Introduction
With an estimated population of 1.3 billion people, China has the largest population in the world. Since its reform in 1978, China has experienced rapid economic growth and an increase in life expectancy, while the population as a whole is aging. Chinese older adults account for the world’s largest aging population with 143 million people aged 60 years and older (Leng et al., 2008). By 2050, approximately one-third of China’s population will be over age 60, accounting for one-quarter of the world’s aging population. In the United States, the Chinese American community is the oldest, largest, and among the fastest growing Asian subpopulation (Bennett and Martin, 1995; Barnes and Bennett, 2002). From 2000 to 2010, the Chinese elderly population aged 65 and over has experienced a growth rate nearly four times higher than America’s older population (U.S. Census Bureau, 2011).
The dramatic growth of the global Chinese aging population has important implications for the health care, social welfare, justice, and financial systems. With this trend comes the potential for greater increased rates of elder abuse. However, the issue of cultural diversity surrounding elder abuse is an increasing challenge to this field of research. Despite ongoing efforts of multiple disciplines across academic, community, state, and federal organizations, we have a limited understanding of cultural and social issues of elder abuse in Chinese populations worldwide. We need to better examine the cultural variations in the construct, definition, and perception of elder abuse (Moon and Williams, 1993; Moon et al., 2002). In addition, there are knowledge gaps in in-depth cultural explorations of the barriers to elder abuse interventions and help-seeking behaviors with respect to the specific social and cultural contexts (Dong et al., 2007b).
Cultural Traditions: Filial Piety
Chinese traditional culture has been heavily influenced by Confucian traditions, which greatly emphasize filial piety, and these ethical principles provide guidelines regarding power, roles, and responsibilities of each family
member. In the teachings of Confucius, filial piety (
Xiào) dictates children’s obligatory roles and responsibilities of caregiving to aging parents. As a well-known Chinese proverb states, “Raising children is protective against older age and frailty” (
Y
ng-Er-Fáng-Lo) (Lan, 2002; Mencius and Lau, 2005). In return, parents are expected to contribute to the harmony of family and society with their guidance and wisdom.
For thousands of years, this system of interdependence among family members has worked well for Chinese society. However, the processes of modernization, urbanization, and industrialization have generated greater mobility of adult children from rural to urban settings in China, which in turn have altered changes in family structures and expected intergenerational filial support of older adults. There is evidence, however, that the younger generations of Chinese are less adherent to traditional Confucian principles of filial piety (Tsai, 1999; Ng et al., 2002). As a result, elderly Chinese are no longer guaranteed prestige, power, and care in the family, and they may be forced into stressful adjustments in their lives. The tradition of filial piety has been now made and monitored by the Chinese government as a legal contract, in which violations will be subjected to penalties by law (Chou, 2010).
In the context of immigration, whereas many Chinese American families are transforming from traditional Chinese collective culture to Western society’s emphasis on individualism (Mui, 1996; Casado and Leung, 2001), acculturation stress, access to health care, and linguistic and cultural barriers may pose great challenges to the families and their traditional values (Casado and Leung, 2001; Tam and Neysmith, 2006). Research suggests that the cultural ideal of filial piety is continually practiced with varying provisions, depending on local circumstances of historical, social, and familial configurations (Ikels, 2004). However, these transformations may threaten the support system of Chinese older adults, which can further exacerbate vulnerability, physical dependency, and psychological distress, and reflect conditions that strongly contribute to the increased risk for elder abuse.
Cultural and Linguistic Diversity
A major complexity in advancing the field of elder abuse among the Chinese population is exemplified by the issues of cultural and linguistic diversity. As the most populous country in the world, China is also inherently diverse. Although the majority Han group constitutes 91 percent of the total population, China’s other 55 minority nationalities amount to 123.3 million people, which is roughly equivalent to 40 percent of the U.S. population (U.S. Census Bureau, 2009). Linguistic diversity as a by-product was well developed (Xu and Wang, 2007). These forms of speech, according to
a renowned Chinese linguist, could be as far apart as English to Dutch, or French to Italian (Chao, 1976). In the case of the U.S. Chinese population, less than one-third of the Chinese American community was born in the United States; nearly half of Chinese Americans speak English less than very well (Shinagawa, 2008). Not only are the language and cultural barriers challenging, Chinese communities are diverse due to the history and development of immigration trajectories (Moreno-John et al., 2004; Parikh et al., 2009). These sociodemographic characteristics further call for culturally sensitive measures for researchers in the field of elder abuse (Norman, 1988; Wong, 1998; Guo, 2000; Shinagawa, 2008).
Prevalence of Elder Abuse
Prior studies in the People’s Republic of China suggest that abuse of older persons is common (Yan and Tang, 2001; Dong et al., 2007b). Caregiver neglect was the most common form of abuse, followed by financial exploitation, psychological abuse, physical abuse, sexual abuse, and abandonment. Of the victims in the study sample, 36 percent suffered from multiple forms of abuse and neglect (Dong et al., 2007b). In a large population-based study of 3,018 Chinese community-dwelling adults aged 60 and older in the greater Chicago area, 24 percent experienced elder abuse since they turned 60. Despite its common existence, elder abuse remains underrecognized among Chinese older adults due to high cultural sensitivity, low level of awareness, reluctance to reveal the case to maintain family harmony and honor, and the perception that elder abuse is a private family matter (Yan and Tang, 2001; Dong et al., 2007b).
Cultural Perceptions of Elder Abuse
Evidence suggests that older adults from different racial/ethnic groups have varying levels of tolerance toward different types of abuse (National Center on Elder Abuse, 1999). Moreover, there has been little qualitative information to provide deeper understanding of the threshold and tolerability of abuse in different racial/ethnic groups. In the first community-based participatory research (CBPR) study of elder abuse among Chinese older adults in Chicago, elder abuse was frequently characterized in terms of caregiver neglect (Dong et al., 2011b). As an older adult described, “Older adults are too frail to work outside. They don’t speak the language (English). They depend on their children for help. If the children do not help, then the older adults will have no one to turn to.” Financial exploitation, physical abuse, and abandonment were considered serious as well. However, psychological abuse, including verbal and emotional abuse, was perceived to be more serious than other forms of abuse. As a study participant reported, “the
most serious one is psychological abuse, like saying, go to die early. Cursing is abusive because it makes people sad.” This is to say, although Chinese older adults were aware of the brutality of physical abuse, they placed more concern toward psychological mistreatment, which fundamentally violates the filial obligations under the influence of Confucius’s teachings. Hence, Chinese older adults may hold higher emotional expectations for their adult children, and may be more prone to emotional distress when the expectation is unmet. The emphasis on caregiver neglect and psychological abuse may be affected by the belief in traditional familial obligations.
Perceived Psychosocial Impact of Elder Abuse
Research suggests that the discrepancies between expectations and actual receipts of care may be detrimental to Chinese older adults’ psychological and social well-being and is further associated with elder abuse. A number of exploratory studies reported the perceived psychosocial impact of elder abuse from the perspectives of Chinese older adults (Dong et al., 2012a,b). Based on the findings of a qualitative study with community-dwelling older adults in Chicago, depressive symptoms were associated with adverse health consequences from physical, cognitive, and mental health perspectives (Dong et al., 2012a). Its results suggest that older adults with depressive symptoms were more likely to associate depression with suicidal thoughts and elder abuse than those who did not report any symptoms. As an older adult reported, “My thought is that depressed seniors may sit at home and feel helpless. What if then they are ill treated by their children? That would make the situation even more alarming.” Moreover, loneliness and worsening social isolation have been reported as adverse health outcomes of abuse in the Chinese population (Dong et al., 2012b). In particular, elder abuse may be a major contributing factor in the feeling of loneliness, while conversely, loneliness may also increase the risk of being abused by a trusted other (Dong and Simon, 2007b).
More importantly, from the viewpoints of Chinese older adults, elder abuse was associated with increases in suicidal ideation and behaviors (Dong et al., 2012a). The sense of shame and cultural stigma on elder abuse may overshadow the motivations to seek interventions. When higher expectation was placed on family harmony, any violation would be deemed as a shame to the family. As a study participant described, “you might not agree with me. But sometimes when I feel bad about things I would rather swallow a pill and die as long as it is not too painful.” In the United States, Chinese older adults were reported to have the highest suicide rate than any other ethnic groups nationwide. Specifically, the suicide rate among older Chinese women is a higher leading cause of death compared with the general population (Foo, 2003; CDC, 2010a,b). A prior study noted a
three-fold higher suicide rate among Chinese women ages 65-74, seven-fold higher among those ages 75-84, and 10-fold higher among those over age 85 compared to white women of the same age groups (Liu and Yu, 1985; Yu et al., 1985).
Help-Seeking Tendency of Elder Abuse
Qualitative studies suggest that Chinese older adults commonly believed that abuse cases “had no solution”; others proposed “sending the victim away” (from the perpetrator); and still others stated that the fear of “losing face” would deter the reporting of elder abuse (Dong et al., 2011a). The violation of a trusting relationship between older adults and their family members was regarded as unsettling. As a study participant described, “How can we help this person? You may talk about it only with your very close friends. Yet most people would neither talk about it nor report it. They would only blame their own children and cry.”
However, the dominance of stigma and fears as a barrier to seeking abuse intervention warrants more attention. Although this was attributable to the traditional Chinese cultural doctrine in family honors and pride, it may also be a consequence of the lack of culturally appropriate intervention programs (Sue et al., 2009). Culturally sensitive approaches to address these barriers will be critical to encourage victims to seek interventions. An initial strategy would involve programs specifically designed to reduce stigma associated with elder abuse and elder abuse interventions. Second, an approach to provide culturally adapted materials to increase older adults’ awareness in elder abuse will be crucial. There is also a need to increase accessibility and availability of elder abuse interventions at a systematic level.
Community Support in Nurturing Filial Piety Values
and Intergenerational Relationships
Studies on elder abuse help-seeking behaviors among Chinese older adults concurred that if elder abuse cases happened in the community, seeking assistance from community service organizations would be the most viable solution (Dong et al., 2011a). Because of the bilingual and bicultural social services that community organizations provide, study participants believed that “other than community service organizations, there is no other way to handle the cases.” The indirect family-centered, community-based intervention preference among Chinese older adults is consistent with previous research in a Native American community where familism was also practiced (Holkup et al., 2007).
Specifically, future interventions would need to be directed toward enhancing social support of Chinese older adults, particularly in the form of
family support. Social service agencies working with Chinese older adults should pay special notice to their social connectedness to adult children, intergenerational exchange, cultural expectations, and satisfaction with family. Community organizations with bilingual services and staff may play a pivotal role. On the one hand, social workers may help Chinese older adults establish an improved social network, better supporting relationships, and physical and mental health, thus reducing the risks of abuse. On the other hand, such organizations could help improve the capacity of family members to offer adequate care and prevent older adults from being isolated. Building a stronger association with people in their own community will provide emotional, social, and practical supports for the older immigrants. Consideration of these variables could be important to the design of culturally appropriate elder abuse interventions.
Community-Based Participatory Research Methodology
Taking culture into account is the prerequisite of delivering high-quality health care services to people from diverse sociocultural contexts (Kleinman et al., 1978; Tervalon, 2003). However, language and cultural barriers often complicate the ability of minority immigrants to understand and participate in research studies (Cristancho et al., 2008; Martinez et al., 2009). Concerning the highly sensitive nature of elder abuse issues among Chinese older adults, the ability to reach out to the community and investigate this health issue was facilitated using the CBPR approach. CBPR is particularly useful to studying the well-being of the minority population, whose health beliefs and behaviors are highly intertwined with their unique cultural insights (Israel, 2000; Minkler and Wallerstein, 2003; Minkler, 2005). By equally engaging both academic and community partners in an action-driven investigation, the quality and quantity of research is enhanced without losing sight of local community values.
Recent elder abuse research in Chinese communities has demonstrated success and has enhanced infrastructure and networks necessary for community-engaged research and community–academic collaborations (Dong et al., 2011a,c). Conducting the CBPR approach allows researchers to gain cultural awareness of community health and to develop appropriate prevention and intervention measures on elder abuse issues. Working with the Chinese community highlights the importance of respecting and embracing diverse cultural philosophies, practices, and preferences in sustaining partnerships. Genuine understanding and practice of culturally sensitive research are critical for advancing social change.
