Abstract
Cultural values are believed to influence perceptions of and solutions to elder mistreatment (EM) perpetrated by family members. This study aimed to understand the influence of family cohesion on EM reported by community-dwelling older Chinese Americans. A mixed-method approach consisting of a quantitative survey built on focus group interviews was utilized. Focus group interviews were conducted to ensure subsequent survey questions about EM were culturally and linguistically appropriate. The revised survey questionnaires were then administered to 266 Chinese American older adults to assess estimated EM prevalence and the effects of family cohesion. Survey findings indicate that 1 in 10 reported at least one occurrence of EM in the past year. Depressed Chinese older adults (OR= 1.14) and those reporting low levels of family cohesion (OR = .82) were more likely to experience EM. Multigenerational family interventions can be designed to reduce older adults’ depression levels and promote family cohesion.
Elder mistreatment (EM) severely threatens the well-being of older adults across ethnic groups in the United States. As Chinese Americans tend to emphasize familism and interdependence (Dong, Chang, Wong, & Simon, 2012), their own definitions of EM perpetrated by family members may subject to these values, whose effects on EM remain unexamined. EM is defined as a general term to incorporate “elder abuse” (e.g., physical, emotional, and financial maltreatment) and “elder neglect” (e.g., lack of attention or minimum care), resulting in a severe threat to the physical and psychological well-being of older adults across ethnic groups (Cooper, Selwood, & Livingston, 2008; Dong, Chang, Wong, Wong, & Simon, 2011; World Health Organization, 2011).
Abundant literature on EM among American older population has existed. It is estimated that 1 in 10 older adults in the United States have experienced some sort of EM (Acierno et al., 2010). Individual risk factors of EM include younger age (Acierno et al., 2010; Laumann, Leitsch, & Waite, 2008), being female (e.g., Dong, Simon, & Evans, 2009), poor health (Dong et al., 2009; Laumann et al., 2008), and having Alzheimer disease or related dementia (Lachs & Pillemer, 2004). Interpersonal variables of EM include older adults’ dependency (Burnight & Mosqueda, 2011), living with a large number of family members (Lachs & Pillemer, 2004), and lack of social support (Acierno et al., 2010). To the best of our knowledge, the association between family cohesion and EM has not been examined among Chinese and other ethnic populations in the United States. However, the protective effect of family cohesion in EM has been reported in a study of older adults from Asian India (Chokkanathan, 2014).
The literature on EM of Chinese American older adults is limited. We identified one group of researchers who has exclusively focused on the EM experiences of Chinese Americans. Dong et al. (2011) used focus groups to explore perceptions of EM among Chinese American older adults. They found that caregiver neglect was the most prevalent form of EM and psychological mistreatment was the most serious form of EM. In a later survey study of 3,159 Chinese older adults living in Chicago, Dong (2014) found that about 24% had experienced some form of EM, 10% for psychological mistreatment, 5% for caregiver neglect, and 1% for physical mistreatment. Associated factors of EM included older age, higher levels of education, fewer number of children, and poor health (Dong, 2014). These two studies shed some light on EM among this population, but left the associations between family factors, cultural factors, and EM unexamined.
Chinese Americans are the second-largest ethnic minority group and the largest Asian group in the United States (U.S. Census Bureau). As about 80% of Chinese American older adults were foreign born (Gallagher-Thompson et al., 2007), they may subscribe to traditional Chinese culture and Confucian teachings that emphasize filial piety. Chinese parents typically sacrifice their wealth raising up children and supporting their education and career development (Cheng & Chan, 2006). In reciprocity, children are obligated to care for their aging parents. The Confucian ideal attaches high importance to the respect and love for parents, which is manifested by adult children showing obedience to parents and providing financial, emotional, and tangible support (Lai, 2009). Thus, it is likely that Chinese older adults may desire higher levels of support and perceive any less to be unacceptable or even abusive. Moreover, immigration to the United States may challenge the norm of a balanced relationship between parents and children in Asian families (e.g., parents losing their authority within the family; Wong, Yoo, & Stewart, 2006). Challenges such as long commutes and the need to rely on personal cars may restrict adult children’s ability to visit their parents as often as it is expected. Because immigrants spend more time on public transit and carpooling than their native-born counterparts (Blumenberg, 2009), relying mostly on public transportation may further exacerbate the perception of abandonment by their parents.
This study aims to examine the influence of family cohesion on EM perpetrated by family members among community-dwelling Chinese American older adults (aged 60 or above). This study took place in the Phoenix metropolitan area with a growing Chinese American population who has yet had access to culturally appropriate supportive resources. Although Arizona has witnessed a rapid growth of the Chinese population in recent decades, it does not have an easily identifiable Chinese ethnic community or Chinatown. This population may be isolated from the mainstream American society, in part due to their lack of English fluency and to their limited access to transportation (Casado & Leung, 2002; Treas & Mazumdar, 2002).
The ecological systems theory (Bronfenbrenner, 1992) provides an appropriate framework to examine interpersonal and sociocultural variables in the context of EM. The connection with families is a crucial factor for Chinese American older adults, a key variable examined in this study. Similar to the importance of “familismo” in Latino culture, family cohesion is emphasized in Chinese culture which “traditionally defines one’s role and responsibility in relation to others” (Dong et al., 2012, p. 3). The influence of “familismo” on EM is typically measured through a family cohesion scale in the Latino sociocultural EM model (Leidy, Guerra, & Toro, 2010). This model goes beyond the traditional focus on individual risk factors (e.g., gender) and extends to factors on a sociocultural level (e.g., family cohesion). It considers family dynamics that directly or indirectly affect older adults. Similarly, family cohesion and Chinese cultural beliefs promote sense of family such as “filial piety” and interdependence (Cheung, Lee, & Chan, 1994). Due to the similar reliance on family in both cultures, we hypothesize that strong family cohesion is a protective factor against EM for Chinese American older adults.
In light of the described sociocultural model, this study aims to (a) identify the estimated prevalence of EM (general EM, elder abuse, and elder neglect) perpetrated by family members among Chinese American older adults; and (b) the direction and strength of associations between family cohesion and EM. We formed an overall hypothesis that the level of cohesion present in the family system would be negatively associated with general EM, elder abuse, and elder neglect.
Method
This is a pilot study in nature but we believe findings for this study or perhaps lessons learned from this study can be enlightening to fellow researchers in the field. In Phase I, focus groups were conducted in order to help refine subsequent survey questions so that questions were culturally and linguistically appropriate. Feedback from focus groups was used to better operationalize EM and create questions assessing EM in a participant self-administered survey. In Phase II, finalized questionnaires were distributed to 266 Chinese American older adults to detect estimated EM prevalence and to test the effects of family cohesion on reported EM.
In Phase I, the first author facilitated four focus groups (i.e., three Mandarin-speaking groups and one Cantonese-speaking group). Self-selected pseudonyms were used throughout the focus group discussions. Draft EM assessment questions were derived from existing scales including the revised Conflict Tactics Scales (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996), Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST; Hwalek & Sengstock, 1986), Acierno’s nationwide survey (Acierno et al. 2010), and Dong’s EM scales (e.g., Dong, 2014; Dong, Simon, & Gorbien, 2007) were read to participants to ensure appropriate wording in Chinese, and all possible indicators of EM were included.
Participants were purposively recruited from the Phoenix Chinese Senior Center, senior apartments, diverse religious institutions, community events, and social clubs for seniors. Recruitment flyers were distributed to prompt self-referrals. To be eligible for this study, participants needed to be 60 years old or older, self-identified as Chinese American, be able to communicate either in Mandarin or Cantonese, and live in a residential setting in the Phoenix metropolitan area.
Each focus group was comprised of six participants, with gender differences and educational variability taken into consideration. In light of a similar approach used in a previous survey in Phoenix (Sun, Gao, & Coon, 2015), each focus group (n = 6) had at least three women, one to two older adults with fewer than 12 years of education, one to two older adults with high school education or some college, and one to two college graduates (or higher levels of education).
Four brief vignettes related to physical, emotional, financial mistreatment, and neglect were presented to solicit the participants’ reflections. Brief vignettes were developed by the research team in light of suggestions of local adult protective service workers who have experience dealing with elder abuse and neglect. Each vignette represents a serious EM case scenario. EM can be a subjective feeling depending on individuals’ perceptions and it is important to allow older adults to define EM in the focus group discussions, but this may also generate some biases due to inconsistency and variations in individuals’ subjective experiences. The investigator emphasized the distinction between culturally inappropriate behaviors (e.g., calling you by name rather than by appellations, such as grandpa, grandma, dad, and mom) and abusive behaviors (e.g., yelling at you so that you felt threatened). Participants were made aware that culturally inappropriate behaviors should not be classified as EM. Each focus group spent one and a half hours on discussions. All focus groups were conducted in December 2014 at two senior apartments with mainly Chinese older adult residents. Focus group interviews were tape-recorded and transcribed. The most frequently emerged indicators in their EM discussions were added to the assessment tool used in later surveys.
Quantitative Component (Phase II)
Building on the findings of the focus group discussions, the most frequently mentioned indicators and risk factors of EM occurrence were incorporated into the questionnaire. Revised questionnaires reviewed by the research team were pilot-tested with six Chinese older adults before the instrument was finalized and distributed to survey participants. Bilingual student interviewers volunteered to collect survey data after 3 hours of training provided by the first author. The first author ensured that they understood the rights of participants, the aims of the study, the survey content, and possible barriers of surveying Chinese American older adults (e.g., hearing problems, feeling ashamed to disclose EM experiences). Generally, surveys were completed by the older adults themselves and were not administrated by interviewers in order to keep a safe environment for the disclosure of EM experiences. However, interviewers read the surveys to participants who had limited literacy or vision.
Survey Data Sampling and Participants
A purposive sampling design was adopted to recruit Chinese American older adults. For a population that is difficult to reach, purposive sampling is appropriate (Tongco, 2007). Similar eligibility criteria were applied: age 60 years or older; self-identified as a Chinese American; capable of speaking English, Mandarin, or Cantonese; and living in a residential setting in the Phoenix metropolitan area. The sample size for this study was 266, based on the estimation that about eight independent variables would be entered into the logistic regression model and the prevalence rates of general EM among Chinese elders would be around 30% (from 24% to 35%), as suggested by previous literature (Dong, 2013; Dong et al., 2007). This sample is sufficiently powered to detect significant results.
Survey Data Collection
Participants were recruited from similar sources as Phase I. The questionnaire was translated into Chinese using a translation or back translation process to ensure that the questions had the same meaning in different languages (Rogler, 1989). The questionnaire was drafted in English first, and then was translated to both simplified and traditional Chinese characters; and another bilingual translator back translated these versions into English. The first author compared discrepancies across versions and approved the final version. All participants in the survey study read the informed consent letter in Chinese or English approved by the University’s institutional review board. The pilot test (n = 6) and followed survey (n= 266) spanned from December 2014 to April 2015. Majority older adults filled out questionnaires by themselves in either English or Chinese at their homes, the Chinese senior center, or other preferred locations. Only a few who could not read or write due to disabilities or low literacy were interviewed and their answers were recorded by the interviewer. Each survey took about 35 minutes to complete. A list of resources (e.g., the adult protective service hotline and the area agency on aging senior helpline) was provided to participants who were interested in such information.
Measurement in the Survey
Dependent variable
The EM assessment tool included four subscales, including physical mistreatment (two items), emotional mistreatment (three items), financial mistreatment (two items), and elder neglect (three items). Items were derived from CTS2 (Straus et al., 1996), H-S/EAST (Hwalek & Sengstock, 1986), Acierno’s nationwide survey (2010), and Dong’s EM scales (e.g., Dong, 2013; Dong et al., 2007), validated in the focus group discussions, and refined with six Chinese American older adults. All EM items are listed in Figure 1. Survey items asked participants whether these situations happened (yes/no questions) to them in the past year. EM has occurred when participants respond “yes” to one or more items. The EM assessment tool and each subscale were scored dichotomously (1= EM occurrence, 0 = no occurrence) and used for the binary logistic regressions.
Frequency of all EM Indicators.
Independent variable
Family cohesion was assessed by the 10-item Family Orientation subscale of the Chinese Personality Assessment Inventory (CPAI-2; Cheung et al., 1996; Cheung, Leung, Song, & Zhang, 2001). Participants were asked to rate the degree to which they agreed with the statements on the importance of family members (e.g., “I often have serious clashes of opinions with my family”; yes/no). The English and Chinese versions of the Chinese Personality Assessment Inventory have been previously validated (Cheung et al., 1996; Cheung, Cheung, Leung, Ward, & Leong, 2003). Higher scores indicate a higher degree of family cohesion.
Control variables included health and demographics. Physical health was assessed by the seven-item Activities of Daily Living (ADL; Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963) and the eight-item Instrumental Activities of Daily Living (IADL; Lawton & Brody, 1969). The difference is that the IADL scale assesses more complicated daily tasks (e.g., shopping and doing laundry) than the ADL scale (e.g., eating and bathing). Scores of the ADL (Cronbach’s alpha =.90) and IADL scales (Cronbach’s alpha =.87) were calculated separately, with higher scores indicating higher levels of physical impairment. Mental health was assessed by the 12-item Centre for Epidemiological Studies Depression scale (CES-D) to assess depression of older adults and its validity with Chinese Americans has been confirmed (Ying, 1998). Participants were asked to rate on a 4-point Likert scale (from 1 = often to 4 = never), with higher scores indicating higher levels of depression. Cronbach’s alpha of CES-D in this study was .79. Demographic control variables included age, gender, education, living situations, number of children, and income adequacy.
Survey Data Analysis
Survey data were entered into SPSS 22 for analysis. First, very little missing data were present in the entire database and mean substitution was used for data imputation. However, some demographic variables had missing data that were not at random. For example, some participants were unwilling to answer the monthly income question. Missing values for these items were not computed because they were primarily for descriptive purposes and were not entered in the logistic regressions. Three dummy variables were created to indicate the prevalence of EM, elder abuse (including physical, emotional, and financial mistreatment), and elder neglect. Descriptive statistics were used to describe the prevalence rate of general EM and each EM type in the sample. Bivariate analyses, including Spearman correlation and chi-square tests, were conducted to test the associations among variables of interest on the bivariate level and to rule out possible multicollinearity issues. Multiple logistic regressions were conducted to test the hypothesis mentioned earlier. The sample size of 266 has sufficient power to include up to eight variables in the logistical model. A total of eight conceptually related variables, including six demographic variables, depression, and family cohesion, were entered at the same time.
Results
Qualitative Component (Phase I)
In Phase I, the average age of the 25 focus group participants was 75.08 (SD = 6.71). Over 60% were female; the average number of children was two and a half; about 50% of the participants had an education level below 12th grade; one third lived alone; about 15% had poor or fair health. All focus group participants were foreign born and the average years of residency in the United States was about 16 years. English-speaking-only Chinese American older adults were not included because of their inability to communicate with the rest of the focus groups.
Focus Group Results
Focus group participants were unfamiliar with the concepts of EM, elder abuse, or elder neglect. Most participants thought abuse is a strong word in itself and only considered “physical attack” and “no feeding in hunger” as EM. Furthermore, participants denied any current EM occurrence around them. Focus group were able to open up and shared their feedback after vignettes related to physical, emotional, financial mistreatment and elder neglect were presented. Draft EM screening assessment items derived from existing scales were read to participants to ensure appropriate wording and the inclusion of all possible indicators of EM. Culturally relevant and major revisions of EM indicators are listed in Table 1 and described later, while minor linguistic tweaks are not discussed here.
Indicators of Elder Mistreatment.
Emotional mistreatment
For the first indicator, “destroying belongings” of older adults is “an impolite way of expressing anger,” but not abusive. The second indicator “discomfort with family” is an inappropriate indicator of emotional mistreatment, because “it is hard to tell who is the victim in an uncomfortable family relationship,” particularly “when a daughter-in-law does not get along well with her mother-in-law.” One participant added that “children may also feel emotionally abused by the elder parents.”
Financial mistreatment
Participants’ attitudes toward the third indicator were mixed. Whether “demanding goods for services” could be described as abusive depends on the economic status of both sides, whether the family member is U.S.-born, and whether the “family member signed for sponsor for the elder in the immigration process.” If “the elder parents live a wealthy life while the family member lives in poverty,” if the family member is an “ABC” (a term for American-born Chinese), and if the family member is not the sponsor, demanding goods for services is acceptable. The third indicator was deleted from the survey questionnaire because this question did not specify the kind of “services” (e.g., daily care or a ride) or “goods” (e.g., food and cash), nor the status of both parts. The fourth indicator was revised to suit the needs of elder immigrants. Most elder immigrants do not have their own bank account due to language barriers; therefore, they deposit their money under the name of adult children in the United States. To avoid tax and other cost, older adults may transfer properties (e.g., an apartment) or savings they have in the home country (e.g., Mainland China or Vietnam) to their adult children staying in the home country. Older adults may also ask them to collect their pension on their behalf. Elder immigrants are most worried that adult children may not “return” properties or money managed on their behalf.
Elder neglect
Participants responded that the fifth indicator is appropriate only “when an elder lacks language and physical competencies to go shopping or see a doctor alone.” The sixth indicator was very confusing. After it was clarified, “bed bound” was still not considered elder neglect by most female participants. They asked what if the family member made you stay in bed to rest and what if the elder did not know he or she was sick. This sixth indicator was assessed as inappropriate; therefore, it was deleted. Then, the investigator further explored participants’ understanding of elder neglect and explored real cases in the Chinese community. Participants agreed “no visits or calls” from adult children or “no help while in need” were examples of elder neglect.
Quantitative Component (Phase II)
The average age of the survey participants was 76.24 (SD = 7.00). Over 60% were female; the average number of children was two and a half; over 30% had an educational level below 12th grade; one third lived alone; about 15% had poor or fair health levels. Over 80% of the participants were foreign born and the average years of residency was about 18 years. The majority of the survey participants (73%) lived in senior apartments. Demographic differences between those residing in non-age-restricted communities and senior apartments were analyzed. Older adults residing in non-age-restricted communities had higher education levels (t = 5.98, p <.01), were of younger age (t = −2.98, p <.01), and had higher income levels (t = 13.58, p <.01).
Estimated Prevalence Rate of EM, Elder Abuse, and Elder Neglect
In this sample, the self-reported prevalence rates of general EM and elder abuse were 10.2% (27/266) and 8.3% (22/266), respectively. The most prevalent type of EM was elder neglect (5.3%), followed by emotional (4.1%), financial (2.3%), and physical mistreatment (0.4%). Participants reporting a single type of EM accounted for 7.1% while those reporting multiple types of EM accounted for 3.0%. The most prevalent EM indicator was “verbal attack” from family members, followed by “abandonment in public” and “no help while in need.” The least prevalent EM indicators were “physical attack” and “physical restraint” (see Figure 1).
Bivariate Analysis
Spearman correlation analyses indicated that general EM was significantly associated with lower levels of ADL competency (r = −.12, p < .10), higher levels of depression (r = .21, p < .01), and lack of family cohesion (r = −.11, p < .10); elder abuse was significantly associated with lack of family cohesion (r = −.10, p < .10); and elder neglect was significantly associated with lower levels of ADL competency (r = −.10, p < .10) and higher levels of depression (r = .22, p < .01). Chi-square tests indicated that being female, living alone, and living in senior apartments were not significantly associated with general EM, elder abuse, and neglect.
Multicollinearity among independent variables may exist. Among health variables, depression was strongly associated with ADL (r = −.38, p < .01), IADL (r = −.43, p < .01), and self-rated health (r = −.55, p < .01), particularly with a very small sample size. Taking into account the significant associations between depression and EM or elder neglect at the bivariate level, depression was selected as the only indicator of health to avoid multicollinearity. Although the correlation coefficients did not exceed the typical cut-off score (0.80 in most cases), multicollinearity may still exist because bivariate correlations may not reflect multicolinearity and it is difficult to “define a cut-off value that will always be appropriate” (Berry & Feldman, 1985, p. 43), particularly with a small sample size. Taking into account the significant associations between depression and EM or elder neglect at the bivariate level, depression was selected as the only indicator of health to avoid multicollinearity.
Logistic Regression Results
Risk factors of EM
Logistic regression models were run (see Table 2). To ensure the statistical power in logistic regressions, a total of eight variables were put into each model. Lack of family cohesion was positively associated with EM occurrence (OR= .82, p<.05), elder neglect occurrence (OR=.82, p<.10), and elder abuse occurrence (OR=.84, p<.10). Chinese American older adults with higher levels of depression and lower levels of family cohesion were more likely to experience general EM, elder neglect, and elder abuse.
Results of Logistic Regression Analysis.
†p < .10 (2-tailed). *p < .05 (2-tailed). **p < .01 (2-tailed).
Discussion
This study aimed to advance our understanding of EM, an understudied and possibly a hidden social problem among Chinese American older adults. While previous studies have focused on the perception, prevalence, and associated factors of EM among Americans overall, the present study identified elder abuse and elder neglect as two important components of EM and examined the effects of family cohesion on general EM, on elder abuse, and on elder neglect.
Perceptions and Estimated Prevalence of EM
EM, elder abuse, and elder neglect are unfamiliar concepts to Chinese older adults. The uniqueness of Chinese American older adults’ perceptions of EM lies in their understanding of emotional mistreatment and elder neglect. It seems that Chinese American older adults tend to tolerate the conflicts within the families, such as “destroying your belongings,” “uncomfortable relationship,” and “verbal attack without causing serious emotional outcomes.” “Destroying belongings” differs from beating or hitting in that it does not cause body injuries. From the perspective of older adults, it may be a way to divert one’s anger from a person toward an object. However, Chinese American older adults may not tolerate “no help while in need” and “no contacts/indifference” of family members and label such behaviors as elder neglect, which may result from Confucian teaching that emphasizes providing health care, financial support, and showing obedience to parents (Lai, 2009). Showing obedience to parents is an ideal state that older parents aspire to. It is likely that there is a hierarchy of tolerance levels when the ideal state fails to come true. We found the least tolerable behaviors, such as “no help while in need” and “no contacts/indifference,” are considered abusive. The newly revised Elder Rights Protection Laws (2013) mandating the frequent visits or greeting of adult children may also affect Chinese older adults’ perceptions of elder neglect. Moreover, elder immigrants in the United Ststes may lack English literacy and transportation; therefore, their daily lives may heavily depend on the support of family members (e.g., taking the elder shopping or to a doctor). With “no help while in need” and “no contacts/indifference” of family members, elder immigrants may not only suffer from the emotional distress but could also seriously limit their functioning within American society and their access to needed services.
In this study, the estimated prevalence rate of general EM perpetrated by family members was 10.2%, which resonates with the most recent nationwide study on EM in the United States (Acierno et al., 2010). Acierno et al. (2010) reported that the past-year prevalent rate of EM (excluding financial mistreatment) was about 11%, regardless the identity of the perpetrator. In the present study, the prevalence rate of general EM would be much higher if EM perpetrated by strangers or acquaintances were to have been included. The estimated prevalence rate in this study is lower than the one reported by Dong’s study on EM in Chinese American older adults in Chicago (not limited to family perpetrated EM). Dong’s study (2014) with a sizable sample (n = 3,159) found that the prevalence rate varied from 13.9% to 25.8%, depending on the number of “yes” responses to more than 50 EM indicators. Considering that only 10 EM indicators were used in this study, the comparatively lower prevalent rate was not surprising.
In our study, the most prevalent form of EM perpetrated by family members was elder neglect (5.3%), followed by emotional (4.1%), financial (2.3%), and physical mistreatment (0.4%), which appears consistent with Dong’s study (Dong, 2014; Dong et al., 2011).
Associated Factors of EM
Younger age was associated with elder abuse (i.e., emotional, physical, and financial mistreatment), which is consistent with the two nation-wide studies on EM (Acierno et al., 2010; Laumann et al., 2008) but in contrast to previous findings that older age is associated with more EM occurrence (e.g., Dong, Simon, & Evans, 2009; Lachs, Williams, O'Brien, Hurst, & Horwitz, 1997). One possible explanation is that EM within families may be “a long-term pattern of interaction between these individuals, and probably began prior to older adulthood” (Acierno et al., 2010, p. 62). The inconsistent findings may also be explained by the differences in EM definitions and measurement.
Depressed Chinese American older adults were more likely to experience general EM, elder abuse, and elder neglect, in line with previous studies on EM in Mainland Chinese older adults (Dong, Simon, Odwazny, & Gorbien, 2008) and American older adults (e.g., Dyer, Pavlik, Murphy, & Hyman, 2000). It is possible that depressed older adults are emotionally more dependent on family members and their depression symptoms add to the caregiving stress, therefore increasing EM occurrences within families. However, most studies including this one are cross-sectional in nature; thus, the causal relationship between depression and EM could not be confirmed. A possible fact is that EM may result in or worsen depression symptoms (Dong et al., 2008). Further studies are needed in order to explore the pathways of EM influencing depression or vice versa. It is possible that verbal mistreatment and neglect are two EM forms that directly influence depressive symptoms (Yang, 2004).
The hypothesis that Chinese older adults’ family cohesion is negatively associated with EM was supported. Chinese older adults lacking family cohesion were more likely to experience general EM, elder abuse, and elder neglect. These findings provide empirical evidence to support the sociocultural model (Parra-Cardona, Meyer, Schiamberg, & Post, 2007) that highlights the importance of family as an important ecosystem. Chinese American older adults may heavily rely on the interdependence within families and have higher cultural demand for family support. “There is a long history in which the Chinese family functions as a close-knit social unit from which its members draw on each other's resources for meeting psychological, social, and physical needs” (Cheng & Chan, 2006, p. 262). Historically, older adults in China were taken care of by the young family members with “minimal state interventions” (Cheng & Chan, 2006, p. 262). Parents sacrificed for the well-being of their children and in return when they got old, they took for granted that a filial adult child should visit them frequently and provide emotional, financial support, and instrumental support when they were in difficulties. Those expectations may not materialize in American society. For example, with transportation and language barriers, Chinese American older adults may expect to be accompanied by one or more adult children to a hospital or a clinic, rather than using an unknown helper for transportation or translation purposes. When older adults are in financial hardships, they may expect family members to help pay medical bills, rent, or for groceries. Such expectations cannot be met by unsupportive family members or in noncohesive families. For this reason, Chinese older adults under the influence of Confucian teaching may feel neglected by family members.
Implications
The findings of this study implies a need to design and implement health literacy campaigns promoting EM awareness with the goal of preventing, reducing, and eliminating EM and encouraging the reporting of suspected EM. Older Chinese immigrants’ cultural understanding of EM (particularly emotional mistreatment and elder neglect) may not be in line with the American legal systems or American service professionals. Because mandatory reporting or EM laws do not exist in Mainland China and older Chinese immigrants lack awareness about the phenomenon. In educational programs, Chinese immigrant older adults must be informed of such differences as soon as possible to prevent EM. Considering Chinese older adults’ emphasis on family cohesion, family members should also be included in educational programs to understand the cultural needs of elder parents (e.g., frequent visits).
The 10-item EM screening assessment tool developed in this study is both culturally and linguistically appropriate and it may aid Chinese older adults themselves, family members, and service professionals to quickly identify the incidence of EM among Chinese American older adults. Multigenerational family interventions can be designed to strengthen family cohesion. Culturally grounded interventions that emphasize the assets of the culture while helping participants identify risks can have a preventive effect on EM in the Chinese American communities.
Future research may use the screening assessment tool developed in this study and replicate the study in other cities or rural areas in the United States. The validity and reliability of this EM screening assessment tool may also be tested in Mainland China. The screening assessment tool may be revised after taking into account the ethnic and rural–urban differences in perceptions of EM in Mainland China. The 10-item screening assessment tool (yes or no responses) is a simple and quick way to detect EM in practice settings. Future studies may develop a more comprehensive scale to systematically detect EM among Chinese and Chinese Americans.
This study has several limitations. First, this is a cross-sectional pilot study, neither epidemiological nor etiological. Given its nature, we cannot draw definitive conclusions about cause and effect. In future studies, a longitudinal research design is needed to include the possible predictors and outcomes of EM. We also recommend a full-blown mixed methods study be conducted to examine EM among ethnic minority groups to gain a deeper understanding of the impact of sociocultural factors. Second, this study used a nonrandom sampling strategy to recruit Chinese older adults in [BLIND REVIEW]. The sample may not be representative and have certain level of selection bias. Moreover, the findings of this study cannot be generalized to all Chinese American older adults concentrated in culturally exclusive communities (e.g., Chinatowns). The estimated EM prevalence rate of this nonrandom study and the effect of family cohesion should be interpreted with caution. Third, given the family cohesion is the concept most emphasized in Chinese culture, we elected to use family cohesion in this study, rather than other characteristics of family relationships, such as closeness, conflict, or ambivalence. But other aspects of family dynamics are worth consideration and could be included in future studies. Finally, this study did not inquire about sexual mistreatment, as it was done by previous studies (e.g., Acierno et al., 2010; Dong, 2013; Dong et al., 2007). Because of this discrepancy in definition, caution should be used when making comparison with the existing literature.
Conclusions
We know that 1 in 10 Chinese American older adults experience general EM perpetrated by family members. The most common forms of EM, elder neglect, and emotional mistreatment may have serious emotional outcomes and threaten the well-being of Chinese older adults. To prevent EM, service professional and paraprofessionals in the community need to work with Chinese American families to reduce older adults’ depression levels and promote family cohesion. The findings of the present study call for public EM awareness campaigns, evidenced-based EM interventions, and treatment modalities that are culturally appropriate for the Chinese American population. The strengths of culture of origin and the dynamic nature of culture need to be recognized and reconciled as researchers and practitioners partner with communities to more effectively address the unmet needs of vulnerable older Chinese immigrants.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work is supported by a grant from the Fundamental Research Funds for the Central Universities (2016AD019).