I N T E R NAT I O NA L

J O U R NA L O F
SOCIAL WELFARE

DOI: 10.1111/j.1468-2397.2011.00808.x
Int J Soc Welfare 2011: 20: S121S134

ISSN 1369-6866

The role of the family in institutional

long-term care: cultural management
of filial piety in China
ijsw_808

121..134

Zhan HJ, The role of the family in institutional

long-term care cultural management of filial piety in
China
Int J Soc Welfare 2011: 20: S121S134 2011 The
Author(s), International Journal of Social Welfare
2011 Blackwell Publishing Ltd and the International
Journal of Social Welfare.
This study used both qualitative and quantitative data
collected in Nanjing, China, from 2008 to 2009, to
examine the role of the family in long-term institutional elder care. The qualitative data reported on four
separate groups of family members and their elderly
parents residing in institutions. The survey included
information from 140 elder care institutions (over
95% of all urban elder care institutions) in Nanjing.
The quantitative data provided a background from
which to understand the qualitative responses of
family members obtained during the focus group discussions. The qualitative data added a contextualized
understanding of the reasons for institutional placement and aspects of the families continued involvement in long-term care. In conclusion, Chinese
families, unlike families in the West, are currently
struggling to manage the cultural demands of elder
care together with the usual financial, caregiving, and
emotional concerns. Managing stigma has been one of
the adult childrens prevalent themes in the transition
from familial to institutional care.

Introduction
What should be the role of families when
older adults are placed in long-term care
institutions? Are family members relieved
from the burden of care duties so that
they can get on with their lives? In the
USA, there exists a multi-tiered institutional
system for elder care that spans independent
living, assisted living, nursing homes, and

Heying Jenny Zhan1,

Zhanlian Feng2, Zhiyu Chen1,
Xiaotian Feng3
Department of Sociology, Georgia State
University, USA
2 Brown University, USA
3 Nanjing University, Nanjing, China
1

Key words: long-term care, family role,

Chinese culture, institutional care, stigma
Heying Jenny Zhan, Department of Sociology,
Georgia State University 38 Peachtree Center
Ave., GCB 1041, P.O. Box 5020, Atlanta, GA,
30302-5020, USA
E-mail:
heyingzhan@gmail.com;
hzhan@gsu.edu
Accepted for publication March 4, 2011

continuing care facilities. According to the

Centers for Medicare and Medicaid Services
(2004), roughly 19 percent of persons over
the age of 85 are living in long-term care
facilities, while only 5 percent of persons
aged 65 and over resided in such facilities.
However, it has been estimated that more
than 40 percent of Americans who turned 65
in 1990 will spend some time in a nursing
home (Foner, 1994). The utilization of

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Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA

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Zhan

long-term care services in the USA could

serve as a good reference point when
considering the future of Chinas aging
baby boomers.
In China, it was in the 1990s that institutional care first became available for older
adults who have children (Chen, 1996; Zhan,
2000). It was widely believed that older
adults who entered government-sponsored
elder care institutions were less fortunate,
childless elderly people who had no loving
family to lend a caring hand; social stigma
was attached to these seemingly helpless
institutionalized elders (Chen 1996; Shang,
2001). Recent studies have shown, however,
that it has become government policy in
China to encourage the establishment of nongovernmental private elder care homes. Since
the late 1990s, an increasing number of elder
care homes have opened for business in the
major cities (Chu & Chi, 2008; Zhan, Feng,
& Luo, 2008; Zhan, Liu, & Bai, 2005,
2006a). A large percentage of the residents in
these elder care homes are older adults with
more than one child.
The long Confucian tradition of filial
piety indoctrinates adult children to provide
direct physical, financial, and emotional care
for their aging parents. Consequently, today,
Chinese families are facing demographic and
cultural dilemmas with respect to the care of
their elders. The demographic dilemma is
expressed by the decreasing number of adult
children available for parental care, due in
part to the decreasing family size and the
one-child family policy, and in part to the
increasing number of older people who are in
need of care as the large number of Chinese
baby-boomers enter into old age. The cultural
dilemma is constituted in part by the cultural
expectation that adult children will provide
for the direct care of their parents and in
part by the pronounced social stigma against
institutional care that was associated with
welfare assistance for childless elders prior
to the 1990s.
It has been estimated that the dependency
ratio for older people (65+) in China is going

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to increase from 11.6 per 100 working population in 2010 to 39.5 per 100 in 2050 (Chen,
2006). In the next four decades, the demand
for long-term care will undoubtedly increase.
Although many if not most adult children
may wish to follow the tradition of filial piety
and provide for the direct personal care of
their parents, work and family demands may
force them to place their parents in a care
institution. In families where there is only
one adult child available for elder care, the
adult child is likely to find direct hands-on
care problematic. What, then, is the role of
family members, particularly adult children,
in China when parents are placed in longterm care institutions? This article adds to the
literature by addressing the evolving new
roles of the Chinese family when elders
reside in long-term care facilities. In particular, it highlights the missing juncture in the
literature concerning family members psychological and emotional management of the
cultural tradition of filial piety after elderly
parents have entered a care institution.
To understand the role of family members
after their relatives have entered a long-term
care facility, we need to first have an understanding of the factors that influence older
adults entry into institutional care settings.
Below, we review two bodies of literature so as to provide a background for this
study: the predictors for institutionalization,
and the role of the family in the West after
institutionalization.
Background
Predictors of institutionalization
There is an extensive body of literature in the
West concerning the predictors for institutionalization (Bharucha et al., 2004; Howard
et al., 2002; Ness, Ahmed, & Aronow, 2004).
In general, the major predictors include
the elders health status, age, and family
resources. Bharucha et al. (2004) found that
the most frequently cited reasons for choosing institutional care were cognitive decline

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Role of the family in long-term care

and an inability to perform daily life activities such as cooking and shopping. Ness
et al. (2004) showed that advanced age was
positively related to using institutional elder
care. Using data from the Asset and Health
Dynamics among the Oldest Old Survey in
the USA, Aykan (2003) reported that older
adults who had been married and had children were less likely to move into elder care
institutions than were those who were unmarried or had no children. Howard et al. (2002)
examined the influence of race on institutionalization and showed that the racial
gap between African Americans and White
people in terms of institutional care usage
had narrowed in recent years. Nevertheless,
most of the elder care institutions were still
relatively racially segregated, tending to be
comprised of either predominantly African
American or White residents.
Rather similarly, research in China has
found that health status, age, and family
resources are major factors influencing institutionalization. Zhai and Qiu (2007) suggested that the oldest-old who suffer from
physical disabilities and/or cognitive impairments are more likely to live in elder care
homes than at home. Woo et al. (1994: 307),
using data collected in Hong Kong, also
found that poor cognitive function, measures of functional disability, poor vision,
Parkinsons disease, stroke, and past fractures are positively associated with institutionalization. Although Hong Kong has a
different social and economic system than
mainland China, it has a rather similar cultural pattern of elder care, with familial care
resources playing an important role in determining institutional placement. Some studies
have found that many Chinese elders with
health problems are unwilling to move into
elder care homes, preferring to remain at
home because of the cultural expectation of
filial piety (Gu, Dupre, & Liu, 2007; Zhan
et al., 2006b). This finding is supported by
the fact that most of the older adults living in
elder care homes in China are those who are
childless or whose adult children are not

available to offer them in-home direct care

(Ministry of Civil Affairs, 2005). Chinese
older adults who have several adult children
or who live in rural areas are generally less
likely to move into elder care homes than are
those who are childless or have no children
living nearby (Chu & Chi, 2008; Gu et al.,
2007; Zhai & Qiu, 2007). However, with the
increasing unavailability of adult children
because of work and other care responsibilities, a large number of urban elders who have
adult children are either choosing to move
into an institution or are being placed in an
institution by their children. In their recent
study in Tianjin, Zhan, Liu, and Guan
(2006b) found that 56 percent of elderly residents in elder care institutions (N = 264) actually had more than one adult child living in
the local area, but that their children were
too busy to take care of them at home. If
adult children are too busy to take care of
elderly parents, are they then relieved from
care duties, or the burden of care, after
their parents have entered a care institution? What are the ongoing roles of family
members when elderly parents are in institutional long-term care?
The roles of the family in elders
long-term care
Earlier research in the West has long demonstrated the familys continued involvement in
institutional long-term care (Gaugler, 2005;
Zarit & Whitlatch, 1992). These studies have
revealed several aspects of family members
sustained involvement, including frequent
visits by family members, continued involvement in personal care, provision of social and
emotional support, and filling the function of
care surveillance.
A common myth in both China and the
West has been that families dump their
elderly relatives in care institutions and
forget about them. On the contrary, however,
data from the American National Center for
Health Statistics for the years 1977 and
1979 indicated that many elders in nursing

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homes commonly had visitors; 61 percent

had visitors at least once a week, and 25
percent less than weekly. Furthermore,
according to data collected between 1973
and 1974 by the American National Nursing
Homes Surveys, more than half of institutionalized elders were visited by their children (Gaugler, 2005). Bitzan and Kruzichs
(1990) study of 332 nursing home residents
in Wisconsin found that 52 percent of the
residents reported that they were visited
every week. In a study conducted by
Tornatore and Grant (2002) among 276 caregivers of elders with Alzheimers disease,
76 percent of the caregivers reported that
they visited the elders at least once a week
after institutional placement.
Other research in the USA on family
involvement has moved beyond visiting to
explore different types of family involvement (Gaugler, 2006: 80). Though it is
known that family involvement after institutional placement differs from familial care
at home, there has been no clear picture of
how family roles tend to change at that
point. The first consideration has usually
been whether family members would keep
offering elderly residents personal assistance
such as grooming and clipping fingernails,
or instrumental assistance such as laundry,
hair grooming, and shopping (Gaugler,
2005). According to Dobrof and Litwak
(1977), family members were generally
involved only in psycho-social support,
whereas the institutional staff offered the
residents personal and hands-on care.
Laitinen (1993) similarly asserted that
family involvement was limited to emotional
support by assisting elders to stand and/or
sit. In their study of 165 caregivers of institutionalized residents in the USA, Moss et al.
(1993) found that the responsibility for
offering personal and instrumental care was
more often than not transferred from family
members to staff. This echoed the finding in
Bowers (1988) study that families shifted
most of the caring responsibilities to the
nursing home staff and viewed themselves

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mainly as supervisors of the staffs work. In

contrast, Gaugler and Kanes more recent
study (2001) indicated that family members
were involved in wide fields of care work,
including personal and instrumental care, as
well as providing socio-emotional assistance.
This view has been widely supported by
other research as well (Bonder, Miller, &
Linsk, 1991; Linsk et al., 1988; Moss &
Kurland, 1979; Schwarz & Vogel, 1990).
After elderly relatives entry into an
institution, the role of the family has tended
to become ambiguous (Gaugler, 2005; Keefe
& Fancey, 2000). However, new responsibilities or care roles have emerged. In the
opinion of family members, providing surveillance has become an important new
responsibility of care. These duties include
being on the look out for and exposing/
reporting abuse, helping their elderly relatives understand and follow the nursing
homes policies and regulations, maintaining harmonious stafffamily relationships
(Gaugler, 2005), supervising the quality
of institutional services (Bern-Klug &
Forbes-Thompson, 2008; Moss et al., 1993),
and representing their elderly relatives interests and maintaining the family connections
(Bern-Klug & Forbes-Thompson, 2008).
There has been, until now, a dearth of
literature on the role of the family in institutional care settings in China, partly
because, as discussed above, institutional
elder care has not been available for older
adults who have adult children until the last
two decades. The research has focused
mainly on factors that influence institutional
placement. Hardly any research has examined in the Chinese context the continuing
roles of family members in long-term care
after the placement of an elderly parent in
an institution. This article contributes to
the literature by focusing on three aspects
of the roles that the family members can
play after their elderly relatives have moved
into an institution: (i) personal and emotional care; (ii) financial care; and (iii)
cultural management.

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Role of the family in long-term care

Methodology
The sample
Data for the study were drawn from two
separate research projects, one conducted in
October 2008 and the other in June 2009 in
Nanjing, China. In 2008, two focus groups
were identified and met (one with elderly
residents, the other with family members). In
2009, two additional focus group discussions
were held (one with residents, the other with
family members). Because the protocols for
the qualitative data collection in these 2 years
were identical and the 8-month time lapse did
not contribute any significant difference to
the central goal of the study between these
studies, the qualitative data from all four
focus groups were combined in this article
into two groups, that is, one consisting of
two groups of elderly residents (n = 19) and
the other consisting of two groups of family
member respondents (n = 15) who had
elderly family members residing in institutional care settings. To provide a context of
recent developments in institutional care, we
supplemented the qualitative data with aggregated data from 95 percent of all elder care
institutions in Nanjing. The operational definition of elder care institution in our research
refers to all facilities that provide residential
long-term care services, with or without
medical staff and equipment, for elders with
various levels of disabilities with respect to
activities of daily living and instrumental
activities of daily living.
The research site
Nanjing, an ancient capital city in south
central China located roughly 150 miles west
of Shanghai, was selected as our research site
for two reasons. First, Nanjing, as a former
national capital and a traditional major
Chinese city, has a location that is slightly
inland where elder care practices are not
likely to have undergone dramatic changes
because of out-migration or industrialization.

Secondly, Jiangsu Province, where Nanjing

is currently the capital city, is one of two
Chinese provinces (the other being Sichuan)
that most diligently carried out the one-child
family policy (Chen, 2006; Zhu, Lu, &
Hesketh, 2009). Consequently, the population of Nanjing is aging rapidly; the elderly
population of 60+ in 1990 was roughly 10
percent of the citys population; in 2000, it
was over 14 percent (Nanjing Gerontology
Office, 2006). Nationally, it has been estimated that China will have doubled its
elderly population in only 27 years, whereas
in Nanjing, it will have doubled in only
2223 years. It has furthermore been projected that in 2025, one in every four people
in Nanjing will be older than 60.
Research procedures
Focus group discussions were held and led by
the senior researcher. They were audio-taped
and transcribed verbatim into Mandarin
Chinese. The discussions were not translated
into English to ensure that the authentic
meaning of the original Chinese language
would be maintained. English translation was
provided by the senior researcher for the
purpose of this research article.
Elderly residents who had a cognitive disability or a speech disability were not included
in the study. Elders were identified by administrators or managers who generally knew the
functional level of the residents. One focus
group discussion with elders was held in a
street-level elder care home contracted to an
individual manager; the other focus group
discussion was held in a private elder care
home. At the time of the discussions, we made
sure that managers and administrators were
not present in the room. These focus groups
were typically held in the activity room or in a
dining room to which the elders had easy
access. Discussions centered on four general
themes: (i) the family context prior to the
placement; (ii) the decision process for institutional placement; (iii) current health and
living conditions; and (iv) future plans.

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The focus group with family members

met at Nanjing University. Family members
were drawn from several elder care homes
where their elderly relatives resided. Guided
by the principles of theoretical sampling
(Strauss & Corbin 1998: 201), we stressed
three important factors that could be
expected to influence respondents opinions:
gender of the respondents; type of facility
(government, community, or private) in
which the care recipients resided; and length
of the care recipients stay. Typically, family
members were first identified by facility
managers. Then, with the list of names and
telephone numbers, we made contact with
and selected persons willing to commit to
a minimum of 2 hours on a weekend for
the focus group discussion. Although the
same number of men and women were
selected, more women than men showed
up at the appointed time. The discussion
involved the same four themes, but the last
question concerned the future plans of both
the elderly residents and the adult children
themselves.
Quantitative data were drawn from all
urban elder care institutions in Nanjing. Our
target population was all elder care homes in
operation as of June 2009 that were located in
the urban districts of Nanjing (total eligible N
= 148). Off all eligible homes, 140 completed
the survey, yielding a very high response rate
of 95 percent. Facilities located in relatively
remote parts of three suburban districts were
distinctly rural in terms of facility characteristics and the environment in which they
operated; such facilities were excluded from
our sampling frame and the actual survey. To
devise the study questionnaire, we adapted
the On-line Survey Certification Automated
Record instrument in use by all US nursing
homes. Through on-site structured interviews with facility administrators or staff
members, the trained researchers collected
aggregated facility-level data on organizational and resident characteristics, based on
all residents residing in each facility at the
time of the survey.

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Data analysis
Data analysis included both qualitative and
quantitative aspects. The discussions of the
four focus groups had been recorded and
were later transcribed verbatim into Mandarin Chinese. Because the senior researcher
and her assistants are fluent in both English
and Chinese, our qualitative data analyses
were grounded on the verbatim Chinese
text. Coding was accomplished by identifying recurring concepts and categories, then
cross-reading to identify shared themes
between different groups.
The senior researcher conducted the qualitative data analysis with assistance from her
graduate research assistant. Although the role
of the family after institutionalization was
not the original goal of the research, using
the methodological insights from grounded
theory (Strauss & Corbin, 1998), we were
able to identify recurring themes during the
discussions of the family environment and
decision-making processes for institutional placement. Consequently, three major
themes emerged from the verbatim transcriptions of the familys involvement in
continued care after a relatives entry into
an elder care facility.
Quantitative data analyses for all institutions were conducted at Brown University in
SAS1 and STATA2 software. For the purpose
of this article, only descriptive data have been
included to provide a general background of
recent developments in institutional care.
Findings
Recent developments in institutional
elder care
Aggregated data from 95 percent of elder care
institutions revealed that the vast majority
(over 80%) of all institutions were established
1
2

SAS Institute, SAS Company Drive, Cary, NC,

USA.
STATA Corp, College Station, TX, USA.

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Role of the family in long-term care

after 1990.3 More than half (62%) did not

open until after 2000. Government-run and
-owned homes accounted for only a third of all
facilities. Over half of all institutions (55%)
were privately run or managed, either individually owned, in partnership, or combined
enterprise ownerships.
Nearly half of all institutions were small to
medium in size, ranging from under 30 beds
to 50 beds per facility. Over one-fourth of the
facilities (28%) had 50100 beds. Large
facilities with over 100 beds were more likely
to be government- or corporation-owned.
Over half of the institutions (57%) accept
welfare recipients, which suggests that
private institutions do in principle accept
welfare patients. Interestingly, 50 percent
of the institutions also accepted adults with
disability and orphaned children.
As stated earlier, qualitative data were
drawn from 2 years of research on four focus
groups. Because the issues raised and discussed were very similar across elderly residents, on the one hand, and across family
members, on the other, to simplify the discussion we combined the two focus groups of
elderly residents into one and the two groups
of family members into one. This gave two
samples of focus groups, one consisting of
institutionalized elders, and the other consisting of family members (Table 1).
Characteristics of elders
There were 19 elders in the two focus groups
in total eight men and 11 women (See
Table 1). Seven of the 19 elderly participants
were in their 70s and as many were in their
80s; the remaining five were in their 90s.
Fourteen of the 19 elders were widowed, and
14 had a pension. According to the elders in
the study, a majority (12 of 19) were able to
pay the full cost of elder care themselves.
Three others depended wholly on their children to cover the cost of the institutional care.
3

For details and table presentations of aggregated

data of the survey, please see Feng et al. (2011).

Two others were sharing the costs with their

children or having costs supplemented by the
children to some extent. The last two of the
19 elders failed to answer this question satisfactorily for clarity. When asked about the
primary reason for their entry to the facility,
six of the 19 elders listed illness and
another six listed children being too busy
to provide care as the most important reason
for choosing institutional care. Among the 19
participants, only two had no children living
nearby, while nine had one child and eight
had more than two children living locally
in Nanjing.
Characteristics of family members
There were 15 family member participants
in all. Two-thirds of them (or ten) were in
their 50s. Even though equal numbers of
male and female family members were contacted, more female family members (11)
participated. A majority of participants (11
out of 19) were already retired. When family
members were asked who paid for the institutional care costs, seven of the 15 replied
that the elders paid in full and five reported
that their adult children helped out. Three
replied that the cost was completely paid by
or shared among the adult children. In terms
of reasons for choosing institutional care,
similar to reports from the elders, a third of
the family members expressed illness,
another third listed children being too
busy as the primary reason. One in five
listed housing problems (being too crowded,
building under reconstruction or being relocated, residing too high up in the building to
climb the stairs) as the primary reason for
the decision for institutional placement. As
reported by the family members, over half
(or eight of 15) family members had two or
more siblings in the same city where the
elder lived, but one-third reported being too
busy to provide direct care.
With this background information in
mind, the following section focuses on the
more nuanced details of family involvement

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Table 1. Characteristics of elderly residents and family members in the focus groups.
Elders (n = 19)

Variables

Frequency
Age
50
60
70
80
90
Gender
Male
Female
Widowed
Yes
No
Having children locally
None
1
2 or more
Have pension
Yes
No
Are you working?
Working
Retired
Who pays
Elderly self
Shared by adult children
Helped by adult children
Primary reason for entry
Illness
Kids too busy
No kids nearby
Housing
Other

Percentage

Frequency

Percentage

10
3
2

66.7
20
14

7
7
5

36.8
36.8
26.4

8
11

42.1
59.9

4
11

26.7
73.3

14
5

73.7
26.3

4
11

26.7
73.4

2
9
8

10.5
47.2
42.1

2
5
8

13.3
38.5
53.3

14
3

73.7
15.5
4
11

26.7
73.3

12
3
2

63.2
15.8
10.5

7
3
5

46.7
20.1
33.5

6
6
1
2
2

31.6
31.6
5.3
10.5
10.5

5
5
1
3
1

33.3
33.3
6.7
20.1
6.7

in the continuing care after the elderly parent

or relative has entered an institution.
Family involvement in continued care
After the placement of their elderly parent
in an institution, most family members continued their care in various ways. While the
amount of direct personal care on a daily
basis may have been reduced, continuing care
did include some personal care. More importantly, family members provided emotional
and instrumental care to help the elder adjust
to the transition. In the case of continued
personal care, some elderly respondents

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Family members (n = 15)

described how their children helped them

bathe, groom, or do laundry so that the
staff members did not have to do those things.
The performance of these daily care tasks
appeared to be related to family members
judgment of being able to provide better
and more loving care compared with what
routine care staff members usually provided.
In one case cited in the 2005 Nanjing study,
the adult daughter would personally bathe
her mother because the elderly mothers arm
hurt after an injury (Zhan et al., 2008). The
daughter wanted to make sure that her mother
received patient and loving care when she
was bathed.

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Role of the family in long-term care

More often, this loving care was demonstrated by family members frequent visits.
One elderly said, My daughter comes to visit
me every week, at least once a week, usually
she would ask me if I need anything, she
always brings me whatever I need. Another
echoed, My children come weekly too . . . A
third elder added, I dont have to tell them,
it has become their habit to come visit
me weekly.
During these visits, family members often
take away dirty laundry, especially when/if
the elderly parents had incontinence or diarrhea problems. In one case, a daughter discovered that her mother mistakenly took
laxative pills for her diabetic medicine and
was having constant runs for a week. After
consulting the doctor about the medicines her
mother took, the daughter discovered that an
administrative problem in the care facility
caused by the change of staff members was
directly related to her mothers problem.
Frequent visits not only reduced elderly
family members loneliness, but also increased their sense of well-being. Most elders
felt that they were still being cared for;
because their children came to visit often,
they were still exhibiting filial piety (or being
very xiao). During these visits, family
members often brought medicine they had
bought at the drug store, or the parents
favorite food, or updates on news from the
home front and gossip about the neighborhood and extended family.
Financial assistance from family members
The financial aspect of care is China-specific
when compared with all other developed
societies. Because the Chinese government
provides financial assistance for institutional
care only for childless elders, no government
assistance is available for the long-term care
of elders who have adult children. When
families decide to place an elderly parent/
relative in an institution, they are fully aware
that they bear the full financial responsibility
for such a decision. Although an increasing

number of elders in elder care homes draw a

pension, some of these pensions are not sufficient to cover the full cost of a care home. In
such cases, the adult children usually pool the
resources together to help pay or supplement
the bill.
One family member, Ms. Wang, described
the financial situation of her mother and her
family in this way:
Her pension is roughly 1400 yuan, but the
cost [for elder care] is about 1800 yuan.
We have 8 siblings, 7 female and one male.
We held a family meeting and jointly
decided to contribute one hundred Yuan
per family per month into a separate
account for our mother. Our only brother
usually gives a little more. We put it in a
separate account, whether or not she uses
it each month, we keep the money there
for her expenditure for hospitalization,
medicine, care service fee, and other additional needs . . .
In the case of another elderly resident, Ms.
Lin (87), her daughter, who now lives in the
USA, pays the monthly bill for her mothers
care in the institution. Ms. Lins own pension
was kept as her spending money. The son,
who was against his mothers move to an
institution, pays nothing.
As reported by family members, a third
of the adult children assisted their parents
with long-term care costs; 20 percent of the
family members in the study reported that
the elders care costs were shared in full by
the pooled resources of the adult children.
Cultural management from the perspective
of family caregivers
Family members continued involvement
with care in China has a context-specific
dimension, that is, the profound adjustment
from the essential cultural expectation of
familial care to the acceptance of institutional
care. In the focus group discussions, both
family members and elderly parents elaborated extensively on their emotional and

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psychological processing of this transition,

which we have labeled here cultural management of filial piety.
One adult daughter, one of eight children
of an elderly mother, reported having difficulty justifying the decision for her mothers
institutionalization.
Respondent: My older sister and younger
brother made the actual decision to place
my mother in the elder care home; I was
at work at the time. By the time I got
home, they had already packed her bags
and were ready to go. I couldnt accept it
at the time. After all, we are 8 siblings!
How can we put our mother in an elder
care home when she has so many children?! Others may spread rumors about
us! But my brother told me that this is
our mothers request . . . Still, I blame
myself for being unfilial. I often think
about bringing my mom home to live
with me . . .
Interviewer: Which floor do you live on?
Respondent: 7th floor.
Interviewer: Then how do you expect your
mother to climb seven flights of stairs
without an elevator?
Housing issues and the lack of elevators in
residential apartment buildings were a recurring theme during our research. Many family
members and elders stressed how hard it was,
in buildings with no elevators, for elders to
walk up to the fifth, sixth or seventh floor to
get home. An 85-year-old man, Mr. Wang,
who lived in an apartment on the fifth floor,
had to routinely use a transfusion tube (port
for dialysis). Every time he had to go see a
doctor, the adult children had to hire a strong
man for 120 Yuan (roughly $20) to carry their
father on his back down five flights of stairs
to ground level where he could get a taxi.
After the doctors visit, they had to pay the
man again to carry their father back upstairs
to the fifth floor.
One family member, Ms. Yu, described
how, prior to institutional care, her family had

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carried around a little stool for their mother,

who was still able to walk, so that she could
slowly climb seven flights of stairs to her
apartment, stopping and sitting down as often
as she needed to.
Another daughter expressed her emotional
distress over the transition from home care to
institutional care:
At the time, I just couldnt accept it. As a
matter of fact, elder care homes might be a
good thing in other countries. But in China,
most people still cannot accept it. Although
Im an educated person and understand
that this is for the benefit of the elder, but
when it comes down to me, myself, I still
cannot accept it.When Mother first went in,
I really could not take it. I went back and
visited her the second day. I actually cried
my way home that day.
Clearly, the daughter had a very hard time
accepting institutional care even though she
saw the benefit of her mother having better
access to medical care. How would the older
adults themselves, the elderly parents, view
this transition? This question is discussed in
the next section.
Cultural management from the perspective
of the elders
Very often we found that the older adults in
this study were the ones who had made the
decision to enter institutional care while the
adult children were often the resistant preservers of tradition who were afraid of
losing face.
In one case, Ms. Gong, an 85-year-old lady,
had to fight for her decision to move out of
her sons apartment and into an elder care
institution. She was opposed by her three children a son and a daughter residing locally
and another daughter living in the USA:
I lived with my son and daughter-in-law.
In one voice, they [son and daughterin-law] said they would never let me go.
My son said, if you enter an elder care

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Role of the family in long-term care

institution, you smear dirt on my face. You

have a son, how can you go to live in an
institution?! I will be blamed for being
unfilial. . . . I told my son, You are dying
to save face, but I am dying living with
you. I have poor health, heart problems,
high-blood pressure. My leg hurts and I
cannot walk properly . . . I cannot live
like this. . . . So, I sneaked out one day
and stayed in an elder care home for 10
months, then moved to this one here. My
son said that if I entered an elder care
home, he would never visit me and never
want to see me again. But I fought, I
insisted, and I am a strong-minded person,
and I got my way.
In another case, Ms. Liu, a 78-year-old
school accountant, firmly asserted that her
independence meant more than family
harmony. Besides, she felt that if she lived
with her daughter and son-in-law, there was
bound to be some family conflict and disharmony. Although the initial move into an
institution could cause family disharmony,
ultimately her move would be for the good of
her daughters family: Why should I make
my presence in their family an inconvenience
for them? I have my own pension, it is my
own decision to make. Id rather listen to
myself than anybody else. . . . For Ms. Liu,
making her own decision and living independently in an institution was her own choice.
She did not want her daughter to make that
decision for her.
Discussion
Findings from this study revealed that institutional care for older adults with adult children in China is still a novel practice. Most
of the institutions in Nanjing were opened
after the 1990s. Nearly half of the institutions opened first after the year 2000. Over
half of the institutions were privately owned
and operated. Elders with children who
moved into institutional care were more
likely to be residing in a private institution.
The most frequently discussed reasons for

making such a choice were: the older persons illness, the adult children being too
busy to provide constant attention or
hands-on care, and housing problems. The
majority of the elders in the institutions
in Nanjing today are those who do have
children. Only a small percentage (roughly
1015%) have no children or no children
living nearby. In this study, the majority of
the elders reported having more than one
adult child living in the same city, but that
the children were too busy. These findings
are similar to those in earlier studies conducted in the city of Tianjin (Zhan et al.
2005, 2006a). In addition, in some cases the
familys housing arrangement was inappropriate for the kind of long-term care that
would be required at home.
Findings from this study echo earlier
findings from studies conducted in the USA
(Bern-Klug & Forbes-Thompson, 2008;
Chen et al., 2007; Curry, Hogstel, & Walker,
2007; Dempsey & Pruchno, 1993; Dijkstra,
2007; Dobbs & Montgomery, 2005; Gaugler,
2005, 2006; Gaugler et al., 2000, 2004).
These studies found that after older adults
had moved into a care institution, family
members continued their involvement, sometimes providing direct care or instrumental
care, as well as providing emotional and psychological care by making frequent visits and
providing instrumental assistance. Similar
to findings in the USA (Bern-Klug &
Forbes-Thompson, 2008; Moss et al., 1993),
family visits in China seem to have the function of monitoring the elders well-being and
surveillance against staff negligence. The
daughter who discovered that her mother
mistook laxative for diabetic pills is a good
example of the importance of family involvement in following up the quality and appropriateness of care.
Different from studies in the West,
Chinese family members involvement has
an added financial dimension: In the USA,
when an older adult has exhausted all funds
in long-term care, government assistance
kicks in as Medicaid. In China, family

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members are still the last tier of financial

security. More than 50 percent of the family
members in the study reported giving partial
or full assistance to their elderly parents to
cover the costs of long-term care. The implications of this finding for the future of
Chinas long-term care are rather bleak;
given the reduction of the size of families
and the increasing number of families with
only one child, the likelihood of there being
several adult children sharing the bill for the
older adults long-term care will become
ever more improbable in the not too distant
future. Government policies in long-term
care appear to be crucial if Chinese baby
boomers are to be able to save and pay for
their own future long-term care.
Also, unlike in the West, a dramatic cultural adaptation was required in China for
families to make the new and sudden transition from familial home care to institutionalization for long-term care. As children
become increasingly unavailable for longterm care at home, is the Chinese culture of
filial piety going to be able to adapt and is
institutional care going to become acceptable? Zhan et al. (2008) have argued that the
acceptance of institutional care is on the rise
and that the concept of filial piety has been
broadened in elders and family members
interpretations so that families could justify
their choice of institutional care as being filial.
Nevertheless, in this study, family members
appeared to be struggling with the social
stigma associated with institutional care; and
they were trying to hold on to the traditional
practice of filial responsibility. Yet, work,
family responsibilities, or living conditions
had made it almost impossible for them to
provide direct care of their elder family members. Older adults, on the other hand, were the
fighters for freedom of choice and freedom of independence. Ironically, the elders
often appeared to be more open-minded and
willing to accept institutional long-term care
than their adult children, whereas, conventionally, they have been depicted as being
too traditional, conservative, or resistant

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to be willing to move away from home. Yet,

this study has revealed this different and
unexpected side to the story. What were the
social conditions that provoked such a
remarkable family dynamics? This question
has unplumbed depths and warrants continued research in future studies.
Of course, this study was based mainly on
the qualitative data from discussions in two
small focus groups. The older adults who participated in the focus groups seemed to be the
ones who were satisfied with institutional
care and were open-minded about its merits
when deciding on long-term care. A future
study of social stigma against institutional
care with a representative sample including
family caregivers, institutional residents, and
family members of elderly residents will add
to the literature for a more comprehensive
understanding of the cultural preparedness
for institutional long-term care at this historical juncture in China.
Acknowledgement
This research was made possible by funding
from the Fulbright Research Award for
Research in China, granted by the Council for
International Exchange of Scholars (0814371), and by a grant from the Department of
Health and Human Services, National Institutes of Health, and Fogarty International
Center (1R03TW008142-01), 20092011.
References
Aykan H (2003). Effect of Childlessness on Nursing
Home and Home Health Care Use. Journal of
Aging & Social Policy 15(1): 3353.
Bern-Klug M, Forbes-Thompson S (2008). Family
Members Responsibilities to Nursing Home
Residents: She Is the Only Mother I Got.
Journal of Gerontological Nursing 34(2): 4352.
Bharucha AJ, Pandav R, Shen C, Dodge HH,
Ganguli M (2004). Predictors of Nursing Facility
Admission: A 12-Year Epidemiological Study
in the United States. Journal of the American
Geriatrics Society 52(3): 434439.
Bitzan JE, Kruzich JM (1990). Interpersonal
Relationships of Nursing Home Residents. The
Gerontologist 30: 385390.

2011 The Author(s)

International Journal of Social Welfare 2011 Blackwell Publishing Ltd and the International Journal of Social Welfare

Role of the family in long-term care

Bonder BR, Miller B, Linsk NL (1991). Who Should
Do What? Staff and Family Responsibilities for
Persons With Alzheimers Disease in Nursing
Homes. Clinical Gerontologist 10: 8084.
Bowers B (1988). Family Perceptions of Care in
A Nursing Home. The Gerontologist 38: 361
368.
CMS (2004). Medicare Current Beneficiary Survey.
Washington, DC, Centers for Medicare and
Medicaid Services.
Chen CK, Sabir M, Zimmerman S, Suitor J, Pillemer
K (2007). Importance of Family Relationships
With Nursing Facility Staff for Family Caregiver
Burden and Depression. Journals of Gerontology: Series B: Psychological Sciences and Social
Sciences 62B(5): 253260.
Chen SY (1996). Social Policy of the Economic State
and Community Care in Chinese Culture: Aging,
Family, Urban Change, and the Socialist Welfare
Pluralism. Avebury, Brookfield.
Chen W (2006). The Development Trend of Chinese
Future Population: 20052050. Population
Research 30(4): 95104.
Chen YH (2006). Several Problems Concerning
Gender Ratio at Birth Nanjing as a Study Case.
Chinese Population Science 1: 8694.
Chu L, Chi I (2008). Nursing homes in China.
Journal of American Medical Directors Association 9: 237243.
Curry LC, Hogstel MO, Walker C (2007). Family
Councils in Long-Term Care Facilities. Annals of
Long-Term Care 15(1): 3339.
Dempsey NP, Pruchno RA (1993). Familys Role in
the Nursing Home: Predictors of Technical and
Non-Technical Assistance. Journal of Gerontological Social Work 21(1/2): 127145.
Dijkstra A (2007). Family Participation in Care Plan
Meetings: Promoting a Collaborative Organizational Culture in Nursing Homes. Journal of
Gerontological Nursing 33(4): 2229.
Dobbs D, Montgomery R (2005). Family Satisfaction With Residential Care Provision: A Multilevel Analysis. Journal of Applied Gerontology
24(5): 453474.
Dobrof RD, Litwak E (1977). Maintenance of
Family Ties of Long-Term Care Patients.
Bethesda, MD, National Institute of Mental
Health.
Feng Z, Zhan HJ, Feng X, Liu C, Sun M, Mor V
(2011). An Industry in the Making: The Emergence of Institutional Eldercare in Urban China.
Journal of America Geriatric Society 59: 733
744.
Foner N (1994). The Caregiving Dilemma: Work
in an American Nursing Home. Berkeley, CA,
University of California Press.
Gaugler JE (2005). Family Involvement in Residential Long-Term Care: A Synthesis and
Critical Review. Aging and Mental Health 9(2):
105118.

Gaugler JE (2006). Family Involvement and Resident Psychosocial Status in Long-Term Care.
Clinical Gerontologist 29(4): 7998.
Gaugler JE, Anderson KA, Zarit SH, Pearlin LI
(2004). Family Involvement in Nursing Homes:
Effects on Stress and Well-Being. Aging and
Mental Health 8(1): 6575.
Gaugler JE, Kane RA (2001). Informal Help in the
Assisted Living Setting: A 1-Year Analysis.
Family Relations 50(4): 335347.
Gaugler JE, Leitsch SA, Zarit SH, Pearlin LI (2000).
Caregiver Involvement Following Institutionalization: Effects of Preplacement Stress. Research
on Aging 22(4): 337359.
Gu D, Dupre ME, Liu G. (2007). Characteristics of
the Institutionalized and Community-Residing
Oldest-Old in China. Social Science & Medicine
64(4): 871883.
Howard DL, Sloane PD, Zimmerman S, Eckert JK,
Walsh JF, Buie VC, et al. (2002). Distribution of
African Americans in Residential Care/Assisted
Living and Nursing Homes: More Evidence of
Racial Disparity? American Journal of Public
Health 92: 12721277.
Keefe J, Fancey P (2000). The Care Continues:
Responsibility for Elderly Relatives Before and
After Admission to a Long Term Care Facility.
Family Relations 49(3): 235244.
Laitinen P (1993). Participation of Caregivers in
Elderly-Patient Hospital Care: Informal Caregiver Approach. Journal of Advanced Nursing
18(9): 14801487.
Linsk NL, Miller B, Pflaum R, Ortigara-Vick A
(1988). Families, Alzheimers Disease, and
Nursing Homes. Journal of Applied Gerontology
7(3): 331349.
Ministry of Civil Affairs. (2005). China Civil Affairs
Statistic Yearbook. Beijing, China Statistics Press.
Moss MS, Kurland P (1979). Family Visiting
with Institutionalized Mentally Impaired Aged.
Journal of Gerontological Social Work 1(4): 271
278.
Moss MS, Lawton MP, Kleban MH, Duhamel L
(1993). Time Use of Caregivers of Impaired
Elderly Before and After Institutionalization.
Journal of Gerontology 48(3): S102S111.
Nanjing Gerontology Office. (2006). Population
Statistics in Nanjing. Available at http://www.
xhby.net/xhby/content/2006-02/25/content_
1160416.htm [last accessed 1 May 2008].
Ness J, Ahmed A, Aronow W (2004). Demographics
and Payment Characteristics of Nursing Home
Residents in the United States: A 23-Year Trend.
Journal of Gerontology: Medical Sciences
59A(11): 12131217.
Schwarz AN, Vogel ME (1990). Nursing Home
Staff and Residents Families Role Expectations.
Gerontologist 30: 169183.
Shang X (2001). Moving Toward a Multi-Level and
Multi-Pillar System: Changes in Institutional

2011 The Author(s)

International Journal of Social Welfare 2011 Blackwell Publishing Ltd and the International Journal of Social Welfare

S133

Zhan
Care in Two Chinese Cities. Journal of Social
Policy 30(2): 259281.
Strauss A, Corbin J (1998). Basics of Qualitative
Research: Techniques and Procedures for Developing Grounded Theory, 2nd edn. Thousand
Oaks, CA, Sage.
Tornatore JB, Grant LA (2002). Burden Among
Family Caregivers of Persons With Alzheimers
Disease in Nursing Homes. The Gerontologist 42:
497506.
Woo J, Ho SC, Lau J, Yuen YK (1994). Age and
Marital Status Are Major Factors Associated
With Institutionalisation in Elderly Hong Kong
Chinese. Journal of Epidemiology and Community Health 48(3): 306309.
Zarit SH, Whitlatch CJ (1992). Institutional Placement: Phases of Transition. The Gerontologist 32:
665672.
Zhai X, Qiu RZ (2007). Perceptions of Long-Term
Care, Autonomy, and Dignity, by Residents,
Family and Caregivers: The Beijing Experience.
Journal of Medical Philosophy 32(5): 425445.
Zhan HJ (2000). The Inverted Pyramid: Chinese
Familial Eldercare in the Era of the One-Child

S134

Policy and Economic Reforms. PhD dissertation,

University of Kansas, Lawrence, KA, USA.
Zhan HJ, Feng XT, Luo B (2008). Placing Elderly
Parents in Institutions in Urban China: A Reinterpretation of Filial Piety. Research on Aging 30(5):
543571.
Zhan HJ, Liu GY, Bai HG (2005). Recent Development of Chinese Nursing Homes: A Reconciliation of Traditional Culture. Ageing International
30(2): 167187.
Zhan HJ, Liu GY, Bai HG. (2006a). Recent Development in Chinese Institutional Elder Care:
Changing Concepts and Attitudes. The Journal of
Aging and Social Policy 18 (2): 85108.
Zhan HJ, Liu GY, Guan X (2006b). Availability and
Willingness: Compare Attitudes Toward Institutional Care Between Chinese Elderly Parents
and Their Adult Children. The Journal of Aging
Studies 20 (3): 279290.
Zhu WX, Lu L, Hesketh T (2009). Chinas Excess
Male, Sex Selective Abortion, and One-Child
Policy: Analysis of Data From 2005 National
Intercensus Survey. British Medical Journal 338:
12111236.

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International Journal of Social Welfare 2011 Blackwell Publishing Ltd and the International Journal of Social Welfare

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