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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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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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• 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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