities have encroached on outlying farmland, transforming these previously rural areas into new urban districts. As a result, quite a large proportion of the rural population, including the elderly, has been integrated into urban life. What effects does this have on rural people who find themselves living in a new and unfamiliar environment? For gerontologists and relevant policy-analysts, one of the most interesting questions about this process is how these newly urbanized elderly are able to receive their old-age support, either from their families or public agencies, and maintain their well-being. Although the impact of urbanization on the life of the elderly in China has been felt and paid attention to (Zeng and Vaupel 1989), past research on support for the elderly has almost exclusively focussed on those who live in either typical rural or established urban areas, as Chi (1998) noted. The elderly living in newly urbanized areas have long been neglected by researchers. So far as today, we still know little about the factors that influence the support for them and their well-being. This research orientation would put them at a disadvantage in promoting their welfare, since the urbanization process has

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impact on the support for the elderly, either from their families or public agencies (Hugo 1991) This chapter tries to reach a preliminary understanding of the conditions faced by older people m the new urban areas of mainland China, with a hope to stimulate more intensive research into this neglected field of study, as the number of elderly persons living in newly urbanized districts is expected to increase further with the acceleration of urbanization in China m the coming decades In view of the fact that the family has been playing a crucial role in providing support for the elderly m China until today, both m cities and m the countryside, and that it has been suggested there is a close association between living arrangements and family support for the elderly (Kendig, Hashimoto and Coppard 1992), this chapter therefore intends to explore the living arrangements of the elderly in some newly developed urban areas in mainland China m the 1990s, and their effects on adult children's support for their elderly parents On the other hand, it has been suggested that urbanization and industrialization will cause a decline in the preference for, and the actual instance of, parents residing with their married children (see Levy 1949, Logan and Bian 1999), and further, there are still different estimations about the impact of changing family p a t t e r n s from multigenerational to nuclear on family support for the elderly m China (Yan, Chen and Yang, forthcoming) With these in mmd, special attention has been given m this chapter to the following questions 1 What are the preferred and actual living arrangements of the elderly m the new urban areas (traditionally being co-residence with their married children, especially with married sons), and what are their determinants 7 2 What are the effects of co-residence with married children on the sons' and daughters' support for their elderly parents in terms of emotion, care and finance 7

H Literature Review and Hypotheses As noted previously, there is little knowledge of the living conditions of the elderly m the new urban areas of mainland China, including the patterns and determinants of the preferred and actual living arrangements Nevertheless, there are some relevant studies Yuan and Yan (1998), by analysing the patterns of living arrangements and the determinants of coresidence of elderly people with any of their adult children, found that the elderly m the new urban areas generally had a preference for co-residence with a son, especially with a married son, and that younger age (60 to 69 years old), better self-rated health and having a preference for living with

LIVING ARRANGEMENTS AND SUPPORT FOR THE ELDERLY IN URBAN CHINA

their married children increased the likelihood of co-residence. Since this analysis pooled both married and unmarried children together, whether the same pattern would apply to living with married children was not clear. In addition, this research did not explore the determinants of the preference of the elderly to reside with their married children. Another relevant study, by Logan and Bian (1999), analysed the determinants of both the preference of the elderly for co-residence with their married children and with married sons and their actual living situations. The results indicated that the factors that influenced the preferred and the actual living arrangements with a married child and with a married son were different. The factors relevant to the present study include the status of widowhood, more advanced age, better education, bigger houses, and bad family relations. The status of widowhood was positively associated with both the preferred and actual living arrangements with a married child, while only the status of a widowed mother was negatively linked to the actual co-residence with a married son. More advanced age was more likely to be associated with a preference for living with married children, but was less likely to result in the actual co-residence with either married children or married sons. Better-educated elderly people were less likely to prefer living with either their married children or married sons, but did not show significant differences from other elderly people in either actual situations of living with married children or married sons. Elderly people with bigger houses were more likely to prefer co-residence with their married children, and in fact, they were more likely to live with both married children and married sons. In addition, Logan and Bian also found that the preference was not always consistent with the actual living arrangements. Many factors prevented the preference from being fulfilled. Although this analysis took into account many variables and factors, the data came from a sample of nine cities, rather than a sample of new urban areas, so to what extent these determinants apply to newly urbanized areas is still a question. With respect to the effects of living arrangements on adult children's support for the elderly in China, except for the study by Yan, Chen and Yang (forthcoming) and some relevant propositions or speculations (Zhang 1991; Wang 1995; Institute of Population Studies, China Academy of Social Sciences 1990; China National Committee on Aging 1994), special exploration of this topic has not been seen until very recently. According to the results of Yan, Chen and Yang (forthcoming), co-residence with any adult children significantly facilitated the support of the adult children for their parents in daily activities (such as doing household chores, shopping, taking buses, making phone calls, managing money, etc.) and in terms of giving them money, and contributed to their maintenance or increase of financial and emotional support for the parents after they had got married, given that other factors, including the characteristics of both parents and adult children, their

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family life cycle and their social and economic status, were the same. The living arrangements did not have any effects on the physical care provided by adult children for their parents. However, the data on which this study was based came from a medium-sized city, and the analysis focussed on the likelihood of support, without including the amount of support. Therefore, although the analysis had a good start, it needs to be refined. In addition, given the different nature of the sample, to what extent the results are applicable to the new urban areas remains uncertain. As for the other relevant propositions or speculations, one of them is quite misleading. This proposition claims that the changing family patterns in China from big households to nuclear families do not necessarily signify that children no longer provide any support for their elderly parents. On the contrary, it argues, children living apart still maintain very close contacts with and provide much support for their elderly parents. Some have even suggested that since many of these children live near their parents, it is convenient for them to provide all kinds of support for their elderly parents. It is argued that under these special circumstances, a new intergenerational relationship, i.e. living independently but not separately, is now emerging in the urban areas of China. However, this proposition fails to clarify to what extent this new pattern of intergenerational relationship is different from the traditional pattern which is based on co-residence, and to what extent the new pattern is a substitute for the traditional one. In this case, it could quite easily lead to a false impression that the living arrangement per se does not have any effects on family support, especially adult children's support, for the elderly. Although the study by Yan, Chen and Yang has tested the validity of this proposition in a city sample, it needs to be further tested in the new urban areas due to their distinctive features. Based on the above review, we postulate the following hypotheses: 1. Elderly people of a more advanced age and with worse health are more likely to prefer, but are actually less likely, to live with their married children or sons. 2. The education level of the elderly is negatively related to the preference for and actual instance of co-residence with married children or sons. 3. Since co-residence is generally the norm for both the elderly and the children, there is generally no housing shortage in the formerly rural areas which are now new urban areas, and there is evidence that most of the elderly in these areas have relatively spacious houses (Gui 1998b), thus, housing constraints will not affect the co-residence between parents and their married children or married sons. 4. Co-residence with married children will be especially beneficial to the elderly in terms of emotional and financial support from adult children, but not in terms of care.

I

LIVING ARRANGEMENTS AND SUPPORT FOR THE ELDERLY IN URBAN CHINA

D Methodology Data The data analysed in this chapter came from a research project jointly undertaken by the University of Hong Kong, Peking University, East China Normal University and other institutions. The project involved a multi-stage probability questionnaire survey in 1995 and 1996, conducted on residents aged 60 or above in the new urban areas of four large cities (Beijing, Shanghai, Suzhou and Guangzhou) in mainland China. A total of 2002 questionnaires were successfully completed. 1

Dependent variables There are two sets of dependent variables in the analysis. The first set includes four dependent variables: the preference for co-residence with a married child and with a married son, and whether or not the respondent actually lived under the corresponding preferred living arrangement. In the survey, the respondents were asked what they thought would be the best living arrangement. If the respondent expressed the desire to live with his or her married children, either sons or daughters or both, then the item for preference to co-reside with married children was coded 1; otherwise it was coded 0. If the respondent wanted to live with his or her married son, then the item for preference for co-residence with a married son was coded 1; otherwise it was coded 0. For the actual living arrangement, if the respondent was living with his or her married child, the item for actual co-residence with married children was then coded 1; otherwise it was coded 0. If the respondent was living with his or her married son, married sons or both a married son and a married daughter, then that item was coded 1; otherwise it was coded 0. The second set of dependent variables consists of six variables: emotional support, financial support and care for the respondents provided by their sons and daughters. In the survey, the respondents were asked to evaluate the degree to which their sons, daughters, other family members, friends and neighbours were willing to listen to them when they had personal problems. The measure used a five-point scale from 0 to 4 (very unwilling to very willing). The greater the score, the more willing the relatives and friends were to listen to the elderly respondents, thus indicating more emotional support. We measured in the same way the amount of support provided by their sons and daughters in terms of care and financial help. The above support scales have a good reliability in measuring the sons' and daughters' levels of support (the Cronbach's a are 0.88, 0.76 and 0.88 respectively).

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Independent variables There are also two sets of independent variables in the analysis. The first set of independent variables was used to predict the preferred and actual living arrangements of the elderly respondents, including their socio-demographic characteristics and housing constraints. Since there was no accurate information available about the income of the respondents, we used their major income sources as a proxy. If the respondents' major income source was independent of the financial assistance received from their children, then they were regarded as having more economic resources; if they relied on their children for the major part of their income, then they were taken as having fewer economic resources. The respondents' housing constraints were measured by whether or not they had their own bedrooms at the time of the survey. If they did, then it meant that there were no housing constraints; otherwise, there were. In the analysis of the actual living arrangements, the preference of the elderly respondents for the living arrangements also constituted an independent variable. The second set of independent variables consists of the respondents' sociodemographic characteristics, family network and actual living arrangements, and the help they had provided to their children (including grandchildren). Since information on the number and gender of the respondents' living children was not solicited in the survey, we used the three items about 'family network' of the Lubben Social Network Scale (LSNS) (Lubben 1988) to create a composite measure of the family networks of the respondents. The measure was used as a proxy to control for the possible effects of the numbers of children, especially those who were not living with the respondents, and of the relationship between the respondents and their co-resident and non-coresident children. The emotional support and the support in daily activities provided for their children by the respondents was measured by two composite measures as a proxy. As regards daily activities, the measure was whether the respondents often helped their families, friends or neighbours with shopping, cooking, repairing, cleaning and minding children, etc. Since in China elderly people mainly provide this kind of support to their family members, it is a reasonable representation of the help they had provided to their children in this respect. In terms of emotional support, the measure was about the help the respondents had provided to their spouses, children, children-in-law and grandchildren. The measure of help with daily activities used a six-point scale from 0 to 5 (never to always), while the measure of emotional support used a five-point scale from 0 to 4 (never to always). The financial support the respondents provided to their children and grandchildren was measured on a five-point scale from 0 to 4 (never to always). The reliability of the scale is acceptable (the Cronbach a is 0.70). Since the salient features of

LIVING ARRANGEMENTS AND SUPPORT FOR THE ELDERLY IN URBAN CHINA

intergenerational relationships in the Chinese society are characterized by reciprocity in a lifelong process rather than in an instant, the 'mutual aid model' (Lee, Parish and Willis 1994) could be well applied not only to the family members in co-residence, but also those living apart. Therefore, the more help the elderly had provided to their children, the more old-age support they would receive from them. The actual living arrangement was divided into four categories — co-residence with married sons, co-residence with married daughters, co-residence with unmarried children, and living independently or with others. Finally, cities were included in the analysis, with Guangzhou as the reference category, since there are great differences in some aspects of the new urban areas of different cities (Gui 1998a and b). In the analysis, such variables in the second set of independent variables as socio-demographic characteristics, family network measures, the help the respondents had provided, and the cities were all used as control variables. This was to examine the effects of different living arrangements after the effects of these variables had been controlled for.

1 Results Preferred and actual living arrangements Table 1 lists the preferred and actual living arrangements of the elderly respondents. Results show that 45.0% of the respondents preferred to live with their married children, 40.4% preferred to live independently, and 14.6% had no definite preference. The proportion of respondents in the present study who indicated a preference for living independently is very close to the results (40.4% vs. 44.0%) of a similar research on the urban elderly in China (Logan and Bian 1999). Given the prevalence among the rural elderly to live with their married children, these results seemed to reflect the impact of urbanization on traditional Chinese family values. It appeared that the preference of the elderly for this living arrangement had been undermined in the new urban areas. On the other hand, however, among those who said they preferred to live with their married children, about 68.8% preferred to live with their married sons, 25.5% had no particular gender preference, and only 6.2% preferred to live with their married daughters. A cross-variable check indicated that among these elderly, about two-thirds had no sons (not reported here). This indicates that although the preference for living with married children was not so prevalent in the new urban areas, for those who preferred living with their married children, living with their married sons was still the most preferable arrangement. Only very few of the elderly

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respondents who had sons preferred to live with their married daughters. These results seemed to suggest that the influence of traditional family values was still profound among the elderly in the newly urbanized areas, even if within the limits of preference. Table 1 Distribution of preferred and actual living arrangements of the elderly Preferred living arrangements Actual living arrangements

Depends on _ ^ , Married Any married Married *\ + Total Independently children daughters situation sons

With married sons

67.7 (415)

51.3 (115)

29.1 (16)

25.9 (208)

36.1 (105)

43.2 (859)

With married daughters

4.4 (27)

152 (34)

34.5 (19)

1.9 (15)

4.1 (12)

5.4 (107)

With unmarried children

9.8 (60)

8.9 (20)

16.4 (9)

8.7 (70)

18.6 (54)

10.7 (213)

Living independently

18.2 (112)

24.6 (55)

20.0 (11)

63.5 (510)

41.2 (120)

40.7 (808)

Total

30.9 (614)

11.3 (224)

2.8 (55)

40.4 (803)

14.6 (291)

100.0 (1987)

However, to some extent, the actual living arrangements were quite different from the preferred ones. Some 48.6% of the respondents were living with their married children, 36.4% were living independently, either with their spouse or alone, and the remaining 15.2% were living with unmarried children or others (not reported in Table 1). Still, living with married sons was the predominant arrangement. Among all the respondents, 43.2% were living with their married sons (far exceeding the proportion of those who expressed a preference for living with their married sons), and only 5.3% were living with their married daughters. In other words, 89% of those living with their married children were living with their married sons. These results seemed to suggest that the elderly in the new urban areas were actually more traditional in their behaviour than in their expressed preference. The discrepancies we found between the preferred and actual living arrangements were not unusual. Merely having a preference for a specific living arrangement does not mean that its realization is guaranteed. This result is consistent with that of the study conducted by Logan and Bian (1999), which suggested that many factors will make the elderly people in cities unable to achieve their preferred living arrangements, while on the other hand, living under a specific living arrangement can possibly change an individual's preference. The results of logistic regression analysis indicate that the predictors of whether the elderly preferred to live with married children or with at least a

LIVING ARRANGEMENTS AND SUPPORT FOR THE ELDERLY IN URBAN CHINA

married son were by and large the same. Widowed mothers were more likely than others to prefer both living arrangements, while elderly people with independent resources were less likely to have the same preference. The respondents in Beijing were less likely to prefer either of the living arrangements, possibly suggesting the influence of Beijing as a modern, international metropolis and a national, political and cultural centre. Beyond these similarities, there were also slight differences between the determinants of preference for living with married children and the determinants of preference for living with at least a married son. First of all, education did have negative effects on the preference for living with at least a married son, but not on the preference for living with married children. The respondents who had reached the level of senior primary school or above were significantly less likely to prefer living with a married son. But since the proportion of the respondents who had attained this level of education was much higher in Shanghai than in other cities, when the 'cities' variable was introduced into the model, the effects of education on the preference were eliminated by the effects of Shanghai. This result probably suggests that the education level of the elderly, which is often used as an indicator of cultural modernization (Logan and Bian 1999), has a greater effect on the more traditional values about living arrangements than on the less traditional values. Secondly, the relatively younger respondents were less likely than others to prefer living with married children, but were as likely as others to prefer living with married sons. The pattern was that the younger the respondents, the less likely they were to prefer living with married children. If we take ten years as the cut-off point for different generations, then this pattern may reflect the overall impact of different decades on different generations. The fact that poor self-rated health had no influence on both preferences was somewhat surprising and needs further exploration. The factors that were associated with the actual living arrangements were somewhat different. Again, the main predictors for both living arrangements were generally the same. Table 2 shows that widowed parents were more likely to live with their married sons. Contrary to the predictors of preference, widowed fathers had an even greater likelihood of living with their married sons. As expected, the preference of the respondent had the strongest effects on the actual arrangement. The elderly respondents in the new urban areas of Shanghai were less likely to live with either any married children or married sons, while those in Suzhou were more likely to live under either arrangement. This pattern may be associated with the education level of the respondents of these two cities — the Shanghai respondents were the most educated and the Suzhou respondents the least. Again, there were also some differences in the predictors of living with any married children and with married sons. Firstly, before the effects of cities were

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Table 2

Logistic regression of the preference for living with married children and married sons and actual living arrangements

Variables

Gender and marital status Widowed father Widowed mother (Married couples) Age 60-69 70-79 (80-89) Education Senior primary school or above Junior primary school (No formal education) Independent resources Have (Do not have) Self-rated health Bad So-so (Good or very well) Own bedroom Have (Do not have) Cities Beijing Shanghai Suzhou (Guangzhou) Preference for living arrangement With married sons With married children With married daughters To live independently (Depends on situation) Constant Model x2 df Number of cases

Preferred living arrangements with

Actual living arrangements with

married children

married sons

married children

married sons

0.734***

0.410***

0.499** 0.467***

0.531** 0.491***

-0.435* -0.393*

-0.377*

-0.521***

-0.472**

-0.390**

-0.590***

-0.776*** -0.586***

-0.776*** -0.438** 0.971***

— — — —

— — — —

1.192*** 1.207*** 0.677* -0.835***

-0.520***

0.587** 117.857 6 1958

-0.330* 102.927 5 1958

-0.652*** 445.047 10 1958

-0.719*** 345.309 10 1958

*p < .05 **p < .01 **p < .001 Notes: 1. Categories in parentheses are reference-omitted categories. 2. The symbol '—' indicates that the variable is not included in the model.

-0.439** 0.609***

1.195*** 0.707***

LIVING ARRANGEMENTS AND SUPPORT FOR THE ELDERLY IN URBAN CHINA

controlled for, the respondents who had attained senior primary education were significantly less likely to reside with any married children and a married son, but after their effects had been controlled for, the effects of education were still significant on the co-residence with married children, but not significant on co-residence with married sons. This seemed to suggest that as one of the components of modernization, education had a greater influence on the preferences of the elderly in the new urban areas for the more traditional living arrangement (co-residence with married sons), while for the actual situations, it seemed to have a comparatively weaker influence. Secondly, the elderly with poor self-rated health were less likely than others to live with a married son, but were as likely as others to live with any married children. This is surprising because according to Chinese traditions, it is usually the son's responsibility to live with and care for the frail elderly members of the family. Since the data was cross-sectional, it was difficult to distinguish whether the poor health led to the non-co-residence of the respondents with their married sons, or the poor health was the result of this living arrangement. A plausible explanation for this result is that among those who did not live with their married sons, many lived independently or even alone but did not receive adequate support, thus leading to poor health. This could be partly supported by the evidence presented in the next section of the chapter that the elderly who lived with their married sons generally received much more care from both sons and daughters. An alternative explanation is that the elderly respondents wanted to maintain their independence as long as possible and did not want to trouble their sons despite their poor health. Or perhaps there was a fear that the intensive care required could cause problems in the relationship between the mother and daughter-in-law. Since we do not have relevant information to support these speculations, further research is needed. Thirdly, the preferences for different living arrangements had different effects on co-residence with married children or married sons. It is worth noting that the preference for living with married sons had robust effects in predicting the actual arrangement of both living with any married children and living with married sons. This suggests that more traditional values had greater effects on the actual living arrangement, and that living with sons was generally the dominant norm for the elderly in the new urban areas.

Effects of living arrangements on the support from sons and daughters Table 3 lists the results of bivariate analysis on the living arrangements and the support from sons and daughters for the elderly in different categories.

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In terms of emotional support, the respondents received significantly more support from their sons if they lived with them and significantly less support from them if they lived with their married daughters. Regarding the emotional support from married daughters, there were no significant differences among different living arrangements. In caring for the elderly respondents when they were ill, the support from sons and from daughters were significantly different under different living arrangements. Generally, if the elderly lived with their married sons, they received much more support from their sons, whereas if they lived with their married daughters, they received much more support from their daughters. With respect to financial support, if they lived with their married sons or unmarried children, they received significantly more support from their sons, and if they lived with their married daughters or unmarried children, they received more support from their daughters. Evidently, living with their married children, either sons or daughters, generally contributed much to the support for the elderly.

Table 3

The mean scores of the support from sons and from daughters under different living arrangements

Living arrangements Support and support sources Emotional support Sons* Daughters Care when ill Sons*** Daughters*** Financial support Sons* Daughters***

With married sons

With married daughters

With unmarried children

Other living arrangements

Total

2.55 (1.04) 2.61 (0.99)

2.28 (1.23) 2.67 (1.11)

2.47 (1.05) 2.62 (1.00)

2.39 (1.06) 2.55 (1.00)

2.47 (1.06) 2.59 (1.00)

3.29 (0.90) 3.06 (0.91)

2.43 (1.30) 3.34 (0.97)

3.03 (1.03) 3.05 (0.94)

2.94 (1.12) 2.94 (1.04)

3.11 (1.03) 3.03 (0.97)

2.23 (1.57) 1.96 (1.45)

1.94 (1.52) 2.45 (1.64)

2.37 (1.50) 2.36 (1.38)

2.02 (1.53) 1.91 (1.49)

2.16 (1.55) 2.01 (1.48)

*p< 5 ***p < 001 Note: Numbers in parentheses are standard deviations.

Next, we analyse the effects of different living arrangements on the support for the elderly from their sons and daughters, after controlling for the effects of the characteristics and the family network of the elderly, and the help the elderly had provided to their children.

LIVING ARRANGEMENTS AND SUPPORT FOR THE ELDERLY IN URBAN CHINA

Effects of living arrangements on emotional support Regression analysis shows that living with married sons and with married daughters both had significant effects on emotional support, even after the effects of other factors had been controlled for. The basic pattern was that living with married sons promoted emotional support from sons, and living with married daughters increased the support from daughters. Living with unmarried children did not have any significant effects on increasing or decreasing the emotional support from either sons or daughters, compared to the arrangement of living independently or with others. Although living with married sons and with married daughters both contributed to the sons' and daughters' emotional support for the respondents, their individual weight on the support was quite different. The standardized regression coefficient of living with married sons was 0.103, while that of living with married daughters was only 0.046, and it was the least important factor that significantly influenced daughters' support. These results suggest that for the sons' emotional support for the elderly, co-residence with married sons was much more important than other arrangements, but for the daughters' emotional support for the elderly, co-residence with married daughters was not so important. This also implies that the daughters' emotional support for the elderly was less influenced by the co-residence with married daughters than the sons' support was. Effects of living arrangements on care when ill With respect to the effects of living with married children on the care for the respondents, the results shown in Table 4 reveal different patterns to some extent. Again, living with married sons and with married daughters both significantly influenced the support from sons and from daughters. As expected, living with married sons increased the care from sons, while living with married daughters significantly decreased it. There are two possible explanations for this pattern. On the one hand, the respondents who had sons, but who lived with their married daughters, might have a bad relationship with their sons or daughters-inlaw, or their sons lived too far away to provide care. On the other hand, in many cases, those respondents living with their married daughters did not have any sons, as noted previously. In this case, they had no choice but to live with their married daughters, and naturally, they could not receive care from non-existent sons. As for the care from daughters, the pattern was contrary to that of the care from sons. The respondents who lived with their married sons also received more care from their daughters than those who had other living arrangements. This may suggest that the elderly who lived with their married sons generally still maintained good relationships with their married daughters. Furthermore, if the elderly had both sons and daughters, to live with a son would conform to the traditional norm, so even

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Table 4

Variables

Effects of living arrangements on the support for the elderly from their sons and daughters Emotional support sons

Living arrangements With married sons 0.219*** With married daughters With unmarried children (other living arrangements) Parents' characteristics Age 60-69 70-79 £80) Gender and marital status Widowed father -0.197* Widowed mother (Married couples) Education Senior primary school or above Junior primary school (No formal education) Independent resources Have (Do not have) Self-rated health Bad So-so (Good or very well) Parents' help Help with daily activities Financial help to sons 0.116*** Financial help to daughters — Financial help to grandchildren Emotional support to immediate families 0.202*** Parents'family networks 0.076*** Cities -0.249*** Beijing Shanghai 0.219*** Suzhou (Guangzhou) Constant 1.115*** R2 0.206

Care when ill

Financial support

daughters

sons

daughters

sons

0.373*** -0.475**

0.150** 0.543***

0.188**

0.196*

daughters

0.511***

0.108*

0.442*** 0.191*

-0.206*

-0.203**

- 0 . 6 2 1 * * * -0.656***

0.178*

— 0.070**

0.355** 0.241***

— —

0.084*** 0.061*

0.053*

0.158*** 0.140*** 0.072*** 0.062***

0.130*** 0.063***

-0.196*** 0.260***

1.576*** 1.942*** 0.170 0.155

0.213**

0.146***

—

—

0.151*** 0.081*

0.198*** 0.067***

0.155*** 0.059***

-0.643*** -0.530*** -0.188*** -1.266*** -1.155*** 2.022*** 0.135

*p<.05 **p<.01 ***p<.001 Notes: 1. Categories in parentheses are reference-omitted categories. 2. The symbol '—' indicates that the variable is not included in the model.

1.737*** 0.302

1.742*** 0.296

LIVING ARRANGEMENTS AND SUPPORT FOR THE ELDERLY IN URBAN CHINA

if the daughter would like to live with the elderly, she could still accept this arrangement and it would not affect her care for her elderly parents. The patterns of the effects of living arrangements, on the care and on emotional support provided from sons and daughters were also different. Results show that the standardized regression coefficients of living with married sons and living with married daughters were 0.373 and -0.066 respectively for the sons' care, and 0.076 and 0.132 for the daughters' care. Apparently, both the negative effects of living with married daughters on the sons' care for the respondents and the positive effects of living with married sons on the daughters' care were not very great. On the other hand, both the effects of living with married sons on the sons' care and those of living with married daughters on the daughters' care ranked as the third most influential among the effects of all the factors that influenced support. Nevertheless, the effects of living with married sons on the sons' care for the respondents were much greater than those of living with married daughters on the daughters' care. These results suggest once again that the daughters' support in caring for the elderly when they were ill was much less influenced by co-residence than the sons' support was. Effects of living arrangements on financial support As for the effects of different living arrangements on financial support from sons and daughters, once again, living with married children had significant effects, even after the effects of other factors had been controlled for. For the financial support from sons, living with married sons significantly promoted it, and by the same token, living with married daughters also increased the financial support from daughters. Other living arrangements had no significant effects. The weight of the effects of these two living arrangements on the sons' and daughters' financial support respectively seemed to present an opposite pattern compared to those of emotional support and of care. The effects of living with married sons on the sons' financial support were somewhat less than those of living with married daughters on the daughters' support (the standardized regression coefficients were 0.061 and 0.083 respectively). This suggests that financial support from sons was less likely to be influenced by the co-residence with married sons than was financial support from daughters by the co-residence with married daughters.

I Discussion and Conclusion Using survey data gathered in the new urban areas of four big cities in mainland China, this chapter analyses the elderly's living arrangements, and

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the effects of different living arrangements on adult children's support for the elderly. Results show that after these previously rural areas had been encroached upon by the cities and transformed into new urban areas, the preference of the elderly for the traditional living arrangement — co-residence with married children — was relatively not so strong, reflecting to some extent the impact of urbanization and modernization. On the other hand, however, the traditionally preferred and dominant living arrangement of living with married sons seemed to be generally less influenced by this process. Education was identified as having negative effects on the preference for living with married sons and on both the actual co-residence with married children and with married sons, but the effects were not as strong as suggested in the typical urban areas. In addition, different from the pattern suggested in typical urban areas, widowed parents were more likely to actually live with their married children or married sons, while only widowed mothers preferred to live with either their married children or married sons. Elderly respondents of a more advanced age were only more likely to prefer living with their married children, but were not different from other elderly respondents in other preferred and actual living arrangements. Parents with independent resources were less likely to prefer living with either their married children or married sons, but did not have any differences in their actual living arrangements from those without independent resources. Housing constraints had no significant effects on the preferred and actual living arrangements. Moreover, there were differences in the preferences of the elderly in different cities. Discrepancies between the preferred and actual living arrangements were also identified in the new urban areas. As for the effects of the traditional co-residence with married children on their support for the elderly, the results unmistakably and consistently show that the co-residence, by and large, had a significantly positive contribution to the sons' and daughters' support. The general pattern was that living with married sons increased the support from sons, and living with married daughters increased the support from daughters, even after the effects of other factors had been controlled for. This suggests that in the new urban areas, the traditional living arrangement — co-residence with married children — still played a more important role than other living arrangements in supporting the elderly. This probably explains to some extent why there was a relatively larger proportion of respondents who still preferred living with married children and were actually living under this arrangement. These findings were generally consistent with relevant results in other research on urban areas. Interestingly, co-residence with married sons seemed to some extent especially beneficial to the care for the elderly in the new urban areas. As noted previously, although this pattern could be interpreted as showing

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that most of the elderly who lived with their married daughters did not have any sons, further analysis needs to be done so as to better estimate to what extent this interpretation is correct and with what factors this pattern is associated. Another point worth noting is that although co-residence with either married sons or married daughters increased the support for the elderly from sons and daughters, the importance of these two types of co-residence was different in terms of the support from sons and the support from daughters. Co-residence with married sons was much more important for getting emotional support from sons and care from both sons and daughters, but less important for getting financial support, while co-residence with married daughters was more important for the elderly in receiving care and financial support from daughters, but less important for getting emotional support. It is generally assumed that the elderly in the rural areas of China are more traditional than their urban counterparts in terms of their preference for living arrangements. However, the above results seem to suggest that the preferred and actual living arrangements of the elderly in the new urban areas were mixed, with some characteristics of the elderly found in both rural and urban areas. In sum, the above findings have shed some light on the living arrangements of the elderly in the new urban areas of mainland China, and the effects of living arrangements on the support for those elderly from their sons and daughters. To some extent, some results are consistent with those of other research on typical urban areas, and some conform to the generally held assumptions about the typical rural areas. However, more detailed and refined research is needed, given the limits of the survey data used in this chapter, i.e., some information which could have been associated with these topics is missing, and proxy variables had to be used in the present study. Nevertheless, this study has provided a beginning for ongoing research.

D References Chi, Iris, ed. 1998. The study on the living conditions and life quality of the elderly in Mainland China and Hong Kong. Beijing: Peking University Press. (In Chinese.) China National Committee on Aging. 1994. Proceedings of National Conference on the Strategy for the Population Aging in China. Beijing. Gui, Shixun. 1998a. The livelihood and living conditions. In The study on the living conditions and life quality of the elderly in Mainland China and Hong Kong, ed. Chi, Iris. Beijing: Peking University Press. (In Chinese.) . 1998b. The socio-demographic characteristics. In The study on the living conditions and life quality of the elderly in Mainland China and Hong Kong, ed.

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Chi, Iris. Beijing: Peking University Press. (In Chinese.) Hugo, G.J. 1991. The changing urban situation in Southeast Asia and Australia: Some implications for the elderly in the United Nations. Aging and urbanization. New York: United Nations. Institute of Population Studies, China Academy of Social Sciences. 1990. Selected papers on the study of old population. Beijing: Economic Administration Press. Kendig, Hal, Akiko Hashimoto and Larry C. Coppard, eds. 1992. Family support for the elderly: The international experience. Oxford: Oxford University Press. Lee, Yean-Ju, William L. Parish and Robert J. Willis. 1994. Sons, daughters, and intergenerational support in Taiwan. American fournal of Sociology 99 (4). Levy, Marion. 1949. The family revolution in modem China. Harvard University Press. Logan, J. and Fuqin Bian. 1999. Family values and co-residence with married children in urban China. Social Forces 11 (4). Lubben, J.E. 1988. Assessing social networks among elderly populations. Family and Community Health 11 (3). State Statistical Bureau. 1996. China statistical yearbook 1996. Beijing: China Statistical Publishing House. Wang, Shuxin. 1995. On the supportive relationship of younger generations for the elderly under separate living arrangement in urban areas. China Demography (3). Yan, Shengming, Jieming Chen and Shanhua Yang. The effects of living arrangement on children's support for the elderly in urban China. In China's revolutions and parent-child relations, ed. Whyte, Martin K. (Forthcoming.) Yuan, Fang and Shengming Yan. 1998. The family and social support. In The study on the living conditions and life quality of the elderly in Mainland China and Hong Kong, ed. Chi, Iris. Beijing: Peking University Press. (In Chinese.) Zeng, Y. andJ.W. Vaupel. 1989. The impact of urbanization and delayed childbearing and population growth in China. Population and Development Review 15. Zhang, Chunyuan, ed. 1991. The study of old population in China. Beijing: Peking University Press.

e Note 1.

For details of the sampling procedures, definition of new urban areas and other information about the project, please refer to Chi 1998.

I Acknowledgements T h e authors would like to thank the Committee on Education and Conference Grant, t h e University of H o n g Kong, a n d the National Health Research Development Program of Health, Canada, for their research grants. The authors are grateful to all w h o helped in carrying out the fieldwork.

LIVING ARRANGEMENTS AND SUPPORT FOR THE ELDERLY IN URBAN CHINA

They are professors Fang Yuan, Shengming Yan and Aiyu Lui at the Department of Sociology, Peking University; Professor Shixun Gui at the Population Research Institute, East China Normal University; Professor Zhongru Zhang at Shanghai University; Professor Chengzhang Chen at Zhongshan Medical University; officials from the Statistical Bureau in Suzhou Municipality; and all the students who helped to conduct the survey in the five cities.

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15 Elderly Chinese in Public Housing: Social Integration and Support in Metro Toronto Housing Company Morris Saldov and May-lin

Poon

By the year 2021, the elderly Canadian population is expected to exceed five million if present immigration levels and mortality rates are sustained (Secretary of State 1988).1 The largest ethnic group in Canada who are unable to speak either of Canada's two official languages is the Chinese (population: 100 185). Elderly Chinese are expected to lead the growth rate among ethnic elderly people between 1991 and 2006, particularly in Toronto and Vancouver where they are projected to have the highest growth rates in the country (Multiculturalism and Citizenship Canada 1993). China and Hong Kong have continued to be among the top ten places of origin of immigrants to Canada (Citizenship and Immigration Canada 1999). Toronto, in particular, has been the destination for many of these immigrants (Citizenship and Immigration Canada 1999). Since the fastest growth rate of persons aged 65 or over is occurring in non-white populations, particularly Asians,2 gerontology research in the field of housing and community services needs to shift its focus from comparative studies to describing and analysing individual elderly groups' requirements. The service needs of ethno-cultural-racial minorities, such as those of elderly Chinese, require definition in their own right and not necessarily by comparison with majority groups. Until the 1990s, Canadian and US researchers had largely ignored the housing and community services utilized by elderly Asians. This ethnic elderly

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population was under-represented in the literature of ageing (Kramer, Barker and Damron-Rodriguez 1991; Saldov and Chow 1994). Since then, however, there has been a growing body of literature assessing the support needs of elderly Asians. For example, Tsai and Lopez (1997) found that in California, families provided the most valued sources of support, while language differences from public and non-governmental service providers and a lack of information about services were significant barriers to utilization by elderly Chinese immigrants. Family support has also been shown to be influenced by the spatial distance from the children of the elderly living in seniors' public housing (Smith 1998). In Hong Kong, family support in Chinese families usually means care by the daughters or daughters-in-law (Ngan and Wong 1995). Heumann and Boldy (1993) have developed a holistic model for assessing the care and support needs of low-income and frail elderly 'ageing in place' in seniors' housing. They concluded that a continuum of services is needed to reflect the diversity of the social, cultural and environmental needs of this population. Some public housing authorities have responded to this challenge of developing a continuum of services by providing more integrated and congruent programmes which help low-income and frail seniors stay in their housing (Suggs, Stevens and Kivet 1986). In the special case of the elderly Chinese, methods which reach out to this population are needed. The National Asian Pacific Center on Aging in Seattle (1995) has strongly recommended culturally and linguistically adapted community-based services for elderly Asians. New York City's Department for the Ageing has responded to the challenge by providing mini-information fairs, bilingual posters and newsletter articles, in addition to survey instruments translated into Chinese aimed at improving needs-assessment methods (New York City's Department for the Ageing 1997). Life satisfaction of the elderly Chinese has been clearly linked to the existence of suitable social support services for diverse elderly populations who are ageing in place in seniors' housing (Lai and McDonald 1995; Bakalchuk et al. 1991).

1 The Canadian Context for Multicultural Services When the official policy of multiculturalism was introduced in 1971, it was the Canadian government's intention to promote institutional changes whereby all cultural groups could gain equal access to public services in Canada. The Multiculturalism Act of 1988, which set out the means by which this was to be accomplished, defined the concept of multiculturalism as integration (i.e., equal membership by ethno-cultural groups in a communalistic society). This meant that ethnic minorities could expect to access public services sensitive

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to their linguistic and cultural needs (Multiculturalism and Citizenship Canada 1991). The Canadian government's aim was to 'promote the full and equitable [emphasis added] participation of individuals and communities of all origins' (Multiculturalism and Citizenship Canada 1990, p. 13). The concept of 'equity', key to the understanding and implementation of the federal government's policy of multiculturalism, represents a higher standard than 'equality' in promoting the elimination of linguistic and cultural barriers to accessing services. The equity principle demands that those who have the least access should gain the greatest advantages in overcoming barriers. Within the housing field, equal access for ethnic elderly to housing and community services has been the goal of various human service organizations. However, this ideal has been difficult to achieve (MacLean and Bonar 1987). The ethnic elderly may be faced with additional barriers to accessing services, owing to generic problems of ageism and disability (Saldov 1991). Therefore, equity considerations may take on greater significance in designing social programmes that serve ethnic seniors who experience the multiple jeopardy of ethno-racial discrimination, ageism and disability. The present study attempts to expand the database on elderly Chinese living in the Canadian institution of public housing, by examining the linguistic and cultural problems they face in accessing both the services of the Metro Toronto Housing Company Ltd. (MTHCL) and those of community agencies.

D Cultural Factors in the Design of Services A major defining characteristic of Chinese culture is the practice of building social networks of support (guanxi) to ensure the availability of help when needed. Guanxi has been described as the development of mutually beneficial networks of support among Chinese people. In a relationship where guanxi is established, each person can ask a favour from others with the expectation of future reciprocity (Yang 1994). Yang (1994, p. 6) defines guanxi as: [t]he cultivation of personal relationships and networks of mutual dependence; and the manufacturing of obligation and indebtedness. What informs these practices and their native descriptions is the conception of the primacy and binding power of personal relationships and their importance in meeting the needs and desires of everyday life. According to King (1994), certain guanxi relations are preordained, and others are voluntarily constructed. Relationships between father and son as

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well as brother and brother are preordained, lifelong and obligatory, while husband-wife and friend-friend guanxi are a matter of choice and can be ended (King 1994). In cities, non-kin relations can be even more important than kinship, as demonstrated by the popular Chinese saying: 'Distant relatives are not as dear as close neighbours.' Distance can weaken the kinship bond of 'familiarity' and obligation. In the absence of family support, where guanxi is operating among neighbours, mutual aid and obligation can develop. In addition to positive neighbour relations, guanxi may derive from nativeplace connections. People who originate from the same village, town, county or province, or speak the same dialect, have an additional basis for guanxi relations (Yang 1994). There may also be gender differences in personal relations. According to traditional Chinese culture, many women are expected to follow their husbands when they are young and follow their children, especially sons, when they are old. Elderly Chinese in public housing may therefore experience a loss of face if not living with family members. Because many Chinese immigrants to Canada had limited exposure to formal social services in China and Hong Kong when help was needed, they relied on guanxi to obtain and exchange favours. Chu and Ju (1990) studied the importance of guanxi to the socio-economic well-being in contemporary China. Over two-thirds of those studied, or 71.7%, stated that they would try connections rather than 'normal channels' to resolve a problem, while only 19.6% said they would go through normal channels (Chu and Ju 1990). In China, housing officials often used their public position as a private possession for the purpose of guanxi exchange (Yang 1994). Residents were careful not to offend housing officials but to develop guanxi to enhance their security of tenure and to promote good services when needed. Guanxi may also have been used to protect oneself from fellow tenants who may curry favour with officials by acting as 'informers' (Yang 1994). The Western practice of providing human services 'as a right' obviates the necessity of exchanging favours, customary in guanxi relations. In Canadian public housing, job-related services are viewed as entitlements rather than favours. The practice of guanxi by Chinese seniors and the entitlement to services while in Canadian public housing may create cultural conflicts resulting in service incongruency. This study was an attempt to describe and explore the congruence of Chinese seniors' cultural and language needs with the structure of housing and community services available to them from MTHCL.

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D Person-Environment Congruence Person-Environment Congruence Theory provides a common-sense model for policy-makers, managers and professionals in the human service field to achieve a better fit between the housing environments they create and the people they purport to serve. A congruence approach may supply a set of culturally sensitive guidelines to assist housing suppliers and managers to accomplish the desired match of housing and community services to the characteristics of the ethnic elderly. According to Kahana (1982, pp. 99-103): In the present congruence model goodness of fit is seen as antecedent to well being rather than synonymous with it. Whenever there is a lack of congruence between the individual's needs and life situation — due to either change in environment (especially new housing or institutionalisation) or a change in needs or capacities — various adaptive strategies are called upon to increase the fit between person and environment. Adaptive strategies may serve to reduce mismatch either by changing needs or by changing the environment. Depending on the success of these adaptive strategies, well being or lack of well being may result. An important role of the environment then is to accommodate as much as possible to the changing needs of the ageing individual. Studies of health and community services in Toronto have revealed that serious incongruency exists between the needs of ethnic seniors and the services they are offered (Doyle and Visano 1987; Saldov and Chow 1994). The Chinese Community Nursing Home (CCNH) for Greater Toronto (1989) conducted health-care research which revealed that 'the cultural needs of the Chinese senior population, particularly as these needs are reflected in the delivery of health care services, are not being met' (p. 11). This study attempts to discover the barriers which prevent the matching of housing and community services to the needs of Chinese seniors in Toronto's public housing environment. It represents an effort to assist mainstream agencies like MTHCL to develop strategies which achieve a better fit of services to the needs of ethnic seniors, in particular, the elderly Chinese.

D 'Ageing in Place' and the Elderly Chinese At the time of the study, MTHCL was engaged with the Province of Ontario and the federal government in a process of creating a new vision for housing the elderly under the long-term care concept of 'ageing in place'. As part of this process, MTHCL was committed through a Task Force on Multicultural/

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Anti-Racism 'to examine issues arising out of the increasingly multi-cultural nature of both the tenants and staff and to develop recommendations which will address those issues' (Metro Toronto Housing Company Ltd. 1993a, p. 8). In its 'Race Relations and Multicultural Policy', regarding race, culture and language, MTHCL (1993b) committed itself to identifying and eliminating 'all barriers that may exist to obtaining or accessing services, programs and/ or employment' (p. 1). In developing its aim of forging new partnerships with tenants, MTHCL went on to suggest a strategic direction which 'recognises and responds to the needs of an increasingly diverse ethno-racial and cultural tenant population' (Metro Toronto Housing Company Ltd. 1994, p. 3). In some MTHCL housing, the ethno-racial composition of the elderly has become quite homogeneous. With the increasing concentration of ethnic elderly in some developments, housing agencies like MTHCL are being challenged to adapt effectively and equitably their services to meet the needs of shifting balances of residents in their buildings. In 1991, MTHCL found that tenants of foreign origin experienced lower levels of satisfaction owing to greater difficulty in forming social networks due to the language and cultural differences from the majority groups in their buildings (Metro Toronto Housing Company Ltd. 1991a). Within a racially and ethnically diverse elderly population in a mainstream housing agency like MTHCL, when one group becomes the majority, how should services be organized? This study gives a voice to the Chinese seniors, who represent the majority of residents, to expound on their experiences when seeking housing and community services.

0 Methodology Participants Chinese seniors were randomly selected from nine MTHCL buildings where at least 50% of the residents were Chinese seniors. The total sample size was 306. The concentration of Chinese seniors ranged from 52% to 84%. The size of the elderly Chinese population in the nine buildings ranged from 13 to 237 residents. To control for the effects of the size of population in buildings with larger numbers of Chinese seniors (i.e., 116 to 237 Chinese seniors), approximately 30% of potential respondents were selected, while about 50% of potential subjects were chosen in buildings with smaller elderly Chinese populations (i.e., 13 to 63 Chinese seniors). The Chinese seniors in our sample were mainly female (76%), a larger representation than that found in the MTHCL population (62%) (Metro

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Toronto Housing Company Ltd. 1993a). A total of 70% of the elderly had lived with their family members prior to entering MTHCL, 83% were born in China, and 79% had lived in Hong Kong or China prior to their arrival in Canada. Their average length of time in Canada was 14 years. Although not all buildings were in Chinatown areas, there was easy access via public transport for those seniors living further away. About 60% of the elderly spoke only Chinese while nearly 40% stated that they also spoke some English. Fifty-two percent said they were able to read Chinese and 44% stated they could write Chinese. Twenty-three percent stated they could read English. Their level of English understanding was not assessed. Sixty percent of the sample was between the age of 70 and 84. There was considerable age variation by housing project, with three buildings having mostly younger populations of the elderly (55 to 74), while the remaining buildings having predominantly older populations (75 to 94). A majority of the Chinese seniors reported that they had good vision (77%), good hearing (86%) and good mobility (77%). These figures suggest that the Chinese seniors sampled saw themselves as mainly healthy. It is important to note, however, that seniors generally report high levels of self-assessed health, even though they may have significant disabilities affecting their activities of daily living (Zimmer and Chappell 1996).

Materials The questions contained in the interview guide were developed, translated into Chinese and checked for content validity by asking key informants for appropriate cultural content. These key informants were either working with Chinese seniors in metro housing or had previously been accustomed to working with low-income elderly Chinese. To further refine the content validity of the interview questions, a focus group was conducted with Chinese seniors from a non-sample MTHCL building of 37% Chinese. The interview guide was pre-tested with Chinese seniors from a building where the percentage of Chinese (49%) most closely approximated the minimum requirement for inclusion in the sample. It was learnt from other research experiences with Toronto and Vancouver Chinese seniors' communities that many elderly were minimally literate or semi-literate. Consequently, mail-out questionnaires would likely have yielded a lower response rate than interviews (Chinese Interpretation and Information Service 1987; Chinese Community Nursing Home 1989; Metro Toronto Housing Company Ltd. 1991b; Lau 1993).3 Since many Chinese seniors in Canada lack literacy skills, it was decided that interviews were to be conducted.

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Design and procedure This is an exploratory-descriptive study using an interview approach focussed on the relationship of language and culture to accessing housing and community services. Demographic and contextual factors are also described in relation to the social environment of MTHCL housing.

Data collection A core group of seven Chinese-speaking volunteer interviewers recruited from English as a Second Language classes, Volunteer Services and the Asian Studies Department of the University of Toronto assisted the Project Co-ordinator (PC) with the interviews. 4 All of the interviewers spoke Cantonese. Some could also speak Mandarin, Tai Shan and Shanghainese dialects. The dialect used for the interviews was primarily Cantonese (73%), although a substantial number (20%) were conducted in the Tai Shan dialect. Additional dialects used were Mandarin and Shanghainese (6%). Training for interview techniques was provided to enhance consistency in applying the interview guide. Care was taken to train the interviewers not to apply any pressure to participate that would suggest coercion. Rather, benevolent persuasion to encourage participation was the approach taken through explaining the purpose of the study. The PC and the Principal Investigator (PI) had spent several years providing voluntary services to Chinese seniors in one of the buildings studied, and were therefore known to many of the residents in that building. This relationship may have contributed to guanxi with the residents and in turn promoted their participation in the study. It was observed that in many of the buildings, 'natural helpers' (i.e., tenants who had the trust of the Chinese residents) acted as intermediaries in facilitating seniors' access to a variety of housing and community services. By accompanying the research team, the natural helper from the building where the PC and PI were known to the residents was able to help develop relationships with other natural helpers in the remaining eight buildings. Often the introduction was given to the research team by the natural helpers. Some natural helpers organized meetings for residents to introduce the interviewers and the study's objectives to potential participants. The considerable trust that had developed through guanxi relations between tenants and their natural helpers could have played a major role in 'opening doors' to the research team. In addition to the critical role of the natural helpers in promoting the study, the MTHCL Manager and her housing staff provided additional support. The General Manager provided a letter, translated into Chinese, which gave an introduction to the study. This letter also made clear to the seniors that the study was being carried out with

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the co-operation and support of MTHCL and that their participation would not jeopardize their tenancy.5

D Results Data analysis The data was analysed using descriptive statistics to provide a summary of the sample characteristics and a report on the responses of the seniors. Frequencies were given on the knowledge and use of housing and community services, and the extent of the seniors' social interaction and participation in meetings within their buildings. To enrich the analysis of the quantitative data, additional notes were taken concerning qualitative statements made by the respondents. The interviewers' observations were also recorded during the debriefing sessions following the interviews.

Social environment To gauge the social atmosphere in their buildings, seniors were asked about the extent of friendliness and racism they had observed. Ninety-four percent of the residents perceived the Chinese seniors in their buildings to be 'very friendly' (e.g., helpful, co-operative, confidante, socializing a lot [going out together]) or 'friendly' (e.g., greet and chat, seldom go out together) towards them. Since 93% of the interviews were conducted in either Cantonese or the Tai Shan dialect, it may be reasonable to suggest that social relationships were formed because of regionalism, with the elderly coming from similar areas in China speaking the same dialect of Chinese, developing strong social bonds. This may reflect native-place ties itongxiang) described by Yang (1994). People coming from the same village, town, county or province, or speaking the same dialect wherein shared values are likely to occur, may have a special inclination to enter into friendly, perhaps guanxi exchange, relations. Fiftytwo percent of the non-Chinese were perceived to be friendly and 47% 'neutral' (e.g., merely greet each other, neither avoiding nor seeking contact). Without special efforts to overcome language and cultural differences, it would have been surprising to find the same high levels of 'friendly' relations between Chinese and non-Chinese residents. When asked about their observations of racism in MTHCL housing, 10% reported what they believed to be racist incidents. The Chinese tendency to seek harmony and not 'make waves' may have contributed to lower rates of

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reporting racism. There was also a degree of uncertainty about the occurrence of racist incidents due to language barriers and cultural differences in interpreting non-verbal actions. Higher rates of reported racism were reported at 14% and 20% in two buildings where the Chinese seniors had a better understanding of English. In these buildings, the social club executives had also experienced a transition from Anglo to Chinese majority representation, which appeared to have generated considerable resentment and alienation among some non-Chinese residents. To further gauge the seniors' social interaction in their buildings, they were asked about their participation in social activities like birthday parties or festive events. Thirty-eight percent of the elderly reported participation in such social activities every two weeks while 28% said they had never participated. When the elderly held parties, they always gave foodstuffs to staff as part of the group's efforts to maintain good relations (guanxi) with them. Half of the residents stated that they had attended meetings with MTHCL staff. This was sometimes confused with meetings at the buildings arranged by politicians who often turned such occasions into social events where food was served and an interpreter made available. Sixty-six percent of the elderly reported that they preferred to live in a building which had a majority of Chinese in it, while almost 30% stated that this did not matter to them. The main reason given for wishing to live in a building where the majority of tenants were Chinese was the ease of communication. Common language made it possible for the elderly to engage in neighbouring behaviour so they could feel more secure in their building. Shared language and native place (tongxiang) would likely enhance the possibilities for the development of supportive social networks among Chinese-speaking residents of MTHCL housing.

Housing services When asked about the duties of different MTHCL staff in their buildings, over 90% of respondents stated (with prompting) that they knew the superintendent and the custodian were responsible for the maintenance of the buildings. Sixty-eight percent of the elderly knew about the services provided by the overnight (key) person while 70% knew about the services of the housing caseworker (social worker). Forty-four percent knew about the services of the recreation/community development worker. Most of the elderly (97%) knew how to reach the superintendent or custodian either at the general office or by phone. Since the offices were usually located near the entrances of the buildings, superintendents and custodians were readily visible to the respondents. There was no attempt, however, to validate the seniors'

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knowledge by asking for phone numbers or the location of the office. About 75% of seniors said they knew how to reach the key person in case of an emergency after-hours. Approximately 70% knew how to reach the housing caseworker (social worker) while less than 30% were aware of how to contact their recreation/community development worker. The study explored the means by which Chinese seniors sought help if they did not or were unable to communicate their service needs directly to staff. In these circumstances, about 32% said they sought assistance from other tenants, while a little more than 50% sought help from family members. The elderly rarely (less than 12%) contacted friends from outside their buildings to assist them. Even fewer respondents (8%) contacted volunteers for help. These figures suggest that Chinese seniors often use other means than direct communication with staff in order to obtain MTHCL services. In a number of situations, the elderly reported giving gifts (tips) and foodstuffs to staff to help develop guanxi so that services would be provided when needed. In China, obtaining accommodation and maintaining good relations with housing officials are often achieved through the use of guanxi (Yang 1994). Chinese seniors may be expected to base their expectations of staff on these types of past experiences with housing officials in China. The practice of giving gifts in exchange for services had become a means of assuring seniors that services would be available when needed, but it presented the MTHCL management with a serious dilemma. Staff were not to accept tips for providing job-related services. How MTHCL is to assure residents of the availability of services while remaining sensitive to the seniors' cultural practice of guanxi development through giving gifts remains a challenge for policy and programme innovation.

Communication barriers For 72% of the elderly, language was the principal barrier in communicating with the superintendents or custodians. Communication problems would also appear to exist when trying to reach key persons (60%). Language barriers were less of a problem for Chinese seniors when contacting housing caseworkers (22%) who could communicate in Cantonese and the Tai Shan dialect. Twenty-one percent had difficulty in communicating with recreation/ community development workers who spoke only Mandarin. Almost 70% of the respondents used body language and 40% used broken English to communicate their needs to staff. Despite the language barrier and the problems in trying to reach MTHCL staff, more than 85% of the respondents said that they neither gave up trying to reach them nor did they seek alternative services.

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|

The respondents gave a clear indication that Chinese was the preferred language in their communication with staff (80%). If the staff cannot speak the seniors' language, they will be severely handicapped in developing a service relationship with them. Ninety percent of the seniors felt it was important that the superintendents and custodians be able to speak Chinese. Very few seniors (7%) thought that this was unimportant. Almost as many seniors felt it was important for key persons (88%) as for housing caseworkers (87%) to be able to speak Chinese. About 73% felt it was important for recreation/ community development workers to speak Chinese. The importance that the seniors assigned to speaking Chinese suggests that they would like to feel more comfortable and secure in communicating with housing staff.

Community services Community services available to the Chinese seniors in their buildings and the methods they used to learn about them are summarized in Table 1. Most seniors who found out about community services did so by 'word of mouth' or through their 'own observation'. A lesser number relied on bulletin boards to get information about services, while a few used the public media of radio, Table 1 Knowledge summary of community services and methods of finding out about them (expressed in percentages of respondents) Don't know

Unclear

Doctor Chiropractor Public health nurse Homemaker Public transport Meals on wheels Police Ambulance Fire protection

17 46 31 32 39 19 20 18 16

Volunteer services Income tax Social contact Translation Filling in forms Others

16 24 23 21 0

7= 2 = 3 = 4 = 5 = 6 =

word of mouth correspondence public media (radio, TV, newspapers) bulletin board own observation in meetings

1

2

3

Know 4

5

6

2 4 1 3 2 2 3 2 2

35 15 26 37 16 28 28 29 28

0 0 0 1 0 0 1 1 1

1 0 0 0 3 1 6 6 6

14 10 14 5 4 7 6 6 6

20 11 17 16 37 43 28 31 3

0 0 0 1 0 0 2 2 2

3 3 2 2 0

41 37 38 39 0

2 0 1 0 0

2 2 2 2 0

8 6 6 6 0

23 21 22 22 0

1 0 1 1 0

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TV or newspapers. A substantial proportion of the elderly did not know about many of the services. When asked about their knowledge of community services, 61% of the elderly said they knew how to obtain volunteers, 29% stated they knew how to reach homemakers, 19% could contact public transport and 28% knew how to obtain meals on wheels. Volunteers were mainly supplied by the Chinese Home Support Services of Greater Toronto and represented a point of entry for many Chinese seniors into other community services. It appears that few seniors knew how to reach many of the community services available to them. Unless Chinese seniors or those people in their support networks become oriented to the community service environment in MTHCL, the former will be unlikely to get help when needed. Approximately 75% of the elderly said that they knew 911 was the number to call for emergency services. The number of elders who stated that they knew about the 911 number was compromised by their confusion about how their calls would be handled. The seniors were unaware that a 911 operator could locate their address from their telephone number when they call. Neither were they familiar with the Language Line Service of AT&T in San Francisco, which Metro Toronto Emergency Services (MTES) uses for interpreter services in handling emergencies. Unaware of these interpreter services, Chinese seniors may be reluctant to telephone 911 if they believe that their call will be disconnected when the language barrier emerges. Moreover, delays in reaching an interpreter may also be a source of confusion. The 25% of elders who did not even know the 911 number, therefore, likely under-represented the extent of the barriers to accessing police, fire and ambulance services. Chinese seniors were at risk in an emergency situation due to communication problems and a lack of orientation to MTES's system of providing interpreter services.

D Discussion Limitations of the study One of the major challenges in conducting research on Asian cultures is to overcome Western bias. Several efforts were made here to help overcome this bias. The study was carried out by Chinese interviewers and assisted by natural helpers. The questions in the interview guide were refined in a focus group and pre-tested with Chinese seniors. Key informants from the Chinese community examined the questions for content validity. Despite these efforts, inconsistencies occurred in communication between colloquial expressions

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and the written Chinese regarding the questions in the interview guide. This required some flexibility on the part of the interviewers in adapting the language of the questions to the respondents, a process the PI and PC were not always able to monitor for consistency. Given the cultural tendency of Chinese seniors to seek harmony and maintain face, many of the elderly's responses to questions about racism, communication barriers, and difficulties with obtaining housing and community services likely under-represented the extent of problems they experienced when trying to get help. The study did not set out to establish the role of guanxi in accessing housing and community services. Rather, the post hoc analysis using this cultural concept is at best suggestive of the need for further research to explore its importance to Chinese seniors in obtaining housing and community services. MTHCL staff m e m b e r s were not interviewed concerning the communication barriers they faced. However, the researchers were able to make several observations of the services they provided and received numerous comments from them regarding the elderly. The housing caseworkers (social workers) and the recreation/community development workers were particularly informative. Their observations and comments helped with the design of the study and the interpretation of the results. It may not be valid to extrapolate findings on Chinese seniors in MTHCL to other ethnic elderly in public housing. Although Chinese seniors' experiences of barriers to accessing services could be similar to those of other ethnic elderly in public housing, the cultural pattern of responding to these barriers may differ by ethnic group. Research is needed to elucidate the experiences of other ethnic elderly groups in order to study the issues of their access to housing and community services.

Conclusion Results of this exploratory-descriptive study would appear to support the need to adapt services provided by MTHCL and community agencies to better meet language and cultural requirements of Chinese seniors. Chinese seniors had difficulties in obtaining services from staff who did not speak their language (particularly superintendents/custodians and key persons). Communication barriers were less apparent when the elderly tried to reach social workers and recreation/community development workers, who all spoke Chinese. Emergency services are critical to the elderly's well-being and require rationalization if they are to be accessible to Chinese seniors. Most Chinese seniors knew about the 911 service, but were reluctant to call due to self-

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235

perceived language barriers. Better information about the MTES response protocol to a non-English-speaking caller could help prevent delays and confusion in times of an emergency. The help of MTHCL staff becomes even more crucial in creating a socially secure environment during an emergency. Overnight (key) persons who are expected to deal with emergencies, however, are unable to speak Chinese. This presents immediate communication problems and barriers when handling crises. MTES could also improve the access to their assistance through developing a less confusing and faster method of obtaining an interpreter. If the emergency services were to negotiate with the local telephone company, to solicit language, age and disability status, from their ethnic elderly customers, computer technology now makes it possible for a 911 operator to quickly access this information. To further enhance communication in an emergency, a recorded message in the senior's language could urge the caller to stay on the line until he or she is connected with an interpreter. Co-operation among MTES, MTHCL and the telephone company in seeking these suggested improvements would help to speed up access to an appropriate emergency service, and hence help to overcome a significant barrier and source of anxiety for Chinese seniors when seeking assistance in times of an emergency. Other services provided to MTHCL buildings, such as homemaking, meals on wheels and public transport, were largely unfamiliar to Chinese seniors. For most of them, community services were not available for use in China or in Hong Kong prior to their immigration to Canada. Consequently, community agencies need to explore effective ways to orient Chinese seniors to their services. 'Word of mouth' seems to be a typical method of finding out about services among Chinese seniors. Notices in English or in Chinese by themselves may be of limited use in communicating information about services. Effective approaches are needed that take into account the language of communication and networks of social support used by Chinese seniors to access services. It appears that roughly half of the Chinese seniors went to their families and one-third sought help from other tenants in their buildings to obtain MTHCL housing services. Whether this indirect approach was due to the language barrier with some staff or was related to Chinese seniors' preferences for seeking the assistance of a neighbour, relative or friend using guanxi was not determined. The extent of using third parties to obtain services raised speculation as to whether language was the only factor influencing the Chinese seniors' pattern of help-seeking behaviour. Further research aimed at exploring the seniors' networks of support and the effects of the language barrier may help to clarify why so many of them did not seek help directly from staff. Social network analysis is needed to answer Bond and Hwang's (1986) question of who the supportive people in the lives of Chinese seniors are, in

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order to better predict their help-seeking behaviour and, therefore, suggest h o w c o n g r u e n t h o u s i n g and c o m m u n i t y services might be developed.

1 References Bakalchuk, L., D.S. Chen, H. Ho, F.F. Kwan and W. Lo. 1991. Cultural competence in the care of elderly Chinese persons in New York City: A symposium. Pride Institute Journal of Long Term Home Health Care 10 (4): 5-17. Berkanovic, E., J.E. Lubben, H.H.L. Kitano and I. Chi. 1994. The physical, mental and social health status of older Chinese: A cross-national study. Journal of Ageing and Social Policy 6 (4): 73-87. Bond, M.H. and K.K. Hwang. 1986. The social psychology of the Chinese people. In The psychology of the Chinese people, ed. Bond, M.H. 213-66. Hong Kong: Oxford University Press. Chinese Community Nursing Home (CCNH) for Greater Toronto. 1989. Health care needs of the Chinese elderly population: A needs assessment. 26. Metropolitan Toronto: CCNH. Chinese Interpretation and Information Service. 1987. A report on the aged Chinese in the city of North York and the city of Scarborough. 58. Toronto: Chinese Interpretation and Information Service. Chu, G.C. and Y. Ju. 1993. The great wall in ruins: Communication and cultural change in China. Albany, New York: State University of New York Press. Citizenship and Immigration Canada. 1999. Strategic policy, planning and research branch, facts and figures 1998: Immigration overview. Ottawa: Government of Canada. Doyle, R. and L. Visano. 1987. Social Planning Council of Metropolitan Toronto: A time for action (Part I); A program for action: Access to health and social services for members of diverse cultural and racial groups in metropolitan Toronto (Part II). Metropolitan Toronto: Social Planning Council of Metropolitan Toronto. Heumann, L.F. and D. Boldy, eds. 1993. Aging in place with dignity: International solutions relating to the low-income and frail elderly. Westport, CT: Praeger. Kahana, E. 1982. A congruence model of person-environment interaction. In Ageing and the environment: Theoretical approaches, eds. Lawton, M.P., P.G. Windley and T.O. Byerts. 97-121. N.Y.: Springer. King, A.Y. 1994. Guanxi and network building: A sociological interpretation. In The living tree: The changing meaning of being Chinese today, ed. Tu, W. 109-26. California: Stanford University Press. Kitano, H.H.L., J.E. Lubben, E. Berkanovic, I. Chi, C.Z. Chen and X.Y. Zhu. 1994. A cross-national study of elderly Chinese and Chinese Americans. In International perspectives in health care for the elderly, ed. Stopp, G.H. 139-53. New York: Peter Lang Publishing. Kramer, B.J., J.C. Barker and J. Damron-Rodriguez. 1991. Ethnic diversity in ageing and ageing services in the U.S.: Introduction. Journal of Cross Cultural Gerontology 6 (2): 127-33.

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Lai, D.W.L. and J.R. McDonald. 1995. Life satisfaction of Chinese elderly immigrants in Calgary. Canadian Journal on Ageing 14 (3): 536-52. Lau, K.K. 1993. An exploratory study on the nature of elder abuse in the Chinese community and the attitude of Chinese seniors towards elder abuse in the city of Toronto. 49. Faculty of Social Work, University of Toronto. MacLean, M. and R. Bonar. 1987. Cooperative practice to overcome socially constructed hardship for ethnic elderly people. In Ethnic dimensions of ageing, eds. Gelfand, D.E. and C M . Barresi. 211-23. N.Y.: Springer. Metro Toronto Housing Company Ltd. 1991a. A lifestyle analysis for the Metro Toronto Housing Company Limited. Final report. Volume I: Synthesis report. Hickling Corporation. . 1991b. A lifestyle analysis for the Metro Toronto Housing Company Limited. Final report. Volume II: Activity needs and preference analysis. Hickling Corporation. . 1993a. Anticipating change. Metropolitan Toronto: Government of Metropolitan Toronto. . 1993b. Race relations and multicultural policy. Metropolitan Toronto: Government of Metropolitan Toronto. . 1994. The Housing Company. Building on Change. A pamphlet, p. 4. Miranda, M. and K.S. Markides, eds. 1997. Minorities, aging, and health. Thousand Oaks, CA: Sage. Multiculturalism and Citizenship Canada. 1990. The Canadian Multiculturalism Act 1988: A Guide for Canadians. Ministry of Supply and Services Canada. . 1991. Multiculturalism: What is it really about? Ministry of Supply and Services Canada. . 1993. Projection of Canada's 1991 people in 2006, Ottawa. National Asian Pacific Center on Aging. 1995. Recommendation for the White House conference on aging. Seattle, Washington: National Asian Pacific Center on Aging. New York City's Department for the Ageing. 1997. Support services for the frail elderly residents of federally assisted housing: Final report findings and recommendations. 105. Ngan, R. and W. Wong. 1995. Injustice in family care of the Chinese elderly in Hong Kong. Journal of ageing and social policy 7 (2): 77-94. Saldov, M. 1991. The ethnic elderly: Communication barriers to health care. Canadian social work review, theme issue on multiculturalism and social work 8 (2): 2 6 9 77. and P.C. Chow. 1994. The ethnic elderly in Metro Toronto hospitals, nursing homes and homes for the aged: Communication and health care. International Journal on Ageing and Human Development 38 (2): 117-35. Secretary of State. 1988. Ageing in a multicultural Canada: A graphic overview. Policy, analysis and research Directorate, Ottawa. Smith, G.C. 1998. Geographic separation and patterns of social interaction between residents of senior citizen apartment buildings and their adult children. The Canadian Geographer 42 (2): 145-58. Statscanada 93-318. 1991. People unable to speak English or French. Ottawa: Ministry of Supply and Services, Ottawa, Canada.

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Suggs, P.K., V. Stephens and V.R. Kivett. 1986. Coming, going, remaining in public housing: How do the elderly fare? Journal of Housing for the Elderly 4 (1): 87-104. Tsai, D.T. and R.A. Lopez. 1997. The use of social supports by elderly Chinese immigrants. Journal of Gerontological Social Work 29 (1): 77-94. Tzuling, T.D. and R.A. Lopez. 1997. The use of social supports by elderly Chinese immigrants. Journal of Gerontological Social Work 29 (1): 77-94. Yang, M. 1994. Gifts, favors, and banquets. The art of social relationships in China. Ithaca, N.Y.: Cornell University Press. Yee, P. 1996. Struggle and hope: The story of Chinese Canadians. Toronto: Umbrella Press. Zhu, X.Y., H.H.L. Kitano, I. Chi, J.E. Lubben, E. Berkanovic and C.Z. Chen. 1994. Living arrangements and family support of the elderly in Beijing. In International perspectives on health care for the elderly, ed. Stopp, G.H. 69-83. New York: Peter Lang Publishing. Zimmer, Z. and N.L. Chappell. 1996. Distinguishing the spending preferences of seniors. Canadian Journal on Ageing 15 (1): 65-83.

Web resources on elderly Asians http://www.ccnc.ca/toronto/history/further.html http://geronet.ph.ucla.edu/atucla/Sphpubs.htm http://www.cacf.org/wwwboard/messages/205.html http://www.psc.isr.umich.edu/asia/data.shtml http://geronet.ph.ucla.edu/CGEC/infoabout.htm http ://medic. ucdavis. edu/cah/Resources. htm

0 Notes 1.

2.

3.

These estimates will need to be revised in light of the 1995 changes to immigration rules limiting the sponsorship of parents of Canadian citizens and landed immigrants. Most elderly immigrants in 1991 came from the People's Republic of China (population: 35 025) which may include Hong Kong since it was not listed separately, followed by Vietnam (population: 4195), other Southeast Asian countries (population: 2325), Malaysia (population: 730) and Taiwan (population: 475) (Statscanada 93-318, 1991, p. 70). It was considered culturally and contextually relevant to recruit as interviewers Chinese seniors from the same cohort as the participants in our study. However, Dr Peter Lomas, anthropologist with the Gerontology Diploma Program at Simon Fraser University, who was concurrently conducting a study with Chinese seniors in the Vancouver area, advised against this owing to literacy problems with interviewers when reading and completing interview guides.

ELDERLY CHINESE IN PUBLIC HOUSING IN TORONTO

4.

5.

239

Interviewers were paid $4.00 Canadian for each completed interview. This was intended to cover their transport and related expenses. Additional benefits included refreshments on the job and a group meal at the end of the day to debrief interviewers and to build a sense of community and co-operation. Respondents were screened for cognitive functioning by their ability to answer questions about background characteristics — age, birthplace and length of time in Canada.

1 Authors' Note This study was financed by a grant from the External Research Program of Canada Mortgage Housing Corporation.

16 Health and Care Utilization Patterns of the Community-dwelling Elderly Persons in Hong Kong Ben C.P. Liu, Y.H. Cheng and S.M. McGhee

D Introduction Hong Kong is no exception to the global trend of population ageing. It is predicted that people aged 65 or over will increase from 10% in 1991 to 13.3% over the next two decades in Hong Kong (Hong Kong Census and Statistics Department 1997). Concerning those aged 60 or over, in 50 years' time, they will make up about two-fifths of the population in Hong Kong. By 2025, the proportion of elderly population in Hong Kong will be higher than that in Japan and China (Ming Pao Daily News 1999). The growing ageing population will bring along social repercussions. Although many elderly people remain fit and active until very late in their lives, chronic illness and disability are not uncommon experiences in old people (Field 1997). In fact, statistics gathered by Bury (1997) suggested that in Great Britain, for those suffering from at least one form of disability, almost 70% of disabled adults were 60 or over. Apparently, those suffering from a high level of disability, living alone or with an inadequate support network may have to rely on formal care (Tennstedt, Harrow and Crawford 1996). Since the health status of individuals has cost implications for formal services (McNamee, Gregson and Buck 1999), the increase in frail elderly people creates a great challenge to the providers of health and social care (Young et al. 1999; Walker and Warren 1996). In addition to formal services, informal care is a fundamental source of

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support to elderly persons, especially those with functional decline (Unger et al. 1999). Informal care — a kind of social support — is a continuum of helping behaviours or assistance that is not derived from legal mandates or public financing mechanisms, but from normative or voluntary interpersonal association (Litwin and Auslander 1990). It is an unpaid care, which is not organized via a statutory or voluntary organization, but is offered mainly by family members, relatives, friends or neighbours (Victor 1997). In terms of financial cost, informal care appears to be less costly than formal care (Tennstedt, Harrow and Crawford 1996). Under the current economic conditions, policy-makers tend to promote informal care as a complement to formal services. As there are factors affecting family care of the elderly, it becomes a new strain on family members (Cooney and Di 1999; Walker 1993) no matter how the cost of care may differ in terms of financial expenses, time, duration, intensity, complexity and prognosis of care required (Rimer 1999; Parker 1981). Many studies (Melzer et al. 1999; Tennstedt, Harrow and Crawford 1996; Chappell 1995) suggest that elderly persons living in the community utilize both formal and informal care. However, there are still some elderly persons who rely solely on either formal or informal care. Efforts have already been made to investigate the utilization patterns of care so as to provide more information to enhance the co-ordination of care (Tennstedt, Harrow and Crawford 1996; Pearlin et al. 1990). In order to generate local data on care utilization patterns of community-dwelling elderly people, the present study aims to answer the following research questions: 1. What are the differences in the level of health-related quality of life among different groups of care-users? 2. What are their care patterns, and what factors determine elderly persons' care patterns?

1 Subjects and Methods This was a cross-sectional study in which the target population was those elderly aged 65 or above and their primary informal carers living in the Kwun Tong and Tseung Kwan O districts of Hong Kong. Based on the findings of a pilot study, we determined the sample size to be 764. Then, we approached the Hong Kong Census and Statistics Department, and a list of randomly selected addresses was obtained subsequently. For the sake of protecting personal information, the selected addresses did not guarantee if a suitable subject was there. Thus, we revised the sampling procedure as follows. If there was no suitable candidate for the study at a selected address, the

HEALTH AND CARE UTILIZATION PATTERNS OF ELDERLY PERSONS IN HONG KONG

interviewer would call on another household residing next to that address until an eligible respondent was found. A primary care-giver identified by the elderly respondent would also be interviewed. The interview was carried out face-to-face by means of a structured questionnaire. The fieldwork was conducted between June and December 1996. Finally, we successfully interviewed 764 elderly persons from the two districts. By using the ShortPortable Mental State Questionnaire (MSQ) as a screening test for differentiation of elderly persons with memory deficit or disorientation (Chi and Boey 1994), the number of valid questionnaires analysed was 702. The number of completed interviews with carers was 530. In this chapter, we mainly report the information concerning the care patterns of the elderly respondents and their relationships with the health of the respondents. As health-related quality of life is a multidimensional construct, there is no single measure which can capture the full picture of what it is. Thus, the present study adopted four measurement tools to measure health-related quality of life. The MSQ (Chi and Boey 1992) is a ten-question scale to measure a respondent's mental functioning, and its value ranges from 0 (the poorest) to 10 (the best). The Activities of Daily Living and Instrumental Activities of Daily Living (ADL) (Kane and Kane 1981) is a ten-item tool for assessing the functional health of a person in terms of his/her capacity to perform basic and advanced levels of self-care. These include bathing, transfer, outdoor activities, household tasks, marketing, visiting relatives, feeding, cooking, using the telephone, and managing personal property. The Current Perceived Health-20 (CPH) (Li and Fielding 1995) is a 20-item tool to measure self-rated general health. The Quality of Life Ladder (QoL) (Cantril 1965) is a self-anchoring scale which requires the respondents to put their quality of life score on the rung that they prefer. The bottom of the ladder is 1 (the worst) and the top is 10 (the best).

D Results Basic characteristics of respondents More than half (57.4%) of the elderly respondents were female, and the mean age of the respondents was 72.9 (SD = 6.4, range: 65-96). These figures were compatible with the 1996 By-Census for the same district (Hong Kong Census and Statistics Department 1996). The mean level of education was 2.7 years. Slightly over half of the respondents (55.7%) were married, while about twofifths of them were widows/widowers. About one in five of the elderly respondents lived alone. As for the health profile of the elderly respondents,

243

244

BEN C.P. LIU, Y.H. CHENG AND S.M. MCGHEE

J

the top five illnesses identified by physicians were arthritis (40.3%), hypertension (26.5%), diabetes (10.8%), heart disease (10.4%) and loss of memory (7.7%). More than 70% of the elderly respondents had at least one chronic illness. Concerning the socio-demographic data of the care-givers, 63% of them were female, the mean age was 52.5, and the mean level of education was 5.9 years. About three-quarters were married, while 18.9% were single. Many care-givers were closely related to the respondents (i.e. spouse, child or son/daughter-in-law). Just under half of the care-givers had at least one chronic disease. Regarding household composition, 50.3% of the elderly respondents belonged to an 'un-extended nuclear family', and 26.1% of the respondents belonged to 'one vertically-extended family'. Slightly more than half of those elderly using 'mixed care' (i.e., both formal and informal care simultaneously) lived in 'one un-extended nuclear family', and nearly half of the informal care-users lived in such type of families as well. However, 46.3% of the 'formal care-only users' lived alone. Most of the elderly respondents had been the recipients of formal and/or informal care during the six months prior to the study. Nearly one-fifth relied solely on informal care. Even though those who relied exclusively on formal care accounted for only a very small percentage of the elderly respondents, they obtained the lowest scores in all the healthrelated quality of life measures (Table 1). Those who received solely informal care obtained the highest scores in all the health-related quality of life measures.

Table 1 Care utilization patterns of the mean scores of the four health-related quality instruments Types of care-users Mixed care (both formal and informal) Informal care only Formal care only Total

N

MSQ

ADL

CPH

QoL

505 130 67 702

7.9 8.0 7.2

9.5 9.7 9.8

48.3 52.5 45.5

6.5 6.7 6.0

F = 5.5 p = .005

F = 3.5 p= .04

F = 27.6 p < .0000

F = 4.8 p = .009

Care utilization and health The elderly respondents tended to consult general practitioners and attend general out-patient clinics and specialist out-patient clinics which, according to Hospital Authority's classification,1 were considered as 'primary care' and 'secondary care' (Hospital Authority 1996). About one-fifth of them utilized

HEALTH AND CARE UTILIZATION PATTERNS OF ELDERLY PERSONS IN HONG KONG245

'community support services', such as social centres for the elderly, most of them used 'primary care' and 'secondary care', and very few of them used extended care (Table 2). Eleven patterns of care utilization were found in the mixed-care group of elderly respondents after categorizing formal and informal care (Table 3). Those who utilized informal care together with 'primary care', Table 2

Frequency of using formal services

Items of formal care

Used* (%)

Primary care General out-patient clinic General practitioner Chinese herbalist Secondary care Specialist out-patient clinic General hospital Community support services Social centre for the elderly Home help service Multi-service centre for the elderly Extended care Day care centre Community nursing service Geriatric day hospital

629 (89.6) 269 (38.3) 260 (37.0) 100 (14.2) 272 (38.7) 213(30.3) 59 (8.4) 187 (26.6) 163 (23.2) 18 (2.6) 6 (0.9) 9 (1.3) 4 (0.6) 5 (0.7) 0

Frequency of use Mean : 5.1 (SD = 11.7) Range: 1-30 Mean 4.6 (SD = 11.7) Range: 1-40 Mean : 6.7 (SD = 10.7) Range: 1-48 Mean : 5.3 (SD = 12.7) Range: 1-30 Mean : 9.2 (SD = 10.8) Range: 1-60 Mean : 37.8 (SD = 54.4) Range: 1-150 Mean = 53.1 (SD = 89.2) Range: 1-168 Mean = 18.5 (SD = 26.6) Range: 1-70 Mean : 54 (SD = 64.1) Range: 1-24 Mean : 7.0 (SD = 12.9) Range: 1-30

/

*The total number of each row is 702. Table 3

Mean scores of the four health-related quality of life measurement scales for those who used mixed care*

Types of care-users Informal care + primary care Informal care + primary + secondary care Informal care + secondary care Informal care + primary care + community support services Informal care + community support services + primary + secondary care Informal care + community support services Informal care + community support services + secondary care Informal care + community support services + extended care Informal care + secondary + extended care Informal care + primary + secondary + extended care Informal care + four types of formal care* Total

N (%)

CPH1 QoL2 ADL3

MSQ3

198(39.2) 81 (16.0) 69(13.7)

49.4 47.2 48.2

6.7 5.9 6.2

9.7 9.5 9.2

8.0 7.7 8.2

67(13.3)

48.6

7.0

9.5

7.7

41 (8.1) 28 (5.5)

44.8 48.1

6.1 7.2

9.0 9.2

7.4 7.8

17 (3.4)

48.1

7.1

9.8

7.8

1 (0.2) 1 (0.2)

41.0 37.0

6.0 6.0

9.0 7.0

10.0 7.0

1 (0.2) 1 (0.2) 505(100.0)

54.0 52.0

6.0 5.0

9.0 9.0

7.0 7.0

'F = 2.2, p = .0146 2F = 3.9, p < .0000 3n.s. * This table does not Include those elderly respondents who used 'only formal' or 'only informal' care. * The four types of formal care were community support services, primary care, secondary care and extended care.

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BEN C.P. LIU, Y.H. CHENG AND S.M. MCGHEE

|

'secondary care' and 'extended care' obtained the highest score in self-rated health, while those who used both informal care and 'community support services' simultaneously attained the highest level of perceived quality of life. On the contrary, those who had to depend heavily on formal care achieved a relatively low score in the QoL measure (Table 3).

Informal care, living arrangements and health There were 25.1% of respondents who did not receive practical assistance from informal care-givers, and 17.5% of respondents who received no emotional and psychological support. However, nearly three-quarters of the respondents had received both practical assistance and emotional support from informal care-givers during the six-month period (Table 4). A total of 17.2% of the respondents received only emotional support. A relatively small number (n = 56) received exclusively practical assistance, such as help with household chores. Those elderly respondents who received both practical assistance and emotional support from carers attained the highest level of health-related quality of life scores compared with those who received only one kind of informal care (Table 4).

Table 4 The use of informal care and mean scores of the four health-related quality of life scales Types of informal care used Practical assistance and emotional support Emotional support only Practical assistance only Total 1

F = 15.8, p<

0000

2

F = 7.5, p < .000

3

N {%)

CPH1

QoL2

ADL3

MSQ4

470 (74.0) 109(17.2) 56 (8.8) 635(100.0)

49.9 48.1 44.6

6.7 6.1 6.2

9.5 9.8 9.3

8.0 7.9 7.5

F = 4.4, p = 02

4

n s.

As for who provided practical assistance, about two-fifths of the male respondents (42.5%) relied on their spouse for such help, 25.7% on their spouse plus children. Nearly one-third of the female respondents (27.1%) depended on their children for practical care, and only 18.2% on their spouse (%2 = 128.9, df = 27, p < .000). Concerning the association between perceived quality of life and the relationship of the person who provided practical assistance, those elderly receiving practical assistance from their spouse only (mean = 6.3, SD = 1.6) had a lower score than those receiving support from other informal care-givers, such as their children and in-laws (mean = 7.0, SD = 1.4), spouse plus children (mean = 6.8, SD = 1.5), and children only (mean = 6.7, SD = 1.4) (F = 2.1, p < .001). Among those who were given

HEALTH AND CARE UTILIZATION PATTERNS OF ELDERLY PERSONS IN HONG KONG247

L

emotional care, the male respondents tended to receive such care from their spouse and children (21.8%), spouse (20.5%), and friends (7.3%). However, the female respondents favoured to receive emotional support from their children (15.6%), friends (10.3%), and spouse (8.4%) (x2 = 189.3, df = 83, p < .000). As for the association between perceived quality of life and the relationship of the person who rendered emotional care, those elderly receiving emotional support from their spouse only (mean = 6.4, SD = 1.5) had a lower score than those given support by their friends (mean = 6.7, SD = 1.8) and children plus in-laws (mean = 6.5, SD = 0.9) (F = 1.5, p < .006). Regarding those who had to render informal care to the elderly respondents, 90.6% of informal care-givers rendered emotional and Table 5

Informal caring tasks provided to the elderly respondents

Tasks

No. of informal providers (%)*

Mean of minutes per day (SD)

267 (50.4) 251 (47.4) 251 (47.4) 91 (17.2) 29 (5.5) 14(2.6) 12 (2.3) 10(1.9) 8(1.5) 7(1.3) 6 (1.1) 5 (0.9)

34.9 (47.8) 31.8(43.8) 37.7 (48.5) 10.5 (31.8) 1.6 (11.1) 0.9(7.1) 0.7 (5.1) 1.2 (9.6) 0.3 (2.7) 1.6(15.1) 0.4 (3.7) 0.5 (5.4)

Household chores Shopping Cooking Escorts in outings, e.g. see(ing a doctor Managing personal properties Health care, e.g. taking medicine Bathing Doing exercise Transfer Others To and from toilet Feeding *The total number of each row is 530

Table 6

Informal caring tasks and the four health-related quality of life measures (mean scores)

CPH Informal carers helped? Household chores Shopping Cooking Escorts in outings, e.g. seeing a doctor Managing personal properties Health care, e.g. taking medicine Bathing Doing exercise Transfer To and from toilet Feeding *p < .005

*p < .05

Note: The total number of each row is 530

Yes 49.4 49.4 49.9 45.7 43.1 40.9 38.2 41.0 38.1 36.2 35.4

No 49.2 49.3 48.9 50.1 * 49.7* 49.6* 49.6* 49.4* 49.5* 49.5* 49.5*

QoL Yes 6.4 6.3 6.3 6.3 6.0 5.7 6.1 5.8 5.3 6.0 6.0

ADL

No #

6.7 6.8* 6.8* 6.6 6.6# 6.6* 6.6 6.6 6.6# 6.6 6.6

MSQ

Yes

No

Yes

No

9.4 9.3 9.2 8.8 7.6 7.4 5.2 6.0 5.3 4.3 4.4

9.7* 9.7* 9.7* 9.6* 9.6* 9.6* 9.6* 9.6* 9.6* 9.6* 9.6*

8.1 7.9 8.1 7.3 6.9 6.7 6.7 6.7 6.7 6.5 6.8

7.8* 7.9 7.7* 8.1* 8.0* 8.0* 7.9* 7.9* 7.9* 7.9* 7.9

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BEN C.P. LIU, Y.H. CHENG AND S.M. MCGHEE

psychological support to their elderly care-recipients. However, only 70.4% of informal care-givers had provided tangible care (listed in Table 5), with the average (arithmetic mean) time spent being 18.3 hours per week (SD = 12.7, range = 1 to 80 hours). The common tasks with which informal caregivers helped were household chores, shopping and cooking, with an average of 34.9 minutes, 31.8 minutes and 37.7 minutes respectively every day (Table 5). Furthermore, significant associations were found between lower levels of health-related quality of life and the need for more assistance in informal caring tasks (Table 6).

Determinants of care utilization As for the determinants of the elderly respondents' care utilization patterns, our findings showed that suffering from at least one type of chronic disease (O.R. = 6.3, 95% CI = 4.2-9.5) was the major predictor for using formal services. In addition to the risk factors affecting health, elderly respondents' feeling that no one could really help was another important determinant influencing their use of formal care (O.R. = 2.0, 95% CI = 1.2-3.2). Regarding the utilization of informal care, having a lower level of perceived quality of life (O.R. = 2.9, 95% CI = 1.9-4.4) and feeling that no one could really help (O.R. = 1.7, 95% CI = 1.2-2.5) affected the elderly respondents' use of practical assistance offered by their informal care-givers. However, co-residing with a spouse had an inverse relationship with the utilization of practical assistance (O.R. = 0.2, 95% CI = 0.2-0.4). Factors affecting the use of emotional support were: (1) obtaining a lower score in QoL (O.R. = 2.1, 95% CI = 2.1-3.3); (2) a lower score in CPH (O.R. = 2.0, 95% CI = 1.3-3.1); (3) utilizing at least one type of formal services (O.R. = 2.0, 95% CI = 1.0-3.9); and (4) obtaining a lower score in MSQ (O.R. = 1.7, 95% CI = 1.1-2.6). However, co-residing with a spouse generated an inverse relationship with the use of emotional care (O.R. = 0.3, 95% CI = 0.2-0.4).

1 Discussion The findings of the present study reaffirmed that elderly persons received both formal and informal support concurrently (Melzer et al. 1999; Tennstedt, Harrow and Crawford 1996; Chappell 1995). Both formal and informal care are complements rather than substitutes for each other (Swane 1999). According to the respondents' experiences, 11 mixed-care utilization groups were delineated in this study. This highlighted that elderly persons' care

HEALTH AND CARE UTILIZATION PATTERNS OF ELDERLY PERSONS IN HONG KONG

utilization was heterogeneous. It also suggested that in their health serviceseeking process, elderly people tended to adhere to different types of care that they perceived as supportive and accessible. Furthermore, our findings revealed that elderly respondents' levels of health-related quality of life were a crucial factor determining their patterns of utilization of formal care. Those respondents whose health was poor tended to rely more on formal care, while those whose health was relatively good utilized more informal care. Therefore, the health condition of the elderly respondents was a major determinant of their care utilization patterns. Logistic regression analyses reported that those respondents suffering from at least one type of chronic illness had five times the chance of using formal health and social services. Those elderly respondents having obtained a lower score in QoL had almost a twofold chance of receiving practical assistance and emotional care. Those elderly respondents who got a lower score in CPH and MSQ had twice and 0.7 times respectively the chance of receiving emotional care from informal care-givers. The existence of co-morbidity influenced the elderly respondents' utilization of different levels of health and medical care. Apparently, although old age is not synonymous with ill health, diseases and disorders are more common in the later years of life (Wu, Leu and Li 1999; Bury 1997; Khaw 1997; Field 1997). Health is regarded as an important element for quality of life among elderly persons. Thus, the perceived seriousness of their health problems may determine their care-seeking behaviours, although, at some point, the perceived seriousness of their health may not prompt them to seek help immediately (Cheng et al. 1997). As discussed, being old may be associated with a number of chronic illnesses, and more frequent contact with medical facilities is expected. Through contact with medical professionals, they can maintain independent living in the community. Obviously, those who live in the community with a manageable level of personal health mainly receive informal care with limited or no formal aged-care services. An aged person's health condition is therefore an indicator of his/her long-term care patterns (Slivinske, Fitch and Wingerson 1998; Long 1995). Our findings also suggested that the health of aged persons had strong associations with their utilization of formal and informal care. Those elderly who utilized informal care together with 'community support services' achieved the highest level of perceived quality of life, while those who heavily depended on formal care obtained a lower level in the same measure. In addition to the health factor, elderly respondents' feeling that no one could really help was an important determinant affecting their use of formal care. Those elderly who felt that their supportive network was poor had a twofold higher chance of utilizing more formal care. In other words, the perceived inadequacy of social support had affected their care utilization

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_J

patterns. For example, a longitudinal study indicates that a decrease in perceived emotional support among aged Jewish Israelis contributed to changes in their care patterns, such as entering long-term care facilities (Walter-Ginzburg, Blumstein and Chetrit 1999). Even though informal caregivers were available and willing to render care, this did not ensure adequate care as perceived by elderly care-recipients. Therefore, the care-recipients' subjective evaluation of the social support network influenced their care utilization patterns. However, many 'community support services' in Hong Kong were designed mainly to prevent the further deterioration of the health of elderly persons (Chow 1994). Furthermore, existing aged-care services were inadequate (Chi and Boey 1994). In some cases, limited publicity concerning the existence of, or access to, care services for the elderly played a part in the level of utilization. Therefore, even though some individuals may be in need of services because of their perceived inadequate social support network, they may avoid the services if they fear that other old people suffer from a greater need for the services (Cheng et al. 1996; Chi and Boey 1994). Accordingly, they may be at risk of receiving none of the care at all. As for the use of informal care, this study showed that living arrangements played an important part in the utilization of such care. Many respondents in this study were living with their spouse and/or children. Under these circumstances, it is very natural for them to consume family care, along with formal care, if needed. Although elderly persons may not be ill or disabled, the existence of this kind of readily available informal support can be viewed as a mechanism for maintaining their physio-psychosocial functioning. This may explain the association between receiving informal care and a higher mean score of measures of health-related quality of life. Those elderly persons with strong social networks were more likely to perceive themselves as being healthy (Wenger 1996). This observation was also evident in the present study, with those elderly persons who had received both practical assistance and emotional support from informal carers achieving higher levels of healthrelated quality of life measures. This study revealed that there was role differentiation in the course of providing informal care. Moreover, a hierarchy of preferences for informal care was evident in the present study. Male respondents expected their wives to be the major provider of practical care, but their female counterparts sought help mainly from their children. Most of the elderly men regarded their wives as primary care-givers, while elderly women had a tendency to rely more on their children than their spouse. This echoes a recent observation that mothers tend to receive more support from their children (Ikkink, van Tilburg and Knipscheer 1999). Traditional Chinese culture suggests that elderly men have a higher position than females and other family members (Hong 1976). Hence, practical assistance, such as housekeeping that is deemed to be females' work,

HEALTH AND CARE UTILIZATION PATTERNS OF ELDERLY PERSONS IN HONG KONG

is not the primary responsibility of those old men. Concerning emotional support, the present study showed that the spouse was not the primary target of the elderly respondents when soliciting psychological support. Children and friends, however, were major sources for gaining emotional care. Our findings suggested that those elderly respondents who received emotional care solely from their spouse had a relatively lower level of perceived quality of life. This may indicate that peer relationship is more important among old Chinese people (Jernigan and Jernigan 1992), and that marital relationships among aged Chinese persons are more functional than emotional. Furthermore, this reflects that intergenerational support may contribute significantly to the elderly's psychological well-being (Chen and Silverstein 2000). Since Chinese people tend to suppress their emotional behaviours and are less likely to express individual needs (Lui and Mackezie 1999; Russell and Yik 1996), effective encouragement from their partners is needed so that they can share their inner feelings comfortably. Although receiving informal support tends to be associated with a higher level of health-related quality of life, the reverse effects of such care on caregivers has been well documented (Cooney and Di 1999; Zarit and Pearlin 1993). Care-givers are at a high risk of physical discomfort, especially when they are chronically subject to the stress of care-giving (Stone and Short 1990). They may suffer from various forms of cost, including financial burdens, conflicts with work, and psychosocial stress resulting from the caring process (Avison et al. 1993). Undoubtedly, decline in the physical health of caregivers is closely related to providing care (Greene and Coleman 1992). However, since filial responsibility and felt obligation are interrelated (Stein et al. 1998), it is not uncommon for informal carers to continue their caregiving process, even though they may experience different costs of care. In this study, those elderly respondents who had lower levels of health-related quality of life required extra amounts of practical assistance from their caregivers. Even though this cross-sectional study cannot clearly identify the causal relationship between care-giving and care-givers' health-related quality of life, the process of care-giving for frail elderly people generated a burden of care on informal care-givers. Since many care-givers are the spouses of elderly persons, care-givers' health may decline solely as a result of the normal ageing process (Kelman, Thomas and Tanaka 1994). This increases pressure on those care-givers who are themselves elderly. This situation may influence the quality of the informal care provided and force the elderly to seek more formal services. Changes in household structures, increases in the divorce rate and a growing number of women in the labour force affect the continuity of informal care for the elderly (Daatland 1996). Moreover, traditional familial obligations are changing in China (Cooney and Di 1999); consequently, there may not be sufficient

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informal care-givers in future to fulfil the needs and expectations of the ageing population. Exacerbating the problem is the fact that the existing informal care-givers cannot be given sabbaticals from their endless caring obligations (Tornstam 1992). The lack of available care-givers at a point in time may induce the utilization of formal care services (Tennstedt, Harrow and Crawford 1996). Therefore, the continued support of family and friends as unpaid carers is very crucial to many elderly persons as well as the health care services (Ebrahim 1997). Undoubtedly, without sufficient social support networks, those with poor health or certain kinds of disabilities will lean less upon informal care but more on formal care to supplement informal support (Cooney and Di 1999; Long 1995).

1 Conclusion In this study, we observed that most of the elderly utilized both formal and informal care. Formal care-users relied more on medical and health services than 'community support services'. Those who relied mainly on formal care had a lower level of health-related quality of life measures, while those who relied mainly on informal care had a higher score of those measures. As for the factors affecting these care patterns, the study suggested that the health condition of the elderly respondents was a crucial determinant for their patterns of formal care. The perceived adequacy of social support was also an influential factor for utilizing formal as well as informal care. In fact, the perceived adequacy of social support affected not only the utilization of formal care, but also informal care patterns. Many family members provided practical and/or emotional support to their elderly relatives who resided with them. However, the role-relationship among elderly couples tended to be more functional than emotional. Receiving emotional support from persons outside the marital relationship was associated with higher levels of perceived quality of life. This suggests that spousal care was mainly targeted on practical assistance rather than emotional support. The cost of care corresponded with the elderly person's health status. Hence, supportive services are needed for care-givers in order to prevent burn-out and to ensure continuity and quality of care for the elderly. Finally, cross-sectional studies of this kind have some major limitations. This study cannot show the direction of the association between health-related quality of life and types of care delineated in this study, nor can it show any change in informal care as a result of the introduction of formal care (Long 1995). It also cannot explain how and under what circumstances elderly persons start using formal care (Crets 1996). A longitudinal study is needed so that more insight into the relationship between

HEALTH AND CARE UTILIZATION PATTERNS OF ELDERLY PERSONS IN HONG KONG

health-related quality of life a n d the utilization of aged-care services can b e obtained.

1 References Avison, A.W., R. Turner, S. Noh and K.N. Speechley. 1993. The impact of caregiving: Comparisons of different family contexts and experiences. In Caregiving systems: Formal and informal helpers, eds. Zarit, S.H., L.I. Peralin and K.W. Schaie. 7 5 105. New Jersey: Lawrence Erlbraum Associates. Bury, M. 1997. Health and illness in a changing society. London: Routledge. Cantril, H. 1965. The pattern of human concerns. New Brunswick: Rutger University Press. Chappell, N.L. 1995. Informal social support. In Promoting successful and productive aging, eds. Bond, L.A., S.J. Cutler and A. Grams. 171-85. Thousand Oaks, Calf.: SAGE. Chen, X. and M. Silverstein. 2000. Intergenerational social support and the psychological well-being of older parents in China. Research on Aging 22 (1): 43-65. Cheng, Y.H., I. Chi, K.W. Boey and L.S.F. Ko. 1996. Community care and the elderly in Hong Kong: Health-related quality of life and service utilisation patterns. Hong Kong Journal of Gerontology 10 (supplement): 355-60. . 1997. An exploratory study on utilisation patterns and costs of aged care in Hong Kong: Implications for formal care in the community. Journal of the Hong Kong Geriatric Society 8 (1): 16-23. Chi, I. and K.W. Boey. 1992. Validation of measuring instruments of mental health status of the elderly in Hong Kong. Hong Kong: Department of Social Work and Social Administration, the University of Hong Kong. . 1994. A mental health and social support study of the old-old in Hong Kong. Hong Kong: Department of Social Work and Social Administration, the University of Hong Kong. (Resource paper series no. 22.) Chow, N.W.S. 1994. Care of the elderly: Whose responsibility? Hong Kong Journal of Gerontology 8 (1): 12-8. Cooney, R.S. and J. Di. 1999. Primary family caregivers of impaired elderly in Shanghai, China. Research on Aging 21 (6): 739-61. Crets, S. 1996. Determinants of the use of ambulant social care by the elderly. Social Science and Medicine 43 (12): 1709-20. Daatland, S.O. 1996. Formal and informal care: New approaches. In Health and mortality among elderly population, eds. Caselli, G and A.D. Lopez. 315-30. New York: Oxford University Press. Ebrahim, S. 1997. Public health implications of ageing. Journal of Epidemiology and Community Health 51 (5): 469-71. Field, D. 1997. Chronic illness and physical disability. In Sociology of health and health care, eds. Taylor, S. and D. Field. 128-48. Oxford: Blackwell Science. Greene, V.L. and P.D. Coleman. 1992. Direct services for family caregivers: Next

253

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BEN C.P. LIU, Y.H. CHENG AND S.M. MCGHEE

steps for public policy. In Family caregiving in an aging society: Policy perspectives, eds. Kane, R.A. and J.D. Penrod. 46-63. Cal.: Sage. Hong, L.K. 1976. The role of women in the People's Republic of China: Legacy and change. Social Problems 23 (5): 545-57. Hong Kong Census and Statistics Department. 1996. 1996 population by-census: Summary results. Hong Kong: Government Printer. . 1997. Hong Kong population projections 1997-2016. Hong Kong: Census and Statistics Department. Hong Kong government. 1994. Report of the working group on care for the elderly. Hong Kong: Hong Kong government. Hong Kong Special Administrative Region. 2000. Social Welfare Department homepage: http://www.info.gov.hk/swd/english/elderly/indexl.htm. 1 April 2000. Hospital Authority. 1996. Hospital Authority: Annual plan 1996-1997. Hong Kong: Hospital Authority. Ikkink, K.K., T. van Tilburg and K.C.P.M. Knipscheer. 1999. Perceived instrumental support exchanges in relationships between elderly parents and their adult children: Normative and structural explanations. Journal of Marriage and the Family 61 (4): 831-44. James, N. 1992. Care = organisation + physical labour + emotional labour. Social Health and Illness 14 (4): 488-509. Jernigan, H.L. and M.B. Jernigan. 1992. Aging in Chinese society: A holistic approach to the experience of aging in Taiwan and Singapore. New York: The Haworth Pastoral Press. Kane, R.A. and R.L. Kane. 1981. Assessing the elderly: A practical guide to measurement. Lexington: Lexington Books. Kelman, H.R., C. Thomas andJ.S. Tanaka. 1994. Longitudinal patterns of formal and informal social support in an urban elderly population. Social Science and Medicine 38 (7): 905-14. Khaw, K.T. 1997. Healthy ageing. British Medical Journal 315: 1090-6. Lewis, J. and B. Meredith. 1989. Contested territory in informal care. In Growing old in the twentieth century, ed. Jefferys, M. 186-200. London: Routledge. Li, J. and R. Fielding. 1995. The measurement of current perceived health among Chinese people in Guangzhou and Hong Kong, Southern China. Quality of Life Research 4: 271-8. Litwin, H. and GK. Auslander. 1990. Evaluating informal support. Evaluation Review 14 (1): 42-56. Long, S.K. 1995. Combining formal and informal care in serving frail elderly people. In Persons with disabilities: Issues in health care financing and service delivery, eds. Wiener, J.M., S.B. Clauser and D.L. Kennel. 245-66. Washington: The Brookings Institution. Lui, M.H.L. and A.E. Mackezie. 1999. Chinese elderly patients' perceptions of their rehabilitation needs following a stroke. Journal of Advanced Nursing 30 (2): 3 9 1 400. McNamee, P., B.A. Gregson and D. Buck. 1999. Costs of formal care for frail older people in England: The resource implications study of the MRC cognitive function and ageing study. Social Science and Medicine 48 (3): 331-41. Melzer, D., B. McWillams, C. Brayne, T.Johnson and J. Bond. 1999. Profile of disability

HEALTH AND CARE UTILIZATION PATTERNS OF ELDERLY PERSONS IN HONG KONG

in elderly people: Estimates from a longitudinal population study. British Medical Journal 318 (7191): 1108-11. Ming Pao Daily News. 20 September 1999. After 50 years, four in ten are old. A2. (In Chinese.) Nolan, M., G. Grant and J. Keady. 1996. Understanding family care: A multidimensional model of caring and coping. Buckingham: Open University Press. Parker, R. 1981. Tending and social policy. In A new look at the personal social services, eds. Goldberg, E.M. and S. Hatch. 26-30. London: Policy Studies Institute. Pearlin, L.I., J.T. Mullan, SJ. Semple and M.M. Skaff. 1990. Caregiving and the stress process: An overview of concepts and their measurement. Gerontology 44: SI 7 7 82. Rimer, S. 27 November 1999. Study details sacrifices in caring for elderly kin. New York Times, section A. Russell, J.A. and M.S.M. Yik. 1996. Emotion among the Chinese. In The handbook of Chinese psychology, ed. Bond, M.H. 166-88. New York: Oxford University Press. Slivinske, L.R., V.L. Fitch and N.W. Wingerson. 1998. The effect of functional disability on service utilization: Implications for long-term care. Health and Social Work 23 (3): 175-85. Stein, C.H., V.A. Wemmerus, M. Ward, M.E. Gaines, A.L. Freeberg and T.C. Jewell. 1998. 'Because they're my parents': An intergenerational study of felt obligation and parental caregiving. Journal of Marriage and the Family 60 (3): 611-22. Stone, R.I. and P.F. Short. 1990. The competing demands of employment and informal caregiving to disabled elders. Medical Care 28 (6): 513-26. Swane, C.E. 1999. The relationship between informal and formal care. In Long-term care for frail older people: Reaching for the ideal system, eds. Campbell, J.C. and N. Ikegami. 49-53. Tokyo: Springer. Tennstedt, S., B. Harrow and S. Crawford. 1996. Informal care vs. formal services: Changes in patterns of care over time. Journal of Aging and Social Policy 7 (3/4): 71-91. Tornstam, L. 1992. Formal and informal support to the elderly in Sweden. In Family support for the elderly: The international experience, eds. Kendig, H.L., A. Hashimoto and L.C. Coppard. 138-46. New York: Oxford University Press. Unger, J.B., G McAvay, M.L. Bruce, L. Berkman and T. Seeman. 1999. Variation in the impact of social network characteristics on physical functioning in elderly persons: MacArthur studies of successful aging. Journal of Gerontology: Series B 54B (5): S245-51. Victor, C.R. 1997. Community care. In Continuing care for older people, ed. Denham, M.J. 131-48. Cheltenham: Stanley Thornes (Publishers) Ltd. Walker, A. 1993. Community care policy: From consensus to conflict. In Community care: A reader, eds. Bormat, J., C. Perieva, D. Pilgrim and F. Williams. 204-26. Basingstoke: Macmilllan. and L. Warren. 1996. Changing services for older people. Buckingham: Open University Press. Walter-Ginzburg, A., T. Blumstein and A. Chetrit. 1999. A longitudinal study of characteristics and predictors of perceived instrumental and emotional support among the old-old in Israel. International Journal of Aging and Human Development 48 (4): 279-99.

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Wenger, G.C. 1996. Social networks and gerontology. Reviews in Clinical Gerontology 6: 285-93. Wu, S.C, S.Y. Leu and C.Y. Li. 1999. Incidence of and predictors for chronic disability in activities of daily living among older people in Taiwan. Journal of American Geriatric Society 47 (9): 1082-6. Young, J., A. Brown, A. Forster and J. Clare. 1999. An overview of rehabilitation for older people. Reviews in Clinical Gerontology 9/2: 183-96. Zarit, S.H. and L.I. Pearlin. 1993. Family caregiving: Integrating informal and formal systems for care. In Caregiving systems: Informal and formal helpers, eds. Zarit, S.H., L.I. Pearlin and K.W. Schaie. 273-92. New Jersey: Lawrence Erlbaum Associates, Publisher.

1 Note 1.

According to the classifications from the Working Group on Care for the Elderly (Hong Kong government 1994) and the Hospital Authority (1996), formal services can be grouped under four categories: a. Community Support Services: to promote the well-being of the elderly in all aspects of their life through provision of a wide spectrum of services (such as Home Help Service, Day Care Centre for the Elderly, Social Centre for the Elderly and Multi-service Centre for the Elderly) to enable them to remain members of the community as far as possible (Hong Kong Special Administrative Region 2000); b. Primary Care: refers to the patient's first point of contact with the health care system, services such as General Out-patient Clinic and General Practitioners (both Western and Chinese medicines); c. Secondary Care: refers to the more specialized and complex medical care, such as Hospital Care and Specialist Out-patient Clinic; d. Extended Care: services aim to provide medical rehabilitation to the disabled, chronically ill and elderly, such as Geriatric Day Hospital and Community Nursing Service. Concerning informal care, physical labour for the elderly dependent is the most obvious and visible form of assistance. However, caring may also involve emotional labour (James 1992) and loving attention (Lewis and Meredith 1989). The role of emotional and affective components is central to care-giving (Nolan, Grant and Keady 1996). Therefore, informal care can be divided into two types of care: practical assistance such as helping in doing family chores by those coresiding or not co-residing persons; and emotional support such as feeling at ease to talk to and gaining emotional support.

Index

absence of disagreement 8, 9 Activities of Daily Living (ADL) 3, 60, 72, 101, 227, 243, 256 activity status 37, 42 theory 93 additive model 190 adjustment 8, 98 age, differences in 132 ageing in place 17, 22, 142, 222, 225 Asian Americans 54, 55, 64 buffering effect (model) burden of being 2

190, 198, 199

care -givers 19, 174 groups 184 -receiving 1, 3, 21, 29, 154, 217, 246, 249-51 support 2-4, 19, 191 utilization 148, 152, 180, 222, 2 4 1 53

Center of Epidemiological Study's Depression Scale (CES-D), The 101, 107-9, 192 Chinese Americans 53-64 culture 2, 5, 8, 43, 44, 46, 67, 125, 126, 154, 167, 223, 224, 250 immigrants 79, 222, 224, 238 chronic conditions 72, 76-8, 92, 139-40 diseases 69, 100, 106-9, 118, 13940, 189, 191-8 church 6, 10, 82, 154, 157 cognitive functioning 153, 162, 239 community care 17, 18, 20-4, 27, 29, 90, 144 service 19-21, 24, 27, 29, 31, 82, 83, 90, 91, 97, 98, 111, 120, 140, 141, 144-8, 171, 172, 182, 183, 185, 186, 221-7, 232-6, 245, 246, 249, 250, 252, 256 confidant "relationships (confidante) 29, 58, 59, 77, 78, 191, 229

258

INDEX

Confucius 32, 127, 135 continuity of care 251, 252 co-residence 54, 176, 202-5, 207, 211, 213, 215-8 country of origin 55, 63, 160, 165, 167 cross-cultural comparison 151, 153 culture of bird-keeping 37, 38, 47 Current Perceived Health-20, The 2 4 3 9 death 3, 18, 90, 139, 144, 155, 157, 172, 175 demographic characteristics 4, 19, 38, 101-5, 138, 146, 151, 152, 158, 167, 171-3, 177, 193, 194, 206, 207, 218, 228, 244 dependency 6, 10, 11, 23, 24, 166, 223 ratio, elderly 172 depression 2, 25, 26, 69, 70, 108-10, 152, 166, 189, 190, 192-8 determinants 1, 12, 24, 60, 61, 69, 137, 152, 153, 160, 166, 202, 203, 248 disability 63, 77, 78, 101, 139, 140, 152, 223, 235, 241 diseases, number of 160, 162-5, 167 economic development 36, 97, 98 elderly Asians 67, 221, 222, 238 emotional support 8, 86-8, 90, 104, 146, 191, 195, 197, 198, 203, 205, 206, 212-5, 217, 246-8, 250-2, 256 equity theory 2, 9 family activities 39, 41, 47 mediation 179, 184 obligations 32, 175-7, 179, 185 relations 72, 75, 76, 203 responsibilities 72, 75, 76 support 22, 23, 60, 63, 85, 86, 88, 89, 103, 110, 141, 153, 171, 172, 174, 176, 180, 185, 186, 202, 204, 222, 224 filial obligations 175, 176, 184 piety 2, 17, 32, 39, 41, 42, 46, 52, 54, 125, 126, 132-5, 146, 167

J responsibility 54, 251 financial support 39, 86-8, 101, 110, 129, 141, 146, 182, 191, 195, 197, 204-6, 212, 214, 215, 217 formal care 27, 181, 241, 242, 244-6, 248-52 formal services 164, 241, 242, 245, 248, 251, 255, 256 friendship, feelings about 13, 72, 75, 76,91 functional health 100, 101, 107, 109, 110, 243 Geriatric Depression Scale (GDS) 20, 25,26 gender, differences in 60-2, 73, 74, 99, 100, 110, 132, 133, 158, 173, 207, 210, 214, 224 guanxi 223, 224, 228, 229, 230, 231, 234, 235 health beliefs 161 Perception Questionnaire 84 problem 72, 140, 162, 165, 167, 189, 190, 191, 195, 197, 198, 249 status 70, 84-6, 88, 89, 98, 100, 146, 149, 152, 153, 166, 241, 252 healthy ageing 97 helplessness (hopelessness) 10, 11, 28 help-seeking 103, 235, 236 homes for the aged 146, 154, 176, 177, 180-3, 185, 186, 225, 237 hospitalized 161 housing 26, 44, 47, 48, 51, 70, 72, 75, 76, 86, 88, 97, 110, 128, 129, 130, 148, 174, 175, 179, 204, 206, 216, 221-36, 239 immigrants (immigration) 2, 3, 7, 8, 11, 12, 42, 53-5, 64, 78, 79, 160, 165, 166, 221, 222, 224, 238 income 6, 11, 26, 46, 51, 55, 69, 73, 76-8, 89, 98, 101, 102, 110, 120, 121, 127, 141, 143, 146, 171, 173-5, 181, 182, 184, 206, 222, 227, 232

INDEX

independent living (resources) 1-3, 6, 10, 11, 13, 24, 26, 4 1 , 69, 97, 98, 175-7, 204, 207, 208-16, 249 informal care 19, 90, 166, 241, 242, 244-52, 256 institutional care 20, 22, 24, 28, 31, 146, 181, 184, 185 Instrumental Activities of Daily Living (IADL) 72, 243 integration programme 138, 147 intergeneration 7, 11, 36, 54, 55, 120, 204, 207, 251 isolation 1, 2, 6, 7, 98, 152, 161, 1635, 167 leisure 48, 90, 91 life expectancy 81, 116, 138, 139, 172 satisfaction 3, 12, 4 1 , 46, 48, 67, 69-79, 84-9, 93, 146, 222 Satisfaction Index (LSI) 74-7, 84-8 stress 2, 90, 153, 189-91, 195, 198, 251 lifelong health education 118 living alone 11, 22, 55, 57, 58, 72, 73, 76, 86, 88, 102, 106, 141, 144, 184, 241 arrangements 55, 57, 58, 67, 69, 74, 76, 100, 102-6, 140-2, 158, 176, 201-17, 246, 250 standards 69, 138, 143, 184 loneliness 2, 6, 7, 92, 163, 166, 167 long-term care 17-23, 25, 27-9, 31-4, 137, 138, 140-8, 171, 225, 249, 250 Lubben Social Network Scale (LSNS) 59, 60, 100, 105, 109, 191, 195, 206 married children 177, 202-5, 207, 208, 209-13, 215, 216 medical symptoms 189, 191-5, 197, 198 medication 151-3, 156, 157, 159-61, 163-7 mental health 11, 12, 23, 25, 69, 72, 189, 190

259

Minimum Data Set for Home Care (MDS-HC) 153-6 modernization 36, 126, 209, 211, 216 mood disorder 190 moral education 119, 125, 126 multiculturalism 221-3 natural helpers 228, 233 neighbourhood 110, 111, 143, 179, 180, 182-6 new towns 9 7 , 9 8 , 100, 110, 111 urban areas 70, 201-5, 207-9, 211, 215-8 nursing facilities 121 one-child certificates 115, 116 elderly 116 policy 115, 116, 178 pain symptoms 161, 164 parents' wishes 127, 128, 131, 133, 135 pension 6, 26, 51, 69, 73, 89, 101, 120, 122, 173, 176, 178 physical health 6, 7, 100, 107, 162, 165, 167, 189-91, 195, 197, 198, 251 polypharmacy 151, 156, 159, 163, 166, 167 population ageing 81, 93, 137, 138, 241 practical assistance 246, 248, 249-51, 256 primary care 256 productive ageing 82, 93 quality of life 35, 36, 67-71, 78, 79, 90, 97, 98, 100, 106-11, 122, 142, 148, 149, 242-53 Quality of Life Ladder (QoL) 243 recreation activity 72 reciprocate 2, 3, 9, 10, 126, 134 Retired Senior Volunteer Program, The 82 retirement 35, 43, 46, 47, 68, 69, 82, 90, 92, 122, 171, 174

260

J

INDEX

risk factors

248

saving 6, 73, 101, 120, 176 secondary care 256 self-help groups 84, 91, 95 senior volunteerism 82 Service Corps of Retired Executives 82 sex ratio 99, 173 Shanghai 68, 69, 116, 118, 119, 120, 172, 174, 177, 181, 190, 200, 205, 209, 210, 214, 219, 228 Short-Portable Mental State Questionnaire 243-9 social assistance 183 development 116 integration 3, 55, 91, 92, 221 policy 17, 18, 20, 22, 27, 28, 32, 53, 54, 90, 94, 115, 116, 123, 126, 138, 142, 145-8, 151, 172, 175, 178, 185, 186, 201, 222, 223, 225, 226, 231, 242 security 138, 143, 171, 174 support 17, 19, 20, 28-30, 32, 35, 5 3 6, 58-61, 63, 65, 67, 69, 70, 72, 7 7 9, 81, 90, 92, 97, 98, 100, 103-6, 108, 110, 137, 138, 140, 146, 151, 153, 166, 167, 185, 189-91, 195, 197, 198, 222, 235, 242, 249, 250, 252 socialization 186

socio-economic status 37, 42, 46, 51, 52, 77, 78, 100 somatic symptoms 100, 106, 107, 109, 110 stratified random sampling 21, 99 successful ageing 48 Suzhou 67-79, 113, 190, 200, 205, 209, 210, 214, 219 Taiwan 125, 137-48, 160, 238 Third Age 93 tongxiang 229, 230 traditional Chinese medicines 152 unemployment 174, 178 uniform groups 84 un-self-care period 118 urbanization 97, 98, 111, 116, 201, 202, 207, 216 value 2, 5, 7, 13, 51, 54-6, 61-3, 67, 90, 134, 135, 142, 143, 146, 185, 207-9, 211, 229 Victoria 67-78 welfare society 174 Western medicines 152, 153, 156, 157, 159, 161, 166 xiao

125, 132, 135