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Well-Being of Caregivers to Older Adults in China

Weiyu Mao's project examines the current policies on care giving in China as well as the challenges and opportunities that family caregivers and their elderly recipients face.

November 28, 2010


Caregiving is based on “a reverence for life” and human beings are encouraged to perform at their personal best according to their mental and physical capacity. One primary aspect of caregiving activity is functional status maintenance, promoting an individual’s physical, emotional, intellectual, and spiritual independence (Bridges, 1995, p.13, as cited in Vitaliano, Zhang, & Scanlan, 2003). Families have long been recognized as the primary source of care for human beings in the inevitable times of dependency—infancy, illness, and disability (Marks & Lambert, 1997).

Due to contemporary social demographic trends, there is a greater probability that family members will become caregivers to older adults. Those trends include an increased human life expectancy, declining fertility rates and an aging world population; prevalent chronic illnesses and health conditions resulting in the need for long-term care; and greater orientation toward home care over institutional care in health care policy (Marks & Lambert, 1997).

These trends together pose a serious challenge for caregiving in aging society. In China, the number of people aged 60 or above is growing rapidly; by the year 2050, elderly people will skyrocket to 459 million, account for approximately one-third of the total population (He, Sengupta, Zhang, & Guo, 2007). The notion of taking care of older adults by family has been reinforced by the Family Law (1980) and the Law of the People’s Republic of China on Protection of the Rights and Interests of the Elderly (1996). Both state family care provided by spouses, adult children, and grandchildren to older adults is obligatory and if not fulfilled by them, penalization will take place (Bartlett, & Phillips, 1997;, 1996).

Due to strict implementation of one-child policy in the mid-1980s, family sizes are decreasing tremendously, the “4:2:1” paradigm stands for family structures in upcoming decades which consist of four grandparents, two adult children and one grandchild (Flaherty, Liu, Ding, Dong, Ding, Li, & Xiao, 2007). More elders need care while there are fewer caregivers in the family. Stress and burden will increase tremendously on individual caregivers. In addition, negative influences resulting from family caregiving will jeopardize the well-being of caregivers and elderly care receivers.

The stress process model (Pearlin, Mullan, Semple, & Skaff, 1990) has been consistently found to be a well-organized and evidence-informed conceptual framework in western countries, especially in US (e.g., Goode, 1998; Haley, LaMonde, Han, Burton & Schonwetter, 2003; Son, Erno, Shea, Femia, Zarit & Stephens, 2007; Whitlatch, Schur, Noelker, Ejaz & Looman, 2001). Along with globalization and free flows of human resources, multi-cultural families become more and more common. Effects of cultural differences between China and western countries on stress of caregivers with older adults have drawn much attention in the research arena (e.g., Ho, Friedland, Rappolt & Noh, 2003; Lai, 2007; Patterson, Semple, Shaw, Yu, He, Zhang, Wu & Grant, 1998). On the other hand, only a limited number of studies regarding this issue have been conducted in China. In a few existing empirical studies on stress of caregivers to older adults (Chappell, 2008; Wong, 2005; Zhan, 2002) carried out in China, atheoretical approach and unsystematic conceptual framework is commonly utilized. In this situation, is the stress process model on caregiving developed in western countries is applied in China it will make enormous contribution to cross-cultural comparison and knowledge-building in the caregiving arena.

Given support by the US-China Institute, I was able to do preliminary fieldwork on well-being of caregivers to older adults in China this summer. I went to Beijing, China in mid- June this year and stayed for about a month. The fieldwork started with a visit to the China Research Center on Aging (CRCA), which launched several ground-breaking longitudinal national surveys. The most recent one is entitled Sample Survey on Aged Population in Urban and Rural China. Two waves of data from 2000 and 2006 are now available to public use upon request. The probability proportional to size (PPS) sampling method was used to select twenty provinces. Sample size was 20,000. Respondent rate was 99.8%. Follow-up sample accounted for 49.6% so far due to changes in division of administrative regions.

The survey questionnaire includes socio-demographic information (e. g. gender, age, marital status, education, working experience, income, insurance, housing condition, situation of residential community), family and children (co-residence status, monetary support from children, perception of filial piety, caregiving situation, etc. ), personal life (e. g. instrumental activities of daily living (IADL), activities of daily living (ADL), instrumental support, etc. ), health status (e.g. chronic condition, health service utilization, physical activities, health behavior, etc. ), and opinions about being elderly (e. g., mental health condition, personality traits, life satisfaction, etc.). 

I met with the vice-director of the center, Mr. Ping Guo. He pointed out the importance of in-home care systems for older adults in China: the reinforcement of family caregiving by the Law of the People’s Republic of China on Protection of the Rights and Interests of the Elderly. In addition, he noted the role of traditional cultural values, for example, filial piety which has served as a guideline for children’s behaviors and attitudes toward their parents, and still has far-reaching impact nowadays as well as the prolonged impacts of chronic disease in an aging population and the need for care.

Mr. Guo also mentioned the new care system for older adults in Beijing. This new care system aims to provide supports (e.g., distribute monthly voucher to older adults to purchase services in the community; provide supplemental coverage of out-of-pocket medical fees for oldest old; promote traditional values that respect and care for older adults and the like ) for in-home care and achieve the goal that 90 percent of older adults receive care in their homes, 6 percent of older adults receive care in the community agencies, and 4 percent of older adults receive care in institutionalized settings in Beijing. Even though there were changes in policy towards in-home care for older adults, which could indirectly support family caregivers to some extent, lack of governmental support for family caregivers still exists.

 I went to visit a pioneering community-based home care agency (i.e., Senior Citizen Cooperative) located at a suburban area in Beijing. Five staff members and a group of volunteers run this grass-rooted non-government agency. The mission of agency is to improve quality of life among disadvantaged older adults. Ford Charity Foundation and Community Care Partnership Grant currently fund it. Programs provided by the agency include community centers for older adults, cooperative program for low-income female older adults (i.e., providing small grants, subsidies, and assistance), and volunteer program (i.e., pair up volunteers with impoverished senior citizens to provide daily care and relieve psychological stress, in turn, learn life experiences from older adults).

I met Director Chuanzi Xu for the in-home service program during the agency visit and asked her about situations of older adults using in-home care services. She said that, from her observation, older adults who use in-home services, have children who are more likely to be 50 to 60 years old. These adult children encounter conflicting roles as children, spouses, and even grandparents, and do not have time and energy to take care of their elderly parents, especially when they do not live together.  Their children are more likely to suffer from debilitating diseases themselves and have difficulties in taking care of their elder parents. Those children co-reside with their parents have limited time to provide care to their elder parents. On the other hand, their parents tend to provide instrumental support for their children. In addition, their children are more likely to be reluctant to shoulder their responsibilities to take care of their elderly parents when they have more than one sibling.
I also went to visit a privately-owned nursing home and had an opportunity to talk to a couple, Ms. and Mr. Chu who lived there. They are relatively healthy and barely have any difficulties in handling their activities of daily living. Mr. Chu is in a better health condition than Ms. Chu. Though Ms. Chu has had two operations to remove tumors in her head, she is still quite independent. Their elder daughter who lives close to them used to take care of them—preparing meals, doing laundries, cleaning room, making doctor appointments, and so on.  However, Ms. and Mr. Chu thought it was too hard for their daughter to balance caregiving tasks and her job and other familial responsibilities such as raising her children and wanted to relieve her burden of caring for them. Therefore, they considered moving into a nursing home would be beneficial for both couple and her daughter. Her daughter refused to put them in a nursing home at first due to her strong sense of practicing filial piety. However, they insisted going to a nursing home and reasoning with her daughter about potential benefits. Then, they came to the nursing home and were satisfied with the services provided by friendly staff members. Their daughters come to visit them often when they have some time off from work. From this anecdotal case, we can see cultural values not only influence who should care for elderly parents in China, but also affect the utilization of formal caregiving services. 

On July 14th and 15th, I attended the International Forum on Chinese Gerontology, which was co-hosted by Renmin University of China, Peking University, and Gerontological Society of China (GSC), funded by the United Nations Population Fund (UNFPA). The theme of the conference was promoting collaboration to advance Chinese Gerontological studies— dialogue between Chinese and Oversea Researchers.  During the conference, I paid attention to caregiving-related policies and research. At the policy level, the Chinese government encourages family caregiving and home care for older adults and aims to build a comprehensive care system and create a platform for family, government, private market, and society to work together. During the conference, I met Dr. Zhe Tang from Xuanwu Hospital, who was working in the geriatric field. I found that he and colleagues had conducted a longitudinally designed survey with a focus on aged population in Beijing since 1992. This multi-dimensional survey included socio-demographic information, family and social network (including family caregiving items), attitudes towards aging, psychological health, and physical health status (perceived health and chronic conditions) and so on. The quality of the data was good and had been used in peer-reviewed papers. It is a potential source for my future research.

During the conference, I also met Dr. Vivian Lou from the Hong Kong University. Her research interest is in caregiving among Chinese older adults. Her research team has conducted a cross-sectional survey funded by the Research Grants Council (RGC), which aims to understand well-being of informal caregivers and frail elderly care recipients by adopting an ecological perspective this year. They have collected data in Shanghai. Screening questionnaire for older adults included hearing ability, cognitive ability, literacy level, ADL, and relationship with caregiver. They collected information on socio-demographic information, health status, family and social support from elderly care recipient and caregiving specific information (e.g. role strain, coping style, family and social support, physical health, depressive symptoms, life satisfaction) from informal caregivers. Since her dataset is highly relevant to my research interest, I talked to her about collaboration in future research and came up with several topics using her dataset. 

To sum up, it was a very fruitful and meaningful month in China. Supported by US.-China Institute, I have successfully finished my project goal, networking with national research center, reviewing relative archives and dataset, visiting related agencies, and seeking potential collaborators for future research. In terms of those efforts, I have learned a great deal on current policies in China, seen challenges and opportunities that family caregivers and their elderly recipients face, and sought out potential collaboration opportunities. Moreover, I think the stress process model developed in western countries could serve as a useful theoretical framework in Chinese context. Modifications will be needed to match Chinese culture. For instance, how filial piety, the traditional value rooted in Confucianism as the guide for children’s behaviors and attitudes toward their parents, plays a role in the caregiving context guided by the stress process model is an important research question in cross-cultural research.

Click here to view projects of other 2010-2011 USCI Graduate Summer Fieldwork Grant receipients.