Diversity & Equality in Health and Care Open Access

Keywords

Caregiver-employees; Gender; Culture; Caregiver friendly workplace policies; Immigrants.

Introduction

In 2001, 13% of Canadians were 65 years old or older [1]. This demographic grew to comprise 16.1% of the national population by 2015, exceeding the percentage of children aged 0-14 years for the first time [2]. Seniors are expected to remain the fastest growing age group over the next several decades, and it is anticipated that approximately one in four Canadians will be 65 or older by 2061 [3]. As life expectancy continues to rise while birth rate declines, Canada must prepare to meet the needs of its aging population [4].

Many seniors are sustained by a system of family caregivers that can include spouses, in-laws and/or children. These individuals create a social safety net for seniors, providing basic emotional, financial and/or health-related support on an unpaid basis [5]. According to analysis of the 2012 Canadian General Social Survey, 13 million (46%) individuals aged 15 years or older had previously provided unpaid care for a family member or friend with age-related needs, long-term health conditions, or disabilities [6]. Over 8 million (28%) reported doing so within the past year, and approximately half specified caring for their parents or parents-in-law. While levels of caregiving differed between regions, rates in Ontario exceeded the national average. Generally, caregivers spent a median of 3 h each week performing tasks such as providing transportation (73%), scheduling appointments (31%) and helping with medical treatments (23%). Approximately, 2 million (28%) were also responsible for a dependent below the age of 18 and around 5 million (60%) were simultaneously employed in a paid position. While elder care can be a rewarding experience, many caregivers must simultaneously maintain paid work to support their basic needs [7].

Maintaining employment is often vital for family caregivers. Many incur out-of-pocket expenses associated with their responsibilities, which can have a concerning impact on their disposable income and personal savings [8]. Yet, fulfilling a caregiving role can result in substantial costs in the workplace. A scoping review conducted by Fast et al., identified labour force exit or preclusion, restricted work hours and absenteeism, decreased productivity, and career limitations to be major employment consequences for CEs. Reports of job loss or early retirement due to caregiving demands were rare, but CEs often worked fewer hours, took more time off, and changed jobs or positions to achieve greater flexibility in their schedules. Many declined or postponed promotions, offers or job-related training opportunities [9]. Employers also observed reduced work output, quality, and focus. Furthermore, Duxbury, interviewed a group of 30 Canadian CEs who, on average, spent 36.5 h engaged in paid employment and 30.3 h fulfilling caregiving responsibilities each week. Two in three respondents reported that being a CE had caused challenges in the workplace, such as the need to reduce working hours or take numerous days off. One in three said their career performance had suffered due to the demands of their caregiving role [10].

Challenges maintaining adequate performance in the workplace contribute to CEs’ existing strain, placing them at increased risk for physical and mental health issues. Duxbury observed emotional strain to be the most problematic aspect of being a CE, more so than physical or financial exertion [10]. Approximately one third of participants reported moderate to high levels of physical strain due to responsibilities that involved heavy lifting or that resulted in significant sleep loss. In comparison, more than half cited high levels of emotional stress due to feeling overwhelmed by heavy demands at work and in their caregiving role. In addition to having reduced time for self-care, CEs also take on the stress and worries of their care recipients and face the pressure of uncertainty concerning the future. This can be particularly true for immigrant CEs. Immigrant CEs face additional stressors due to experiencing language barriers, making cultural adjustments, and managing feelings of isolation, which can further contribute to the negative impacts of their dual roles [11]. The present study aimed to present perspectives from Mandarin-speaking CEs caring for parents or parents-in-law in Southern Ontario, Canada [12].

Immigration is currently the biggest contributor to population growth in Canada and is projected to remain so in the immediate future [13]. From 2006 to 2011, individuals who reported Mandarin as the language most often spoken in their home increased by over 50%, representing the second-largest increase in prevalence of use for an immigrant language [14]. China, the largest Mandarin-speaking nation, accounts for a notable portion of elderly immigrants with nearly 10% of the community being 65 years of age or older, the largest percentile among all visible minorities [15]. By focusing on language, the present study sought to obtain a representative sample of this Asian immigrant demographic while bypassing the complex political and nationalistic nuances surrounding some regions of Chinese territory.

Elder care is part of many Asian cultural values as a component of filial piety, a belief and expectation that seniors should be well taken care of by their children and other family members [15-17]. Filial piety, a primary virtue in Confucianism, is known as “xiào” in the Chinese context. It refers to “emotional support for parents by their children and contains an element of authority” [18]. Lai’s study, in examining the effects of filial piety on caregiving burden, observed that it moderated stress in caregiving situations [15]. Those who identified strongly with this cultural belief demonstrated a more positive appraisal of their role and responsibilities, and found their position to be comparatively less burdensome. However, caregivers in this community faced additional challenges in balancing work and caregiving due to their immigrant status and cultural expectations.

The nature of their traditional beliefs places Chinese immigrant CEs in a different mindset from their more Westerninfluenced counterparts. According to filial piety tradition, children are expected to exhaust all resources to assist and support when a parent becomes ill [19]. This mentality makes it difficult for many to yield to their caregiving role, despite feeling burdened or overwhelmed [20].

The Study

Study aim

The present study has two goals: 1) to understand the perspectives on caregiving of Mandarin-speaking Chinese immigrants residing in Southern Ontario, Canada; and 2) to explore how, post-migration, CEs manage their dual roles of unpaid caregiving and paid work.

Table 1: CE demographic characteristics.

Table 2: Characteristics of CEs’ employment.

Methods

A qualitative approach was taken to obtain a narrative description of the experiences of Mandarin-speaking CEs. Semistructured interviews were conducted with 13 individuals who provided care for a parent or parent-in-law while simultaneously working a paying job. Ethics approval was obtained from the McMaster Research and Ethics Board (MREB 2014-120).

Participants

Mandarin-speaking CEs were recruited in Southern Ontario using a multi-pronged strategy which included: fliers posted at community centers; presentations given at caregiving support and education gatherings, and; personal networks. Three main inclusion criteria were applied to participants, which were: (1) be an immigrant from a Mandarin-speaking background who; (2) cared or was currently caring for a dependent with chronic health issues, while; (3) working a paid position. In total, 13 Mandarin-speaking CEs (10 female, 3 male) were interviewed about their experiences. All participants reported caring for either a parent or parent-in-law. See participant profile for demographic characteristics (Table 1). For characteristics of their employment (Table 2).

Data collection

Participants who met the inclusion criteria were invited to arrange a time and location at their convenience to complete a socio-demographic questionnaire and engage in a one-time faceto- face semi-structured interview that lasted approximately 1 h. All participants gave written and verbal consent prior to beginning the interview, which was conducted in their preferred language. The research assistants conducting the interviews were conversationally fluent in both English and Mandarin and came from Mandarinspeaking backgrounds. The guiding questions focused on the participant’s attitude toward the act of caregiving and their experiences managing their dual roles, as well as improvements they would like to see implemented to better help them manage these roles and responsibilities. As compensation for their time, all participants received $25 in cash.

All participants consented to having the interview be audiorecorded. The research assistants later used the recordings to transcribe the interviews verbatim, translating them into English when necessary. Socio-demographic information from the participants was also consolidated and organized. All participants were identified using a pseudonym that they selected, as noted in italics following each finding or quote.

Data analysis

The interviews were analyzed qualitatively using Charmaz’s Constructivist grounded theory approach (2005) that argues that social reality is co-constructed between the participant and researcher. Charmaz writes: “What observers see and hear depends upon their prior interpretive frame, biographies, interests as well as the research context, relationships with research participants, concrete field experiences, and modes of generation and recording empirical materials” [21]. The interviews were encoded and organized using NVivo software. Utilizing Chamaz’s data analysis method, initial codes were first assigned to small units of data to condense and describe various passages [22]. They were then consolidated into broader categories under focus codes based on the guiding questions. The focus codes formed the basis of overall categories. These categories were consolidated to produce study themes.

Findings

The qualitative analysis yielded five major themes surrounding the primary research focus: 1) Filial Responsibility; 2) Gender Roles; 3) Managing dual roles; 4) Family Conflicts, and; 5) Future Concerns. Due to space limitations and given the focus of the special issue of the journal only the first three themes are discussed in this paper.

Theme 1: Filial responsibility

This theme provides Mandarin-speaking CEs perspectives on caregiving. It offers their meaning, attitude and perceptions towards filial responsibility.

Mandarin-speaking CEs attribute their attitudes toward caregiving to cultural upbringing that emphasized filial responsibility. Participants described caregiving as an “obligation” (George Short), their “first priority” (Karen), a “responsibility” (Leo Kai), “a natural thing” (Lisa Zhao) and a “tradition” (Leo Kai). Mary Tse adds to the cultural aspects of caregiving: “I would say younger people; they really take care of their elderly in our culture. We look after the elderly like this is their right.” Salina agrees with Mary Tse: “It [caregiving] is not a curse or karma, it’s just deep deep inside us because we are Chinese, it’s deep deep inside. We must take care of parents. You cannot abandon them.” Similarly, George Short observes: “In China, we respect seniors. And senior people are kind of like a treasure for Chinese families …it is kind of an obligation to help them [parents] when they are getting old. It’s kind of a culture- it is based on our background. It is a tradition- it is a tradition.”

Filial Piety was about reciprocal relationships. Parents provided for their children and now it was time for children to reciprocate and care for their elderly parents. In the quote below, Amy explains the role of filial responsibility in Chinese culture:

It’s because when we were in China before, this is the traditional education that we learned; so, when I was little, they took care of me, and then when they are old, we need to take care of them. This is not the same in the West. We need to take care of and respect the elderly when they are old and cannot handle some things independently.

George Short agrees with Amy: “We have to think, okay, they took care of their times or their energies to raise you or raise us. It’s kind of a return; it’s kind of like to give something back as much as you can”. Salina reiterates the issue of reciprocity: “Oh, um [laughs], it’s a big responsibility in Asia or in China. As children, you must take care of your family when your parents are getting older or they no longer work. You have to take care of them, right?”

Filial expectations often demanded personal and/or profession sacrifice. “I would say to caregiving it means, it’s kind of a sacrifice.” (George Short). Jing notes:

I think as Chinese people, we know that we always take on responsibilities; we know it is in our role to help them and take care of them as they age. Probably more so than some of the other culture, so that’s always in my mind. That’s our roles and responsibilities. Even though that may mean we have less time for ourselves or our careers or other things that we are interested in- I think that’s just stuff we need to do.

Most participants had a positive attitude towards filial responsibility. Leo Kai observes: “Caregiving, taking care of the seniors, of course I’m sacrificing my own time, but as I’ve said this is my responsibility. So, I have no regrets about giving away this time, I know I am doing what I can.” Salina does not complain about the sacrifices he makes: “They gave up a lot of things in China, as well, for me. So, for this sacrifice, I think I have to sacrifice my time and my… my energy or whatever to be with them”. As the above quotes indicate, even though there was sacrifice involved, upholding filial piety tradition was important.

Participants made efforts to impart these cultural values to their children. John agrees with filial sacrifice and models this tradition to his children: “Of course you have to reduce some time for my family a bit. But I think it's good, you need to show my wife, show my kid, you need to take care of your parents. They understand”. Participants’ narratives indicate that fulfilling filial expectations was important for family harmony. John observes: "Father is the sky and mother is the earth, so you must appreciate the sky and the ground. Then everything will go smoothly.” The well-being of parents and/or parent-in-law was emphasized above CEs own well-being: “For elderly people, putting them first is part of the tradition. It’s part of their culture, happiness and virtue…” (Sophie).

Following the virtue of filial piety, participants defined care as allowing their care recipient to live comfortably by meeting their social, health, emotional and hygienic needs. Dietary needs were particularly emphasized. Most caregivers discussed the importance of providing foods that the care receiver was accustomed to in their native homeland. Participants assisted their care recipients with grocery shopping and preparing meals as part of their caregiving duties. Preparing meals together provided a form of social interaction for their elderly family members. They were concerned that elderly immigrants were often isolated, particularly in smaller towns that lacked a larger Mandarin-speaking community. Due to language barriers and transportation constraints, most care recipients were unable to engage in social interaction. For some, especially those with dementia, their deteriorating health status made it difficult for them to participate in community activities. In these situations, caregivers often accompanied their parents or parents-in-law out for meals. Aside from experiencing language and transportation barriers, care recipients were unfamiliar with operating Canadian appliances which made them more dependent upon their children:

It’s kind of different than here in China. The kitchen appliance they are not used to use here in China. And here to have to familiar with the dishwashers, stoves, microwaves. They are afraid of using them so I have to teach them to use it- to always use those to steam, or sometimes you can just put it in the microwave. But they have no idea how to use it (Salina).

As the care recipient were extremely dependent upon the caregivers, it is not surprising that many caregivers defined caring as being willing and available to meet the care recipient’s needs daily. Many caregivers also mentioned the importance of ensuring their care recipient lived in a clean environment and made efforts to help with housework. Others also discussed assisting with troubleshooting tasks, such as fixing an internet or phone connection. Overall, caregiving was regarded as making the parent or parent-in-law as comfortable as possible, often in surroundings that were foreign to them. Both genders were involved in fulfilling filial responsibility.

Theme two: Gender roles

This theme highlights the gendered dimension of household labour, as well as the role of gender in fulfilling filial responsibilities.

The responsibility of majority of the household chores fell on women, even though they were working outside the home, post-migration. Amy explains: “A lot of guys will think that the main responsibilities in the house belong to them. Like, ‘nan zhu wai, nu zhu nei’, which means the man needs to earn money for the family and the woman needs to do the housework. This is a traditional way of thinking.” She continues:

A lot of men don’t even know how to cook…since childhood, they were never taught to learn how to make food or anything. I don’t think it’s that appropriate - men should also know how to take care of themselves, and do housework. In reality, men and women are all equal; men go to work, and women also go to work. It’s not like they’re at home, not working and just taking care of the family. Women do a lot of hard work, right?

Busy Mommy approves Amy’s viewpoint:

It’s usually women who are taking care of the family right? It’s usually me acting as the mom, because both my kids are sons so they don’t really know how to do chores around the house. If I had a daughter maybe she would have been more aware of these kinds of things, boys you know (laugh), they don’t really notice. Sometimes I would remind my husband to do some things, and he could help my mom at mealtimes, but other things he doesn’t really know how to do. Especially like laundry and helping her shower, he wasn’t so good at, because he’s a man you know.

Within Chinese culture women are considered more skilled or better suited to provide caregiving than men. They are regarded as being more “careful” caregivers than men and possessed the “attributions” and “personality” to provide care (George Short). “Women have a talent to provide help - to provide care. But you know for some caregiving things need some more strength or muscle things, then men would be - that’s the men’s opportunity to do such a job” (George Short). There was a clear division of labour based on gender: “I usually cook, do laundry, clean the house and such. My husband fixes things around the house when it’s necessary and mows the lawn, those types of things” (Cindy). As noted below, Care adds to the understanding of the gendered nature of caregiving:

There is distinction, for example, my younger brother accompanies my father to the bathroom, it’s more difficult to do that as a woman. So, when we all go out to eat together, it will always be my brother or my younger sister’s son taking him to use the bathroom, and they do that very automatically. I can only wait outside the door…

Even though women were considered better at caregiving than men and there were traditionally masculine and feminine tasks, such as, “women do more in the house, and men do more outside of the house” (Sophie). Most CEs interviewed did not mention filial responsibility as a feminine obligation. Rather, the primary caregiver was more likely to be the biological child: “It depends on how many kids you have. Because I’m the only one - if I am a son, I also have to take care of them. So, that’s the big difference about the gender” (Salina). Further, as both men and women were employed in paid labour post-migration, there were efforts to split the caregiving tasks based on availability rather than the nature of the task. Karen Finn explains:

When it’s something like taking them to the doctor, because I have more freedom with my hours, I always take them to appointments and pick up the medications from the pharmacy. My husband usually handles issues with the internet and the phone…My husband doesn’t like eating out, so since I don’t mind it, I’ll drive those places and get a meal together.

Jing adds: “My husband has more flexibility with his time, so I would say that it’s probably at least 50/50 split between the two of us. If not more on his part. That goes for childcare as well.”

Theme three: Managing multiple roles

This theme deliberates the impact of managing dual or multiple roles on paid work and/or health of caregivers.

Regardless of care recipient’s health condition there was a consensus among participants that they spent a lot of time providing help daily to their elderly parents or in-laws, as the care recipients, could not understand and converse in English. Care recipients were also unfamiliar with Canadian systems (health care, taxation, public transport) and/or kitchen equipment, etc. Thus, they required constant help with daily tasks which made managing dual roles (unpaid caregiving and paid work) difficult. One participant noted: “…wherever they go, they need our help because they cannot understand English at all” (Amy).

CEs that were managing multiple roles – taking care of a spouse, children, as well as their primary care recipient, in addition to working in paid labour, dedicated so much time to their caregiving responsibilities that it left them with less mental and physical resources to uphold the same level of care towards their spouses and children. Participants differed in their perspective with regards to the level of stress that their dual or multiple roles, as caregivers and paid employees, created. Amy observes: “You have to maintain your own health, right. So, that’s why this age group faces the most stress - there are elders above you and children below you.” Another participant explained the consequence of managing multiple roles: “You naturally become difficult when you’re under pressure, not as patient, more irritable. I think this also influences how I bring up my child” (Leo Kai). Another participant adds: “Yes, work had to be done, and it wasn’t an easy job, it can get very stressful. So, every day, there’s someone you need to take care of, no matter what your mood, your mood at work, is like, you still have to take care of these responsibilities.” (Busy Mommy). Mary Tse notes: “As I mentioned earlier, lots of stress from looking after the elderly, and you lose the time to contact your workplaces, your family members, you see them less, and my own time. My sleeping pattern changed and social activities decreased. The whole life changed.”

Lisa Zhao explains her challenges in balancing paid work and unpaid caregiving:

Because you cannot have work; without work you cannot sustain yourself and your daily life, but when you’re working and taking care of an elderly dependent, your work inevitably suffers a bit. But right now, it’s still alright, my parents’ health is still not very seriously bad, but even right now I take days off very often.

For most of the participants, their care recipients were in relatively good health condition. Even though helping with daily tasks was tedious, CEs did not really complain of a lot of stress in balancing work and family life. “I don’t think I help them that much, just regular life things. It is not that serious yet, but if they get a major illness, things will become more difficult” (Amy).

For CEs whose parents suffered from dementia/Alzheimer, however, caregiving was found to be particularly difficult, causing them great physical and emotional stress.

I felt so tired. You feel that she depends on you for everything, so you feel so, so tired. I mean, think about it; she doesn’t know how to shower, you have to help her. And after she’s done, she doesn’t know what to do with the old clothes, so she puts them back on So, before she showers, you have to help her take off the dirty clothes and put the clean ones there. And also, she doesn’t understand, you know, because she had Alzheimer’s. (Busy Mommy).

Another participant provides his perspective on how caregiving became difficult as the care recipient’s disease progressed:

So, right now I…because in these last few years, I’ve been taking care of my father. Before he was relatively healthy, he didn’t have dementia, so taking care of him was relatively simple. But these last few years, because he has dementia, he will wander and get lost, so it’s more difficult (Care).

For the last year and a half Lisa Zhao has been struggling with balancing work and family life as her father’s health has deteriorated: “Right now, it’s stressful at work, and when you come home it’s still quite stressful. It always feels like you’re wound up tight. I think, over a long period of time, that definitely has influence. Over a short period maybe I can’t really distinguish anything, but after 3 or 5 years, then I don’t know.”

Even though participants reported a certain level of understanding from their employers about their situation, they did not voluntarily discuss their caregiving role with other coworkers, viewing it as a private circumstance irrelevant to their work life.

I think, from an employer’s perspective, they don’t really understand this situation. If they don’t ask, I wouldn’t volunteer details about my situation because right now I can still handle my responsibilities. As I’ve said, I’m fortunate that my parents are still relatively independent, they’re not bedridden or anything. If it came to a point where I would have to hire someone then I think I would feel more pressure (Leo Kai).

Although Lisa Zhao disclosed her caregiving duties to her boss, she feels that doing this was not very helpful: Yes, my boss has said to me that he can understand. But you know, work is work, just because he understands doesn’t mean that I can just not go, you always have to do your work. I’m sure that my boss is obviously not happy that I am constantly taking time off. Honestly, I’m unclear about how my co-workers are taking it. Although nobody says anything, but…they don’t say anything to your face, I don’t know what happens behind my back.

Many participants also acknowledged that their caregiving responsibilities were hindering their ability to advance in the workplace. Some had declined promotions because they did not have time to take on the extra responsibilities that came with the new role, and therefore also missed opportunities to obtain a higher salary. Others were unable to acquire the skills they felt they needed to advance in their career. For example, one participant notes:

The good thing about my job is that the content I encounter is very contemporary. However, this also means that you have to keep learning continuously…otherwise you can fall behind. And once you fall behind, it’s very difficult to keep growing in your line of work. For…learning, you need a long period of time- 3-4 h of non-distraction – but that’s very difficult to achieve if there are seniors at home. For example, I’ll want to concentrate for 2 h, but often the case is that after 10 min, I’ll have to go do something. I took a class not long ago and then wanted to become more familiar with that material…but there just wasn’t enough time. (Leo Kai)

Care reduced her work load to be able to take care of her father:

I got the news that my father had dementia, so I decided to decrease my workload and work part-time. I hoped that working part-time, I have some tasks like test filing, when I’m doing file tests for clients I can take them home and work on them on the computer, so I can still be close to my father and keep him company.

As her parents’ health deteriorated and they required more support, Lisa Zhao was not able to take her yearly vacation. Mary Tse feels stressed with lack of time for leisure: “Caregiving is very difficult sometimes and frustrating, because it’s very timeconsuming. I hardly have time to do my own things.” Like Care, she has reduced her workload and now works part-time to help her fulfill her caregiving role: “I work 30% less. Because I’m a part-timer, so mostly they call you and you go to work. But with taking care of him most of the time, I reject the work.”

Most of the CEs did not have comprehensive workplace accommodations to balance their paid work and unpaid caregiving. When asked about the best workplace supports they had received, most CEs cited flexible work hours to be especially helpful. This allowed them to take brief periods of time off when they needed to take their parents or in-laws to health appointments. Jing explains:

Because of my work and my role, I have some flexibility myself. Not that I don’t work enough hours in a week, it’s just that I have a bit more flexibility in when I work. So, I could take the time I needed during the day, let’s say, and compensating it by working later in the night or over the weekends to make up for it.

Such flexibility prevented loss of both income and productivity. Those who did not have flex time found it hard to manage paid work and unpaid caregiving: “Yeah, because fulltime you don't have like flexible time right? So, yeah, it's more difficult and you tired and when you get home, you're tired and you still need to take care of your mom. So yeah, it's harder [laughs] difficult” (John).

Some participants did not even know what they would do if they needed extended leave to care for a loved one:

If something happened at home and I couldn’t make it to work, it’s usually alright. I would just call in and take a day off…Long-term? Long-term would be more difficult. The first option is to take an extended leave, but there aren’t that many days off you can take in a year. The second option…I don’t know. I don’t know whether there are accommodations for that, if you had to miss work a lot (Cindy)

All CEs expressed a desire for greater workplace accommodations to help them balance caregiving and paid employment. Sophie notes:

I think it’s a very important trend that this society should pay attention to as the generations are aging. And then I think that there should be some specific policies and programs designed to help people who need to provide care to their older relatives or family as that becomes more of a norm in the society. So, right now for example, the workplace usually has policies and services to help people who need to take care of their kids. But there isn’t anything specific for caregiving. So I think there should be an increased focus on that and with the accommodating or associated services or programs. Whether that means, allowing flexibility, or reduced workload, or providing services or care that would provide some relief. I think that’s all a part of it.

Overall, it was clear from some of the participants’ narratives that family was a higher priority than work:

You have to think about the family, the family is more important. Even the work you can change the work, but the family is not easy to change. It’s kind of like to think which one is higher priority…Because you know what - there is a Chinese saying like ‘wen shi he wei guai’...You know why the family is more important in Chinese culture? Because the relationship of the family members it cannot be cut (George Short).

Regardless of the level of stress and sacrifices made, participants agreed that upholding filial tradition was important and that may have helped them manage life and work challenges. John feels happy that he takes care of his parents: “Yeah, I think it's good you need to take care of your parents. So yeah, I think it's a good thing to do.”

Discussion

Participants understanding of caring and their perceived caregiving responsibilities were founded in cultural attitudes of filial responsibility. In line with Donovan and Williams, Sharma and Kemps study with South-Asian older adults, participants in the current study described the notions of filial piety to include “providing older parents with daily support, love, affection and respect” [15,20]. Like Ron’s study with three generations of Arabs in the Israeli society, the present study found that Chinese adult children’s motivation to fulfill their filial responsibility was out of respect for their parents and was “grounded in cultural values, social norms” and “longstanding traditions” [23].

Data suggests that their caregiving role is often burdensome due to their care recipients’ inability to access existing support infrastructure due to a language barrier. Further participants, had to make personal sacrifice to provide caregiving. Despite these difficulties, most participants believed that they needed to reciprocate the kindness their parents had shown them when they were children. The element of returning a kindness or reciprocity as a factor motivating adult children to fulfill their filial responsibility is also visible in Ron’s study [23]. Literature provides evidence that when parents model filial responsibility, it influences their children and grandchildren. They are more likely to feel a sense of filial responsibility or a commitment towards maintaining this tradition if the parents positively modeled it [24]. “Observing and imitating a significant role model forms the basis for learning the behaviour of filial responsibility and adopting the role of caregiver to one’s elderly relatives.” Like Sharma and Kemp’s and Ron’s multigenerational study, it would be worthwhile to conduct a similar study with Chinese immigrants to understand if the modern generation born in Canada follows the traditional attitude that their parents or grandparents had towards this tradition. Such knowledge would be important for policy and practice “to anticipate the needs of and provide individualized, culturally appropriate” services to Chinese immigrant families [25].

The current study’s finding of gendered division of labour is supported in other studies (see for example, Williams et al., Donovan and Williams [16,17]. However, compared to other studies (see for example, Ron) the current study cannot claim that women had a more positive attitude towards filial responsibility as compared to men [23]. While specific caregiving tasks were somewhat gendered, the primary caregiver was more likely to be the proximate biological child or the spouse with more time and capacity to care rather than defaulting to the daughter or daughter-in-law.

There are few studies on how Chinese CEs manage paid work and unpaid caregiving while fulfilling filial responsibility. The current study found that CEs experienced stress in trying to manage their dual and multiple roles. However, the elements of filial responsibility may have helped them manage the stressors arising from caregiving. For example, the positive attitude towards filial responsibility may have helped them cope with work and life challenges. Like Lai’s study, participants seemed to fall back on their cultural foundations of filial piety to cope with difficult aspects of their caregiving experiences. Regarding caring as a natural duty allows CEs to accept their caregiving role, together with its challenges and gratifications, rather than view it as an additional responsibility [26]. During instances of strong emotional strain, many CEs seem to depend on their cultural foundation to remind them not to be too mindful of the difficulties associated with their present situation and, instead, rather be more focused on their care recipient’s needs and attitudes. For example, Jon believed in the attitude "Father is the sky and mother is the earth, so you must appreciate the sky and the ground. Then everything will go smoothly”, helping him cope with stressors in his life. It is also possible that since most of the care recipients were in good health, filial responsibility expectations did not result in CEs’ ill health. There is evidence from Lai’s study that that filial piety can serve as a buffer that protects individuals with the mental strength and endurance necessary to persist through more difficult aspects of the caregiving experience. Considering the evidence that CEs are at a risk of experiencing: role strain, depressive symptoms, and decreased workplace productivity, large-scale quantitative or mixed-methods studies are needed to understand the relationship between immigrant CEs attitudes and perceptions of filial responsibility, and their health and well-being [27,28].

The consequences of caregiving on employment followed patterns discussed in Fast et al. scoping review [29]. CEs in the present study reported reduced hours and missing career advancement opportunities as major consequences of their caregiving. Furthermore, some also reported strain due to perceived tension with their employer or co-workers due to their absenteeism or reduced productivity. Regardless of whether employers or co-workers hold negative thoughts about the CE’s actions, the perception that they do has the potential to be significantly damaging. This can make both the home and the workplace highly tension-filled environments, leaving the CE with very few options for opportunities to de-stress.

As with those suggested by Williams et al. (2015), results from the present study can be incorporated into suggestions for policy specific to helping Mandarin-speaking CEs provide care, post-migration [15]. Efforts should be made to increase the availability of support workers who can communicate in a second language. Where this is not possible, working in collaboration with cultural centers and ethnic community groups can also be useful for developing culturally sensitive services and improving the concept of formal help in the minds of those who do not already view it favourably. In the meantime, it is also vital to continue improving culturally sensitive mental health assistance to CEs, who continue to feel the strain of their dual or multiple roles.

Workplace conditions could also be improved to allow for flexible hours when possible (if this policy is not already being implemented). Employees and employers may perhaps be exposed to more materials that explain the challenges of caregiving and, in so doing, promote an enhanced understanding of the CE experience. This is especially so for Mandarinspeaking CEs, who generally do not volunteer details about their situation. In general, the workplace should be functioning towards best accommodating CEs’ needs for time off, and being supportive of their difficulties during what should be understood as a very trying time in their lives.

The scope of the present study is limited and can be expanded upon in several ways. Most caregivers in our study were not caring for an individual with a very severe or multiple chronic conditions; most care recipients retained a notable degree of independence, or were already in long-term care at a nursing facility. Thus, many could only speculate as to what they would do if it became extremely difficult to maintain both employment and care. Caregivers in a more precarious situation would offer greater insight into the difficulties faced by this targeted participant group. Furthermore, the present sample could be more representative across a greater number of participants who represented a greater geographical reach. Expanding into spousal caregivers or other family members who were not immediate children or children-in-law would also provide a broader perspective.

In conclusion, the struggle between providing care and maintaining economic support is an issue that is facing more and more Canadian immigrants. If we are to face the challenges of our aging population, the Canadian system must improve support for informal caregivers, particularly those from visible minority groups. Policies and programs in Canada must recognize and address the barriers faced by these minority groups to provide culturally sensitive resources to those caring for aging family members.

Acknowledgement

This study was funded by a CIHR Chair in Gender, Work and Health (CG! 126585). The authors express gratitude toward all participants who generously shared their time and experiences. The authors report no conflicts of interest.

References

1. Statistics Canada (2002)Profile of theCanadian population by age and sex:Canadaages.Statistics Canada Catalogueno.96F0030XIE2001002.
2. Statistics Canada (2015) For the purpose of this document, these population projections have been adjusted to reflect recent population estimates
3. Statistics Canada (2010) Population projections for Canada (2013 to 2063), provinces and territories (2013 to 2038). Statistics Canada Catalogue no. 91-620-X.
4. Léonard A (2011) Canada’s aging population and public policy: 1. Statistical overview.Publication no. 2011-63-E. Revised 28 February 2012. Ottawa, Ontario.
5. Lai DW, Leonenko W (2007) Effects of caregiving on employment and economic costs of Chinese family caregivers in Canada.J Fam Econ Issues. 28: 411-427.
6. Sinha M (2013) Portrait of caregivers, 2012. Statstics Canada Catalogue no. 89-652-X. No. 001 Spotlight on Canadians: Results from the General Social Survey, no. 001.
7. Cohen CA, Colantonio A, Vernich L (2002) Positive aspects of caregiving: Rounding out the caregiver experience.Int J Geriatr Psychiatry. 17: 184-188.
8. Turcotte, M. (2013) Insights on Canadian society: Family caregiving:What are the consequences? Statistics Canada Catalogue no. 75-006-X.
9. Fast J, Keating N, Lero DS, Eales J, Duncan K, et al. (2013)The economic costs of care to family/friend caregivers: A synthesis of findings. Research on Aging, Policies and Practice, Department of Human Ecology, University of Alberta.
10. Duxbury LE, Schroeder B, Higgins CA (2009) Balancing paid work and caregiving responsibilities: A closer look at family caregivers in Canada. Canadian Policy Research Networks.
11. Spitzer D, Neufeld A, Harrison M, Hughes K, Stewart M (2003) Caregiving in transnational context “My wings have been cut; where can I fly?”Gender and Society. 17: 267-286.
12. Stewart MJ, Neufeld A, Harrison MJ, Spitzer D, Hughes K, et al. (2006) Immigrant women family caregivers in Canada: Implications for policies and programmes in health and social sectors.Health Soc Care Commun. 14: 329-340.
13. Statistics Canada (2015) Canada's population estimates: Age and sex. The Daily.Statistics Canada Catalogue no. 11-001-X.
14. Statistics Canada (2012) Linguistic characteristics of Canadians: Language, 2011Census of Population. Statistics Canada Catalogue no. 98-314-X2011001.
15. Lai DW (2008) Intention of use of long-term care facilities and home support services by Chinese-Canadian family caregivers.Soc Work Health Care.47: 259-276.
16. Williams A, Donovan R, Strajduhar K, Spitzer D (2015) Cultural influences on palliative family careging: Program/policy recommendations specific to the Vietnamest. BMC Res Notes. 8: 280.
17. Donovan R, Williams A (2014) Caregiving as a Vietnamese tradition: “It’s like eating, you just do it”. Health Soc Care Commun. 23: 79-87.
18. Sharma K and Kemp CL (2012) “One should follow the wind”: Individualized filial piety and support exchanges in Indian immigrant families in the United States. Journal of Aging Studies. 26: 129-139
19. Fung KK (1998) Origin and development of Chinese cultures. Understanding Chinese cultures. A handbook for health care and rehabilitation professionals Toronto: Yee Hong Centre for Geriatric Care, pp: 16-42.
20. Ho B, Friedland J, Rappolt S, Noh S (2003) Caregiving for relatives with Alzheimer's disease: Feelings of Chinese-Canadian women.Journal of Aging Studies.17: 301-321.
21. Charmaz K (2005) Grounded theory in the 21st century: Applications for advancing social justice studies. In N.K. Denzin and Y.S. Lincoln (Eds.). The Sage handbook of qualitative research, 2nd ed. Thousand Oaks, CA: SagePublications, pp: 203-241.
22. Charmaz K (2006) Constructing grounded theory: A practical guide through qualitative research.Sage Publications Ltd., London.
23. Ron, P (2014) Attitudes towards filial responsibility in a traditional verses modern culture: A comparison between three generations of Arabs in the Israeli society. Gerontechnology. 13: 29-36.
24. Even-Zohar A, Sharlene S (2008) Grand childhood: The role of the adult grandchild from an intergenerational perspective (in Hebrew). Society and Welfare. 28: 441-468.
25. Park M (2012) Filial piety and parental responsibility: An interpretive phenomenological study of family caregiving for a person with mental illness among Korean immigrants. BMC Nursing. 11: 1-8.
26. Lai DW (2007) Cultural predictors of caregiving burden of Chinese-Canadian family caregivers.Canadian Journal on Aging/La Revue canadienne du vieillissement.26: 133-147.
27. Burton WN, Chen CY, Conti DJ, Pransky G, Edington DW et al. (2004) Caregiving for ill dependents and its association with employee health risks and productivity.Int J Occup Environ Med. 46: 1048-1056.
28. Fine MD (2012) Employment and informal care: Sustaining paid work and caregiving in community and home-based care.Ageing International.37: 57-68.
29. Fast J, Keating N, Lero DS, Eales J, Duncan K (2013) The economic costs of care to family/friend caregivers: A synthesis of findings. Research on Aging, Policies and Practice, Department of Human Ecology, University of Alberta.