Measuring Eastern Family Care

To the Editor: Caring for aged parents has remained an unquestionable virtue in Chinese and other East Asian societies.1,2 In contrast, elder care is a shared responsibility of older adults themselves, the family, and society in Euro-American societies.1 Because of cultural differences, beliefs valued by Chinese caregivers are found missing in translated caregiver scales.3 Therefore, a culturally sensitive instrument for the Eastern population was developed to evaluate a new online intervention for Chinese-Canadian family caregivers.4 This letter reports on the development of this new scale: the Eastern Family Care (EFC). The EFC scale was developed in two substudies. The methods of the main study have been reported elsewhere.4 Ethics approvals were obtained from the study sites. Study 1 used in-depth interviews to generate EFC items. Participants were selected using purposive sampling. The interviews were translated and transcribed verbatim and then coded line by line. Thematic analysis, constant comparisons, and analytical memoing were used to identify salient themes.5 Study 2 tested the 25 items generated from Study 1. First, items in each theme were subjected to a principal component analysis. To minimize unstable solutions because of the small sample size, only scales that were reduced to a singular factor were selected, and items with a loading less than 0.6 were excluded. Next, associations between the EFC and Burden Scale for Family Caregiver (BSFC)6 were assessed. It was hypothesized a priori that EFC would be mildly to moderately correlated with BSFC. All measures were available in English and Chinese. Ten caregivers participated in Study 1 and 20 in Study 2. A typical caregiver was female, in her 50s, had college or university education, had immigrated 10 to 20 years earlier, and had provided care for more than 20 hours a week. Four salient themes were identified, which described the caregiving experience of the participants. Embracing traditional family values: Taking care of their parents was more than a responsibility; it was a way of life. One caregiver said, “It is a few thousand years of Confucian thinking. … The younger ones should take care of the elderly. But in Western education, there is nothing like this.” Not knowing enough: Caregivers felt that they did not know enough about dementia and did not provide good enough care. A caregiver said, “For example, she had hallucinations, about Hong Kong's stuff. She saw many people in the house, many kids. [I wondered] ‘Why was it like this?’” Trying hard to stay calm. A caregiver said, “[We have learned that] our family, family members, parents, and so on, … [should] get along harmoniously.” Therefore, having conflicts with their parents was the caregivers' greatest emotional struggle. They tried hard to avoid reacting emotionally but felt frustrated because it was not easy to stay calm. Not knowing whom to ask: When caregivers needed help, they were not sure where to get help, whom to ask, and whether they were doing the right thing or not. For instance, a caregiver said, “The bath tub … should have a hand rail. … Do I go and get someone to install it?” Factor analysis resulted in four constructs of the EFC: the Caregiving Belief Scale (CBS), the Caregiver Competence Scale (CCS), the Caregiving Interaction Scale (CIS), and the Support Resources Scale (SRS) (Table 1). Alphas ranged from 0.760 to 0.885, and the variances explained ranged from 60.5% to 75.4%. Correlation analysis showed each scale contributing to a unique dimension of the EFC. The CCS was moderately correlated with CIS (correlation coefficient (r)=0.665, P=.004) and SRS (r=0.535, P=.03), whereas the CIS and SRS were not correlated with one another. The CBS was not correlated with the CCS, CIS, or SRS. The BSFC was correlated with the SRS (r=−0.622, P=.006) but not with the CBS, CIS, or CCS. The results supported the hypothesis that the construct of the EFC contained caregiving quality that is missing in Western caregiving measures. This study supports the need for a measure of family care for the Eastern culture. The EFC consisted of four distinct caregiving constructs: belief, competence, interaction, and resources. Of the four constructs, only the SRS was correlated with the BSFC, although the sample size was small, and the sample was restricted to caregivers enrolled in the online intervention. The preliminary findings confirm the need for the continuous development of the EFC as a potential tool for understanding the unique needs of caregivers who value traditional beliefs of the Eastern culture. Special thanks go to Dr. Rhonda Cockerill and Dr. Mark Chignell for their guidance to the first author when completing this study as part of her PhD thesis. We thank the family caregivers who participated in the study. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. This study was supported in part by the Alzheimer Society of Canada, Toronto, Ontario, and by a fellowship award from the Canadian Institutes of Health Research, Ottawa, Ontario (Dr. Chiu). Author Contributions: T. Chiu: Study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript. G. Eysenbach: study concept and design, analysis and interpretation of data, and preparation of manuscript. Sponsor's Role: The funders had no role in the design and conduct of the study, collection, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript.

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