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Impact of housing arrangements on social support and health status among Chinese American elderly

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Impact of housing arrangements on social support and health status among Chinese American elderly

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Content IMPACT OF HOUSING ARRANGEMENTS ON SOCIAL SUPPORT AND HEALTH STATUS AMONG CHINESE AMERICAN ELDERLY by Elaine Chan Pang A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (SOCIAL WORK) May 2004 Copyright 2004 Elaine Chan Pang Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UMI Number: 3140532 Copyright 2004 by Pang, Elaine Chan All rights reserved. INFORMATION TO USERS The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleed-through, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. UMI UMI Microform 3140532 Copyright 2004 by ProQuest Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. ProQuest Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, Ml 48106-1346 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 1 DEDICATION To my father, mother, and mother-in-law whose love and grace deepen with age Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Ill ACKNOWLEDGEMENTS I would like to thank Dr. Marilyn Flynn, Chair of my Ph.D. Committee, and Dean of the School of Social Work at U.S.C., for her generous support, advice, and guidance, and to the other members of my Committee, Dr. Kathleen Ell, Dr. Merril Silverstein, Dr. Winnie Kung, and Dr. Maria Aranda, for their intellectual insights and encouragement. My deepest gratitude especially goes to Dr. K5 ai Talk Sung for his confidence in me and for his wise guidance. For their generous assistance in the research of this dissertation, I would like to acknowledge many individuals and organizations, including the Evergreen Senior Center; the Golden Age Village; Cathay Manor; Town and Country Manor; Angelus Plaza; Little Tokyo Service Center; Chinatown Service Center; Senior ministries of Bread of Life Church, First Baptist Church, True Light Presbyterian Church; and the GRACE Group and the Mandarin senior group of Chinese Christian Alliance Church. My gratitude goes to Eleanor Kwong for her editing assistance; to Christi Lane for statistical consultation; to Dr. James Lubben for the use of Lubben Social Network Scale (LSNS); and Quality Metric Inc. for the use of Health Survey SF- 12v2; to Dr. Daniel Lai for supplying the Chinese version of SF-36; as well as Dr. Shengming Yan for supplying the Chinese version of LSNS. I am blessed with the enthusiastic support of relatives and friends around the globe. To them I express my deep appreciation. Most importantly, I would like to Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. IV thank my family, my daughter Hannah and son Jonathan, and especially my husband Wing, for their patience and unconditional love throughout my long academic journey. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS Page DEDICATION ii ACKNOWLEDGEMENTS.......................................................................... iii LIST OF TABLES........................................................................................ vii LIST OF FIGURES...................................................................................... ix ABSTRACT.................................................................................................. x Chapter 1 INTRODUCTION............................................................................ 1 Statement of Purpose........................................................................ 1 Theoretical Background.................................................................... 3 Focus of the Study............................................................................. 7 Chinese American Elderly in Los Angeles....................................... 9 Significance of the Study.................................................................. 20 The Research Questions..................................................................... 21 2 LITERATURE REVIEW................................................................. 23 Housing Arrangements..................................................................... 23 Social Support................................................................................... 38 The Influence of Social Support on Health Status............................ 46 The Living Environment and Chinese American Elderly................. 47 Summary........................................................................................... 50 3 METHODOLOGY............................................................................. 51 Research Design................................................................................. 51 Sampling Strategies............................................................................ 53 Instrumentation and Data Collection................................................. 57 Operationalization of the Variables................................................... 68 Research Hypotheses........................................................................ 70 Data Analysis Procedures.................................................................. 71 4 RESULTS......................................................................................... 73 Descriptive Statistics of the Sample.................................................. 74 Type of Housing Arrangements and Personal Characteristics 80 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. VI Page Type of Housing Arrangements and Social Support Networks 81 Personal Characteristics and Social Support Networks..................... 85 Health Profile of the Sample in the Four Housing Arrangements..................................................................................... 88 The Impact of Social Support Networks on Health Status............... 91 Satisfaction with Housing Arrangements......................................... 93 Summary of the Elderly Residents’ Comments................................ 95 Summary of the Major Findings....................................................... 98 5 DISCUSSION................................................................................. 102 Diversity in Personal Characteristics................................................ 103 Housing and Arrangements and Social Support Networks............... I ll Housing Arrangements and Health Status........................................ 115 Social Support Networks and Health Status...................................... 118 Personal Factors, Social Support Networks and Health Status 123 Satisfaction with Housing Arrangements......................................... 124 6 CONCLUSION AND IMPLICATIONS......................................... 127 Current Housing Programs................................................................. 131 Implications for Policy Development............................................... 134 Implications for Social Work Practice............................................... 140 Limitations of the Study..................................................................... 144 Delimitation....................................................................................... 147 Implications for Future Research...................................................... 148 BIBLIOGRAPHY......................................................................................... 153 APPENDICES.............................................................................................. 165 1 . Historical Highlights on Chinese Americans in Los Angeles............ 166 2. Agency on Aging: Summary of Services.......................................... 173 3. Introductory Letter, English Version............................................... 176 4. Introductory Letter, Chinese Version............................................... 177 5. Informed Consent Form, English Version....................................... 179 6. Informed Consent Form, Chinese Version...................................... 185 7. The Questionnaire, English Version................................................. 188 8. The Questionnaire, Chinese Version................................................ 198 9. Sources of the Sample....................................................................... 207 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Vll LIST OF TABLES Page 1. Characteristics of Older Chinese Population in Los Angeles County: 2000 ............................................................... 10 2. Trends In Living Arrangements of The Elderly.............................. 28 3. The Continuum of Housing............................................................. 30 4. LSNS-18 Factor Matrix................................................................... 60 5. LSNS-18: Item - Total Scale and Subscale Correlations............... 61 6. Reliability Estimate for SF-12v2 and Summary Measures, Respondent Subgroups in the General U.S. Population................... 64 7. Health Profile Norms by Age Groups, Males and Females Combined Ages 65-74 ...................................................................... 66 8. Health Profile Norms by Age Groups, Males and Females Combined Ages 75+......................................................................... 66 9. Operationalization of the Variables................................................. 69 10. Type of Housing Arrangements...................................................... 76 11. Characteristics of the Study Sample................................................ 77 12. ANOVA: Selected Personal Characteristics by Type of Housing Arrangements................................................................................... 81 13. Summary Scores of Social Support Networks in the Four Types of Housing Arrangements................................................................ 82 14. Regression: Type of Housing Arrangements by Family and Neighbors Social Support Networks................................................. 84 15. Regression: Type of Housing Arrangements Friends and Total Networks........................................................................................... 85 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Vlll Page 16. Regression: Personal Characteristics by Family and Neighbors Networks........................................................................................... 86 17. Regression: Personal Characteristic by Friends Networks........................................................................................... 87 18. Health Profile of the Chinese Elders in the Four Housing Arrangements.................................................................................... 89 19. Regression: Type of Housing Arrangements by Health Profile.................................................................................................. 90 20. Correlations of Family, Neighbors and Friends Networks by Physical and Mental Health Status.................................................... 92 21. Regression: Physical and Mental Health Profile by Social Support Networks........................................................................................... 93 22. Frequency Distributions: Satisfaction on Type of Housing Arrangements.................................................................................... 94 23. Multiple Comparisons on Satisfaction by Type of Housing Arrangements................................. 95 24. Summary of Selected Personal Characteristics, Social Support Networks, and Health Status by Types of Housing Arrangements........................................................................................... 100 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. IX LIST OF FIGURES Page 1 . Conceptual Framework of the Study............................................... 52 2. Types of Housing Arrangements: Ethnic Association by Housing Type.......................................................................... 53 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. X ABSTRACT This study investigated housing issues concerning Chinese American elderly, with a focus on the influences of ethnic association and housing types on social support networks and health status. An adequate housing environment that fits one’s needs is essential to the well-being of the elderly. Housing is more than a physical unit, it is an environment supporting the personal, social and emotional needs of the individual. While progress has been made in the United States to provide senior housing and service programs to assist older Americans in maintaining their independence and well-being, dominant cultural values generally guide policymakers and professionals in planning and implementing senior programs, without considering the specific needs of ethnic elderly immigrants. The Chinese American population is the largest Asian Pacific American subgroup in the United States, with those aged 65 and above growing at the fastest rate among all older Americans. More than 80% of Chinese elderly are immigrants who face cultural and language barriers, which keep them from accessing existing senior housing programs. This study sought a deeper understanding of the housing characteristics of Chinese American elderly for the purpose of guiding future development of ethnic-appropriate senior housing and related social services. A sample of 260 elderly Chinese Americans was drawn from community senior organizations and aggregated senior housing facilities in both Chinese communities Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. XI and general communities. Data were collected using semi-structured survey questionnaire including the Lubben Social Network Scale (LSNS-18) and Health Survey (SF-12v2). All demographic and contextual factors were analyzed in relation to four residential settings based on ethnic association and housing types. Findings based on descriptive statistics, analysis of the variance, and multiple regression analysis, revealed a diverse pattern of housing settlement, which influenced social support networks and physical health status according to the demographic and socioeconomic characteristics of the Chinese elders. Mental health status appeared to be independent of housing arrangements. Educational level, number of children, and age were major personal factors predictive of housing arrangements, social networks and health status. Quantitative findings were complemented by qualitative data, providing an in-depth explanation of the results. Implications for policy and practice were discussed. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 1 INTRODUCTION Statement of Purpose America's elderly population aged 65 and over is rapidly increasing in number and diversity. The demographic changes have a profound impact on the way services are planned and delivered. Elderly Chinese Americans are part of the aging tidal wave that is changing the social structure of our society, and demand equal attention to their social needs as all older Americans. This study investigates the housing characteristics of elderly Chinese Americans with a focus on the effect of ethnic association and housing types on their well-being. Findings from this study aim to provide a deeper understanding of the changing characteristics of ethnic and cultural groups and their specific needs in order to improve policy decision, program design and practice of services. The phenomenal growth of the aging population is in part attributed to the increase in longevity and decrease in mortality due to medical advancement. In 1998, the average life expectancy of Americans was 76.7 years, compared to 47 years in 1900. The elderly population increased 11-fold from 1900-1994, while the non-elderly population increased only 3-fold. In year 2000 there were 33 million Americans aged 65 and over, almost 13 % of all Americans. This number is estimated to reach 70 million by year 2030, and will make up about 20 % of the total population. The older population is getting older. People over 85 who are most likely to need care, are the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 fastest growing age group. There are currently over 3 million Americans over 85. This number is expected to reach over 8 million by 2030, and over 18 million by 2050 (Administration on Aging (AoA), 2001). The older population in America is becoming more diverse because of past and present immigration trends, economic and political influences. It is a population with many different languages, cultures, religions and classes. Within this fast growing heterogeneous population, ethnic minority groups are experiencing even more phenomenal growth. Minority populations are projected to represent 25.4 % of the elderly population in 2030, up from 16.4 % in 2000. Within the minority population group, Asians and Pacific Islander elders, including Chinese elders, are projected to increase 285 % between 1999 and 2030, compared with 81 % increase of white elderly population during the same period (Administration on Aging (AoA), 2001) The increasing number and diversity of the older population have propelled researchers and public policymakers to examine the social, health, and policy issues concerning the emerging aging society. Among these issues, housing has been identified as one of the most critical issues affecting the older Americans (Advisory Task Force on Senior Issues, 2000; Pang, 2001; Takamura, 2002). Affordable housing options are overall in short supply in major urban areas and many rural and suburban areas. In California, severe housing shortage reported in year 2000 is reflected by the waiting list of 465,340 families for public housing and rental subsidies, while only 130,000 families have been able to secure housing units in existing public housing, or have received federal tenant-based rental subsidies (Williams, 2000). Older persons Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3 are less competitive in the housing market and are therefore even more limited in their housing choice than the general public. Consequently, many older individuals live in substandard housing that they can barely afford, while other frailer elderly persons are forced to move to institutional settings such as nursing homes, instead of staying in a more satisfactory residential environment (Glionna, 2003). Theoretical Background Adequate housing arrangement is an essential factor for successful aging. This implies that housing is more than just a physical unit; it is an environment that supports the personal, social and emotional needs of the elderly individuals. A living environment that fits the needs of older individuals is the antecedent to their well-being. Kahana (1982), in presenting the Person-Environment Congruence Theory, stresses the importance of goodness of fit of individual and environment based on Lawton’s work on ecological psychology (Lawton, 1975, 1985). The environment plays a more central role for older people than for younger people, because older persons tend to have less capability to control their surroundings due to changes in social, physical and psychological functioning. An environment that is congruence with the needs of the elderly person enables the individual to continue living independently by having "the ability to remain living in the community with the help of supportive services and environments adapted to their needs" (AgeLine, 2002, p. 69). According to a series of survey by the American Association of Retired Persons, the majority of older Americans prefer to Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4 "age in place" without moving to another location, because of their attachment to their present housing environment (AARP, 1996). With home modifications and available supportive services, older persons can conduct their normal daily fimctioning "in place" until health and financial circumstances make it necessary to relocate to more supportive housing environment. On the other hand, while most elderly Americans prefer to live in their own homes in the community, multi-unit senior housing arrangements have gained favorable acceptance in recent years by a growing number of senior citizens, as long as the buildings are located in their neighborhood (AARP, 1996; Administration on Aging (AoA), 2003). Congregated senior housing units are usually designed with safety features and supportive services to allow the residents to continue living independently in their own familiar community (AgeLine, 2002). For the ethnic Chinese elders, an important element of the living environment is ethnic association, referring to life in a community with a high concentration of Chinese people. Another element is the type of housing where the elders reside, whether it is a senior housing facility or a regular community dwelling. Between these two housing types, senior housing is viewed as a choice for the Chinese elders to live independently from their families. Both of these elements of ethnic association and housing type can influence the social support networks and health status of the elderly residents. Social support networks are spatially dependent. Locations and types of residences often influence the elder's social ties with family, friends and neighbors, as Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 5 well as access to public social services. This is because older people tend to stay at home and the neighborhood more often, and are more limited in mobility than younger people. Social support can be manifested in many forms, including social bonds, social networks, and social ties (Ell, 1984; Sung, 1991). Positive social support provides physical assistance as well as emotional strength to the elderly individuals. Whereas negative or lack of social support leads to social isolation, conflictual interactions and disruption of social relationships. Negative social support can cause mental and somatic health problems such as depression and fibromyalgia (Caplan, 1974; Cobb, 1976; Ell, 1984; Henderson, 1977; Lubben, 1988; Miller & Ingham, 1976). Further, social support can also be "too much of a good thing.” According to Silverstein, Chen, and Heller (1996), family members can help the older individuals up to a threshold point, beyond that, negative effect on well-being can result, due to unnecessary actions and overly concern of the family members. Many theories point to the relationship between social support and health-related quality of life. A buffering effect theory posits that healthy social relationships may strengthen the immune system and thus may increase the body's resistance to stress-related illnesses. Similarly, strong social relationships may enhance the body's defense mechanism to fight off diseases more effectively (Cassel, 1976; Cobb, 1976; Mor-Barak, Miller & Syme, 1991; Thoits, 1982). Another theory suggests that close social relationships can lead to adherence of healthy habits. In times of need, social networks may also provide essential support that may contribute Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 6 to quicker recovery and better adaptation (Kelsey, Earp & Kirk, 1997; Potts, Hurwicz & Goldstein, 1992). On the contrary, inadequate social support networks have been associated with increase in morbidity and mortality. For example, social isolation has been related to problems of psychological distress and somatic symptoms (Lubben & Lee, 2001). Social support is dependent on cultural factors. Therefore, different etiology may lead to deficiencies in social relationships among elderly ethnic minority immigrants than the white or general population. MacKinnon, Gien and Durst (2001) noted that Chinese elderly immigrants are more likely to encounter problems associated with loneliness and isolation than are younger or longtime residents because of social and cultural adjustments to a new environment. Traditionally Chinese elders are expected to live with their sons and/or daughters, playing the role of patriarchs in the community. Their support networks have been closely integrated with family and friends in their home country. However, upon immigration to the United States, they have lost many friends and family members and have to form new social ties in an unfamiliar environment. Monolingual Chinese elderly immigrants who live with their children in the mainstream community are likely to become isolated, with only their immediate family as their primarily social support. Unfortunately, while relying on their family solely for support, many of these elder oftentimes have problems with cultural conflicts within a multigenerational household (Wong & Ujimoto, 1998). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 7 A growing number of Chinese elders have chosen to live independently in Chinese-speaking communities. While they may receive social support from their peers in a culturally convenient environment, they may have to trade off their regular family support. There are also other Chinese elders have no choice hut living on their own for various reasons, including widowhood and abandonment. Because of limited income and high cost of housing rental, some Chinese elders can only afford to live in small housing units that are in decrepit conditions. Studies have shown that Chinese elders, especially elderly immigrants, face widespread depression both living with their families and living alone (Chen, 1979; Kung, 2001; Wong & Ujimoto, 1998). By exploring the effects and consequences of housing choices on health and social well-being, this study aims to identify what type of housing environments might enhance the quality of life of different Chinese elders. Focus of the Study This study focuses on housing issues among elderly Chinese Americans for several reasons. First, the American Chinese population is increasing rapidly as a significant part of the demographic tidal wave of older Americans. During the last 10 years, a surge of immigration boosted this nation's Chinese population by 48 %, to more than 2.4 million in year 2000 (U.S. Census Bureau, 2001). This increase was fueled by the arrival of elderly parents and relatives sponsored by the large number of family members who have become United States citizens after the relaxation of immigration policy in 1965 (Lai & Arguelles, 2003). Many of these immigrants were Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8 in their middle age and beyond when they arrived in the United States (The Asian American Federation of New York & Brookdale Center on Aging at Hunter College, 2003). In California, the growth in elderly Chinese population is even more phenomenal than the national trend. Being on the Pacific Rim, this state has been the most popular destination for Chinese immigrants (Shinagawa, 1996). During the 30-year period between 1970 and 2000, the elderly Chinese Population in this area has been estimated to increase by 800 %, with more than 80 % of this group being immigrants (Lubben & Lee, 2001; Ong, 1994). The tremendous increase in number of older Chinese Americans has profound implications on public policy issues such as Medicare, Social Security and senior housing (Ong, 1994). Secondly, there is a lack of specific data on the Chinese American elders. With a few exceptions, information on Chinese elders has been inferred from studies on aggregates of Asian Pacific Americans (Fowles, Dunker & Greeberg, 2000; Kitano, 1988; Morioka-Douglas & Yeo, 1990; Tanjasiri, Wallace & Shibata, 1995; The Asian American Federation of New York and Brookdale Center on Aging at Hunter College, 2003; Tsai & Lopez, 1997). Often aggregated data on Asian Pacific Islanders (API) are adequate enough to provide a general profile of the Chinese Americans. However, as this subgroup increases in number, more fine-tuning is needed in order to have an accurate understanding of this specific ethnic group. Without the current information, stereotyping will continue, which will lead to mismatch of services, and even neglecting the social services that are truly needed. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 9 Thirdly, cultural changes are a dynamic phenomenon. Both immigration and modernization can impact cultural changes among the Chinese family. Therefore, our understanding of traditional Chinese culture needs to be re-examined. For example, Silverstein (2000) pointed out that cultural expectations in the Chinese families are shifting from filial piety to filial autonomy. Filial piety is a central concept of Confijcianism which demands total devotion of children to honor and care for their elderly parents daily ( Chow, 2001; Chow & Chi, 2000). This traditional concept gives rise to the expectation that parents in their old age live with their adult children. However, the process of modernization in various global societies has changed the value and practice of care for the elders in the Chinese families, as well as other Asian families rooted in Confiicianism (Sung, 1998). Therefore we see a growing tendency of Chinese elders seeking separate housing rather than living with their grown children (Pang & Sung, 2000). Chinese American Elderly in Los Angeles Demographic Trends According to the U.S. Census, Los Angeles County had 329,352 Chinese Americans in year 2000, with 37,000, or 11.2% aged 65 and over. As shown in Table 1, this % is higher than the % of general older population in the County of Los Angeles (9.7%). The young-old (age 65-74) and middle-old (age 75-84) Chinese elderly groups had larger proportions than the general population, with 6.5% aged 65 to 74, and 3.8% Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 10 aged 75 to 84 for the Chinese population, compared to 5.2% aged 65 to 74, and 3.4% aged 75 to 84 for the general population. A very small proportion of Chinese households were headed by elderly individuals (4.1%) compared to the general population (7.1%), while more Chinese elders (25.3%) lived with other relatives in the same household than the general population (21.5%). These proportions confirmed the cultural tradition of stronger family tie among Chinese families. However, this cultural expectation is shifting with more older Chinese choosing to live independently from their grown children (Pang et.al., 2003). Table 1 Characteristics of Older Chinese Population In Los Angeles County: 2000 Subject Los Angeles County Race or Ethnic Group: Chinese (including Taiwanese) Los Angeles County General Population Number % Number % Total population 329,352 100.0 9,519,338 100.0 65 year and over 37,003 11.2 926,673 9.7 65 to 74 years 21,260 6.5 492,833 5.2 75 to 84 years 12,435 3.8 324,693 3.4 85 years and over 3,308 1.0 109,147 1.1 M ^e 17,043 5.2 383,240 4.0 Female 19,960 6.1 543,433 5.7 Householder 65 + 4247 4.1 223,473 7.1 Household with 26,343 25.3 674,787 21.5 individuals 65+ Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 11 Immigration History The profile of elderly Chinese Americans in Los Angeles today is shaped by the history of immigration of Chinese in this area. Appendix 1 presents historical highlights on Chinese Americans in Los Angeles. The Chinese elderly population today is composed of mostly immigrants (Lai & Arguelles, 2003; Ong, 1989; Ong, 1994). Even after 160 years of immigration history, there are relatively few older U.S.-born Chinese Americans. This abnormal family development was the result of racial discrimination and legal exclusion between 1882 and 1943 when women were barred from entering the United States. Therefore, prior to the World War II era, the Chinese community was primarily a bachelors society comprising of merchant class and working class of sojourners who expected to return to their homeland China. It was not until the end of World War II that immigration laws were relaxed with the improved relationship between China and the United States. Since then there has been a steady increase of immigrants, and U.S.-born Chinese began to grow in numbers. The period between 1960 to 2000 marked the turning point in the 10-fold increase in number of Chinese Americans and in social transformation of the Chinese community (Lai & Arguelles, 2003). Since the relaxation of the Exclusion Act and the enactment of the 1965 Hart-Cellar Act, a tsunami of ethnic Chinese immigrants came from Hong Kong, Taiwan, China and Southeast China. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 12 Contemporary Elderly Chinese Americans Their diversity in places of origin, patterns of geographic settlement, and socioeconomic background change the face of Chinese in America today. Accordingly, older Chinese in Los Angeles can be distinguished into the following six categories: 1) Chinatown-centered Chinese: Many Chinese elders in Chinatown Los Angeles, are early immigrants who have established their families after the World War II. They are primarily immigrants from the Guangdong Province of South China and speak mostly Taishanese and Cantonese. Lacking education and English language proficiency, these elders remain in the ethnic enclave of Chinatown, even after their children have moved away to work in other cities, or to live in more affluent suburbs such as the San Gabriel Valley, Cerritos and Orange County. Beginning in the 1970s, longtime Chinatown residents have gradually moved away to other Chinese communities, only to be displaced by Southeast Chinese immigrants. These new arrivals regard Chinatown as their entry community because of their familiarity with the Chinese culture and language. Residents of Chinatown Los Angeles have experienced much discrimination and hardship throughout the years. However, strong civic leaders and highly motivated citizens have overcome the barriers and are able to bring in culturally appropriate social services, senior housing and health care facilities inside Chinatown proper. This environment is especially Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 13 attractive to monolingual older residents since they can shop freely, eat Chinese food in the neighborhood restaurants, seek medical care with Chinese-speaking professionals, and above all, see their friends who live nearby. It is not surprising that an increasing number of Chinese elders are moving back into the Chinatown community from the suburbs. 2) Ethnic Chinese Vietnamese: As mentioned before, after the Vietnam War in the 1970s, many Southeast Chinese joined the longtime Chinese and settled in Chinatown as well. These newer immigrants have become successful grocers and merchants. A large number of Southeast Chinese have also settled in Westminster and Garden Grove located southwest of downtown Los Angeles, giving Westminster the nickname "Little Saigon." Historically, Chinese had immigrated to Vietnam before the Vietnam War because of Communist takeover in China. While in the first host country of Vietnam they had little integration with the local Vietnamese. In fact, they had to endure much discrimination and persecution as Chinese immigrants in Vietnam. From 1977 to the 1980s, older Southeast Chinese parents fled the Vietnam War with their children to the United States as refugees and "boat people," simply to save their own lives. Only when the political situation took a turn in 1986 that other Vietnamese migrated to America for the purpose of seeking better social and economic opportunities. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 14 After arriving in the United States as immigrants for the second time, the Southeast Chinese immigrants are still bound by their own distinct Chinese sub-cultural traits and social organization, with their education primarily received in Chinese schools. The actual number of Chinese Vietnamese is estimated to be about one-third of the Vietnamese American population (Lai & Arguelles, 2003; Weinberg, 1997). 3) Taiwanese Chinese: The Taiwanese are ethnic Chinese, though they speak their own dialect in addition to Mandarin. They hold strong views about maintaining their own identity because of opposition toward reunification with China. In the late 1940s, the Communists defeated the Nationalist government. Headed by Generalissimo Chiang Kai Shek, the Nationalists fled Mainland China for the Island of Taiwan, along with 1.5 million Chinese. When a new U.S.-backed government was established, the native Taiwanese were repressed and their traditions were quashed, breeding resentment even until today. The Democratic Progressive Party (DPP) now governs the Island, which represents the majority of indigenous Taiwanese population. The 2000 Census recorded 144,795 Taiwanese Americans, a small number compared to the 2.7 million population who identified themselves as Chinese. However, more than half of this number lives in California. In Los Angeles County, 35,174 identified themselves as Taiwanese in 2000. The Los Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 15 Angeles suburb of Monterey Park, known for its title as "Little Taipei" is the unofficial capital of Taiwanese Americans. U.S. Immigrants from Taiwan displayed high levels of educational attainment with 62 % having competed at least four years of college. More than three-quarters of Taiwanese Americans hold managerial positions, earning high income. At the same time, there is a disparity in their economic status, as one out of eight families declared having income level below the poverty level. Similar to other Asian groups, Taiwanese began coming to the United States during the 1960s, under the new immigration laws which allowed entry for the skilled and highly-educated. Today, many of them have become older American citizens. Their parents who followed them to the U.S. are now reaching their 80s and 90s. The 2000 Census recorded 9.8 % Taiwanese in the Los Angeles County who are 62 and older; and 7.6 % who are 65 and older (U.S. Census Bureau, 2001). 4) Professionals, scholars, specialists and technicians: In the 1960s, a flood of Chinese immigrants came to the United States to further their education. Some started as college students, while others who had already obtained their educational skills prior to their arrival, began practicing their expertise. These immigrants were able to secure well-paid jobs that would allow them to prosper, although they often encounter a greater probability of facing the glass ceiling in the American corporate world. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 16 This group of professionals is more easily assimilated into the American culture than the other immigrant groups and is likely to face aging issues similar to the mainstream Americans. Nevertheless, many also tend to still attach to their cultural heritage. These elders may face the dilemma of seeking independent living as desired by most mainstream elders (American Association of Retired Persons (AARP), 1990), while at the same time, they expect the practice of filial piety from their children, which demands honor and total devotion from their offspring (Sung, 1998, 2001). 5) American-born Chinese elders: Despite the fact that Chinese Americans arrived in the United States at a much earlier time than many European and other Asian groups, such as Italians, Jews, and Japanese, the Chinese Americans remain predominantly an immigrant-dominant community (Logan, Stowell & Vesselinov, 2001; Wong, 1995). This skewed demographic development was the result of 60 years of legal exclusion that lasted between 1882 and 1943. In the mid-19* Century, Chinese began working in Hawaii and West of the Rocky Mountains in plantations, mines, and railroads. In 1882, widespread anti-Chinese sentiment led the Congress to pass the Chinese Exclusion Act. It was renewed again in 1892 and later excluded all Asian immigrants until World War II. During this time, the shortage of women prevented normal development of Chinese American family. As a result, less than 9% of the Chinese American population were in 1900. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 17 After the relaxation of immigration laws in the early 1940s, there was a surge of birth rates, resulting in the U.S.-born outnumbering the foreign-born Chinese. However, the absolute number of U.S.-born Chinese is small to begin with and relatively younger than the average U. S. population. According to the 1990 census in Los Angeles, 23% of the Chinese American population was American-born, compared to 27% born in Mainland China, 20% in Taiwan, 8% in Hong Kong, and 22% from other parts of the world, (Lai & Arguelles, 2003). The older American - born Chinese have mostly assimilated into mainstream American life, although many still retain a part of their family's dialects and customs. Among these elders are those who have rekindled their interest in their roots. They study Chinese history, take Chinese painting lessons, and travel to China to visit the villages of their ancestors. 6) Recent elderly immigrants: While early immigrants came to the United States as young men and women to work in the labor force, to study or to be married as war brides, many recent immigrants came at an older age after the relaxation of immigration laws which encouraged family unification. These immigrants have come from Taiwan, Hong Kong, China and various part of Southeast Asia to escape the unstable political and economical conditions at home. They came to the U.S. to join their grown children who have already established a new life in this foreign country. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 18 In this study, Chinese American elders in the sample included elders in all the above subgroups. As described before , contemporary Chinese elderly immigrants came from a variety of backgrounds. Some came to the United States with limited education and financial resources, others came with vast savings and educational achievement. However, due to age and declining health, they may share many common problems. Many lack English speaking proficiency and transportation skills. Therefore they become totally dependent on their family members. Those who live in the suburbs are especially isolated from their friends and lack the mobility to shop and eat in restaurants of their choice. An important contribution of the Chinese elders to their families in the United States is providing childcare for their grandchildren. While many families live in harmony and appreciate the grandparents' efforts in caring and passing on the cultural heritage to the grandchildren, family tension can occur due to different opinions in childcare methods between grandparents and parents. Multigenerational conflicts also occur when the younger generation speak very little Chinese and pursue western lifestyle while the elderly grandparents still hold on to their traditional viewpoints. In addition, the elders often feel guilty for being a burden on their grown children because of their dependence on their family for language and transportation assistance. They, therefore, try not to bother their children, while they struggle privately with the feeling of uselessness, helplessness and depression (Pang et al., 2003). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 19 The diversity in language, culture and socioeconomic status among Chinese elders in Los Angeles mirror today's general demographic trend. They are primarily immigrants from Mainland China and the greater Chinese Diaspora of Hong Kong, Taiwan, Vietnam, Cambodia, Malaysia and the Americas. They speak numerous regional dialects - Mandarin, Cantonese, Toisanese, Fujianese, Chaozhounese, Taiwanese, Hakka, and Shanghainese, just to name a few. Even the ancestral written language now is divided into traditional and simplified characters. The bifurcation in socioeconomic status among the older Chinese Americans is also striking. Some have little money and job skills, and have no other choices but to take minimum-paying jobs until they retire. Others arrived with family savings, education and professional skills above that of average Americans, and are able to prosper in the mainstream economy. A more recent mode of social mobility is ethnic entrepreneurship. Between the year 1970 to 1980, Chinese-own business firms nearly triple at a rate faster than any other ethnic groups. By year 1997, Chinese-American owned business enterprises accounted for only 9% of the total minority-owned business enterprises in the nation, but they made 19% of the gross receipts. The older Chinese Americans can be credited for this economic success (Zhou, 1992). Recent demographic trends show that foreign born Chinese have dropped substantially to 47%, eompared to more than two-third a decade ago. This indicates that the Chinese Americans community is being transformed from a predominantly immigrant community to a native ethnic community. Thus we find that, at the dawn of the 2 1 ® ^ Century, the Chinese American population is facing not only issues relevant to Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 20 settlement as immigrants, but also new challenges as citizens of the United States. Among these challenges is getting equal and appropriate care for their rapidly growing elderly population. Signifieance of the Study Much research has been devoted to understanding the housing needs of mainstream older Americans and helping this population live independently, an important factor of successful aging (AARP, 1996; Administration on Aging (AoA), 2003; Advisory Task Force on Senior Issues, 2000; Pynoos & Redfoot, 1995). As a result, numerous programs have been developed to link supportive services, and to promote universal design in home modification for the seniors to "age in place." In addition, various private senior housing have been developed to meet the demands of senior individuals who can afford the amenities and convenience specially adapted for the aging consumers. Despite the attention given to the housing needs of mainstream elderly population, very little has been done to understand the needs of ethnic elders, including the Chinese elders. As more Chinese elders seek independent living in contrast to the traditional norm of filial piety that leads to the expectation of older parents living with their grown children, it is not known if, or how muc, this trend will affect the elders' quality of life. This study will address the issue, and the findings will help researchers draw some conclusions on what type of housing arrangements are conducive to the social, physical and mental well-being of the elderly residents. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 1 The study focuses on elderly Chinese Americans in Los Angeles. Chinese have a long history of immigration in Southern California and a larger number than any other Asian Pacific Americans (Lai & Arguelles, 2003; Spolidoro & Demonteverde, 1998). This population has well-defined cultural characteristics and established communities in Los Angeles area and is, therefore, a good laboratory to study specific ethnic issues. What we can learn about the impact of housing arrangements on the quality of life among Chinese American elders has implications on other ethnic groups, especially East Asian groups with strong Confucian heritage. The Research Questions For Chinese elders who face cultural and language barriers in the American society, the location of their residence and cultural characteristics of their neighborhood have direct bearing on their social support and health-related quality of life. However, housing arrangement for the ethnic elderly population has been a neglected area of gerontological social work research. This study attempts to fill in the gap by exploring the following research questions: 1. What are the major factors that influence the housing arrangements of Chinese American elders? 2. What is the relationship between housing arrangements and social support networks of Chinese American elders? 3. How do housing arrangements and social networks influence the health of the elders? Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 22 4. How satisfied are the elders about their housing situations and why? 5. What are the policy implications concerning housing programs for the ethnic elderly population? Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 23 CHAPTER 2 LITERATURE REVIEW This chapter reviews theoretical and background studies pertaining to housing environment and its effects on the social, physical and mental well-being of older Americans in the general population. It includes three major sections. The first section explores the literature on housing environment with an emphasis on independent living of older Americans. The second section presents theories on social support and the impact of positive and negative social support on health-related quality of life. The third section examines studies on elderly Chinese Americans from the perspectives of culture, environment, and social gerontology. Housing Environment Person-Environment Theories of Aging The process of aging involves constant adjustment between the environment and the individuals. According to Lawton (1985), changes would occur over time, causing an imbalance in the individual needs and the environmental resources. With the elderly persons, changes are more likely to occur in the individuals rather than the environment. As competence in sensory functioning, physical and cognitive health, and financial strength decline with advanced age, the older individuals are expected to face the disparity between the environment and personal resources, and require adjustments to adapt to the environment. Individual needs and abilities to mediate Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 24 adjustments to the impact of the environment define the limit of the individual's competence. The competence model has been described by Hooyman and Kiyah (2002, p.7) as "useful way to view the dynamic interactions between the person's physical and psychological characteristics and the social and physical environment." Competence refers to the potential of an individual "to function in areas of biological health, sensation-perception, motives, behaviors and cognition" (Lawton, 1975, p.7). Kahana (1982) also stresses the importance of goodness of fit between person and environment. Because older people tend to spend more time at home, a living environment that meets their daily needs allows them to maintain their activities of daily living, to socialize with friends, and contribute to family and society. An adequate living arrangement allows the elderly individuals to express freely their personal characteristics and cultural values. It provides the them with the security and autonomy they need to connect with familiar resources in the homes and in the neighborhood. According to person-environment theories of aging, the elders tend to be more satisfied with life in an environment that fits, or, is congruent with their physical and cognitive abilities, and provides for their social and emotional needs. Stewart (2003) describes a "naturally occurring retirement community" (NORC) which is an excellent example of person-environment congruent community. The NORC aims to help elderly people stay in their homes by designing and monitoring the utilization of community services. NORC allows elderly persons to remain in their neighborhood where they have "raised children, celebrated holidays and made memories" (p. Kl). The elders live in their own homes, apartments and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 25 board-and-care homes among their own peers. Rather than being institutionalized prematurely, they are able to enjoy quality of life in the community in which they live. To help these elders maintain their independence, social workers develop plans for services according to individual needs. The services include connecting the elders to Meal on Wheels, a type of home-delivered meals. Home modifications such as shower bars, raised toilet seats and emergency call button are commonly installed in the elders' homes. NORCs are gaining the attention of policymakers who are drafting plans to meet the housing and social services needs of senior citizens, whose number is expected to double within the next three decades. For public agencies, providing services in the home is more cost-effective than nursing homes. As for the elderly individuals, NORC services allow them to continue staying at their home and neighborhoods where they are in eontrol and are able to make decisions for themselves. That is what contributes to their quality of life, giving them a sense of independence and empowerment. Independent Living The phenomenon of "age in place" has been a subject of discussion by many authors (AARP, 1990; AARP, 1996; Advisory Task Force on Senior Issues, 2000; Baker, 1990; Brandt, 1989; Himes, 2001). Many older Americans share the desire to remain in their homes and communities. A report by AARP (2000) showed that 84% of individuals aged 45 and above indicated that they would prefer to remain in their Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 26 current residence for as long as possible rather than moving into retirement homes. This housing preference has led to increase in various type of housing aimed at maintaining the independent lifestyle of elderly individuals. Independent living is a prevailing goal of successful aging both for the older persons themselves and for society. The AgeLine database (2002, p. 69) defines independent living as "ability of older adults to remain living in the community with the help of supportive services and environments adapted to their needs." Beeber (2002) analyzed the concept of independence of older adults residing in the community and describes independence as the ability to provide for oneself with little or no burden exerted to others. Independence has been generally viewed as freedom from control by others. This implies a lack of need for help from outside sources. In the context of old age and chronic illness, independence is delineated into three domains. 1) In the individual domain, the older person has the ability to recognize his physical and cognitive limitations and has the freedom of choice to use an outside party (family member or care provider) to perform activities of daily living. 2) In the interpersonal domain, the older person has the ability to incorporate interdependence to create a notion of optimum independence. 3) In the societal and cultural domain, the older person projects the image of healthy or successful aging within cultural stereotypes. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 27 The independence of the elderly individuals is demonstrated by performance of activities of daily living (ADL) (AgeLine, 2002), including eating, bathing, dressing, toileting, walking and transferring from a bed to a chair. The individual is able to maximize his or her physical capabilities and initiate self-care behaviors. Psychosocially, the individual's independence leads to empowerment and confidence, and performance of instrumental activities of daily living (lADL), including telephoning, shopping, cooking, and handling finances (AgeLine, 2002). Relational consequences of independence are seen in the development of interpersonal relationships and interdependence. These relations may be reciprocal in nature; the older adult receives the support they need, and the supporter receives the benefits of engaging in a caring relationship (Beeber, 2002). Fuller (1978) also demonstrated the positive effect of empowerment of elderly individuals. In a research on nursing home residents, the investigator found that perceived opportunities to participate in decision-making and making choice were important to improve morale, and was a predictive factor of well-being of elderly individuals. Further, Ziegler and Reid (1979) examined samples of elderly community residents and hospital patients. They reported that life satisfaction and concept of self were significantly correlated with having control of one's life. Based on U.S. Census information, Table 2 shows the percentage distribution of living arrangements of persons aged 65 and over between 1960 and 2000. The most striking change during the last four decades occurred in those living alone, from 19% to almost 30%. In I960 about one-quarter of elders lived with relatives, most likely Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 8 their sons and daughters; but in year 2000, less than half of that proportion lived with relatives other than their spouses. There are notable differences in living arrangements among the elderly by age and sex. According to 2000 Census, 40% of elderly women lived alone, while only 17% of elderly men lived alone. More than half of the women who were 75 or older lived alone, compared with only one in four men in this age group who lived alone. Table 2 Trends in Living Arrangements of the Elderly Year Living Alone (%) With Spouse (%) With Relatives (%) With Non-Relatives (%) 1960 18.6 51.1 24.8 5.5 1970 26.6 51.1 18.9 3.4 1980 30.3 53.6 14.1 2.1 1990 31.0 54.1 12.6 2.2 2000 28.5 57.0 12.0 2.5 Sources: Current Population Reports: Population Characteristics, Series P-20 March 1985/1990; Population Bulletin December 2001; U.S. Bureau of Census (Himes, 2001, December; U.S. Bureau of the Census, 2000) The proportion the elders who are married and living with their spouses has increased somewhat from 1960, whereas the proportions living with either other relatives or non-relatives have declined. The tendency of many elderly people now living separately from their relatives may be explained by the fact that living apart is a voluntary choice rather than the result of abandonment (AARP, 1990; McAuley & Blieszner, 1985; Shanas, 1979). Instead of sharing the same household with sons or daughters many older people choose to maintain their own independent lifestyle. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 29 Housing Options for the Elderly It is important to know the various housing options that are available to the elderly people, so that one can understand what constitutes adequate or appropriate housing arrangements, and the potential barriers in getting adequate housing. According to the National Resource Center on Housing and Long Term Care (1998), there is a continuum of housing arrangements for seniors, based on the functional abilities of the individuals, ranging from the level of independent living to dependent living. Independent living refers to housing designed for individuals and couples capable of handling their own housekeeping, cooking, and personal care needs. An interim level, semi-independent living housing refers to residences designed for those with some chronic limitations. Occupants are self-sufficient and capable of self-care, but may rely on the facility for meals, housekeeping, and transportation. Dependent living housing is at the other end of the continuum, referring to housing that provides 24-hour nursing care for severely impaired individuals. A great variety of housing options are available for the elderly within these three levels of housing. Some housing options have provisions for more that one level of housing. For example, a continuing care retirement community (CCRC) has all three functional levels of housing-independent, semi-independent and dependent living facilities. Among the housing options, only skilled nursing care facility is for completely dependent living. Table 3 presents the continuum of housing according to information provided by the National Resource and Policy Center on Housing and Long Term Care (1998). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 30 Table 3 The Continuum of Housing Housing options for the Elderly Independent Semi- Dependent independent Single Family Housing X X Conventional Apartments X X ECHO Housing X X Accessory Units X X Shared Housing X X Retirement Communities X X Supportive Housing X X X Single Room Occupancy (SRO) Hotels X X X Congregate Housing X X X Assisted Living X X X Skilled Nursing Care X Continuing Care Retirement Community X X X X X X X (CCRC) Source: National Resource and Poliey Center on Housing and Long Term Care (2002) The variety of housing options listed above are rendered by both public and private agencies depending on the needs and fiscal capability of the elderly individuals. These housing options are briefly described below based on information from Administration on Aging (AoA) (2003) and National Resource and Policy Center on Housing and Long Term Care (1998). 1 . Assessory Units: Separate units typically created in the surplus space within single family homes. 2. Assisted Living: Long term care alternative that involves the delivery of professionally managed personal and health care services in a group setting which is residential in character and appearance. It has the capacity to meet unscheduled Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 31 needs for assistance and does so in ways that optimize the physical and psychological independence of residents. 3. Congregate Housing: Semi-independent multi-unit living arrangement that generally provides group meals to residents. 4. Continuous Care Retirement Community (CCRC): A type of retirement community that allows the elderly to receive all levels of living arrangements from independent to dependent living. These facilities provide shelter, social, health care and support services under a contractual arrangement. 5. Elder Cottage Housing Opportunity (ECHO Housing): A temporary moveable unit, designed for use by the elderly and handicapped. It is small enough to be installed in a side or rear yard, and made well enough to withstand repeated moves. Or it can be a small, self-contained cottages placed at the side or rear of a single-family home. 6. Retirement Communities: Self-contained complexes for older persons that provide at least minimal services for residents. 7. Senior Apartments: These apartments are developed like standard apartments but have age restriction. Some apartments are equipped with assistive technology such as handrails and pull cords to aid the residents. 8. Shared Housing: Arrangement in which two or more unrelated people share a house or an apartment. Usually private sleeping quarters are available; the rest of the house is shared. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 32 9. Single Room Occupancy (SRC's): Renter-occupied one-room housing units in an apartment building or a residential hotel available to low-income older adults. 10. Supportive Housing: Housing complexes in which the owner or manager coordinates a range of supportive services, many of which are provided by third parties, for residents who typically live in their own apartment units. Most do not provide continuous protective oversight and are unlicensed. 11. Programs of all-inclusive care for the elderly (PACEs): Housing for frail elderly that are dependent on substantial public subsidy. In addition to the above senior housing options, there are board and care homes or assisted living homes, which are community residences that provide rooms, meals, and help with daily activities such as bathing, dressing and grooming. Residents can live in a home setting with only a few individuals and receive 24-hour care. Other resources for elderly individuals to stay in the community include home modification/repair services to provide adaptations to home environments of functionally impaired individuals intended to make it easier and safer to carry out activities such as bathing, cooking, walking, navigating steps, and opening doors. Linking existing housing and services for the elders are programs that seek to make supportive services more available to frail tenants of multi-unit housing. Such programs often use service coordinators or case managers to assess problems and arrange for services. In the independent communities, the type of housing includes houses, town houses and apartments. Occupants generally do not require medical services. If Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 33 independent living is a part of an established pay community such as in the case of a CCRC, the services offered to the dependent population are the same ones offered to the independent population if they choose to utilize the services as well. Among the housing options, three types of housing models warrant special attention because of their distinctive features and growing importance in housing and social services for the elderly. These are continuous care retirement communities (CCRS), assisted living facilities, and nursing homes (Himes, 2001; Housing the Elderly Report, 1997). Continuous Care Retirement Community (CCRS) A continuous care retirement community is a housing campus with security enforcement and a blending of independent living, assisted living and skilled nursing care. The CCRCs are designed to provide a continuum of housing, services and health care services for the elderly. As the residents' needs change, they may change from one type of housing unit to another to match their health conditions. The CCRC usually provides each resident a written contract offering a continuum of care. Most residents move into the community while they still can enjoy an independent lifestyle with the knowledge that if they become sick or frail, their needs will continue to be met. The usual service provided by CCRCs include housekeeping, meals, and laundry services for the elderly residents. Most CCRCs have exercise facilities such as a gym, shuffle board, and putting green. There are educational programs and educational programs including reading, poetry, craft, and painting classes. Regular Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 34 recreational activities usually include table games, shopping trips, concerts and travel. Religious services are regularly held in some sites. Many have on-site beauty parlors. Physical therapy, personal care assistance and skilled nursing care are also available to those in assisted-living units and in independent quarters. Unfortunately, CCRC is an expensive senior housing option that the average elderly persons cannot afford. An entry fee ranging from $20,000 to $400,000 is required. In addition, there are hefty monthly service fees, which vary on the type of housing units and the needs of the individuals. Due to the heavy demands, CCRCs are popular and are becoming financially viable businesses, with hospitality industry building and managing the facilities rather than health care industry. For example, the Marriott Hotel enterprise is actively involved in developing senior retirement communities. Because of the strong demand for senior housing, CCRCs tend to carefully screen their residents before accepting them, selecting those who are wealthier, healthier and better educated (Himes, 2001). Assisted Living Facilities This type of facility is either operated separately or as part of a CCRC. It provides more support than is available in a retirement community, combining personal and health care with housing services, but they usually do not provide skilled nursing care. In recent years, assisted living facility has become an indispensable housing choice for older people who live longer and are more likely to have chronic illnesses and disabilities. Residents of assisted-living can still live independently, but Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 35 they require some level of help with activities of daily living (ADLs) including eating, bathing, dressing, toileting, walking, and transferring from a bed to a chair. They receive cooked meals either in congregated setting or delivered meals, housecleaning and laundry service, and assistance with transportation and medication. The amount of help is provided according to individual need. Some facilities have professional nursing and other health care staff on site to provide regular and individualized care. Residents of assisted-living facilities are mostly female and older than the general elderly population, with an average between 75 and 85 year of age. On the average, they need assistance with 2.25 ADLs, according to a survey by the National Center for Assisted Living, a trade organization (1998). Compared to the cost of living in a nursing home, assisted-living is much less expensive. However, assisted living is not covered by Medicare or Medicaid in some states because it does not qualify as skilled nursing care. As the residents' health conditions decline and bank accounts are drained, some move back to stay with their families, and about one-third move to skilled nursing facilities. Nursing Homes Nursing homes usually provide skilled nursing care services to residents who are too frail to live independently. These residents include long-term residents who have serious chronic conditions, and short-term residents who are recovering from injuries, surgery or acute illnesses. According to U.S. Census, in 2001, less than 5% of the older population live in a nursing-home type residence. They are primarily female Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 36 and white. The average age at admission to a nursing home among those 65 or older is 82.6 years. About half are age 85 or older. On the average, nursing home residents have problems with at lease four out of six ADLs. The key contributor to the decision to enter a nursing home is incontinence, which is suffered by nearly 60% of nursing home residents. Most nursing-home residents have serious physical impairments. About one-half of the residents are cognitively impaired. Most of them are sent to the nursing home directly from a hospital (Himes, 2001). A recent report by Gabriel (2000) revealed a changing role of nursing homes as traditional primarily long-term care facilities for elderly persons. People regardless of their age are now placed in these facilities for recovery following an injury or acute illness because of shorter hospital stays. This change has been caused by the need to cut medical cost, so patients are transferred to the nursing homes for recovery rather than being cared for in the hospital. Following a short-term rehabilitation, most of the residents are discharged back to the community. In 1997, the average length of stay in a nursing home was almost 870 days. Among those admitted for recovery after an illness, and after surgery for rehabilitation, the average length of stay was 60 days. Although there are many housing choices for elderly Americans, most people still live in their own homes. However, a closer examination shows that most homeownership is among those younger-old who are aged 65-69, accounting for 83% of elderly homeowners. Therefore, the older-old (75-85) and oldest-old (85+) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 37 individuals are more likely to move to other senior housing arrangements (U.S. Bureau of the Census, 2000). Various factors influence older people to move, including wanting to live closer to family, to enjoy better climate, declining health, and death of a spouse. As people increase in age and the oldest-old cohort becomes larger, more people tend to accept the option of relocating to a smaller, more convenient residence or to retirement housing. Silverstein and Zablotsky (1996) found migration to retirement communities is more likely among those whose children do not live nearby and among those who live alone. However, most of these people who relocate prefer familiar surroundings and do not move too far away. According to Census 2000, more than one-half of older people who moved stay within the same county. Only about 5% of older Americans move during any year (U.S. Census Bureau, 2001, Sept 19). Less than 5% of older Americans live in nursing homes, which are generally considered the only form of institutionalization for the elderly individuals. Issues Concerning Housing and the Well-being of the Elderly During the past few decades, mortality rates for older people have declined dramatically, but the morbidity rates have not dropped at the same pace. As a result, many older people are living with some form of chronic conditions that are likely to increase with age. Housing problems for the increasingly frail population are expected to exacerbate. At the same time, the aging population seeks independent lifestyles by continuing to stay in the community. The combined circumstances of increase in Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 38 number of frail elderly, along with the trend on independent living pose a challenge for policymakers and housing providers. Pynoos and Redfoot (1995) pointed out that, until the 1990s, housing policies have emphasized the development of residences for independent older persons, as well as incentives for frail older persons to live in institutions such as nursing homes. However, the cost of nursing homes is prohibitive to many older people and their families. During the last two decades, legislators have made some efforts to remedy this situation by integrating supportive services into government-subsidized housing for the elderly, including the creation of Congregate Housing Services Program (CHSP) to provide service coordination and a variety of services to older residents of public housing (Pynoos, 1992). Unfortunately, strong political and bureaucratic forces have made it difficult to develop and implement programs such as CHSP successfully and continuously (Advisory Task Force on Senior Issues, 2000; Pynoos & Redfoot, 1995). Furthermore, much of the research, policies, and program development on housing have been based on research on the white population or mainstream populations. There is a lack of data on the housing needs of the ethnic elderly populations and how their quality of life is affected by their housing arrangements. Social Support Consistent with the person-environment perspective, housing environment is closely tied to social environment of the elderly persons. With age, the social role of older people change, along with the sustainability of physical and cognitive abilities to Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 39 maintain or build relationships in the individual's living environment. For example, many older individuals are limited in mobility because poor eyesight and slower reflexes have prevented them from driving. Public transportation is often difficult to navigate, especially in a large metropolitan city such as Los Angeles. Therefore, the elders' social activities are largely restricted to their residences and immediate neighborhoods. As health professionals and policymakers turn their attention toward a holistic approach to improving the quality of life of the elderly population, research on social relationships has become increasingly significant. Social relationship is an intricate tie between individuals and society, hence it has been difficult to defined. Lubben and Gironda (2003) listed numerous labels for this construct based on studies conducted during the last four decades; social bonds, social supports, social networks, social integration, social ties, meaningful social contacts, confidants, human companionships, reciprocity, guidance, information given, emotional support, and organizational involvement. Two constructs in the social milieu, social support and social network, have been carefully defined by some researchers ( Berkman & Glass, 2000; Ell, 1984; Vaux, 1988). Social support refers to the subjective traits of social relationships, with a focus on the characteristics of social interactions among individuals and groups. Ell (1984) describes social support as follows: ...the emotional support, advice, guidance, and appraisal, as well as the material aid and services, that people obtain from their social relationships. In turn, this support is used to maintain identity and enhance person’s self-esteem and coping repertoire Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 40 throughout their lives. A social support system is that subset of person in an individual's total social network on whom he can rely for support (p. 134). According to Ell (1984) and Lubben & Gironda (2003) social networks can be regarded as the sociological construct that provides the emotional, financial and other instrumental resources to the individual. Emotional support includes empathy, caring, respect, friendship, and understanding. Instrumental support includes more tangible assistance such as financial help, household help and physical care. The various structural aspects of social networks include types, sources, degree of intimacy, size, geographic proximity, frequency of interaction, level of trust, intensity, consistency, and source of support, homogeneity, durability, and reciprocity. Despite the lack of clarity in definition, researchers have recognized social relationship as a critical variable in quality of life during the last few decades (CapIan, 1974; Cobb, 1976; Ell, 1984; Henderson, 1977; Lowenthal & Haven, 1968; Lubben, 1988; Miller & Ingham, 1976). For older people especially, the changes during the process of aging accentuate their social dependency. Positive social ties such as formal social services and informal family support can enhance their physical and mental well being. Formal social services include government-funded community programs such as congregate and home delivered meals, case management, in home supportive services, respite care, adult day health care, legal assistance, transportation, and preventive programs of elder abuse. Appendix 2 shows public services for the aging provided by the United States Administration on Aging and Los Angeles County Area Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 41 Agency on Aging. A larger number of elderly also seek informal support from family, neighbors, friends, and voluntary organizations such as church and senior centers (Kim, 1993). Contrary to positive social relationships, negative social ties such as loneliness and family conflicts, contribute to depression, stress, and even suicide (Wong & Ujimoto, 1998). More discussions on studies pertaining to positive and negative social support and their association with the care of older persons are presented below. Positive Social Support A prevailing theory shows that family support is the most significant social resource for the elderly (Ell, 1984, 1996; Kim, 1993; Sung, 1991). For example, Ell (1996) reviewed studies on serious illness and disability, and found that family support is a primary source of patient support, underscoring the impact of illness on families and their need for caregiving support. Other reports by Hooyman & Kyak (2002) and Felton & Berry (1992) show that family support is often crucial in predicting institutionalization. Family members, especially daughters, are responsible for caregiving for the frail elderly, enabling them to stay in the community rather than entering a nursing home (Stone, Cafferata & Sangl, 1987). Lawton, Silverstein and Bengtson (1994) investigated the intergenerational relationship between older parents and their adult children, their affection, frequency of contact and geographic proximity. A total of 72% of respondents reported being "very close" to their mother, and 56% reported Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 42 being "very close" to their father, with 20% having daily contact with their mother and 68% weekly contact. Contact with fathers was less frequent, with 12 % daily contact and 57% weekly contact. This study found that there was only a reciprocal influence between contact in the mother-child relationship, but not in the father-child relationship. In another study by Silverstein and Angelelli (1998) the intentions of older parents to move near or in the same household as their grown children was examined. Findings demonstrate that parents are more likely to move closer to a daughter than a son. Further, parents tend to target a child who has a greater potential to provide assistance, such as a child who is better off financially. In addition, most of these older parents are female, older, and anticipate moving out of need for closer family support. Other primary social and personal ties in later life beside family members are friends and neighbors. Although family is often considered the most central social support group, friends and neighbors can be as important as family ties, especially when the elders live in age-specific retirement housing. Neighbors in the same housing project, and friends living nearby are more easily available than sons and daughters who live further away or are at work. They are often helpful in relieving some burdens of family caregivers. Pang et al. (2003) examined the health-seeking behaviors of Chinese elders living in senior housing. Their findings suggested a pathway for the elderly seeking help for their health problems. First, they would try self-care, then they would go for help from their spouses. Next, the elders would seek help from friends and neighbors. Then, as a final alternative, they would call upon Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 43 their grown children. Chinese elderly often perceive their sons and daughters as being too busy and should not be bothered unless it is urgently necessary. However, from the perspective of the grown children, they are generally willing to help, especially with driving to the doctors or making major medical decisions. Besides depending on primarily social support from family, friends and neighbors, the elders may belong to social groups, clubs and religious organizations in their neighborhood, where they can enjoy secondary social support. For those who are still employed, the workplace is also an important place for social connection. Social participation of older persons has been a common theme in gerontological literature. Some earlier theory on aging proposed social disengagement as normal with advanced age. This theory has been generally refuted recently and replaced by a new model of active aging, promoting broad integration of older people in society (World Health Organization, 2002). Such secondary social support provides social interaction and stimulation that has a strong impact on the quality of life of the elderly individuals. Social Isolation and Loneliness Social isolation and loneliness are two negative constructs of the social milieu, yet they can be distinguished from each other. Social isolation is used to depict individuals who have very restricted social support networks. The causes for isolation can be many. For the older adults, some common causes are poor health conditions, spousal caregiving burden, and depression due to bereavement (Dorfman et al., 1995). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 44 First, older and frailer individuals are less likely to participate in regular activity because of their physical limitations. They may not be able to drive around anymore because of poor eyesight, and they may be homebound because of ill health. The less they socialize, the more isolated they become. Another reason for isolation is family caregiving. Elderly women are usually the primary caregivers for their spouses. They may be too overwhelmed with daily caregiving tasks to find time for themselves. Thirdly, a widow who is in bereavement may withdraw from her circle of friends. In addition, ethnic elderly immigrants who are culturally and linguistically isolated may simply have no acquaintance outside of their own family circles. The differences in needs of individuals in social isolation have different practice implications, and are likely to affect the selection of intervention approaches. As Lubben and Gironda (2003) have pointed out, although social isolation can be viewed as a rather objective circumstance, loneliness is perceived more as a subjective experience that is usually recognized only through self-disclosure. The authors noted two types of loneliness in the literature; emotional isolation and social loneliness. Emotional isolation is the need of a specific type of relationships, including intimate ties between two individuals. Social loneliness is the need of connections with friends, neighbors, family and associates. Older individuals are more at risk of losing their social network and facing social loneliness, especially those who belong to the middle-older or oldest-old cohorts, who are not married and suffer from poor health. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 45 Even when there is a large social support network of family, friends and neighbors, if the relationship becomes strain, personal ties can increase the stress rather than reduce it. Therefore, social support appears to have a threshold point beyond which involvement of support network may decrease the quality of life of the older individuals. Silverstein, Chen and Heller (1996) examined the influence of intergenerational social support on the health of older parents. Psychological well-being was measured. The analysis found that support and involvement of adult children could enhance their parent's positive mood up to a threshold point. Beyond that threshold, fiarther involvement would decrease the well-being of the older parents. Results of this study suggested that undesirable support could compromise independence and reinforce feelings of powerlessness and vulnerability connected with aging. The author suggested that overprotection could be more harmful than undersupport. Another study by Mullin, Sheppard and Anderson (1991) shows that some older persons desired only the availability of social support from family and peer but not necessarily the actual practice of support. This expression is confirmed by a qualitative analysis of older adults living in senior housing. Participants in this study stated their satisfaction of living by themselves or with their spouses. They enjoyed taking care of themselves. Only as a last resort would they call on their children to help. Nevertheless, they also felt confident that their sons and daughters would help if they ask for it (Pang et al., 2003). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 46 The Influence of Social Networks on Health Status There is an extensive body of literature on the influences of social environment on health and illness. In a salient review on this subject, Ell (1984) pointed to the "burgeoning" body of literature suggesting the positive immunological effect of social ties. This buffering theory proposes that strong social relationship may have a preventive effect by strengthening the body's immunological mechanism. As a result, a person's risk for illnesses caused by stress is reduced. A stronger immune system may also fight off diseases more effectively (Cassel, 1976; Cobb, 1976; Mor-Barak, Miller & Syme, 1991; Thoits, 1982). Other basic psychological and social functions of social ties can directly enhance the well being of the care recipients by assuring that they are loved and valued, and by providing or seeking the appropriate resources to "modify the environmental demand" (Ell, 1984, p. 140). Further, Pott, Hurwicz and Goldstein (1992) referred the importance of social support on health promotion and disease prevention among older adults. A close social relationship can help the elderly to adhere to healthy habits, and to provide essential support that may contribute to quicker recovery and better adaptation. In fact, public health experts compare the strong association between social support networks and health with epidemiological data relating to the hazards of smoking on health (House, Landis & Umberson, 1988). Another study by Cohen et al. (1997) even suggested that social ties can lessen people's susceptibility to the common cold. The negative consequences of loss of personal independence and isolation of older persons are examined in a substantial body of literature as well. Seligman's work Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 47 (1975) found that extreme feelings of loss of control may result in serious health consequences, even death. Rathbone-McCuan and Hashimi (1982) identified four causes of loss of independence: 1) physical isolators such as transportation and language barriers; 2) loss of financial sufficiency; 3) change in roles in the family structure, and 4) psychological problems such as depression, uncertainty, and worry about the future. Ell (1996) emphasized the negative effect of social ties on the family of the elders during illness or when facing disability. While family relationships provide beneficial care for the elderly recipients by way of tangible and emotional support, at the same time, the family member may need support for themselves. The interdependencies and interactive coping between the caregivers and care recipients without support outside the family structure is a serious issue, since the impact of caregiving can be substantial, underscoring their own need for support. The Living Environment and Chinese American Elderly Studies focusing on the Chinese American elders are very limited. However, several studies concerning some aspects of the living environment of the Chinese American elderly population exist in the literature. An earlier study by Wu in 1975 on Chinese elders in Los Angeles introduced the idea that elderly parents preferred to live by themselves rather than with their grown children because of multigenerational conflicts. Kuo and Torres-Giil (2001) examined factors that affect the use of home- and community-based care, and health care services by older Taiwanese immigrants in Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 48 Southern California. They found that living arrangements and cultural preference of co-ethnic service providers were closely associated to the use of health care and other community support services by elderly Chinese immigrants. Another study by Lai and McDonald (1995) on Chinese elderly persons who were "aging-in-place," found a clear link between life satisfaction and culturally relevant social support services. Saldov and co-investigators (1994, 2001) studied ethnic elders in public housing, hospitals, nursing homes and homes for the aged, and emphasized the need to study individual ethnic groups because of their special characteristics that demand culturally appropriate services. MacKinnon, Gien and Durst (2001) noted that Chinese elderly immigrants are more likely to encounter problems associated with loneliness and isolation in their living environment than are younger or longtime residents. Coming to North America they have left behind their families, friends, neighbors and co-workers, as well as properties and a lifetime of work in their homeland. In a foreign country with new language, customs and values, their world may suddenly become limited to only their immediate family. Both physical and mental health problems, even suicides have been found among Chinese elders due to the stress of relocation adjustment, and the burden and guilt of being totally dependent on their families (Sue & Sue, 1990; Wong & Ujimoto, 1998). Recent studies have suggested cultural shifts of the Chinese elders' social relationships leaning toward the mainstream population. Lubben and Lee (2001) reported on the social support networks of elderly Chinese Americans and found that Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 49 Chinese elders are more similar to the white, non-Hispanic Americans and Japanese Americans who are mostly US-born, than a group of Korean Americans who are exclusively made up of immigrants. Pang et al. (2003) also found shifts in cultural expectations in their research on health care seeking behaviors of elderly Chinese Americans. Rather than relying on their grown children, older parents living in senior housing would turn to their spouses, neighbors and friends first before asking for help from their sons and daughters. In a needs assessment reported by Pang (2001), affordable senior housing stood out as the top priority of needs among the Chinese elderly sample. These elders desired to live apart from their grown children and wanted to live independently. Another report on filial piety by Pang and Sung (2000) revealed a change in the practice of showing respect to the elders among Chinese families. Grown children were no longer expected to live with their parents, but they still honored their parents with other forms of practice including seeking advice, paying regular visits and offering to perform tasks whenever they are needed, such as providing transportation and helping with shopping and visit to the doctor. Reports on Chinese American elders show that they are mostly immigrants and are increasing rapidly in number and diversity. Despite having better health and education than earlier immigrants, most Chinese elders are limited by language and cultural barrier. Therefore, while many are seeking to live independently, the Chinese elders are still dependent on ethnic association, that is, they need Chinese-speaking services and culturally appropriate environments to maintain their quality of life. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 50 Research is therefore needed to examine what types of housing is most fitting to their social, physical and mental well-being. Summary This chapter reviewed the literature on theories pertaining to the significance of environment-person congruence, and an overview of housing arrangements available for older adults with different functional capabilities and social preferences. Further, theories linking environment and social relationships and health status, and the impact of social networks on health were examined. The final section of this chapter focused on studies of elderly Chinese Americans pertaining to their living environment, particularly concerning the effect of ethnic association on the quality of life and behaviors of the Chinese elderly immigrants. Overall, the theoretical and background information presented in this chapter formed the foundation for the design of this investigation on the interrelationship among four major groups of variables: housing arrangements, social networks, health status, and personal characteristics of elderly Chinese Americans. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 51 CHAPTER THREE METHODOLOGY This chapter describes the research design of this study and its application based on theories in the existing literature. Strategies of sampling in the Greater Los Angeles Area are specified. Information on instrumentation is then presented, with special introduction of the Lubben Social Support Scale (LSNS-18), and Short Form Health Survey (SF-12v2). Development of the survey questionnaire including the Chinese translation is described. Data collection process, operationlization of all variables, and procedures for statistical analysis are subsequently reported. Research Design This study aims to answer the overarching question of how housing arrangements impact social support networks and the health of Chinese American elders. Based on the theories of Kahana (1982), Lawton (1975) and others, goodness of environmental fit is seen as antecedent to social, mental, and physical well-being of elderly individuals. In addition, theories linking social relationships and health status, as well as the dynamics between cultural and social demographic characteristics and social support among elderly Chinese Americans, guide the development of the following conceptual fi'amework. Figure 1 presents the conceptual framework for this study. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Figure 1 Conceptual Framework of the Study 52 Personal Characteristics Demographic Cultural Housing Arrangements Social Networks A. Co-ethnic community Family B. General community <----------- ► Neighbors C. Co-ethnic senior housing Friends D. General senior housing Health Status Physical Mental This figure shows the relationships among four major groups of variables: 1) personal characteristic; 2) housing arrangements; 3) social networks; and 4) health status. The main emphasis of this study is on the relationships among the four types of housing arrangements on social network and health status. The four housing arrangements represent common housing for elderly Chinese Americans. They are distinguished by two criteria: ethnic association and housing type. Ethnic association Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 53 pertains to Chinese elders living in co-ethnic Chinese communities and housing facilities with a high concentration of Chinese people. Housing type refers to whether the residence is a regular community dwelling or in a multi-unit senior housing facility. The housing type criterion includes all the housing options described in the previous chapter. For this study, the housing arrangements are organized into four categories: A) regular housing in co-ethnic communities; B) regular housing in the general community; C) co-ethnic senior housing; and D) general senior housing. Figure 2 depicts the four types of housing arrangements. Figure 2 Type of Housing Arrangements: Ethnic Association by Housing Type Housing Type Ethnic Association ^ General Housing Senior Housing Co-ethnic A C Community Co-ethnic Co-ethnic community senior dwellings housing B D General General General Community community senior dwellings housing Sampling Strategies A sample of older Chinese persons aged 62 and above were recruited from diverse areas in Los Angeles and its neighboring cities, with the aim of obtaining at Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 54 least 50 men and women (N) for each of the four housing arrangements specified above. The number (N) was based on Power Analyses performed to obtain an appropriate number for each group (Kachigan, 1986). Using the data analysis plan presented later in this chapter, and assuming a moderate amount of variability accounted for by independent variables, it was concluded that an N of 50 should have a power of .80, using a .05 significance level. A nonprobability, purposive, snowball sampling method was used in order to locate the Chinese elders in senior apartments, retirement communities, Chinese senior centers, Chinese social clubs or associations, churches, and service agencies. These organizations served Chinese elders exclusively or they had Chinese elders among their clients and residents. They were located in both Chinese communities such as Chinatown and Monterey Park, as well as in communities with low concentration of Chinese residents, such as Northridge and Santa Ana. Most of the interviews were conducted face-to-face, with a small number conducted by telephone, by mail and through the Internet. In most cases, recruitment of subjects was made with the assistance of managers and directors of the agencies, organizations and residential facilities. These service providers arranged for survey interviews either by incorporating interview sessions into regular senior programs, or by arranging for special meetings. During the regularly scheduled activities such as senior center programs and church senior ministry meetings, the researcher was introduced to senior participants as a special guest speaker. The researcher spoke on various topics regarding aging and available Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 55 resources for Chinese senior citizens. The presentation was then followed by an explanation on this research study. The introductory letter and an informed consent form were then distributed to those who volunteered to participate in the study, and were collected after the formed were signed. The questionnaire was then administered to the participants. The informed consent form assured the elders that their participating was entirely voluntary and their personal information would be kept confidential. Since the research was conducted anonymously and the data would be analyzed as an aggregate, their answers would not be linked to any individual persons. After the informed consents were gathered, they would be stored separately from the rest of the questionnaires. A copy of the Introductory Letter in English and Chinese are presented in Appendices 3 and 4, respectively, and English and Chinese versions of Informed Consent form are presented in Appendices 5 and 6, respectively. A semi-structured, self-administered survey questionnaire was used for data collection. Since both Chinese and English versions of the questionnaire have been developed by the researcher, participants could choose to use either the Chinese or the English version during the survey interview. Copies of the English and Chinese versions of the questionnaire are presented in Appendices 7 and 8, respectively. During the sampling process, most of the older Chinese participants chose to use the Chinese version of the questionnaire, with the exception of a group of participants who were American-born and long-time U.S. residents. The participants were given as much time as they needed to complete the questionnaire, often with Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 56 the help of the researcher and other agency staff members who were bilingual in English and Chinese. In most cases, interviews were conducted with Chinese elderly who were participants of senior programs in their neighborhood areas. However, some senior program participants were not from the neighborhoods but lived in different areas of Los Angeles County. Because of the limitation of Chinese speaking social programs, some elders regularly took long bus rides to attend Chinese-speaking programs held in different locations. Many other elders were transported to the senior programs by special buses or vans arranged by the senior centers or agencies. All housing types and neighborhoods of study participants could be identified by their checking out one of the four housing arrangement categories on the questionnaire. Senior housing residents who could not be reached through community programs were interviewed in their residential facilities. Arrangements were made with the help of senior housing directors to recruit potential participants. For example, the president of Golden Age Village arranged for four sessions of small group interviews, which brought in 56 voluntary respondents in the co-ethnic senior housing category. Similarly, the program director of Angelus Plaza was instrumental in bringing 20 persons living in non-ethnic general senior housing category. Finally, a small portion of Chinese seniors was interviewed by telephone, in the mail, and via the Internet. These individuals had been contacted by the researcher and had given their consent to participant in the study. They had also received specific instructions on how to respond to the self-rated questionnaire. Appendix 9 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 57 shows a map depicting the sources of the sample collected in Los Angeles County and the adjoining Orange County. Instrumentation and Data Collection A self-rated, semi-structured survey questionnaire was used to collect data from a sample of Chinese elders. The questionnaire was divided into three major parts: 1) housing arrangements A, B, C, and D as described, and personal characteristics including birthplace, length in the U.S., marital status, number of children, level of education, English proficiency, employment status, income level, type of insurance, age, and gender; 2) social support including the standardized Lubben Social Network Scale (LSNS-18), and a single item on living arrangements, and 3) health status including the standardized Health Survey SF-12v2 scale, and a single item on number and type of health problems. A final question asked for the rating of satisfaction of the respondents' housing situations and an explanation of their answers. Measures and Scales Personal characteristics, a group of variables measuring socio-demographics and acculturation characteristics of the sample made up the first part of the survey. A composite score of length in the U.S., English proficiency and nativity was used to measure acculturation. As mentioned above, housing arrangement was divided into four categories and was used as the basic context for statistical analysis. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 58 Two standardized scales were used: The Lubben Social Network Scale (LSNS-18) was used to examine the family, neighbors, and friends social support networks of the sample; Health Survey SF-12v2 scale was used to assess their physical and mental health status. More details on these two standardized scales are presented below. The Luhben Social Network Scale (LSNS-ISf (Lubben & Gironda, 2003). The LSNS-18 was used to measure the social support networks of the respondents. This scale is one of several careful modifications of the validated measurement scale, the Lubben Social Network Scale (LSNS), which has been used for a variety of studies during the last decade (Ceria et al., 2001; Chou & Chi, 1999; Lubben, 1988; Lubben & Beccerra, 1987; Martire, Schulz, Mittelmark & Newsom, 1999; Mor-Barak, 1997; Mor-Barak, Miller & Syme, 1991; Potts, Hurwicz & Goldstein, 1992; Rubenstein et al., 1994; Rubinstein, Lubben & Mintzer, 1994). The LSNS scale was a refinement of the Berkman-Syme Social Network Index (BSNI) (Berkman & Syme, 1974). It was modified specifically for use with elderly populations. Greater importance was given to recording more distinct levels of social interaction with relatives and friends. The LSNS has been used among diverse elderly population with relative stability in its psychometric properties. It has been ' Permission to use LSNS-18 has been obtained from Dr. James Lubben. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 59 translated into Chinese, Japanese, Korean, and Spanish (J. Lubben, personal communication, Aug 5, 2002). Three modified versions of LSNS scale have been developed to address the goals of brevity and completeness, depending on the applications. The LSNS-R version has been developed for a relatively short measure of kin and non-kin social ties. The LSNS-6 is an abbreviated version of LSNS-R developed to address the needs of applied researchers and clinicians. The LSNS-18, used in this study, is an expanded version for the application of social scientist and health science researchers. The LSNS-18 is divided into three subscales of family, friendship and neighborhoods networks, allowing the examination of these three distinctive dimensions of social support. It is therefore usefiil for social science research seeking quantification of key functional as well as structural elements of social support networks. The psychometrics of LSNS-18 have been compared with the two other modified versions LSNS-R, and LSNS-6, based on a sample of individuals aged 65 and over (N= 201) (Moon, Lubben, & Villa, 1998; Pourat, Lubben, Yu & Wallace, 2000). Even though all three versions were within the acceptable parameters for health measurement scales as suggested by Streiner and Norman (Streiner & Norman, 1995), the LSNS-18 presented the highest level of internal consistency, with Cronbach alpha score = .82, while LSNS-R score had an alpha score = .78; and LSNS-6 had an alpha score of .78. Reliability tests also showed high internal Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 60 consistency among LSNS-18 subscales of family networks (alpha = .82); friendship networks (alpha = .87); and neighborhood networks (alpha = .80). Table 4 shows factor analysis of LSNS-18 reported by Lubben and Gironda (2003). The investigators found that there was little loss of explanatory power, items in the three family, friendship and neighborhood groups counted for 56.5% of the total variation, and cross loadings to other factors did not occur. Table 4 LSNS-18 Factor Matrix (3 factor solution) Friends Factor Family Factor Neighbo rs Factor L1 2F Friends: has confidant .82 .10 .12 L9F Friends: private matters .81 .14 .12 L8F Friends: frequency of contact .78 .02 .05 L1 IF Friends: is confidant .75 .12 .18 L7F Friends: size .75 .23 -.03 LI O F Friends: call for help .74 .13 .10 L4 Family: Call for help .11 .78 .06 L3 Family: private matters .13 .76 .09 L6 Family: has confidant .12 .73 -.10 LI Family: Size .00 .70 .07 L5 Family: is confidant .19 .69 -.05 L2 Family: Frequency of contact .12 .67 -.14 L9N Neighbors: private matters .05 -.09 .75 LI IN Neighbors: is confidant .05 .10 .74 L12N Neighbors: has confidant .10 -.07 .74 LION Neighbors: call for help .16 .11 .72 L7N Neighbors: size .02 -.01 .66 L8N Neighbors: frequency of contact .11 -.08 .61 Eigenvalues 4.83 3.18 2.15 Source; Lubben & Gironda (2003) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 61 Table 5 shows correlation analysis of LSNS-18 reported by Lubben and Gironda (2003). Coefficients ranged from 0.34 to 0.67, revealing homogeneity without redundancy. There was a range from 0.67 to 0.78 for the family subscale, 0.65 to 0.78 for neighbor subscale, and 0.74 to 0.84 for friendship subscale. Therefore all correlation coefficients fell within the range acceptable for internal reliability (Streiner & Norman, 1995). Table 5 LSNS-18: Item -Total Scale and Subscale Correlations LSNS-18 Items LSNS- Family Friend Neighbo 18 r LI Family: Size .39 .67 L2 Family: Frequency of contact .40 .73 L3 Family: Discuss private matters .54 .75 L4 Family; Feel close to call for help .51 .79 L5 Family; Subject is confidant .54 .77 L6 Family; Subject has confidant .48 .78 L7F Friends; Size .60 .77 L8F Friends; Frequency of contact .56 .76 L9F Friends; Discuss private matters .67 .82 LlOF Friends: Feel close call for help .58 .74 LI IF Friends: Subject is confidant .66 .79 L12F Friends: Subject has confidant .67 .84 L7N Neighbor: Size .34 .65 L8N Neighbor: Frequency of contact .38 .66 L9N Neighbor: Discuss private .34 .71 matter .51 .67 LION Neighbor: Call for help .47 .76 LI IN Neighbor; Subject is confidant .44 .78 L12N Neighbor; Subject has confidant Source: Lubben and Gironda (2003) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 62 In this study, this LSNS-18 scale was used to measure the levels of support the Chinese elders received from family members, friends and neighbors and how their social support networks were affected by different housing situations. An additional variable, living arrangement (with whom do you live?) was included in the group of variables pertaining to social support for the purpose of getting a broader background of the respondents. Since it was expected to be highly correlated with family social network, it would be examined separately from the LSNS-18, and the information would be used for the interpretation of results only. Health Survey Short Form-12 version 2 (SF-12v2f The SF-12v2 is a self-reporting multipurpose scale used for assessing perceived health-related quality of life for eight concepts of physical and mental health (Ware et al., 2002). The eight health scales include the following: 1) physical function (PF); 2) role physical (RP); 3) bodily pain (BP); 4) general health (GH); 5) vitality (VT); 6) social functioning (SF); 7) role emotional (RE); and 8) mental health (MH). There are 12 questions in this scale, all selected from the original SF- 36 Health Survey (Ware, Kosinski & Keller, 1996). As a precursor of SF-12v2, the SF-36 is widely used throughout the world for measuring health status and monitoring health outcomes in both general and specific populations. Nevertheless, the psychometrically-sound and readily available SF-36 ^ Permission to use SF-12v2 Health Survey has been obtained from QuahtyMetric, Inc. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 63 was considered too long for some large scale surveys. A shorter version SF-12 was then developed measuring the same eight concepts of health. This simplified version is easier to administer and less culturally bias. The SF-12 has proven to be very useful in measuring outcomes in clinical trials. Another shorter version SF-8 has also been developed to address the need for brevity. However, this version does not provide the necessary precision, as it has only one single item for each of the health subscales. SF-12v2 scale used in this study is an improved modification of SF-12 with substantial gains in the range and precision of measurement, and is considered a versatile alternative to the SF-36 Health Survey. Because of the similarity of content, the measures of the corresponding concepts tend to be highly correlated. An advantage of SF-12v2 over SF-12 is the availability of updated norms for general U.S. populations. It has both the standard 4-week recall form and acute 1-week recall form. In addition, it has more familiar wording, improved layout, better cultural adaptations, and more precision in some categories. For these reasons, SF-12v2 is replacing the SF-36 as the instrument of choice in many surveys that require a shorter instrument. Cross-validation studies were performed in nine countries for the purpose of selecting items from SF-36 to construet SF-12. With sample sizes ranging from 1,483 to 9,151, product-moment correlations between SF-36 and SF-12 summary measures were very high, ranging from .94 to .96 for the physical component Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 64 summary scale (PCS) measure, and .94 to .97 for the mental component (MCS) measures. Estimation of Reliability Alternate forms reliability methods were used to estimate the reliability of the eight SF-12v2 scales by correlating scores and testing the equivalence of individual answers across alternate forms of the instrument. Internal consistency methods were used to estimate the reliability of the PCS-12 and MCS-12 scales, by examining the equivalence of responses within the same test from a single administration (Nunnally & Bernstein, 1994). Table 6 presents reliability coefficients for the eight SF-12v2 scales and the PCS-12 and MCS-12 measures estimated in age group 65+ compared with general population who reported as healthy individuals who were not having any chronic conditions (Ware, Kosinski, Turner-Bowker & Gandek, 2002). Table 6 Reliability Estimate for SF-12v2 Scales and Summary Measures, Respondent Subgroups in the General U.S. Population Sample PF RP SF-12 Scales BP GH VT SF RE MH SF-12 Summaries PCS MCS 65+ Healthy 0.85 0.70 0.87 0.79 0.71 0.68 0.77 0.78 N/A 0.70 0.82 0.66 0.72 0.68 0.76 0.77 0.89 0.82 0.80 0.82 Source: Ware et al., 2002 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 65 Reliability of SF-12v2 scales shown in this table was estimated in the 2000 general U.S. population by correlating each SF-12 scale with its respective "theta" score estimated from the total item pool that consisted of the SF-36 source instruments, and other widely-used items measuring the same concept. Reliability of SF-12 summaries was estimated in the 1998 general U.S. population using the internal consistency method that takes into account the reliability of each SF-12 scale as well as the covariances among them. Reliability of the SF-12v2 GH scales came from the Medical Outcomes Study (MGS) (Ware, 1998). Note that all respondents in the MGS had one or more conditions, so reliability was not available for a "healthy" sample. Besides this study on U.S. general population, at least ten other published studies presented reliability estimates for the SF-12 PCS and MCS measures. The results confirmed the findings of Ware and co-investigators (2002) that the two summary measures met standards for use in group comparisons. Two studies on elderly populations were particularly note-worthy. In one series of studies, the model for the PCS and MCS structure was modified based on the relatively small sample size in the analysis (N=185) and the specific sample of elderly living in a retirement community. Initial testing of the traditional summary measures model resulted in alpha coefficients of 0.84 for the PCS and 0.70 for the MCS (Resnick & Nahm, 2001). In another study by Ford et al. (2000) on a sample of urban elderly individuals, internal consistency for PCS was reported to be 0.87, and MCS was 0.84. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 66 Normative Data for SF-12v2 Since the scores for the scales and summary measures of SF-12v2 are "norm-based," they have the benefit of providing direct interpretation of the results compared with what one would expect to find for the individuals or groups. The expected scores are called norms. At the individual level, norms are scores that are typical of the individual under stable conditions. At the group level, norms are average values calculated from the general population or a sample of those with a particular characteristic. For purpose of comparison in this study, normative data for two elderly groups were selected, those who were aged 65 to 74, and those who were aged 75+. Tables 7 and 8 present the norms for these two groups, respectively. Table 7 Norms by Age Groups, Males and Females Combined Ages 65-74 PF RP BP GH VT SF RE MH PCS MCS Mean 44.87 45.28 47.97 46.72 50.10 50.27 48.34 52.60 43.93 51.57 Minimum 22.11 20.32 16.68 18.87 27.62 16.18 11.35 15.77 7.25 18.80 Maximum 56.47 57.18 57.44 61.99 67.88 56.57 56.08 64.54 65.13 70.05 S.D. 9.91 9.27 9.32 9.75 9.25 8.63 9.61 8.05 9.29 8.36 N 852 848 845 838 826 828 851 851 835 838 Source: Ware et al., 2002 Table 8 Norms by Age Groups, Males and Females Combined Ages 75+ PF RP BP GH VT SF RE MH PCS MCS Mean 39.26 40.38- 45.01 43.46 46.92 46.85 43.36 50.57 39.75 48.89 Minimum 22.11 20.32 16.68 18.87 27.62 16.18 11.35 15.77 12.29 13.92 Maximum 56.47 57.18 57.44 61.99 67.88 56.57 56.08 64.54 62.89 71.19 S.D. 10.40 9.84 10.50 10.29 10.06 10.49 11.40 9.25 9.30 9.33 N 760 756 739 745 721 719 751 750 731 728 Source: Ware et al., 2002 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 61 These groups were large enough to satisfy minimum standards for precision, and corresponded with standard practices for defining age-specific groups. Generally, the scores for all physical health scales and summary measures decline with age. For example, the mean PF score for the total sample is 50.00. The mean for 65-74 group is higher (44.87), and the mean for the 75 and older group is lower (39.26). Both LSNS and Health Survey SF-36 scales have Chinese versions^, and the reliability and validity of these versions have met psychometric criteria for use among Chinese elders (Chi & Boey, 1994; Ren, X. S. & Amick, B. C. 1998). Since there are no empirical studies on the psychometrics of the Chinese versions of LSNS-18 and SF-12, reliability and validity were assumed to be similar to the validated Chinese versions of LSNS and SF-36. Further psychometric analysis of these two scales from the results of this study could be an important contribution to the literature. The questionnaire was translated into Chinese using Chinese versions of LSNS and SF-36 to convert to LSNS-18 and SF-12, together with other non standardized items such as socio-demographic characteristics, health conditions, living arrangements, and satisfaction with housing. Copies of each of the English and Chinese versions of the questionnaire can be found in Appendices 7 and 8, ^ The Chinese version of LSNS was obtained from Dr. Shengming Yan of the University of Hong Kong; and the Chinese version of SF-36 Health Survey was obtained from Dr. Daniel Lai of the University of Calgary, Canada. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 68 respectively. Both Chinese and English versions of the questionnaire were field tested at the Evergreen Senior Center, a non-profit senior day activity center with mostly Chinese participants. Four senior center participants completed the survey questionnaire. After reviewing the completed forms with the senior center staff members, modifications on the survey questionnaire were made before administering it to the sample population. Depending on the preference of the respondents, either English or Chinese version might be used for the survey. Operationalization of the Variables As depicted in the conceptual framework, the relationships among four major groups of variables were examined in this study. Table 9 presents the operationalization of each group of the four variables. 1) The housing arrangements group includes four housing types A, B, C and D, based on ethnic association and whether the elders lived in senior housing or not. The four housing arrangements were operated together as a single categorical variable for analysis of the variance statistical tests. Each housing arrangement was also operated as a dummy variable for multiple regression analyses. In addition, a single item on “satisfaction with housing situation” as included in this group. This variable was operated as an ordinal variable. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 69 Table 9 Operationalization of the Variables Variable Operationalization Housing Arrangements Residential type Dummy variable in regression: Type A; general community welling 1 = yes; 0 = no Type B: co-ethnic community dwelling Categorical variable in ANOVA Type C; general senior housing Type D: co-ethnic senior housing. Satisfaction with housing Ordinal variable Personal Factors Demographic Characteristics Marital Status 1 = married; 0 = all others Sex 1 = male; 0 = female English proficiency Ordinal variable (4 levels scale) Income 1 =>$15,000; 0 = <$15,000 Retirement 1 = yes; 0 = no Birthplace 1 = foreign-born; 0 = US bom Number of children Continuous variable Length in the US Continuous variable Level of education (Year of education) Continuous variable Age Continuous variable Social Support Networks Family network Continuous variable LSNS-18 subscore Friend network Continuous variable LSNS-18 sub score Neighbors network Continuous variable LSNS-18 sub score Total LSNS-18 score Continuous v., sum of all LSNS-18 scores Living Arrangements Ordinal variable 1= w/spouse; 2=w/child; 3=w/other relatives; 4=w/unrelated person; 5=alone Health Status Health conditions Categorical variable SF-12 Physical health score Continuous variable SF-12 Mental health score Continuous variable Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 70 2) The personal characteristics group of variables includes demographic characteristics and acculturation factors. Marital status, gender, income, retirement, and birthplace were operated as dummy variables. English proficiency was an ordinal variable; and number of children, years in the U.S., level of education, and age were operated as continuous variables. 3) Social support networks scale, including the three variables of subscales of family, neighbors and friends LSNS scores, and total LSNS score were continuous variables; and a single item on living arrangements was operated as an ordinal variable. 4) Health status group includes continuous variables of SF-12 mental health component scores and physical component scores. Research Propositions This study is concerned with the factors that influence housing arrangements of elderly Chinese and how such arrangements affect social networks, health status and satisfaction with housing. Ten research propositions have been explored; Proposition 1: There will be significant differences in personal characteristics among Chinese elders in four different housing arrangements. Proposition 2: There will be significant differences in family support networks among Chinese elders in four different housing arrangements. Proposition 3: There will be significant differences in neighborhood networks among Chinese elders in four different housing arrangements. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 71 Proposition 4: There will be significant differences in friendship networks among Chinese elders in four different housing arrangements. Proposition 5; There will be significant differences in total social support networks among Chinese elders in four different housing arrangements. Proposition 6: There will be significant differences in physical health status among Chinese elders in four different housing arrangements. Proposition 7: There will be significant differences in mental health status among Chinese elders in four different housing arrangements. Proposition 8: There will be significant correlations between family, neighborhood, friendship, total social support networks and physical and mental health status of Chinese elders in the study sample. Proposition 9: Social support networks will predict significant variance in health status. Proposition 10: Chinese elders in four different of housing arrangements will vary in their satisfaction with housing. Data Analysis Procedures All collected data were computed using the SPSS 10.1 program (SPSS Inc., 2001). Several levels of statistical analyses were employed in order to obtain the characteristics of the sample and to test the above hypotheses. 1) Descriptive statistics: A profile of the sample was obtained from this descriptive analysis which provided the important information on the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 72 socio-demographic characteristics of the Chinese elders and their acculturation status, living arrangements, health conditions, subscale and social support network score, and physical and mental health scores. 2) The analysis of variance (ANOVA) and chi-squares models were applied to examine the relationships between housing arrangements and all other variables. Each of the subscales of social support networks - family, neighborhood and friendship, as well as the total social support network scores were tested separately since the four housing arrangements were expected to have different impact on each aspect of their social relationships. Similarly, mental and physical health profiles were examined separately, as recommended by the developer of the measuring instrument (Ware et al., 2002). If the relationships were significant, post hoc analyses were made to make multiple comparisons among the four housing groups. 3) At the multivariate level, multiple regression analysis was applied to assess the relationships between housing arrangements, subscales and total social support networks, and physical and mental health status. Similarly, analyses were made to examine the extent to which Chinese American elders' health and mental health status could be influenced by housing arrangements and social networks. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 73 CHAPTER 4 RESULTS This chapter describes demographic characteristics of the Chinese American elderly sample and the results of analyses of the variance, correlations and regressions showing relationships among housing arrangements, personal characteristics, social support networks, and health status. In addition, a summary of the elderly participants' comments regarding their satisfaction of housing arrangements is included to provide an in-depth understanding of the quantitative findings. Descriptive Statistics of the Sample Housing Arrangements o f the Sample In all, 260 completed questionnaires were gathered from a sample of elderly Chinese Americans during a six-month period from March to September 2003. The elderly participants were recruited from various senior centers, community programs, senior housing facilities, and faith-based organizations. Data were divided into four groups according to the type of residential arrangements of the participants. The first type was regular housing in the Chinese community identified as "type A: co-ethnic communities." A total of 50 responses were collected from elders who indicated that they lived in their own homes or apartments in Chinatown, Alhambra, Monterey Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 74 Park, and other parts of the San Gabriel Valley East of the City of Los Angeles, including San Gabriel, Hacienda Heights, Rosemead, and Rowland Heights, where more than 25% of the population was of Chinese descent (Lai & Arguelles, 2003; U.S. Census, 2000). The second housing type B included general community housing - homes and apartments either owned or rented by the Chinese elders. Chinese elders in this group resided in different suburban neighborhoods throughout Los Angeles County and Orange County, including Northridge, Chatsworth and other parts of the San Fernando Valley located in the Northwest of downtown Los Angeles; Santa Monica and Torrance; and the Orange County cities of Santa Ana and Anaheim (see Appendix 9). More samples were collected from people living in this general community than from the other three housing groups, with a total of 82 completed questionnaires collected. Type C was co-ethnic senior housing. A total of 67 questionnaires were collected from elders in this housing group. These residents were living in government-subsidized affordable housing facilities for those who were aged 62 and above. Data were mostly collected from residents of Golden Age Village in Monterey Park, Cathay Manor in Chinatown, and Telacu Pointe in Downtown Los Angeles. More than 50% of the residents in these facilities were Chinese Americans. Other data in this housing group were collected from participants of senior center programs who identified themselves as residents in senior housing facilities where the majority of residents were also Chinese Americans. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 75 Type D was general senior housing. This group included residents of independent senior housing, assisted living facilities, nursing homes, and continuous care retirement communities. A total of 57 samples were collected from this group. The senior housing facilities where these seniors resided were scattered in different geographic locations. Chinese elders who lived in this type of housing were very diverse in their personal backgrounds and physical abilities. On one extreme, some elders were healthy and living independently in senior housing by their own choice. They were quite adapted to their senior living communities, even though most of the residents were non-Chinese. The only complaints expressed by these residents were the type of non-Chinese food served and the inconvenient hours of meal service. About 20 samples of the general senior housing group were collected from residents living independently in the Angelus Plaza, a multicultural senior-housing complex. This large housing facility is located in downtown Los Angeles. It is a government subsidized low cost senior residential community with close to 1,300 senior citizens residing in several multi-level housing and recreational buildings. On another extreme, some elders were very frail and dependent. They were placed in assisted living facilities and nursing homes because they were too weak to take care of themselves, and their family members had neither the time nor the skills to provide them with 24-hour care. Many elders considered living in this type of housing as a last resort. They had difficulty with communication because of poor Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 76 English language skills. Because of this, they were unable to convey their needs to the staff and to make friends in the facilities. Table 10 shows the frequency and percent distributions of the study sample in the four housing arrangements. Table 10 Type of Housing Arrangements* Housing Arrangements Frequency (N) Percentage (%) Cumulative Percentage (%) A 50 19.2 19.2 B 85 32.7 51.9 C 68 26.2 78.1 D 57 21.9 100.0 Total 260 100.0 *Types of housing arrangements: A = Co-ethnic community dwellings B = General community dwellings C = Co-ethnic senior housing D = General senior housing Personal Characteristics Table 11 shows the general demographic characteristics of the study sample. The average age of these elders was 78 years, with a range between 62 and 99 years old. Women participants outnumbered men by more than double, with 70.4% female versus 29.4% male. Slightly more than half of the participants were married (54%). About 44% were widowed. The elders had an average of three children. With the exception of nine individuals, all had at least one child in their families. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 11 Characteristics of the Study Sample (N = 260) 77 Personal Characteristics Frequency (N) Percentage (%) Mean ± S.D. Age (years) 77.8 ±8.0 Gender Male 77 29.6 Female 183 70.4 Marital status Married 139 53.5 Widowed 115 44.2 Other 6 2.3 Number of children 3.2 ± 1.8 Years in the United States 29.4 ± 15.3 Level of education Primary school 44 16.9 High school 95 36.5 College 91 35.0 Post graduate 25 9.6 Other 5 1.9 English proficiency Cannot understand 35 13.5 Understand a little 41 15.8 Read a little 1 3 5.0 Understand and read 103 39.6 a little Read and write well 68 26.2 Income <$15,000 188 72.3 $15,000 to $50,000 50 19.2 >$50,000 22 8.5 Retired (yes) .246 94.6 Living arrangement Living with spouse 105 40.4 Living alone 88 33.8 Living with spouse and 33 12.7 son/daughter Living with 29 11.2 son/daughter Living with unrelated 5 1.9 persons Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 78 The birthplaces of the elderly participants reflected the diversity of the study sample. Their birthplaces included seventeen different countries, with China being identified as the place of birth of most elders (77.7%), followed by 6.5% elders who were bom in Hong Kong, and 3.5% elders who were born in the United States. Other countries of birth included Taiwan, Macau, Singapore, Vietnam, Thailand, Lao, Cambodia, Korea, Malaysia, Indonesia, New Mexico, Philippines, South America, and Mexico. The average length of stay of these elders in the United States were 29.4 years, with a range between those who were born in the United States and have now reached an advanced age, to recent elderly immigrants who have arrived for only two years. On the whole, the elders were well educated; most of them (81.1%) had at least a high school education. Slightly more than one-third (35%) had a college education. Even more strikingly, almost 10% of the elders had attended graduate schools. On the other hand, approximately 2% of the elders indicated that they have never attended any school. In spite of the relatively high level of education, only about a quarter (26%) of the elders indicated that they could understand and read English well. Slightly more than one-third (40%) of the elders could understand and read a little, but 14% of them could not understand English at all. With regards to employment, except for fourteen individuals, all of the elders had either retired or had never held a job outside of their homes. Thus, most had income below $15,000 (72%), while about 10% had more than $50,000 annual income. As for health insurance, all of the elders Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 79 had some form of coverage. More than half of the elders had MediCal insurance. Others had Medicare and a mixture of private, HMO and supplemental policies. Health problems of the elders included one or a combination of the following: allergies, arthritis, back and sciatica pain, cancer, diabetes, digestive problems, eye problems, hearing problems, heart condition, high blood pressure, high cholesterol, kidney problems, lung disease, skin problems, thyroid problems, prostate or gynecological problems, memory loss, fall, walking difficulties, general pain, foot problems, depression, low bone density, Alzheimer, and stroke. The most common health problem was high blood pressure (30%), followed by arthritis (28%), high cholesterol (15%) and heart problems (14%). Sight and hearing problems were also among the chronic health concerns more frequently cited. Living Arrangements The respondents answered the question "With whom do you live?" regarding their living arrangements. As expected, two of the four groups of residents living in aged-specific co-ethnic or general senior housing were not living with their children. Thus most of the study participants were living with their spouses (40.4 %) or lived alone (33.8%) either in senior housing or in community dwellings. Elderly couples who were living with their children accounted for 12.7% of the sample, while elderly persons who were widows or widowers living with their children, constituted 11.2% of the sample. Those who lived with unrelated persons such as elderly Chinese Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 80 individuals living in assisted living facilities, accounted for almost 2% of the total sample. Type of Housing Arrangements and Personal Characteristics Results obtained from analysis of variance (ANOVA) showed significant relationships between the type of housing arrangements and personal characteristics of the Chinese elders. Significant relationships were found among socio demographic and acculturation characteristics including years in the United States, marital status, number of children, education, English proficiency, income, age, and gender (p <.05). Health insurance and retirement did not show significant associations primarily because almost all of the elders had some type of health insurance and almost all of them were retired. Table 12 presents the significant results based on analysis of variance. Chinese elders who resided in the general community (housing type B) were more likely to be longtime residents in the United States, compared with the other three groups, as shown by an average of 36.98 years of this group living in this country. These elders were also more likely to be married, had better education and income, and were most proficient in English. Those who lived in co-ethnic senior housing (housing type C) had the most children and were the oldest group, with an average age of 84 years. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 81 Table 12 ANOVA: Selected Personal Characteristics by Type of Housing Arrangements (N = 259) Characteristics d f F p-value Years in the U.S. 3/256 15.73 <.000* Marital status 3/256 9.09 <.000* Number of children 3/256 4.32 .005** Education 3/256 7.91 <.000* English proficiency 3/256 12.28 <.000* Income 3/256 38.66 <.000* Age 3/256 23.98 < 000* Gender 3/256 3.44 Qjy*** *p<.001; **pS005; ***p < .05 Type of Housing Arrangements and Social Snpport Networks Data of the Lubben Social Network Scale (LSNS-18) produced three sub scale scores for the social support networks of the elderly Chinese American sample: family, neighbors and friendship networks. In addition, total scores combining all three social networks (total LSNS) were computed to examine the overall social ties of the elders. Table 13 presents a summary of mean scores in each of the four housing groups, as well as LSNS scores based on the percentage of raw scores in a total possible score of 30 for each level of social networks. Overall, total LSNS scores indicated that family networks were the strongest social support for all housing arrangements (LSNS = 62.5). Among the four housing Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 82 Table 13 Summary Scores of Social Support Networks in the Four Types of Housing Arrangements* (N = 260) Social Support Networks Housing Arrangements N Mean Scores S.D. Lsns** Family A 50 21.08 6.22 70.27 B 85 19.80 5.80 66.00 C 68 17.75 6.63 59.17 D 57 16.39 7.19 54.62 Total 260 18.76 6.61 62.54 Neighbors A 50 10.82 7.58 36.07 B 85 8.22 6.85 27.41 C 68 17.79 6.91 59.31 D 57 12.88 7.12 42.92 Total 260 12.25 7.96 40.81 Friends A 50 14.44 7.78 48.13 B 85 14.89 6.39 49.65 C 68 14.13 7.88 47.11 D 57 12.37 7.59 41.23 Total 260 14.05 7.35 46.85 LSNS Total A 50 46.34 15.86 51.49 B 85 42.92 14.55 47.69 C 68 49.53 18.94 55.03 D 57 41.61 18.06 46.24 Total 260 45.02 17.02 50.02 *Types of housing arrangements: A = Co-ethnic community dwellings B = General community dwellings C = Co-ethnic senior housing D = General senior housing ** LSNS = Lubben Social Networks Scale (LSNS-18) groups, elders in co-ethnic community (A) received the most family support (LSNS = 70.3), while elders in the general community (B) had the second highest level of family support (LSNS = 66.0). As expected, those who lived in senior housing Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 83 facilities had less contact with family members. When comparing only the elders who lived in senior housing facilities, co-ethnic senior housing residents (C) had more family support than those who lived in general community senior housing (D) (LSNS = 59.2, 54.6, respectively). Neighborhood networks showed the most fluctuations. Co-ethnic senior housing (C) residents had more contact with their neighbors (LSNS = 59.3), while those who lived in the general community (B) had less than half of the social contact with their neighbors (LSNS = 27.4). Elders who lived in general senior housing (D) had stronger social support from their neighbors (LSNS = 42.9) when compared with those who lived in the co-ethnic community (A) (LSNS = 36.1). The friendship networks were more even in the LSNS scores among the four housing groups, with elders in the general community (B) receiving slightly more social support from friends than the other group (LSNS = 49.6). Those living in general senior housing (D) had the least support from friends (LSNS = 41.2). Total LSNS scores indicated that the group who lived in co-ethnic senior housing (C) had the strongest social networks (LSNS = 55.0), followed by those who lived in the co-ethnic community (A) (LSNS = 51.5). Chinese elders who lived outside of the Chinese communities in regular housing (B) or senior housing (D) had less social support (LSNS = 47.7 and 46.2, respectively). As shown in Table 14, regression Einalysis revealed that being residents of non-Chinese oriented senior housing had the greatest impact on family support of the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 84 Chinese elders (Beta = -.214, F = -3.104, p = .002). Elders in co-ethnic senior housing were only mildly affected (Beta = -. 137, F = -1.961, p = .051). On the other hand, being residents of both ethnic and non-ethnic senior housing had very positive impact on the neighbors support networks (Beta = .530, t = 8.32, p = .000; Beta = .242, t = 3.845, p = .000, respectively). Further, co-ethnic community also contributed to neighbors social networks of the elders (Beta = . 129, t = 2.060, p = .040), but this was not true for elders who lived in the general community. Table 14 Regression: Type of Flousing Arrangements by Family and Neighbors Social Support Networks (N = 260) Social Support Beta Family t P Beta Neighbors t P Housing Type 28.418 .000 10.723 .000 A Co-eth Com .076 1.118 .265 .129 2.060 Q4Q*** C Co-eth SH -.137 -1.961 .051*** .530 8.320 .000* D Gen SH -.214 -3.104 .002** .242 3.845 .000* DV: Family networks: R = .258; ANOVA statistics: F = 6.07; df = 3; p = .001 DV: Neighborhood networks: R = .468; ANOVA statistics: F = 23.96; df = 3; p - .000 * p < .001; ** p <.005; ***pS05 As for the effect of housing environment on friendship networks, the only significant predictor was non-ethnic oriented general senior housing (see Table 15). This type of senior housing had negative effects on friendship networks of the Chinese elders (Beta = -.142, t = -2.011, p = .045). Table 15 also presents the effect of housing on all three subscales social networks together (total networks). Among Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 85 all four housing groups, co-ethnic senior housing had the most positive impact on the overall social support networks of its residents (Beta = . 171, t = 2.416, p = .016). These results pointed out clearly that co-etllinic senior housing was the most desirable housing environment for the social health of the Chinese elderly individual. Although elders in this type of environment had lost some support from their families, the effects were rather minor. Compared with elders in the other three types of housing situation, people who lived among their Chinese peers and in familiar Chinese speaking environment had much strong social networks. Table 15 Regression; Type of Housing Arrangements by Friends and Total Support Networks (N = 260) Social Support Friendship networks Beta t p Total Networks Beta t p Housing Type 18.718 .000 23.526 .000 A Co-eth Com -.024 -.347 .729 .079 1.142 .255 C Co-eth SH -.046 -.638 .524 .171 2.416 .016* D Gen SH -.142 -2.011 .045* -.032 -.453 .651 DV: Friendship networks, R = .128; ANOVA statistics: F = 1.423; df=3;p = ..236 DV: Total networks, R = .183; ANOVA statistics: F = 2.95; df=3;p = .033 *p<.05; Personal Characteristics and Social Snpport Networks Regarding the relationship between personal characteristics and support networks, results from multiple regression analysis showed that only a few factors Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 86 had significant influences on the Chinese eiders’ social support networks, with some factors exhibiting more influence in different social networks subscales than the others. As shown in Tables 16, the number of children was a good indicator of strong family support for the Chinese elders (Beta = .252; t = 3.952; p = .000). Age also had marginal significanee on family support, although negatively, reflecting that, as the elder’s age increased, available family support also decreased (Beta = -. 126; t = - 1.810; p = .06). Table 16 Regression: Personal Characteristics by Family and Neighborhood networks Personal Characteristics Family Networks Beta t p Neighborhood networks Beta t p (Constant) 5.549 .000 2.270 .024 YRINUS .009 .122 .903 ,074 1.002 .317 MARITAL .101 1.396 ,164 ,078 1.050 .295 CHILDREN .252 3.952 ,000* -,025 -.385 .701 EDUCATIO .053 .718 .473 ,142 1.893 .059*** ENGLISH -.018 -.235 ,815 -047 -.609 .543 INCOME .119 1.399 .163 -.136 -1.561 .120 AGERANGE -.126 -1.810 .060*** .179 2.511 .013** GENDER .016 .232 ,817 .046 .660 .510 DV: Family networks, R = .314; ANOVA statistics: F = 3.43; df = 8; p = .001 DV: Neighborhood networks, R = .231; ANOVA statistics: F = 1.77; df = 8; p = .083 *p<.001; **pS05; ***p<.10 Age was also strongly related to social support from neighbors among the Chinese elders (see Table 16 neighborhood networks. Beta = .179, F = 2.51, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 87 p = .013). This finding could be attributed to the older average ages of senior bousing residents who bad more contact with tbeir neighbors, comparing with younger average ages of residents in the community who bad less contact with tbeir neighbors. In addition, higher educational level also bad positive influence on social ties with neighbors among the Chinese elders (Beta = . 142, t = 1.89, p = .059). Regarding friendship support networks, marital status, and again age, bad significant impact on this subscale of social tie. As revealed by data in Table 17, married couple bad more positive friendship ties than those who were single or widowed (Beta = . 130, t = 1.803, p = .073). . On the contrary, age bad a negative impact on friendship networks (Beta = -. 163, t = -2.350, p = .02), indicating that the elderly individuals’ friendship circle would decrease with age. Table 17 Regression: Personal Characteristics by Friendship networks Personal Characteristics Friendship networks Beta t p (Constant) 4.902 .000 YRINUS .067 .933 .352 MARITAL .130 1.803 .073** CHILDREN -.078 -1.241 .216 EDUCATIO .084 1.153 .250 ENGLISH .077 1.043 .298 INCOME -.045 -.535 .593 AGERANGE -.163 -2.350 .020* GENDER .033 .494 .622 DV: Friendship networks, R = .333; ANOVA statistics: F = 3.91; d f= 8;p = .000 *p<.05; **p<.10 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Health Profile of the Sample in the Four Housing Arrangements The health profile of Chinese elders in the four housing situations was measured by SF-12 supplied by the QualityMetric Inc.(Ware et al., 2002). For the purpose this study, only the composite scores of the physical and mental components were examined without including the eight specific scores of 1) physical function (PF); 2) role physical (RP); 3) bodily pain (BP); 4) general health (GH); 5) vitality (VI); 6) social functioning (SF); 7) role emotional (RE); and 8) mental health (MH). The physical component scores (PCS) represented the physical health profile of the elders in the sample, and the mental component scores (MCS) represented the mental health profile of the elders. Table 18 shows the physical and mental health profile of the elders in the four housing groups. The average physical component score (PCS) for the total sample population (N = 259) was 41.46 + 12.01 and the average mental component score (MCS) for the sample was 46.80 ± 10.89. As shown in Table 8 in Chapter 3, the mean score of norms for the general U.S. population aged 75+ were 39.75 + 9.3 for PCS (N = 731), and 48.89 ± 9.33 for MCS (N = 728) (Ware et al., 2002). Therefore, both the physical and mental health status of the Chinese elderly sample were very close to the national norms. The elderly group who lived in the community (housing group B) had the strongest physical health profile (PCS = 45.1), while those who lived in senior housing for the general population (housing type D) had the weakest profile (PCS = 36.8). Comparing co-ethnic housing groups A and C, the elders who lived in co Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 89 ethnic community (A) were in better physical conditions than those who lived in co ethnic senior housing (C), with PCS = 42.99 and 39.80, respectively. Mental health profiles of the four housing groups were much closer than their physical profiles, with general housing group B almost the same as co-ethnic housing group C (MCS = 48.60, 48.00, respectively); while Co-ethnic community group A were similar to general senior housing D (MCS = 44.27, 44.92, respectively). Table 18 Health Profile of the Chinese Elderly Sample in the Four Housing Arrangements* Health Profile Type o f Housing Arrangements N Mean S.D. S.E. PCS** A 50 42.96 12.86 1.82 B 84 45.11 10.23 1.12 C 68 39.76 9.45 1.14 D 57 36.80 14.50 1.92 Total 259 41.46 12.01 .75 MCS*** A 50 44.27 9.09 1.29 B 84 48.60 10.99 1.20 C 68 48.00 10.01 1.21 D 57 44.92 12.64 1.67 Total 259 46.80 10.89 .68 *Housing arrangements: A = Co-ethnic community dwellings B = General community dwellings C = Co-ethnic senior housing D = General senior housing ** PCS = SF-12 Short Form Health Survey Physical Component Scores *** MCS = SF-12 Short Form Health Survey Mental Component Scores Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 90 Concerning the relationships between housing arrangements on health status of the elders, people who lived in both ethnic and non-ethnic senior housing had poorer physical health, as reflected by their advanced ages (Table 19). Between the Table 19 Regression: Type of Housing Arrangements by Health Profile (N = 260) Housing Type * * * * Physical Component Mental Component Beta t Sig. Beta t Sig. (Constant) 35.516 .000 41.246 .000 A -.071 -1.035 .302 -.157 -2.242 .026*** C -.196 -2.818 .005** -.024 -.342 .733 D -.287 -4.161 .000* -.140 -1.983 Q4g*** DV: Physical component, R .268; ANOVA statistics: df = 3, F = 6.56, p = .000 DV: Mental component, R = .170; ANOVA statistics: df = 3, F = 2.54, p = .057 *p< .001; **p< .005; Q 5 **** Type of housing arrangements A = Co-ethnic community dwellings C = Co-ethnic senior housing D = General senior housing two senior housing groups, elders who lived in non-ethnic general senior housing were in worse physical health (Beta = -.287, t = -4.161, p = .000) compared with elders in co-ethnic senior housing (Beta = -.196, t = -2.818, p = .005). As for the mental health status of the elders, people who lived in co-ethnic community (housing type A) and general senior housing (housing type D), had significantly poorer mental health profiles than those who lived in the other housing groups (Beta = -.157; Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 91 t = -2.242; p = .026 for housing type A; and Beta = -.140; t = -1.983; p = .048 for housing type D). The results brought out an intriguing picture showing that people who lived in co-ethnic community were mentally more impacted by their housing arrangements than older and frailer individuals who lived in general senior housing. The Impact of Social Support Networks on Health Status Correlation Analysis A series of Pearson correlation analyses were performed to examine the relationships between social support networks and health status. Variables including family, neighbors, friendship networks, and the indicators of physical health (PCS) and mental health (MCS) were entered into analyses. The resulting correlation coefficients were presented in Table 20, showing that all variables were positively correlated. Family networks appeared to be even more closely associated with mental health status (r = .235, p < .001) than physical health status (r = .207, p = = .001). Neighborhood networks were significantly associated with mental health status (r = .231, p <. 001), but were not significantly correlated with physical health of the elders. Friendship networks were significantly correlated to both physical and mental health networks (r = .286, p <.001; r = .324, p <.001, respectively). Again, findings suggested that friendship networks had more influence on mental health status than physical health status of the elders. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 92 Table 20 Correlations of Family, Neighbors and Friendship networks by Physical and Mental Health Status (2 tailed, N = 260) NEIGHBOR FRIENDS PCS MCS Family .279 .000* .393 .000* .207 .001* .235 .000* Neighbors .500 .000* .089 .152 .231 .000* Friends .286 .000* .324 .000* PCS .140 .025** *p <0.001;**p <0.05 Regression Analysis To determine the contributions of support networks of family, neighbors and friends to the health status of the elderly sample, separate regression analyses were performed for physical health profile, measured by the physical component scores of sf-12v2 (pcs) and mental health profile, measured by the mental components scores of sf-12v2 (mcs). Table 21 presented a summary of the results of the analysis that identified friendship networks as being most predictive about the physical health status of the sample (Beta = .282; t = 3.904; p < .001). Family networks was also mildly predictive of physical health status (Beta= .12;t = 1.843; p = .067). Overall, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 93 model statistics showed that social support networks only explained about 10% of the variance in the physical health status of the sample (r^= .098). Table 21 Regression; Physical and Mental Profile by Social Support Networks Social Support Networks Physical Component Scores (PCS) Mental Component Scores (MCS) Beta t p Beta t p (Constant) FAMILY NEIGHBOR FRIENDS 14.414 .000 .120 1.843 .067** -.085 -1.231 .219 .282 3.904 .000* 18.273 .000 .120 1.866 .063** .078 1.149 .252 .238 3.350 .001* Dependent Variable: MCS, R = .351, df = 3, F = 11.96, p = .000 *p = .001; **p<10 Results of regression analysis again showed very positive impact of friendship networks on the mental health status of the elderly (Beta = .238; t = 3.35; p = .001). Family networks suggested a marginal influence on mental health (Beta = .120; t = 1.866; p = .063). Neighborhood networks did not show significant influence on the mental health status of the elders. Overall, the three networks were statistically significant in predicting the variance of mental health status, although only about 12% of the variance of mental health profile was explained (r^ = . 123). Satisfaction with Housing Arrangements A final question was administered to the elders concerning their satisfaction with housing. Specifically, the elders were asked whether they were satisfied, not Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 94 satisfied, or if they had mixed feelings about their present housing arrangements. They were subsequently asked to explain their answers. Table 22 presents the frequency distribution of the elders' expression of satisfaction on housing. Table 22 Frequency Distribution: Satisfaction on Housing Arrangements Satisfaction Frequency % Satisfied 238 91.2 Not Satisfied 11 4.2 Mixed Feelings 10 3.8 Total 259 99.2 Missing System 1 .4 Total 260 100.0 An overwhelming majority of the elders had accepted their housing situations as satisfactory (91.2%). Only about four percent expressed dissatisfaction and another four percent had mixed feelings. ANOVA was performed to determine the relationships between satisfaction and housing arrangements. Results obtained pointed to statistically significant relationships (p < .001; F = 7.40). Multiple comparisons among the housing group suggested that people who lived in co-ethnic community showed most dissatisfaction, as reported in the negative relationships in Table 23. The difference in satisfaction was most pronounced between the group in co-ethnic community (housing type A) and residents of the co-ethnic senior housing (housing type C), with p < .001. Compared to residents of the general community Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 95 Table 23 Multiple Comparisons on Satisfaction by Type of Housing Arrangements* (N = 259) Mean Difference S.D. P HOUSING A HOUSING B -.181 .048 . 001** C -.225 .050 . 000** D -.170 .052 . 006*** *Housing arrangements: A = Co-ethnic community dwellings B = General community dwellings C = Co-ethnic senior housing D = General senior housing **p<. 001; ***p<.01 ANOVA statistics: F = 7.4; df = 3; p = .000 Note: Only multiple comparisons with significance at the .01 level are reported in this table. (housing type B), group A were also less satisfied, with p = .001. Similarly, group A residents were not as satisfied about their housing as those who lived in general senior housing (housing D), although in a less degree (p <.01). Summary of the Elderly Residents’ Comments The residents were asked to provide explanations on their expressions of satisfaction with housing. A summary of the residents' positive and negative comments, and their preferred housing arrangements is presented below. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 96 Group A: Co-ethnic Community Residents (N = 50) Most of the respondents were satisfied with their housing. They offered many positive reasons for living in the neighborhood where there was a high concentration of Chinese. Positive comments included living near Chinese shops, restaurants, and places of worship, and the ease to get around without driving. Some had good neighbors, and some elders were happy that they were living with their sons and daughters. They also enjoyed living in their own places and growing their own gardens. Some had no thoughts of moving because they had been living in the same places for many years and did not know where else to go to. However, more than 10% of these elders expressed their desire to live in senior housing rather than with their children in their current residences. The negative aspects of living in co-ethnic community included poor conditions of the rental housing units, conflicts with younger generations in the same households, the cost of living in a place on your own, and lack of friends in the neighborhood. Most of the people who were dissatisfied with their housing situations wanted to move into senior housing, especially government-subsidized affordable senior housing. Some were already on the waiting lists, but they complained that the waiting period was too long. Group B: General Community Residents (N = 85) The reasons for the elders to be satisfied with staying in their community dwellings included good clean air, good and safe environment, good views, quiet Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 97 neighborhood, and being close to their children. Many elders owned their residences, and had been living in the same locations for a long time and, therefore, had no plan to move in the future. Still about 20% of this group expressed desire to move to places near their friends, in the Chinese communities, or in affordable senior housing facilities. One elderly person desired only for a place where everyone could live in harmony, and another person dreamed of living in China again. Group C: Co-ethnic Senior Housing (N = 68) On the whole, people who lived in co-ethnic senior housing were most satisfied with their housing arrangement. Many found their facilities very suitable for older people because the Chinese-speaking environment allowed them to live independently but still could be involved with their own families. They had good friends and neighbors nearby to take care of one another. Their facilities were well maintained and managed, and above all, affordable, because they were government subsidized. Some elders attributed their good mental and physical health to the attractive environment around them. However, in spite of all the positive comments, some elders complained that they did not have any other places to live because their children were very far away. They felt abandoned. They wished to be with their families. One elderly woman found her residential unit undesirable, but due to lack of affordable housing she had to stay in the same place. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 98 Group D: General Senior Housing (N = 57) Most of the residents in this group were satisfied with their housing situation. Many expressed their gratitude to the U.S. government for their subsidized housing and all the free services they eould enjoy, although some were not happy with their dilapidated and unsafe neighborhoods in urban redeveloped areas. To some elders, living in the general senior housing also meant taking the same western meals as the rest of the residential population. Some elders in this group missed their Chinese food and the flexibility of taking meals at their own time. For those who lived in the nursing homes and assisted living facilities, they were placed in these residences either by their doctors or family members because they needed 24-hour care. They were in poor health or needed long periods of convalescence. They could not take care of themselves and their families lacked the skills and time to provide them with the proper care. These facilities were not ethnic- oriented and mostly did not have Chinese-speaking staff members. The Chinese elders entered these facilities as a last resort. Summary of Major Findings The subjects in this study came from a diverse background, with most of them foreign-born, and only 3.5% who were bom in the United States. Their average age was 78 years old. They had a high level of education, but were inadequate in English language skills. Compared with older Americans of similar age, these Chinese elderly persons were in similar physical and mental health status. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 99 Based on the results of statistical analysis, major findings regarding relationships among the three groups of variables, personal characteristics, social support networks, and health status in the context of the four types of housing arrangements are summarized in Table 24. This table was based on ANOVA with subsequent multiple comparisons among the four housing groups. For each variable in the groups of personal characteristic, social support networks and health status, the housing group with the highest or most favorable value served as the reference point (marked with “ - “ ), for the other three housing groups. The p-value of each variable was added to show the strength of the relationships among the variables. As noted, negative relationships were marked by parentheses. Among the group of personal factor variables, most tested significant associations with housing arrangements, suggesting that the diverse backgrounds of elderly Chinese Americans were strongly related to their residential choices. However, only educational levels, age, and number of children had statistically significant but varying relationships with housing arrangements, social support networks and health status. For example, elders living in the community had the highest level of education when compared with the other groups, those who lived in co-ethnic senior housing was the oldest group. People in co-ethnic senior housing had the most number of children, closely followed by elders who lived in the co ethnic community. Compared with elders who live in the general community, the other three groups were less likely to be married. Results showed that overall, social Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 100 Table 24 Summary of Selected Personal Characteristics, Social Support Networks, and Health Status by Types of Housing Arrangements Type o f Housing Arrangement A B c D Variable Co-ethnic General Co-ethnic General Community Community Senior Senior Housing Housing (N = 50) (N = 85) (N = 68) (N = 57) M/% M/% M/% M/%0 Educational level (1-5) 111 2.82 2.28 2.21 P (.001*) - (.000*) (.000*) Age (Year) 76.61 73.54 84.18 79.37 P .000* - .000* .037*** Number of children (n) 3.36 2.79 3.78 3.18 P .555 - .002** .203 Marital status (married %) 48 48 42 37 P (.001*) - (.000*) (.000*) Family support (LSNS)^ 1021 66.00 59.17 54.62 P .265 .678 (.051***) (.002**) Neighbor support (LSNS)^ 36.07 27.41 59.31 42.92 P .040** - .000* .001* Friends support (LSNS)^ 48.13 49.65 47.11 41.23 P .729 - .524 (.045***) Total support (LSNS) ^ 51.49 47.69 55.03 46.24 P .255 .074 .016** .651 Physical health (pcs)^^ 42.96 45.11 39.76 36.80 P .302 - (.005**) (.000*) Mental health (mcs) 44.27 48.60 48.00 44.92 P (.026***) - .733 (.048***) *p<001; **p<.005; ***p <.05 ^LSNS = Lubben Social Network Scale pcs = Physical Component Score mcs = Mental Component Score Number in parentheses indicated negative relationships with types of housing arrangements. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 101 support networks were strongest among elderly in co-ethnic senior housing, and weakest among elders in general senior housing. Family networks were strongest among co-ethnic community dwellers, and neighborhood networks were strongest among co-ethnic senior housing residents. However, the results suggested that friendship networks were quite similar for all housing groups, with general senior group showing the weakest friendship ties. The data demonstrated that housing arrangements had significant association with physical and mental health status. Elderly individuals who lived in senior housing had lower health profile than those who lived in the community. However, elders who lived in the co-ethnic community had the lowest mental health profile, as were those living in general senior housing. Other major findings included the significant relationships between social support networks and both physical and mental health among family and friendship networks. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 102 CHAPTER 5 DISCUSSION The purpose of this study was to investigate major factors that influence housing patterns of elderly Chinese Americans, and to determine if any relationships existed between the elderly's housing arrangements and their personal characteristics, social networks and health status. This chapter begins with a discussion on the characteristics of the sample. The findings revealed a picture of contemporary Chinese American elderly population, with characteristics that mirror current Asian Americans in terms of diversity in places of origin, socioeconomic backgrounds and places of settlement (Lai & Arguelles, 2003). The discussion emphasized on how these personal characteristics related to the housing arrangements of the elderly Chinese Americans in the study. Next, findings on social, physical, and mental health profile of the Chinese elders based on their ethnic association and type of housing are discussed. Ethnic association refers to whether the elderly individuals were living in a predominantly Chinese environment with a high concentration of Chinese population. Housing type refers to whether the elders were living in age-aggregated senior housing or in regular community dwellings. These two factors were the criteria delineating the four housing arrangements in this study. Finally, this chapter discusses findings on the impact of social support networks on the health status of the elderly subjects in the context of their various housing arrangements. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 103 In addition to results obtained from quantitative analysis, the elders’ direct comments on their housing situations were integrated into the discussion. These qualitative comments serve as support and explanations of the quantitative findings. Diversity in Personal Characteristics Consistent with reports on contemporary Asian and Chinese American populations, analysis of the data on personal characteristics in this investigation revealed a striking intra-group diversity among elderly Chinese Americans (Lai & Arguelles, 2003; Pang, 2003; Yee, 2002). Unlike earlier Chinese immigrants who came to the United States from primarily the Guandong Province of China to work as laborers and small merchants, and eventually settling down in the ethnic enclaves such as Chinatown, the elderly Chinese Americans surveyed in this study had different places of origin, socioeconomic backgrounds and patterns of settlement. Places o f Origin The Chinese elderly sample included a small proportion of American-born Chinese (3.5%), and a much greater proportion that were foreign-born, from a total of 17 different birthplaces. The small number of U.S.-born Chinese elderly reflected the low birth rate before World War II as a result of the Chinese Exclusion Act. During this era, the shortage of women due to immigration laws barring their entry, in conjunction with the phenomenon of "paper son" who bought their way to this country illegally, created a skewed gender ratio that led to an abnormal development of the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 104 American Chinese families. As expected, elderly Chinese Americans in this study who were bom and raised in this country were more similar to mainstream American senior citizens in terms of their socioeconomic characteristics, housing, and service needs, than the elderly Chinese Americans who came to this country as immigrants. Among the foreign-bom elderly immigrants in the study sample, most were born in Mainland China and the greater Chinese Diaspora, including Hong Kong, Taiwan, Vietnam, Cambodia, Malaysia, the Philippians, Mexico, and the Americas. Many of those who were born in Mainland China had also lived in other places such as Taiwan and South America before their immigration to the United States. Although they might have similar Chinese culture and traditions, the elderly Chinese Americans spoke different dialects, and had different lifestyles and social preferences of the cultures they had been exposed to prior to coming to America. Length o f Stay in the U.S. The length of stay of the Chinese elderly in America also differed widely in the study sample, ranging from those who just arrived during the last two years, to those who were born in this country 80 years ago. Overall, the elderly study participants have been longtime residents of the U.S., with an average of 29.4 years. This number reflected the immigration history of Chinese in the United States. Beginning with the year 1965, there has been a tremendous growth of Chinese population, because of the passage of the Hart-Celler Act that made the enactment of liberal immigration reforms possible. Between 1960 and 2000, Chinese from a variety of backgrounds entered the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 105 United States, raising the Chinese American population more than ten-fold, from 237,292 to 2,879,636 (U.S. Immigration and Naturalization Service, 2000). The biological growth of young people arriving in the 1960 have also contributed to the sharp increase in number of the elderly Chinese American population today, together with the subsequent arrival of aging parents and grandparents coming to the United States with their families. Socioeconomic Backgrounds The elderly Chinese Americans surveyed in this study had come from diverse socioeconomic backgrounds. Some of them had entered America with little money, education, and skills; while others had family savings and high levels of educational and professional training. Most of the elderly individuals had retired and were receiving only social security income. About 30% had annual income above $15,000; and approximately 10% had relatively more comfortable income of more than $50,000. Nationally, the median income of older person in 1999 was $19,079 for males and $10,943 for females. Household containing families headed by persons 65+ reported a median income in 1999 of $33,148 (U.S. Bureau of the Census, 2000). On the average, the sample had a significantly higher level of educational attainment, with 80% having gone through high school education, compared with 68% of the older U.S. population in 1999. About 45% of the Chinese elderly have obtained a college education, compared to only 15% of older adults nationally. Among the Chinese American in the general population, 41% of those who were aged 25 to 64 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 106 have received a college education. Immigrants from Taiwan reported the highest level of education (62%), followed by those from Hong Kong (46%), and those from Mainland China (31%). While there were indications of economic strength and high level of education among the Chinese American elderly in this study, the trend of bifurcation was still striking. Some elderly indicated that they had never attended schools in their lifetime. Many had come to the United States with little money and had to struggle with their families in order to survive. A few expressed that they were neglected by their families, and living in loneliness and poverty in deteriorating urban neighborhoods. More noteworthy was that most of the elders have obtained their education in their home countries without a strong background in the English language. Therefore, in spite of their impressive educational achievement, only about one-third of them could understand and write in English proficiently. Inadequate English language skills have prevented many elderly Chinese Americans from living a life that ordinary citizens in general take for granted, such as going shopping, talking to their neighbors, and seeing the doctor (Nagasawa, 1980; Pang, 2001; Tanjasiri, Wallace, & Shibata, 1995). Settlement In this study, the Chinese elderly displayed a dichotomous pattern of dispersion and concentration with regards to their housing settlement. As Lai and Arguelles (2003) pointed out, although urban enclaves such as Chinatown still exist. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 107 they no longer serve as primary places of settlement for the Chinese immigrants. In fact, the Census 2000 shows that only 50% of all Chinese Americans live in urban neighborhoods. Elderly Chinese, along with the majority of the Chinese American population, have expanded to nearby communities or suburbs. The elderly Chinese Americans who have dispersed in the general suburban communities included most of the elderly American-bom Chinese, and many foreign-born Chinese elderly in the young-old age group who were quite well established in the society, and were fluent in English. These elderly individuals have mostly integrated into the mainstream American life albeit retaining their ethnic identity. In addition to the acculturated elderly individuals, the survey also found many other older Chinese immigrants scattering in the general community. These individuals are disadvantaged, low-income, and being denied an adequate quality of life due to cultural and structural barriers such as lacking English proficiency and limited mobility because of their poor health, inability to drive, and their reluctance to take public transportation. These elders lived in the general community with or near their children. Some of them had been living in their own home in the same community for a long time and had no plan to move to another unfamiliar environment. Many of these monolingual Chinese elderly in the general community are more inclined to live in isolation with very few friends in the neighborhood, and have limited access to social activities and social services (Pang, 2001; Pang et al., 2003). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 108 During the last two decades, a growing number of Chinese elderly population have taken up residence in different communities with a high concentration of Chinese residents partly because of the convenience of living in a Chinese-speaking environment, and partly because of the recent economic growth in these areas. In fact, not only are there a variety of shops and restaurants, there are also enormous grocery stores and sophisticated hospitals and clinics. More importantly, these communities have been successful in developing affordable housing projects for senior citizens. Besides providing the much-needed housing services, these facilities have drawn a variety of social service agencies for the local citizens. For example, the Golden Age Village in the suburb of Monterey Park and the Cathay Manor in Chinatown have been providing affordable housing and social services to the Chinese elderly population since the 1980s, and have been recognized as the beacons of senior services for the Chinese community. The Golden Age Village was opened in 1980 for those who were 62 years old and above. At that time, the majority of the residents were under 70 years old (58.7%). In year 2000, most of the residents (69.9%) were between the age of 80 and 100, since most of the residents have remained living in the same facility during the past 20 years. This well-maintained affordable senior housing is still in such great demand that there is a waiting period of several years for the 120-unit housing complex (Golden Age Village 20th Anniversary Year Book, 2001). The Cathay Manor was the first federally subsidized senior housing project in Chinatown. Largely through grass-roots organizations working with the federal Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 109 government, the 16-story senior citizen housing project was officially opened in 1985 (Holley, 1985). With rental of 30% of residents' monthly income, the housing project was so attractive to Chinese elders with limited English, that more than 2,300 people have signed the waiting list for the project's 270 one-bedroom units. There are many good reasons why Chinese elderly desire to live in co-ethnic senior housing such as the Golden Age Village in Monterey Park and the Cathy Manor in Chinatown. The reasons include affordability, safety, large neighborhood networks, and proximity to the Chinese community. First, the elderly in government-subsidized housing need only to pay about one-third of their income, which amounts to about $200 per month for Social Security recipients. The residences usually have government-subsidized nutritional programs that provide healthy meals at a nominal price. Some have both western doctors and doctors of traditional Chinese medicine coming to the premises regularly. MediCal recipients can have free medical care. Thus, the financial burden for residents in this type of low-cost housing is lighter than most elderly in the community. Secondly, most subsidized senior housing facilities are regarded as safer than community dwellings because the former are monitored by government regulations. Senior housing managers are responsible for the safety and maintenance of the residences, although some facilities are better maintained than others. Those who have housing units in nicely landscaped and managed residences have expressed great satisfaction about their housing environment. Nonetheless, some senior housing facilities are located in neighborhoods with high crime rates, and the facilities have Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 110 substandard management. Such facilities need closer monitoring and oversight, and necessary funding to improve staff quality, and to upgrade and maintain the buildings. Thirdly, elderly in co-ethnic housing have more social contact with their neighbors than the other three housing groups. Although many have different native dialects, most of them know how to speak the two major dialects of Mandarin and Cantonese. These elderly have the opportunities to meet their neighbors in common areas and participate in regular activities together. Caregiving can even he organized among the residents. In one senior housing campus, the elderly residents are divided into small groups, so that they can watch out for one another on a daily basis. Fourth, the location of co-ethnic senior housing in the Chinese community is another attraction for the Chinese elderly. They do not needs special transportation to get to Chinese shops and to visit their doctors. They can participate in many cultural events in the neighborhood. Some elderly residents even had opportunities to serve the community by taking part in political campaigns and volunteering in hospitals as translators for patients. The different patterns of housing settlement among the Chinese elderly support the Person-environment congruence Models described in Chapter 1. This model assumes that individual's levels of abilities and needs mediate the impact of the environment (Lawton, 1975). Contemporary elderly Chinese Americans have become increasingly diverse in their backgrounds. They have different immigration history, cultural values, socioeconomic status, language skills, and health status. The differences in these personal characteristics among the elderly Chinese Americans Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Ill today have an impact on their ability to live independently, and consequently on their settlement patterns. Findings from this study provided evidences to answer the first research question concerning personal factors that have influenced the housing arrangements of the Chinese elders. As reported in the last chapter, personal characteristics including years in the United States, marital status, number of children, educational level, English proficiency, income level, age and gender all had significant differences among the four housing groups. However, only marital status, number of children, educational level and age factors were significant to the social, physical and mental health of the elderly individuals in various degrees. Housing Arrangements and Social Support Networks The next group of analysis attempted to answer the second research question posed in Chapter 1 regarding the relationships between housing arrangements and social support networks of the Chinese elderly. The concept of social support includes emotional or tangible exchange, frequency of contact, and the depth of the supportive interactions (Lubben & Gironda, 2003). Using scores obtained from the Lubben Social Network Scale (LSNS-18), statistical analyses resulted in various degrees of relationships among family, neighbors and friends social support of the Chinese elderly residents in the four types of housing arrangements. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 112 Family Networks This study confirmed reports in the literature regarding the importance of family as the primary source of social support for older people (Ell, 1996; Silverstein & Angelelli, 1998; Uhlenberg, 1996). The LSNS scores showed that among the three types of informal support networks, family networks were the strongest social support for the elderly subjects in all housing arrangements. Report on the general profile of older Americans noted that 67% living in a family situation such as living with spouse, children, grandchildren (AOA, 2000). As expected, in this study, those who lived in community dwellings had more contact with their families than those who lived in senior housing facilities when compared with the elders who lived in senior housing. Family members in the same household could have daily interactions with each other, providing reciprocal support. Even those who lived by themselves in the community, the elderly persons were likely to live near their kinfolk with whom they had regular contacts (Silverstein & Angelelli, 1998). In the case of senior housing residents, contacts with family members were less frequent because the interactions could only be made through telephone calls or visitations. Between the two groups of senior housing residents, the elderly in co-ethnic senior housing were found to have closer contacts with their families than those who lived in general senior housing. This observation suggested that family members visited their elderly parents in co-ethnic senior housing facilities more frequently because they were located in or near the Chinese communities. During their visits, besides seeing the elderly parents, they could also run other errands such as Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 113 purchasing grocery supplies for the week, and eat out in authentic Chinese restaurants. As for the general senior housing residents, they were more scattered throughout the Los Angeles area, and often in isolated areas in the suburbs. Visitations to these residents could be inconvenient and, therefore, less frequently than to those living in the more concentrated co-ethnic Chinese community. Some of the residents of general senior housing were in poor health and were expected to be under the care of professional caregivers, without the need for constant attention of family members. Neighborhood and Friendship Networks For many older adults, neighbors and friends can be as important as family in providing social support for the promotion and maintenance of health and well-being. In fact, many Chinese elders prefer to live in senior housing rather than living with their children in a multigenerational household partly because they want to avoid family conflicts (Wu, 1975), and partly because they would have more connections with their peer groups. When the elderly and adult children are separated by geographical distance such as those elderly persons who live alone or in senior housing, neighbors and friends play an important role in these persons' social support networks. The neighbors are more immediately available to help in emergencies, and are more ready to help with small chores. A Chinese saying sums it all up: “Relatives who live far away is not as good as neighbors nearby” (Pang et al., 2003, p. 868). This study showed that Chinese elderly who lived in co-ethnic senior housing had a much richer neighborhood social support environment than their counterparts in Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 114 the other three housing groups. Especially when comparing with the Chinese elderly who lived in the general community, co-etlinic housing residents had more than twice the level of social support from their neighbors. These latter senior housing residents had the benefit of living in a surrounding with mostly Chinese speaking tenants, with whom they could easily share their cultural values and interests, and were ready to help each other in times of need. In contrast, elders who lived in the general community were more separated from their neighbors by the distance between houses and/or apartment units. They were also likely to have language and cultural barriers with their neighbors and therefore did not go beyond superficial greetings even if they made any social contacts at all. Friendship networks among the Chinese elders were more similar across different housing groups. Since most of the elderly were recruited from senior centers, church senior programs, and senior housing projects, they might belong to the same social circles. The lack of differences might also imply that these elders had few friends outside of the small number of opportunities for socialization. They might already have left many friends behind in their original homeland when they immigrated to the United States, as well as having lost friends due to mortality. A closer look at the data showed that seniors who lived in community dwellings had relatively stronger friendship ties than those who lived in senior housing, especially when comparing with those who lived in senior housing in the general community. The stronger friendship networks for the general community dwellers could be attributed to the personal characteristics of these residents. They Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 115 were a relatively younger group compared with the other three housing groups. They also had more capabilities to live independently, including having better English language skills and more economic resources. Therefore, general community dwellers had more opportunities to interact with their friends than the other groups. Some community dwellers have expressed that they have lived in the same places for a long time. Consequently, they have had time to cultivate friendship support networks with people such as those in their neighborhoods, in places of worship, and in community senior centers. Housing Arrangements and Health Status Using SF-12v2 standard form to obtain a health profile of the Chinese elderly sample (average age = 78), it was found that both their physical and mental health profiles were surprisingly similar to the norms for U.S. population aged 75+ (Ware et al., 2002). Since 92.7% of the participants selected the Chinese version in the survey, the findings suggested that, as a measuring instrument, this Chinese translation has potential usefulness for evaluating and planning health care. This portion of the study also provided answers to the third research question on how informal social networks influence the health status of the Chinese elderly in reference to the four housing situations. The findings showed that elderly Chinese living in both general and co-ethnic community dwellings had better physical health status than residents of the other two senior housing groups. The reasons may be twofold. First, community dwellers were Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 116 relatively younger. Their average age was 74 years, while the average age of co-ethnic community dwellers was 77 years; compared with the average age of general senior housing residents and co-ethnic senior housing residents (79 years and 84 years, respectively). Therefore, the elders living in senior housing were older and frailer. Secondly, community dwellers were likely to be more active, since they had to take care of the more complex daily routine of a household. Further, these community dwellers were more acculturated in the United States than the other groups, and therefore had the tendency to lead a more active social life. In general, elderly Chinese living in mainstream community and in co-ethnic senior housing had better mental health conditions than residents of the other two housing types. Co-ethnic senior housing residents were especially ready to express their positive views on life in spite of their advanced age. Because of the lack of culturally appropriate and affordable senior housing, Chinese elderly who managed to secure living units in these facilities generally felt that they were very satisfied with life. They could enjoy the low monthly payment and many free services available in their facilities. Medicare or MediCal insurance usually covered the cost for these services. Above all, these elderly residents could enjoy the company of people speaking their own language and sharing their cultural heritage and interests. Some facilities even have traditional Chinese landscape designs that allow the residents to have a place to reminisce and rest in tranquility. In contrast, the elderly who lived in the Chinese communities such as Monterey Park or Chinatown, were less satisfied with their living situation and had Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 117 lower mental health status. There are a few possible explanations for the dissatisfaction. Some co-ethnic communities are in high crime areas and the elderly residents are afraid to go out after sundown. In addition, as homeowners, elderly individuals generally experience a continuous depletion of financial holdings to pay for large medical bills. This might mean having fewer assets available for home maintenance and repairs, or vice versa. For the renter, the high cost of rental has forced many elderly individuals to live in small, substandard housing units that are unsafe for elderly persons. Problems with housing conditions have caused many Asian elderly, included the Chinese elderly, to suffer from depression (Wong & Ujimoto, 1998). Further, some community dwellers indicated that they were unhappy living with their grown children or grandchildren and wanted to live in senior housing. Being in the same Chinese neighborhood as co-ethnic senior housing residents, these community dwellers could be familiar with the senior housing in their neighborhood. They would know the advantage of living in senior housing. However, the chance to secure a place is very small for them to secure a place in senior housing, especially affordable subsidized senior housing. It is easy for the community dwelling elderly to be disappointed. The strong desire to live in culturally appropriate senior housing is unique among elderly Chinese Americans. It does not support the results of the national survey conducted by AARP which reported that older Americans prefer to "age in place" in their own homes in the community (AARP, 2000). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 118 Social Network and Health Status This study used the Lubben Social Networks Scale (LSNS-18) to quantify the social environment of the elderly Chinese individuals. In essence, informal social support networks including family, friends, and neighborhood networks are generally viewed as the primary social support networks in later life. Older persons may also have membership in an array of secondary social groups such as senior centers and religious institutions (Lubben & Gironda, 2003). Informal reciprocal social relationships are "a crucial concomitant of an older person's physical and mental well-being, feelings of personal control, morale, and autonomy" (Hooyman & Kiyak 2003, p. 277). On the other hand, extreme social isolation could contribute to mental depression and even higher mortality rate (Hansson & Carpenter, 1994; Hobfoll & Vaux, 1993; Krause & Borawski-Clark, 1995; LaVeist et al., 1997). Findings in this study strengthened the literature regarding the contribution of social support on healthy aging. Results obtained from data analysis showed that as a whole, social support networks could predict both physical and mental health status of the Chinese elderly. However, when individual levels of family, neighbors and friendship networks were analyzed, the results were not as definitive. In fact, only family and friendship networks could predict physical and mental health status of the elders. Between these two predictors, friendship networks were much stronger predictors than family networks. Neighborhood networks appeared to be independent of the health status of the elderly subjects. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 119 The ability to interact with friends is a strong indication of both physical and mental health, as mentioned extensively in the literature (Hooyman & Kyak, 2002; Lubben & Gironda, 1996, 2003). Friends provide psychological as well as tangible supports that are different from that of the family. In fact, in reporting a study comparing the effects of satisfaction between family and friends, Cronhan and Antonucci (1989) suggested that family members were more likely than friends to have negative effects on the well being of older adults. Findings from this investigation demonstrated the importance of friendship to the health of the elderly Chinese Americans. Impact of family support networks on health status were not as strong as friendship networks, since only marginal relationships were found on both physical and mental health status. Among the four housing groups, Chinese community dwellers were in better physical health, which might be due to the fact they had stronger family support. The data showed that elders in this co-ethnic housing group had more children and were more likely to live with family members than the other housing groups. Therefore, when they need medical attention, this group of elders was more likely to get immediate help from their family members, and to be cared for at home afterwards. Comparisons among residents of the four different housing groups on their mental health status drew inconclusive results. These findings reflected the mixed emotional conditions of community dwelling elderly - some had problems getting along with their families, others were perfectly satisfied with living in a reciprocal Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 120 multigenerational relationship. Concerning senior housing residents, even though they could enjoy their independence and the company of their peers, some elderly expressed that they were lonely and felt that their families had abandoned them. Regarding the relationship between neighborhood networks and the health status of the elderly, the results were also inconclusive. Even though the data showed that residents in co-ethnic senior housing had strong neighborhood networks, and even though that they expressed overwhelming satisfaction on their housing situation, and even had higher mental health scores than the other housing groups, their advanced age confounded the positive impact of the other factors. As mentioned, the average age of co-ethnic senior housing residents was 84 years old, compared with 79 years for elders who lived in general senior housing, 77 years for those living in the co-ethnic community, and 74 years for elders living in the general community. Therefore, unfortunately, the highly desirable environment co-ethnic housing could not contribute to the physical and mental health of the residents. The longevity of Chinese elders in senior housing demands our attention because it signals the increasing social needs of the wave of the oldest old population in this country. As technology and medical sciences advance, they have created the paradox that, while people live longer, more of them are likely to face serious, often deliberating chronic disabilities. A growing number of older adults are expected to need long-term care (ETC), especially the oldest-old, who depend on informal supports as well as formal services. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 121 In the general community, LTC is available to provide a wide range of supportive services and assistance to persons who have difficulties performing activities of daily living. These services aim to reduce, rehabilitate, or compensate for the deficiency of fimctioning. Nursing homes are considered the major institutional setting for LTC. However, the line between nursing home and other non-institutionalized environments is becoming blurred. Many other housing options mentioned in Chapter 2, including congregate care and residential care facilities (assisted living, board and care and adult family homes), also provide LTC services. Within home and residential care settings, services provided include home-delivered meals, visiting nurse, social work service, homemaker/home health aides, respite service, and telephone assurance. For those who live in the community, home modification and assistive device such as canes and walkers, and emergency alert are available to allow the elders to “age in place.” Other services for senior citizens in the community include transportation, nutrition programs, senior center, adult day care and adult day health care, respite service, home health, and hospice. In spite of the wide array of senior citizens services mentioned above, only a small portion of the Chinese elderly has accessed the services. In fact, Chinese elders were among the Asian Pacific Islanders group that had “the lowest rate of participation in Older Americans Act funded services of all the ethnic groups during fiscal years 1994 through 1998,” according to Spolidoro and Demonteverde (1998, p. 2). The lack of service utilization is due to various barriers including linguistic isolation, lack of information and cultural bias. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 122 Even though some efforts have been made to improve access to services such as providing Chinese-speaking service providers in some organizations, ethnic- appropriate services are still severely lacking. Government subsidized senior housing facilities that are ethnic appropriate for monolingual Chinese elderly are especially scarce. Since the development of senior housing projects such as the Golden Age Village in Monterey, and the Cathay Manor in Chinatown in the 1980s, few similar age-specific government-subsidized senior housing have been built. Therefore residents who were successful in obtaining their units at the minimum age of 62 twenty years ago, would hang on to them for the next twenty years. Hence most of them are now octogenarians and older. As the Chinese elderly population increases in size and longevity, their long-term care becomes an important issue. Studies in the general population have shown that elderly parents expect to move closer to their children when they are older (Silverstein & Angelelli, 1998). However, little is known about whether Chinese elderly who have moved to senior housing are expected to move back to live with or live closer to their family members. Although the emerging trend is for older Chinese parents to live independently from their sons and daughters, when the elderly parents grow older and become more dependent, it is not clear whether the grown children will want to take care of their elderly parents during their final years. For the gerontologist interested in ethnic minority aging, it will be meaningful to know whether the Chinese cultural traditional value of filial piety would influence the reversal of independent living. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 123 Personal Factors, Social Support Networks and Health Status Findings showed that among the personal characteristics, only number of children, age, educational level, and marital status were predictors of social support networks and the physical health status of the elderly sample. Number of children was a strong predictor of family support networks as well as physical health status of the Chinese elders. This finding reflected the importance of family members as caregivers (Ell, 1984; Ell & Castaneda, 1998). Even when the elderly parents did not live with their children, sons and daughters could help secure the most appropriate senior housing and find adult support services if necessary. They also provide informal support such as going to the doctor and making medical decisions (Pang et al., 2003). With more children, the network of family support could also expand to grandchildren and other relatives in the extended family, providing the support necessary to benefit the elderly persons' health. Age was another major factor that could predict family networks, neighborhood networks, friendship networks, as well as the physical health status of the elderly individuals. Age was found to be negatively related to family and friendship networks. These findings showed that the older the individuals, the less family support they would get. This was especially true with older Chinese immigrants. Unlike traditional Chinese families that would stay together in the same village, elderly immigrants gradually lose contact with their relatives due to health, mortality and geographical separation. This was also true with friendship networks. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 124 Age was also a strong predictor of the physical health conditions of the elders. This was a reasonable finding because the older the individual, the more likely they are to face the array of health problems than by younger people. For example, high blood pressure and arthritis are common problems that tend to increase with age. The elderly residents of senior housing, both co-ethnic and general housing groups, were among the oldest of the study sample, and therefore were shown to have the poorest physical health status. Education was found to be a positive predictor of neighbor networks. The data showed that elders who lived in co-ethnic senior housing had strong neighbors support networks. It is intriguing to find that this group was also highly educated. The elders in this housing group could have more information to share and to assist one another in their housing facilities. Finally, marital status also had some impact on friendship networks. However, the effect was negative for the group living in general senior housing, showing that those elders were less likely to be married and their friendship networks was also significantly lower than the other groups. Besides this finding on the fi’ iendship networks, no other significant relationship could be detected among the other housing groups. Satisfaction with Housing Arrangements Both quantitative and quality data on satisfaction of housing have been obtained from the elderly respondents. The greatest contrast was between elders who Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 125 lived in co-ethnic senior housing and those who lived in co-ethnic community dwellings. There are several reasons for the differences in satisfaction. First, as mentioned before, senior housing facilities are in short supply and subsidized housing with Chinese-speaking staff and neighbors are even more scarce. Chinese elderly of co-ethnic senior housing considered themselves very fortunate to be living in such a facility. Secondly, government subsidized co-ethnic senior housing projects generally have good designs and management. Some of these projects have pleasant landscapes. For example, the Golden Age Village has fhiit trees, rose gardens, vegetable gardens, lotus pond and Chinese pavilion; as well as security features such as grab bars and alarm system for emergency. Thirdly, subsidized senior housing facilities are regulated by the government and usually have to be maintained in good conditions. In contrast, private dwellings owned by the elderly individuals might be neglected because of the high cost of renovation and maintenance. Better living conditions, safer environment and cheaper rental have made subsidized housing in the co-ethnic community more attractive to many elderly Chinese. While most of the respondents of the survey indicated that they were satisfied with their housing situations, their personal comments displayed an attitude of resignation. Many of these elders were limited by cultural and language barriers, and health conditions. Therefore, they did not have much choice or capability to change their present living environments. For example, some elders living in Chinatown Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 126 would very much like to be near their sons and daughters who live in the suburbs. However, because they also regarded living independently and being in a Chinese-speaking environment as being more important, they had chosen to live in the inner city a long distance away. This meant that the elders could have less contact with their family members and could receive less support in times of need. Therefore, many Chinese elders like these individuals might not be in an environment where they could have an optimal level of social, physical and mental functioning. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 127 CHAPTER 6 CONCLUSION AND IMPLICATIONS This study explored the housing environment of Chinese elders in Los Angeles based on the diverse sociodemographic characteristics of contemporary Chinese Americans. While environmental factors had direct bearing on the physical and social well-being of older people, a given housing situation is not necessarily good or bad inherently. Some individuals might find certain housing environments more fitting to their optimal functioning; others might fare better in different kinds of settings. This study has identified some important housing characteristics unique to ethnic Chinese elderly immigrants that could have both positive and negative impact on their quality of life. These findings had strong implications for policy makers and service practitioners, as the lesson learned from this exploratory study can also be applied to other ethnic elderly groups. Several unique housing characteristics among the Chinese American elders found in this study included 1) diversity in settlement due to differences in socioeconomic, immigration background, and health conditions; 2) overwhelming preference of living in senior housing; 3) culture as a resource and culture as a barrier for housing. First, the Chinese elders have settled in various Chinese communities as well as the suburbs according to their diverse socioeconomic backgrounds and health Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 128 conditions. Much of the housing settlement was self-selecting. Thus, we found that people who were younger, healthier, more educated, more fluent in English and have been in the U.S. longer, were more likely to live in the general mainstream community. These elders were more mobile and had a larger circle of friends. Other elders who were monolingual were more likely to live in the Chinese communities where they could use Chinese language to shop, eat at restaurants, and visit medical clinics where staff members could understand them. Many lived with their children and therefore received more family support. Still there were other elders who wanted to be independent from their grown children, and have chosen to live in senior housing, where they could obtain stronger social support, especially from their peers who live in the same housing neighborhoods. Secondly, an overwhelming number of the elders expressed that they wanted to live in senior housing. This housing preference is a growing trend among Chinese American elders for various reasons, including a desire for independent living; an escape from family conflicts in a multigenerational household; and a way to get affordable housing. However, as mentioned, affordable ethnic-appropriate senior housing facilities are very scarce, therefore, those who have secured living units in these places seldom move away. Thus we found many of these residents having reached very advance ages. Other Chinese elders in the community were on the waiting list to get into co-ethnic senior housing. However, the waiting became a Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 129 source of frustration because the waiting period is long, and there was no guarantee that they could get in. Finally, culture could he a resource, hut it can also he a harrier for housing environment among the Chinese elders. Traditional expectations of filial piety have led many elders to stay with their families, and this could he an important source of social support. In addition, data showed that the groups of elders who lived with family had better physical health. However, living with family members might also he "too much of a good thing" (Silverstein, Chen & Heller, 1996, p. 570). In a multigenerational family, frictions could occur often, due to cultural and lifestyle differences among different generations. Conflict within family is often a source of depression among Chinese elders (Kung, 2001). As mentioned above, many elders have chosen to live apart from their families and to live in senior housing in order to avoid family conflicts. Since many elders who live in senior housing have language limitations, the only appropriate senior housing for them is co-ethnic housing, where most of the residents and staff are Chinese-speaking in order that these elders can have healthy social contact and receive proper care. Other important cultural necessary is Chinese food, as it is very hard for the elders to do adjust to other culinary taste. Although Chinese residents of general community in this study were most capable of independent living, cultural and language harriers hindered their contact with neighbors. Cultural harriers also prevented them from accessing senior services Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 130 such as neighborhood senior centers activities, adult transportation assistance, and "meals on wheels" delivery service. As a whole, the elderly living in mainstream senior housing faced the most severe cultural barrier. Most of the residents were placed in this type of housing facilities because of severe frailty that required 24-hour care; or because they could not find culturally appropriate housing, although a small number of Chinese elders lived in mainstream senior housing by choice. Living in a mostly English-speaking environment, and with limited social interaction, monolingual Chinese elders were most likely to face social isolation while they battled with poor health. They not only needed help with activities of daily living, but also the support of staff and care providers who could understand their needs in order to provide appropriate assistance. Residents of co-ethnic government-subsidized senior housing demonstrated the greatest satisfaction about their housing situation among all housing groups. The reasons for their satisfaction regarding their living environment included affordability, safety, large neighborhood networks, and proximity to the Chinese community. Co-ethnic government-subsidized senior housing is a good model of housing for elderly Chinese Americans. Unfortunately, this type of affordable senior housing largely occupied by monolingual Chinese elders is severely limited in number. Those elders who have been successful in obtaining residential units seldom leave, in spite of their advancing age and frailty. This situation reflects a lack of continuous care or skilled long-term care facilities that are suitable for frail Chinese elderly. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 131 Current Housing Programs In order to maintain a satisfactory quality of life for the elderly residents, adequate housing accommodations are necessary that meet their needs to carry out various activities of daily living. However, currently housing for older citizens in Los Angeles area is reaching critical needs (Advisory Task Force for Senior Issues, 2000). To meet the demand for housing, both public and private sectors have various housing programs to address the issue. Public support for housing has taken many forms, including “grants, subsidies on mortgage debt, direct payments to landlords on behalf of low-income citizens, the provision of liquidity and stability to the housing finance system through Federal Housing Administration mortgage insurance, the creation of the Federal Home Loan Banks, Fannie Mae, and Freddie Mac, and Housing- related tax code measures, such as mortgage interest and property tax deductions, accelerated depreciation, tax-exempt mortgage financing, and Low Income Housing Tax Credits.” (The Bipartisan Millennial Housing Commission, 2002, p.l). Public housing programs have been successful for most households, as reflected in the tremendous increase of homeowner ship. However, these programs have been insufficient to cover the growing needs for affordable and appropriate housing among the low-income sector. Existing programs aimed at filling the gap between the demand and supply of affordable housing include the following. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 132 Section 8 This is a federal housing choice voucher program called Section 8 program. It has provided rental subsidies to nearly 1.6 million households in 2002. This program assists low-income families, the elderly and the disabled to rent housing from participating landlords. Individuals can choose among different housing types such as single-family homes, townhouses, and apartments. Department of Housing and Urban Development (HUD) pays the local housing agency, which issues vouchers and certificates to families who select housing units from the private market (Williams, 2000). Public Housing The major source of affordable housing units for low-income households is public housing. In contrast to Section 8 program, public housing facilities are owned and managed by local Housing Authorities. Based on availability and the income limits set by HUD at 50% to 80% of the median income, housing agencies arrange for living units in local metro areas in which different households choose to live. Many of the large, generally high-rise, urban public housing developments are now being replaced by mixed-income developments under the HOPE VI program, established in the 1990s to allow separate allocations for elderly and handicapped persons, to fund the revitalization of severely distressed pubic housing. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 133 Low-income Housing Program Incentives The Low Income Housing Tax Credits (LIHTC) and HOME Investment Partnerships (HOME) programs support multifamily rental housing production. The LIHTC program was established in the early 1980s to provide private-sector incentives for the development of rental housing for low-income households. The HOME program was introduced a decade later to offer block grant used by state and local governments to address affordable housing needs. Recipients can develop their own programs and activities to meet affordable rental or homeownership housing needs. In addition, the federal government promotes multifamily rental production by permitting issuance of tax-exempt bonds, through Federal Housing Authority (FHA) mortgage insurance products, and in rural areas, through direct and guaranteed loans provided through the Rural Housing Service (RHS) (The Bipartisan Millennial Housing Commission, 2002). Because of the shortage of senior housing facilities, the private sectors are beginning to develop senior housing for independent elderly, as well as assisted living facilities for frail elderly persons. Nonetheless, these housing options are too costly for many families, only persons with middle and upper incomes can afford the hefty entrance fees and monthly payments. Further, even though there is a growing number of continuous care complexes developed in the general community, few exist in the co-ethnic community. Instead, Chinese elderly residents rely on hospitals in the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 134 vicinities to provide skilled nursing care. This is a serious long-term care issue that demands the attention of senior care planners. Decent and appropriate housing are essential for the well-being and dignity of individuals, leading to better communities and society as a whole. Despite public support and incentives, many ethnic elderly persons, including Chinese American elders, are unable to find affordable and suitable housing. The ethnic elderly are characterized by diverse languages, cultures, religions, and classes, stemming from past and present immigration, economic and political influences. Since dominant Western values generally guide policymakers and service professionals in planning and implementing programs, ethnic elders are less likely to benefit from the existing housing programs when compared to indigenous American elderly, even when they are available. The double jeopardy of housing shortage mentioned above, and the cultural diversity of the ethnic populations, demands the special attention of policy-makers to demonstrate equality and fairness that this country claims to value. Implications for Policy Development Increase Public Resources for Housing Programs There is currently a severe lack of government resources on housing for the diverse ethnic population, the underserved minorities, in rural and inner city areas. Many who are qualified for housing assistance are receiving no help. For example, Section 8 certificate and voucher program, the major housing program that reduces Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 135 housing costs, has over 40,000 persons on the waiting list. This problem is so severe that some elderly people expired before they reached their turn (Advisory Task Force on Senior Issues, 2000). Besides making more housing facilities available, some existing senior housing need better monitoring procedures by both government and senior housing staff. Since some ethnic senior housing facilities are located in neighborhoods with high crime rates, more funding should be allocated to protect the neighborhoods, to upgrade and maintain the buildings, and to improve staff quality. Increase Housing Options to Facilitate Independent Living With shifting cultural expectations, more elderly Chinese Americans are seeking to live independently from their sons and daughters, in senior apartments, retirement communities, or in their own places in the community. This trend is moving toward the mainstream general older Americans community. Therefore, elderly Chinese need more housing options from both public and private sectors to facilitate independent living and to upgrade their housing standard. It is important to increase the supply of affordable supportive housing by constructing more residential buildings or transforming existing buildings to affordable housing. Public, private and non-profit groups can all be involved in the development of affordable housing. Moreover, the city housing authority can require all housing developments to put aside certain percentage of total units for affordable housing. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 136 Currently, assisted living facilities, a type of residential option serving frail elderly persons, is mainly available for the middle and upper income families. As people live longer, the number of frail elderly population will increase. The elderly Asian Pacific Islanders, including the Chinese elderly, are growing at the fastest rate among all ethnic groups. Thus, more ethnic frail elderly will need assistance with activities of daily living. It is therefore necessary to make assisted living and similar residential care homes affordable to people with lower income. Small group homes such as coop housing and homes for Alzheimer's disease patients are helpful to the elderly because of their home-like settings. Studies have shown that older people could improve their sense of well-being after moving from living alone to a group home (Hooyman & Kyak, 2002). Therefore, this type of small group homes can be incorporated into community planning process. Since the Chinese elderly are scattered in the suburbs as well as concentrating in the Chinese communities, these co-ethnic small group homes can be planted in the neighborhoods near the families of the elderly. The close proximity can allow the family member to visit often while the elderly parents can enjoy their independence. In addition, supportive services can be arranged to care for the elderly parents in their own homes. Support Home Modification Programs for the Elders to “ Age in Place ” In spite of the expressed desire of many Chinese elderly to live in senior housing, most Chinese elderly in this study remained living in the community. This Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 137 housing option is consistent with the overwhelming desire of America's people aged 55 and above to remain in their own home and community, according to a national survey conducted by AARP (AARP, 1996). These senior individuals need adequate, supportive housing connected to services. Unfortunately, the rising cost of living competes with the cost for repairs of homes these seniors have lived in for many years. To insure safety and to accommodate the elderly individuals’ declining physical and mental conditions, their houses need restoration and modification. Therefore, funding is needed for ethnic sensitive handyman and home security programs for adaptations such as walkin showers and wheelchair accessible ramps. In addition, assessment programs are needed to examine older persons' fimctioning abilities and their needs for home modification. Link Supportive Services to Housing Facilities As the functions of nursing homes, assisted living and adult family home continue to merge, it is critical to link ethnic sensitive services to existing housing with high concentrations of frail older persons. Housing sponsors can provide service coordinators to assess the residents' needs and link service coordinators to existing organizations serving the elderly. Services such as skilled nursing care, rehabilitation, personal assistance and household care can be connected to the elderly’s housing facilities. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 138 Home care is a fast-growing personal care service for the elderly and is reimbursed by Medicare and Medicaid. It provides the necessary adult support services for the elderly who stay in the community to "age in place." Adult day care is another type of service available for the elderly in the community. The participants only spend a few hours a day at the day care center, where they have opportunities for social interaction while receiving rehabilitation and nursing services. Meanwhile, their family caregivers can work at their jobs or have some respite time from the demands of caregiving. Adult services such as assisted living, home care and adult day center are still quite new to many Chinese elderly and their family caregivers. More outreach efforts are needed to inform this ethnic community about the available services. Further, adults supportive services such as these need to be developed in a culturally appropriate manner, so that more Chinese elderly can be served effectively. For example, a new government-subsidized senior day health center in the northwest suburb of Los Angeles is serving Chinese dim sum for lunch nutrition program. This center has become a very popular drop off spot for Chinese families with elderly members. Enhance Transportation Assistance Adequate means of transportation is crucial for the independence and dignity of the elderly. Problems due to lack of mobility are strongly associated with low Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 139 income, isolation, loneliness, and self-care problems (Ecosometrics Inc., 1994). To the elderly individuals, housing, medical, and social services are useful only to the extent that transportation can make them accessible. In Los Angeles County, public provisions such as Cityride bus service have been made available especially for older riders. However, most ethnic elderly population, including the Chinese elderly who are limited in English skills, seldom utilize these services. To these elders, the transportation system in this city is very bewildering, complex, and costly (Pang et al., 2003). More effective options are therefore necessary. In addition, public education campaign designed to educate ethnic Chinese seniors on the use of public transportation system and how they can access special transportation services need to be conducted. Increase Representation in Housing Programs Currently, the older Chinese American community is under-represented in decision making on housing and service policies. Often service provision is based on insufficient understanding of the needs of this ethnic subpopulation. Consequently, the Chinese elderly population is known for underutilization of existing services, or is assumed that there is no need for the services. To improve this situation, public officers and representatives from the elderly Chinese community should work together with government officials to assure quality and appropriateness of public services. Particularly, Chinese Americans need to increase their representation in existing legislations, programs, and agencies on housing. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 140 Community groups should be encouraged to generate political support through coalition building and networking. Contrary to traditional Chinese philosophy of “every family sweeps only the snow in front of their door,” that people are supposed to keep to their own interests, community building among different families and organizations should be promoted, so that they can have a stronger voice to advocate the unique needs of their own population. Implications for Social Work Practice Increase Relevant Data on Housing Needs of Ethnic Elderly With changing demographic trends, it is necessary to compile data on Chinese and other ethnic elderly populations that are current and are readily available to the public for program design, implementation and evaluation. Accurate data can lead to proper housing and services provisions that can effectively promote the well-being of the elderly individuals. As mentioned, gerontological research on Chinese elders and other ethnic minority groups is still lacking. Much of common perceptions on Chinese elders are still based on stereotypes such as the expectation of traditional filial piety. As a result, elderly parents are assumed to stay with their grown children. In contrast, this study found that a large number of elders indicated that they wanted to live independently. This shift in expectation points to the need to develop more ethnic-appropriate senior housing for the elderly Chinese population Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 141 Promote Neighborhood Programs Participation This study found that the Chinese elderly had very little interaction with their neighbors, except for those who lived in the co-ethnic neighborhoods or in housing facilities mainly occupied by elderly Chinese persons. General community dwellers had even less contact with their neighbors. This lacking of neighborhood networks deprives the elderly of the important social and emotional support, especially when their families are unavailable. It is vital to build neighborhood programs to connect the older adults, such as senior peer support groups, telephone and/or computer communication services, and skill building programs to improve social integration among older isolated adults. Some programs can be conducted through church senior ministry in Chinese church and local Chinese centers and clubs. Furthermore, there should be neighborhood programs for elderly persons from different backgrounds to mix, in order that they can learn to appreciate one another’s cultures, and to support and learn from one another. Facilitate Empowerment o f the Chinese Elders The study found that most Chinese elders were immigrants. Although most of them had high levels of education, only a small percentage could read and write English well. The elderly need opportunities to make the most of aging by developing their language ability, continuing making friends, learning new skills, pursuing their interests, and be contributing members of society. These opportunities can be Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 142 provided in the community as well as within the senior housing facilities. For example, education programs such as English as a Second Language (ESL) classes can provide the elderly immigrants with the necessary skills to survive in their new country, and to find new friends among fellow adult students. A common function of older Chinese grandparents is providing childcare for their grandchildren. This trusted role is rewarding for many older people, and is meeting the needs of the family. It can be expanded to the development of intergenerational centers. Increasingly, senior housing complexes are including a multitude of divisions such as a senior activities center as well as a children's center. Older residents can serve as staff or volunteers in these centers to provide childcare during the day. This type of opportunity can enhance the well-being of the elderly individuals by giving them a sense of purpose and the chance to continue functioning in society. Provide Information and Referral Services Elderly Chinese and their family caregivers need to know where to get help. Whether there is a life-threatening emergency, or a minor plumbing problem, many Chinese families are unprepared to find the right services. A comprehensive resource directory compiled and translated in different languages for the Asian and Pacific Americans, should be created and made available to all household. The directory should include names of contact persons, telephone numbers, addresses and emails of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 143 senior service organizations, as well as specific services such as handyman service and health and emergency services. Counseling services have become vital for the mental health of Chinese elders and their families because of the growing incidences of mental health, especially in depression among the Chinese elderly. Unfortunately, not many families are aware of these services, nor would they recognize their needs for the services. Information on mental health counseling should be made available in senior services agencies and other agencies serving Chinese clients. Staff in these organizations can make referral to assist the elders and their families. Provide Gerontological Education for Care Providers, Family Caregivers and the Elderly Homeowners A variety of gerontological educational opportunities should be made available for the care providers, family caregivers, and the Chinese elderly themselves. Professional development opportunities for care providers should include training social workers to be effective liaison with ethnic community organizations serving Chinese senior residents of Los Angeles. They need to increase their sensitivity to cultural issues. While it is easier to treat the Asian and Pacific Americans (APA) as a group, it is important to recognize the cultural differences between different APA subgroups. There is even diversity among older Chinese as mentioned before. Therefore, social workers need to have a thorough understanding of their clients and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 144 find services that can match the needs, so that professional practices will be seen as a familiar help and not a foreign hindrance to the clients’ health and well-being. Family caregivers also need to learn proper techniques in caring for their elderly members at home. Information regarding the social, physical and psychological needs of their elderly relatives is important background knowledge for the caregivers, as well as practical training such as assisting with activities of daily living. Lessons for the caregivers to care for their family members are also good preparation for themselves as they all face the aging process themselves. Education opportunities for the elderly can include workshops for senior homeowners on home repair and home modification to enhance safety in their living environment. Basic home repair and improvement skills, home safety equipment, and owner contracting project management skills are important for those who plan to stay in their own homes for as long as possible. Limitations of the Study Sample Selection Bias There are a number of limitations in this study. A major limitation was sample selection bias inherent in nonrandom purposive sampling. Participants of this study were recruited from senior centers, churches, and residences for senior citizens. Due to the limited number of co-ethnic senior housing, only four senior housing complexes were represented in this study. A disproportionately large group of participants came Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 145 from one co-ethnic senior housing called the Golden Age Village. This might cause a clustering effect. Therefore, results on co-ethnic senior housing might not be representative of all the co-ethnic housing residents. Further, since most of the Chinese elders in the sample were participants of senior center activities and were residents of senior housing, they demonstrated higher degree of independence and were likely to be more socially active than the average Chinese elderly immigrant population. As a result, this sample might show a higher level of social support in the data than Chinese American elders in general. Since many participants were mobile enough to attend senior center programs, the Chinese elders who were home-bound or were bed- ridden, were under-represented in this study, except for a few individuals who were recruited in assisted living and nursing homes. Barriers in Sampling In most cases, the researcher was well received by agency managers and elderly Chinese individuals. However, at times the researcher was treated with suspicion and reluctance. In one pre-arranged visit to a senior organization, the group leader who was not informed about the project, refused to let the researcher interview the elderly participants on site. Instead, the senior participants were asked to volunteer their telephone numbers so that they could be interviewed later. This resulted in the loss of many potential co-ethnic community respondents. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 146 Lack of funding also prevented an agency director from supporting this project. This community agency was facing budget cut and had to shorten the hours of services for their elderly clients. Although the director was willing to cooperate with the study, he was not able to arrange for potential respondents for the interviews. Without the cooperation of agency managers and directors, and proper incentives, it would have been difficult to contact many of the participants. Individual Chinese elders were hard to reach without some referrals. Many elderly immigrants were not familiar with interviews and were reluctant to answer any questions that would disclose their personal information. Having to sign a consent form before the interview was especially intimidating to the elders, and required a lot of explanation by the interviewer. Therefore, although about 500 individuals had been invited to participate in this research, only about half of them participated, due to difficulties described above. Variations among Chinese Elders in Each Housing Arrangement The four types of housing arrangements were distinguished by the concentration of Chinese residents in the neighborhoods and housing type, without taking into account specific variations within each housing arrangement. The differences were especially pronounced within the mainstream general community and the general senior housing groups. The elders in the general community dwelling group had very different socio-economic backgrounds and language abilities. With Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 147 regards to the elders living in general senior housing, their health conditions were very diverged, ranging from severe frailty to well-adjusted independent living. Because of these variations within groups, findings from the analysis had to be interpreted with caution. Delimitation Generalization o f the Findings on Older Chinese Immigrates As pointed out in the literature, about 80% of Chinese elders in Southern California are immigrants (Chow, 1999). The characteristics of the sample were found to be similar to general Chinese American elderly. Therefore, the data could be generalized to older immigrants in the United States. Discussions on American-born Chinese elders were made separately to show the differences due to acculturation, as well as similarities because of the continued influences of Chinese traditions. Adequate Sample Size for Statistical Analysis A total of 260 completed questionnaires were included in this study. At least 50 respondents were assembled for each of the four housing groups. This number was determined by power analyses performed to obtain an appropriate number for each group. Using the data analysis planned and assuming a moderate among of variability accounted for by independent variables, it was concluded that an N of 50 should be Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 148 large enough to satisfy minimum standards for statistical analysis, using a .05 significance level. Direct Comments from the Respondents to Support Quantitative Findings The questionnaire included a semi-structured item regarding the elders’ satisfaction on their housing situation. After rating their satisfaction, the elders were asked to explain their answers. The elders’ direct comments were useful in gaining understanding of their attitudes on their own housing situations, and in what type of housing arrangements they actually desired to live. Furthermore, the personal experiences and opinions of the elders were helpful in the interpretation of the quantitative findings concerning the effects of their living situations on their social support, social networks, and physical and mental well-being. Since this was an exploratory study, no special considerations were taken to distinguish the differences among specific groups such as the differences among age-cohorts groups and the disparity in health status among people who were aged 65 and above and were considered “elderly.” The limitations of this study and lack of gerontological research on Chinese elderly , as well as other ethnic minorities in general, lead to the following implications for future research. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 149 Implications for Future Research Intra-group Comparison among the Chinese American Elders For a future study, efforts should be made to recruit a larger sample of Chinese elders living in different residential locations in a wider area such as in the state of California. To conduct intra-group comparison, the instruments should be administered to all older Chinese subgroups: Chinatown-centered Chinese, ethnic Chinese Vietnamese, Taiwanese Chinese, Professionals, American-born Chinese and recent elderly Chinese immigrants. These groups have their own distinct immigration history and settlement patterns, as well as social and political characteristics, and the study results will provide intriguing and important information about the Chinese elderly population. A comparative study should also be made on residents of the different type of congregated senior housing. As this study showed, people who lived in independent living senior apartments had different characteristics from those living in assisted living facilities and nursing homes. These three housing types should be compared as separate groups in order to provide clearer results than if the housing groups were put together as one general form of senior housing. Compare Age-Cohort Samples In this study, the age range of the sample was wide, from 62 to 99 years. Since people tend to stay healthier and longer, those who are in their 60’s might have very Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 150 different health status as well as a different life style as those in their 90’s. Many of the respondents in their 60’s who live in the community did not admit that they were “elderly” and did not seem to have any social and health problems. However, those in the 80’s and above did show signs of decline and more dependence. Therefore, future study should compare social, physical and mental health of Chinese elders in three age cohort groups: young-old (65-74), middle-old (75-84), and oldest-old (85 and above) groups. Age cohort difference can address acculturation issues and explain the social and health care needs, as well as guiding policymaking for the difference age groups. Psychometric Analyses on the Standard Instruments LSNS-18 and SF-I2v2 In this study, only the composite physical and mental health scores of SF-12v2 standard form (pcs and mcs, respectively) were used to provide the physical and mental health profiles of the elderly individuals in different housing groups. Not included in this study were the data obtained on individual scores of the eight subscales which evaluated eight concepts of physical and mental health - physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health. This specific information can be analyzed, interpreted, and used as a tool to guide health care professionals to plan interventions. Psychometric analysis can be conducted on both SF-12 and LSNS-18 scales in the Chinese translated versions. The reliability coefficients of both scales for the Chinese elderly sample can be compared to published coefficients for the normative Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 151 English versions. For SF-12v2, one can evaluate the mcs, pcs as well as the eight subscales, for the sample compared to published national norms for English versions of SF-36, and translations in other languages (Ware, 1998, 2000). For LSNS-18, results obtained in this study can be compared to other published LSNS versions (Lubben, 2002). Psychometric analysis of the data will determine the usefulness of the Chinese versions of SF-12 and LSNS-18 as standard health measurement device for the Chinese elderly population. Long-term Care for the Chinese Elders Further inquiry is needed to assess the long-term care needs of Chinese American elders and to identify effective means to meet the needs. As the elderly Chinese American population increases in size and longevity, their long-term care is an important issue. Chinese tradition of filial piety might expect grown children to take care of their elderly parents, but more investigations on how contemporary Chinese grown children practice filial piety in America are essential. Findings showed that co-ethnic senior housing residents had the average age of over 80 years. The elders did not seem to be willing to leave their present housing situation partly because this type of housing was very desirable, and partly because it was difficult to obtain a similar kind of housing. 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The Journal o f Applied Gerontology, 73(1), 58-72. Saldov, M. & P. C. Chow (1994). The ethnic elderly in Metro Toronto hospitals, nursing homes and homes for the aged: Communication and health care. International Journal on Ageing and Human Development 38(2): 117-135. Saldov, M.& M. Poon (2001). Elderly Chinese in Public Housing: Social Integration and Support in Metro Toronto Housing Company. Elderly Chinese in Pacific Rim Countries: Social Support and. Integration. I. Chi, N. L. Chappell and J. E. Lubben. Hong Kong, Hong Kong University Press: 221-239. Seligman, M. (1975). Helplessness: On depression, development and death. San Francisco: W.H. Freeman. Shanas, E. (1979). “Social myth as hypothesis: The case of the family relations of old people.” The Gerontologist 19: 3-9. Shinagawa, L. H. (1996). The impact of immigration on the demography of Asian Pacific Americans. In O. Hing & R. Lee (Eds), The state o f Asian Pacific America: Reframing the immigration debate (pp. 59-126). Los Angeles: Leadership Education for Asian Pacifies (LEAP) and the UCLA Asian American Studies Center. Silverstein, M. (2000). Supportfor the elderly in China, the United States and Sweden: A cross-cultural perspective. University of Southern California International Seminar: Harmonizing Social Welfare for the Aged through Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 162 Socioeconomic Development in China, Japan, South Korea, Israel and the United States, Los Angeles, CA. Silverstein, M., & Angelelli, J. (1998). Older parents' expectations of moving closer to their children. Journal o f Gerontology: Biological Sciences and Medical Sciences Series B 53B(3): S153-S163. Silverstein, M., Chen, X. & Heller, K. (1996). Too much of a good thing? Intergenerational social support and the psychological well-being of older parents. Journal o f Marriage and the Family, 58, 970-982. Silverstein, M. & Zablosky, D. L. (1996). Health and social precursors of later life retirement-community migration. Journal o f Gerontology: Series B, Psychological Science and Social Sciences, 51B(3), 150-156. Spolidoro, A. & Demonteverde, S. (1998). Asian and Pacific Islander elderly in Los Angeles County: An information and resource handbook. Los Angeles: Los Angeles County Area Agency on Aging. SPSS Inc. (2001). Chicago, IL. Stewart, J. Y. (2003, March 23). On their own turf, on their own terms. Los Angeles Times, pp. Kl, K6. Stone, R., Cafferata G.L. & Sangl, J. (1987). Caregivers of the frail elderly: A national profile. The Gerontologist, 27(5), 616-626. Streiner, D. J. & Norman, G. R. (1995). Health Measurement Scales: A Practical Guide to their Development and Use. (Second Edition). New York: Oxford University Press. Sue, D. W. & Sue, D. (1990). Counseling the culturally different: Theory and practice (2nd ed.). New York: John Wiley. Sung, K. T. (1991). “Family-centered informal support networks of Korean elderly: the resistance of cultural traditions. ” Journal of Cross-Cultural Gerontology 6(4): 431-447. Sung, K. T. (1998). An exploration of actions of filial piety. Journal o f Aging Studies, 72(4), 369-386. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 163 Sung, K. T. (2001). Elder respect: Exploration of ideals and forms in East Asia. Journal o f Aging Studies, J5(l). Takamura, J. (2002). Social policy issues and concerns in a diverse aging society: Implications of increasing diversity. Generations, 33-38. Tanjasiri, S. P., Wallace, S. P. & Shibata, K. (1995). Picture imperfect: Hidden problems among Asian Pacific Islander elderly. The Gerontologist, 35(6), 753-759. The Asian American Federation of New Y ork, & Brookdale Center on Aging at Hunter College. (2003). Asian American Elders in New York City: A study of health, social needs, quality o f life and quality of care. New York: Asian American Federation of New York. The Bipartisan Millennial Housing Commission (2002). Meeting our Nation's Housing Challenges. Washington DC, The Congress of the United States. Thoits, P. A. (1982). Conceptual, methodological and theoretical problems in studying social support as a buffer against life stress. Journal o f Health and Social Behavior, 23, 145-159. Tsai, D. T. & Lopez, R. A. (1997). The use of social supports by elderly Chinese immigrants. Journal o f Gerontological Social Work, 29(1), 1997. Uhlenberg, P. (1996). The burden of aging: A theoretical framework for understanding the shifting balance of caregiving and care receiving vs. cohort ages. The Gerontologist, 36, 761-767. U.S. Bureau of the Census. (2000). U.S. Census Bureau. (2001, Sept 19). Profile of general demographic characteristics: United States 2000. Census o f Population and Housing, access on line at: www.census.gOv/prod/cen2000/index.html. U.S. Immigration and Naturalization Service. (2000). Statistical Yearbook of Immigration and Naturalization Service, 1998. Washington D. C.: U.S. Government Printing Office. Vaux, A. (1988). Social Support: Theory, Research and Intervention. New York: Praeger Publisher. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 164 Ware, J. E. (1998). The SF-36 Health Survey. In M. E. Maruish (Ed.), The Use of Psychological Testing for Treatment Planning and Outcome Assessment (SecondEd.) (pp. 1227-1246). Mahwah, NJ; Lawrence Erlbaum Associates. Ware, J. E., Kosinski, M. & Keller, S. D. (1996). A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(2), 220-233. Ware, J. E., Kosinski, M., Turner-Bowker, D. M. & Gandek, B. (2002). How to Score Version 2 o f the SF-12 Health Survey (With a Supplement Documenting Version 1). Lincoln, RI: Quality Metric Incorporated. Weinberg, M. (1997). Asian-American Education: History Background and Current Realities. Mahwah, New Jersey: Lawrence Erlbaum Associate. Williams, A. K. (2000). The long wait: The critical shortage o f housing in California.: The Corporation for Supportive Housing and Housing California. Wong, M. G. (1995). Chinese Americans. In P. G. Min (Ed.), Asian Americans: Contemporary Trends and Issues (pp. 58-94). Thousand Oaks: Sage Publications. Wong, P. & V. Ujimoto (1998). The elderly: their stress, coping and mental health. Handbook o f Asian American Psychology. C. L. Lee andN. W. Zane. Thousand Oaks, Sage. World Health Organization. (2002). Active Aging: A policy Framework. Geneva: WHO Ageing and the Life Course Section. Wu, F. (1975). Mandarin-speaking aged Chinese in the Los Angeles area. The Gerontologist, 15, 271-275. Yee, D. (2002, Fall). Recognizing diversity in Aging. In D. Yee (Ed.), Generations. San Francisco: American Society on Aging. Zhou, M. (1992). Chinatown: The Socioeconomic Potential o f an Urban Enclave. Philadelphia, PA.: Temple University Press. Ziegler, M. & Reid, D. (1979). Correlates of locus of control in two samples of elderly persons: Community residents and hospitalized patients. Journal of Consulting and Clinical Psychology, 47(5), 977-979. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 165 APPENDICES Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 166 APPENDIX 1 CHINESE AMERICANS IN LOS ANGELES: A TIMELINE Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 167 Chinese Americans in Los Angeles: A Timeline Source: Chinese American Museum Los Angeles, California, USA 1769 Spanish explorers, led by Gaspar de Portola, enter the area that is now Los Angeles on their way northward. 1781 El Pueblo de la Reina de Los Angeles is founded by Felipe Neve. 1822 News of Mexico's independence from Spain reaches the pueblo. 1848 The discovery of gold at Sutter's Mill starts the California Gold Rush, bringing many people from all over the world, including Chinese. California is ceded to the United States of America 1850 On September 9, California gains statehood. First US census: 2 Chinese men are listed: Ali Fou and Ah Luce. They were house servants at the Los Angeles residence of Robert Haley. They are gone from the city by 1852. 1854 Many Chinese leave south China with some coming to the U.S. for the reasons of: 1 . the Triads uprisings in the Pearl River Delta (1854-61), 2. the attack and occupation of Guangzhou by English and French troops during the Second Opium War (Arrow War) (1857-58) 3. the Punti-Hakka War in Sze Yup (1854-68) 4. the need of colonies of the European powers and frontier areas of Australia and North America for labor. California Supreme Court upholds laws prohibiting people of color from testifying against whites (People Respondent vs. George W. Hall). 1855 Chinese fishermen establish camps along the California coast, including the Channel Islands off Santa Barbara, thereby beginning the state's fishing industry. 1857 Three Chinese, John Tambolin, et al., are brought to Los Angeles by an Englishman to work in a laundry. With a continuing presence of Chinese in Los Angeles, the first Chinese New Year celebration takes place. 1859 A newspaper. The Los Angeles Star, reports the arrival of the first Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 168 1859 A newspaper. The Los Angeles Star, reports the arrival of the first Chinese woman in Los Angeles. 1860 Los Angeles has 4 Chinese-owned laundries. 1865 Thousands of Chinese from the Guangdong Province are recruited by Central Pacific Railroad Co. to work on westem portion of transcontinental railroad. 1869 The transcontinental railroad was completed when the eastern and western portions were joined at Promontory Point, Utah. Chinese laborers come to Los Angeles to work on a wagon road north of Los Angeles. 1870 According to the Census, of tlie 5,728 citizens in Los Angeles, 172 of them are Chinese. Approximately one third of the Chinese population lived in Negro Alley. The rest are scattered about Los Angeles. 1871 An altercation between Sam Yuen and Yo King leads to the accidental shooting of a Robert Thompson. This brings to a head fermenting racial and economic strife within the community and becomes directed toward the Chinese. A mob of some 500 whites go on an arson and looting spree leaving 19 Chinese dead. The event is known thereafter as the Chinese Massacre of Los Angeles. 1875 67 Chinese arrive in Los Angeles aboard the steamer Senator from San Francisco. They are the vanguard of workers arriving for the construction of the L. A. & Independence Railroad. 1876 The Southern Pacific railroad connecting San Francisco and Los Angeles is completed. The Chinese activity in truck gardening begins to flourish in Los Angeles. 1878 F. See On is founded. It is the oldest continuing mercantile enterprise in the Los Angeles Chinese community. Chinese are hired to build the Semi-Tropic Water Company tunnel north of today's City of Orange. Los Angeles County voted against Chinese immigration (98% to 2 % ^ 1879 The State Constitution contains a provision specifically banning Chinese from public work. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 169 1880 During this decade, the city, following the state's position of 1879, excludes all Chinese labor from city contracts. 1881 The convention of the American Federation of Labor adopts a resolution calling for Congress to prohibit Chinese immigration. 1882 The Los Angeles City Council passes an ordinance which would remove all Chinese from the city limits. It is ruled invalid by the city attorney as it violates the 14th Amendment and the Burlingame Treaty. The Chinese Exclusion Act is passed by the U.S. Congress. Its major provision includes suspension of further immigration of Chinese laborers. Laborers already in the U S. can not bring their wives and children. Exempted from exclusion are government officials, teachers, students, merchants and travelers. All Chinese residents are denied naturalization. 1890 Important satellite Chinatowns, some with a population of several hundred, flourish with the Los Angeles Chinatown being the hub. These satellite communities are located in places such as Riverside, Ventura and Santa Barbara. 1893 Los Angeles labor vm ions initiate the first proceedings in the county to register Chinese resident laborers under the newly enacted Geary Act (1892). 1894 Los Angeles holds the first Fiesta de las Flores on April 10-13 and the Chinese community is invited to participate. The Chinese become a familiar sight in subsequent yearly fiestas and other civic occasions. 1898 Los Angeles' first Chinese newspaper, Wah Mei Sun Po, is founded by Ng Poon Chew a Presbyterian minister. After Ng moved to San Francisco, he renamed it to Chung Sai Yat Po. 1899 The Los Angeles City Council calls for a delineation of the borders of Chinatown and a thorough investigation of sanitary conditions therein. 1900 The Boxer Rebellion takes place in China in an attempt to drive all foreigners out of the country. Lives of Americans living in China are threatened. As a result of the Boxer Rebellion, reentry of Chinese into the U.S. is made more difficult, especially through San Francisco. 1901 Many Chinatown youths cut off their queues as a gesture of their opposition to the Qing dynasty. A Chinese cadet corps of over 1000 members forms shortly after the queue cutting. 1904 As part of his cross-country trip Sun Yat-Sen visits Los Angeles on June 14, 1904 to seek support for the revolution in China. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 170 1905 K'ang Youwei, an advisor to the Qing emperor, visits Los Angeles on March 16. 1910 Sun Yat-Sen again visits Los Angeles to raise money for the revolution in China. 1911 The Qing dynasty is overthrown by the Chinese Republic in a major victory on October 10. Overseas Chinese, including those of Los Angeles, play a major role in financing the revolution. 1912 The Native Sons of the Golden State establish a lodge in the Los Angeles Chinatown. The organization is unique in that the membership consists of American bom Chinese who were bom in Califomia. The Republic of China is officially established with Sun Yat-Sen as the first president. Many men in Chinatown cut off their queues. 1914 A large portion of L.A.'s Chinatown is sold in preparation to the constmction of the Union Passenger Terminal. The plan to build the terminal is stopped by litigation over ownership of land. 1917 Chinese Americans fight in World War 1 . Low Chew, a prominent leader of the Chinese American Citizens Alliance, volunteers for Army service and recmits several of his fiiends in Chinatown. 1919 Consolidated Benevolent Association establishes a Chinese cemetery at First and Evergreen Streets. Tlie cemetery still exists today. 1927 Nationalist-Communist civil war begins. 1931 Mei Wah Club, a social and athletic organization for Chinese American women, is founded in Los Angeles. 1933 Beginning in December, part of Old Chinatown east of Alameda Street is condemned and razed to make way for the new Union Passenger Station which officially opens in 1939. 1937 The Sino-Japanese War begins. The following year, many of the Chinese American children who had been sent to China to be educated retum to Los Angeles. The Moon Festival is held for the United China Relief. The effort draws many supporters from the Chinese and non-Chinese communities. 1938 New Chinatown and China City open in June within three weeks of each other. 1941 Tourist trade brings prosperity to New Chinatown and China City during the 1940's. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 171 Relations improve between China and the U.S. when the two become allies in World War II. 1943 Madame Chiang Kai-Shek addresses audiences in the Hollywood Bowl and at Los Angeles City Hall to solicit American support for the Chinese war relief effort. She also speaks to the assembled members of the U.S. Congress and asks them to strike down all Chinese exclusion laws. Congress repeals the laws and establishes a token quota of 105 Chinese immigrants per year. The figure is based on 1/6 of 1% of the number of Chinese in the U.S. in 1920. Chinese are the first Asians granted naturalized citizenship. 1946 The number of Chinese women in Los Angeles begin to increase largely because of the passage of the 1945 War Brides Act, the 1946 Fiancees Act, and the enactment of Public Law 713 in 1946, as well as by immigration from other U.S. Chinatowns. American Legion Chinese Post 628 is founded by Chinese World War II veterans. 1948 Displaced Persons Act allow 5,000 Chinese scholars already in the U.S. to change their status to residents. 1949 The Chinese Communists win the civil war in China and establish the People's Republic of China. The Nationalists move to Taiwan (Republic of China). 1951-53 Chinese Americans participate in the U.S. forces during the Korean War. Passage of a number of laws, including the McCarran-Walter Act and Refugee Relief Act, contributes to the increase in the Chinese population in Los Angeles. 1953 Military experience and college education, made possible by the various G.I. bills, help the Chinese to move into mainstream American life. 1955 The Chinese Chamber of Commerce of Los Angeles is established. 1960 Residential dispersion of the Chinese continues throughout the Los Angeles area, especially with American bom Chinese. 1962 The first Chinese American bank in Southern Califomia, Cathav Bank. opens and provides much needed services and capital for development of the area. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 172 1965 The Immigration Act of 1965 opens the door to Chinese immigration. Subsequent immigration leads to a revitalization of the New Chinatown. 1970 During the 1970's, the new wave of Chinese immigrants tend to settle outside of New Chinatown. The Chinatown Service Center, offering referral services to the community, is established. 1972 Construction of the Mandarin Plaza on North Broadway, represents the first significant development in New Chinatown in over twenty years. It heralds a new era of commercial expansion. President Nixon's trip to the People's Republic of China opens diplomatic relations between the U.S. and the People's Republic. This once again improves the attitude of Americans toward China. The normalization of U.S.-People's Republic of China relations causes political polarization in the Chinese community. 1975 Chinese Historical Societv of Southern Califomia is established. The end of war in Southeast Asia results in many ethnic Chinese immigrants and refiigees, some of whom eventually relocate to L.A.'s Chinatown. 1977 The Chinatown Branch of the Los Angeles Public Librarv opens. 1979 A large influx of Chinese Vietnamese boat people into New Chinatown occurs. 1980 The Los Angeles Community Redevelopment Agency designates Chinatown as a redevelopment area. 1984 Cathay Manor, a large senior citizen, low income housing project, is built. The Chinatown Service Center is relocated to the Cathay Manor. 1986 Monterev Park, a small city east of Los Angeles, is identified as the first suburban Chinatown in the United States. Center of aetivity for Chinese moves to San Gabriel Valley. 2003 The Museum o f Chinese American History moves to its permanent location Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 173 APPENDIX 2 AGENCY ON AGING SUMMARY OF SERVICES Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 174 T i i c L*ts AiM«>KLt:.% T V oiv a c i n g L.A COUNTY AREA AGENCY ON AGING - SUMMARY OF SERVICES Information & A ssista n c e ; Information,comprehensive assessm ent, linkage, follow-up: 800-510-2020 Care M anagem ent: A ssessm ent, care planning, payment or purchase of services, monitoring of care plan. In Hom e S erv ice s & Registry: Assists older persons to remain at home. R espite Care: Assists primary caregivers of frail elders. Legal S ervices: Legal assistance, administrative and judicial representation, advocacy. Meals: Congregate and Home delivered. O m b u d sm a n : Ensures rights of older persons in long term care facilities, excluding hospitals. Com m unitv S ervices: Maintains/improves the well-being of older persons through social, creative and volunteer opportunities, education, recreation. D isease P revention & Health Prom otion: Adult Day Health Care, Adult Protective Services, GENESIS (fieriatric Evaluation Networks Encom passing, Services, Information and Support), and ENHANCE (Effective (Nutritional Health A ssessm ents and Networks of Qare for the Elderly). Preventive of Elder A buse: Physical and mental ab u se senvices, fiduciary abuse (FAST • Fiduciary A buse Specialist Jeam ), County-wide Forums. E m plovm ent: Senior Community Service Employment Program (SCSEP). Other: Alzheimer’s Day Care R esource Centers, Brown Bag, Foster G randparents,Senior Com panions Health Insurance Counseling & Advocacy(HICAP). 6/99 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 175 A® Services for the Aging in the United States i H M 1O{0) U.S. Administration on Aging Regional AoA Offices (10) (^57 f@ ) State Units on Aging (57) (^ •67211) Area Agencies on Aging (672) m Access Services Multipurpo Local Service Providers A .ssistance Community Base Services n m m m .i ; § . 8 S V oluntary Institutional Services In-home Services mm N utritional S ervices Elaine C. Pang June, 2001 U.S. Services for the Aging Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 176 APPENDIX 3 INTRODUCTORY LETTER TO CHINESE SENIORS Dear Sir/Madam, We are from the University of Southern Califomia School of Social Work. Currently we are conducting a study regarding how well older Chinese are adjusting to various residential settings in Los Angeles. Please answer the following questions and feel free to include any comments you may have in the spaces available on the back of the questionnaire. It will take you about half an hour to answer all the questions. Your answers are important for planning better services for you. Your answers will be comnletelv confidential and anonvmous. so please do not sign vour name. The information collected from you will be combined with answers from other participants, and your identity will not be revealed in any way. No risk or discomfort is involved. No one will be allowed to know how you answer. If you do not want to answer a particular question, you do not have to answer it. Your participation is strictly voluntary. You may choose not to participate at all or you may withdraw at any time. If you have any questions, the researcher who conducts this interview will be glad to help you. If you have any questions about this study, please contact Elaine C. Pang at the USC School of Social Work at 818-789-9731, or the USC Institutional Review Board at 213-740-6709. Your participation is deeply appreciated. Thank you. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 177 APPENDIX 4 INTRODUCTORY LETTER TO CHINESE SENIORS Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 178 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 179 APPENDIX 5 INFORMED CONSENT FOR NON-MEDICAL RESEARCH Date of Preparation: 3/19/03 USC UPIRB #03-03-071 Expiration Date: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 180 School of Social Work INFORMED CONSENT FOR NON-MEDICAL RESEARCH «|^ «|^ CONSENT TO PARTICIPATE IN RESEARCH Title o f the study: Social-environmental Factors and Health-related Quality of Life among Elderly Chinese Americans You are asked to participate in a research study conducted by Marilyn Flynn, Ph.D. and Elaine Pang, Ph.D. Candidate, from the School of Social Work at the University of Southern California. The results will contribute to Elaine Pang’s dissertation. You were selected as a possible participant in this study because you represent the older Chinese American population aged 65 and above who will benefit from our study. A total of 200 subjects will be selected from senior housing facilities, senior centers, adult schools, churches and community-based agencies to participate. Your participation is voluntary. PURPOSE OF THE STUDY The purpose of this study is to examine the social support networks and health status of older Chinese who live in different kinds of housing arrangements and neighborhoods. By comparing the conditions of different groups of older Chinese persons we hope to find out what type of housing choice might be most appropriate for seniors like you. The information will help professionals and policy makers to develop housing and social policies that might be most effective in enhancing the well-being of Chinese seniors, and other older immigrants as well. PROCEDURE If you volunteer to participate in this study, we would ask you to do the following: We would ask you to complete a survey questionnaire where you will check out the items that match your personal background, your health status, your living arrangements, and your social relationships. A bilingual (Chinese/English) researcher will interview you in person, or she will distribute this questionnaire to you at the Date of Preparation: 3/19/03 USC UPIRB #03-03-071 Expiration Date: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 181 agency where you participate in senior programs. She will help you complete the survey form if you need help. The whole process will take about 30 minutes. POTENTIAL RISKS AND DISCOMFORTS There are minimal foreseeable risks to your physical and psychological well-being from being involved in this study. You might feel uncomfortable answering some of the items in the questionnaire concerning your personal background, and you might feel tired because of the time spent in completing the questionnaire. If you do not want to answer a particular question, you do not have to answer it. You may also stop the interview at any time. In addition, all the information you give will be kept confidential, and to maintain anonymity, you do not need to put your name on the questionnaire. POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY Although there are no direct benefits for you, the information you give will be very important for understanding the relationship between housing arrangements and the well-being of older Chinese people. The data collected from this study will help planners and social service professionals to develop appropriate housing policy and programs for older Chinese as well as for other older immigrants in America. PAYMENT FOR PARTICIPATION Upon completion of the survey questionnaire, you will receive $10.00 to compensate you for your time. However, you will not receive any payment if you withdraw before you have completed the questionnaire. There will be no other reimbursements such as parking and transportation. CONFIDENTIALITY Any information that is obtained in connection with this study which can be identified with you will remain confidential and will be disclosed only with your permission or as required by law. All the collected information will be stored in a locked file cabinet and will be available only to the investigators and research staff. When the results of the research are published or discussed in conferences, no information will be included that would reveal your identity. Date of Preparation: 3/19/03 USC UPIRB #03-03-071 Expiration Date: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 182 All signed consent forms will be kept in a separate folder from the questionnaires in a random order so that your identifying information will not be linked to the questionnaire at an3 dime. However, each questionnaire will have a study number for tracking where the sample is collected. PARTICIPATION AND WITHDRAWAL You can choose whether to be in this study or not. If you volunteer to be in this study, you may withdraw at any time without consequences of any kind. You may also refuse to answer any questions you do not want to answer and still remain in the study. The investigator may withdraw you from this research if circumstances arise which warrant doing so. IDENTIFICATION OF INVESTIGATORS If you have any questions or concerns about the research, please feel free to contact Marilyn Flynn, Ph.D., Principal Investigator, at (213) 740-8311; or Elaine Pang, Ph.D. Candidate, Student Investigator, at (818) 789-9731; or write to the School of Social Work, University of Southern Califomia, Los Angeles, Califomia, 90089-0411. RIGHTS OF RESEARCH SUBJECTS You may withdraw your consent at any time and discontinue participation without penalty. You are not waiving any legal claims, rights or remedies because of your participation in this research study. If you have questions regarding your rights as a research subject, contact the University Park IRE, Office of the Vice Provost for Research, Bovard Administration Building, Room 300, Los Angeles, CA 90089-4019, (213) 740-6709 or upirb@usc.edu. Date of Preparation: 3/19/03 USC UPIRB #03-03-071 Expiration Date: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 183 SIGNATlfRK OF RESEARCH St'BJECT, PARENT OR LEGAL REPRESENTA IIVE. I understand the procedures described above. My questions have been answered to my satisfaction, and I agree to participate in this study. I have been given a copy of this form. Name of Subject Name of Parent or Legal Representative (if applicable) Signature of Subject, Parent or Legal Representative Date SIGNATliRE OF IN VESTIGATOR I have explained the research to the subject or his/her legal representative, and answered all of his/her questions. I believe that he/she understands the information described in this document and freely consents to participate. Name of Investigator Signature of Investigator Date (must be the same as subject’s) Date of Preparation: 3/19/03 USC UPIRB #03-03-071 Expiration Date: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 184 SIGNATURE OF WITNESS (If an oral translator is used.) My signature as witness certified that the subject or his/her legal representative signed this consent form in my presence as his/her voluntary act and deed. Name of Witness Signature of Witness Date (must be the same as subject’s) Date of Preparation: 3/19/03 USC UPIRB #03-03-071 Expiration Date: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 185 APPENDIX 6 INFORMED CONSENT FORM, CHINESE VERSION Date of Preparation: 3/19/03 USC UPIRB #03-03-071 Expiration Date: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 8 6 M W U m : n i ¥ : Ml li,iM^iF A # ^ A M f t ° m % A i f t 6 < ] , m m m m o n m ^ m m i m m x i p ^ i m m m , t m r m x m m ^ • ■ Marilyn Flynn, Ph.D., (213) 740-8311 Elaine Pang, Ph.D. Candidate, (818) 789-9731 ftP ll^ ^ 0 # ftll:[l]^ m P n » p q ([< ]P n !M o University Park IRI3, Office of the Vice Provost for Research, Bovard Administration Building, Room 300, Los Angeles, CA 90089-4019 (213) 740-6709 orupirb@usc.edu Date of Preparation: 3/19/03 USC UPIRB #03-03-071 Expiration Date: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 8 7 B T 0 ^ Date of Preparation: 3/19/03 USC UPIRB #03-03-071 Expiration Date: Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 8 8 APPEJsLDIX 7 QUESTIONNAIRE Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 8 9 Date of Interview; I /_____ Study #: Interviewer:______________________ Zip code of residence:____________ Source of data collection (hom e, ch u rch , se n io r c e n te r, etc.): Thank you for participating in this study. Your answers will help us find ways to improve your well-being through better housing arrangements. Please complete this questionnaire, and do not put your name on the form, as the information will be looked at collectively. PART A: BACKGROUND INFORMATION A1) What type of housing do you live in? (Please check one) A. I live in my own place or apartment in a neighborhood with many Chinese people. B. I live in my own place or apartment in a neighborhood with very few Chinese people. C. I live in a senior housing community with many other Chinese people. D. I live in a senior housing community with very few other Chinese people. A2) What is your birthplace?____________________________ A3) How long have you lived in the U.S.?__________________Year(s) A4) What is you present marital status? (Please circle one number) 1. Single 2. Married___ 3. Separated___ 4.Divorced___ 5. Widowed 6. Other___ A5) How many children do you have? 1. Number of son(s) 2. Number of daughter(s)___ 3. None/Not applicable____ Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 9 0 A6) What is your highest level of education? 1. Primary school 2. High school 3. College___ 4. Graduate school 5. O ther__ A7) How good is your English? (Please circle one number) Cannot Can Can read a Can Can read understand understand a little understand and write little and read a well little 1 2 3 4 5 A8) Are you retired? (Please circle one number) 1.Yes 2. No If No, what is your occupation? A9) What is your income level? 1. Less than $15,000 2. $15,000 to $50,000 3. More than $50,000 A 10) What type of health insurance do you have? (Please check all that apply) 1. Medicare 2. MediCal 3. Private insurance 4. Supplemental policy 5. No health insurance 6. Other, please specify____________________ A 11) What is your age range? (Please circle one number from 1 to 7) 60 to 64 65 to 69 70 to 74 75 to 79 80 to 84 85 to 89 90 and over 1 2 3 4 5 6 7 What is your age? (optional) A12) Are you: 1. Male 2. Female A 13) What are your primary health problems, if any? (Please check all that apply) Allergies ___ Digestive problems Kidney problems Arthritis ___ Eye problems ___ Lung disease Back and sciatica Hearing problems Skin problems pain ___ Heart condition Thyroid problems Cancer ___ High blood pressure Prostate or Diabetes ___ High cholesterol gynecological problems Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 191 Do you have any other medical problems? Please specify; No health problem PART B: LUBBEN SOCIAL NETWORK SCALE (LSNS-18) FAMILY: Considering the people to whom you are related either by birth or marriage.... B1) How many relatives do you see or hear from at least once a month? (Please circle one number) None One Two Three or Five thru Nine or four eight more 0 1 2 3 4 5 B2) How often do you see or hear from relative with whom you have the most contact? (Pease circle one number) Less than Monthly A few Weekly A few Daily monthly times a times a month week 0 1 2 3 4 5 B3) How many relatives do you feel at ease with that you can talk about private matters? (Please circle one number) None One Two Three or Five thru Nine or four eight more 0 1 2 3 4 5 B4) How many relatives do you feel close to such that you could call on them for help? (Please circle one number) None One Two Three or four Five thru eight Nine or more Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 9 2 B5) When one of your relatives has an important decision to make, how often do they talk to you about it? (Please circle one number) Never Seldom Sometimes Often Very often Always 0 1 2 3 4 5 B6) How often is one of your relatives available for you to talk to when you have an important decision to make? (Please circle one number) Never Seldom Sometimes Often Very often Always 0 1 2 3 4 5 NEIGHBORS: Considering those people who live In your neighborhood.... B7) How many of your neighbors do you see or hear from at least once a month? (Please circle one number) None One Two Three or Five thru Nine or four eight more 0 1 2 3 4 5 B8) How often do you see or hear from the neighbor with whom you have the most contact? (Please circle one number) Less than monthly Monthly A few times a month Weekly A few times a week Daily 0 1 2 3 4 5 B9) How many neighbors do you feel at ease with that you can talk about private matters? (Please circle one number) None One Two Three or four Five thru eight Nine or more 0 1 2 3 4 5 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 193 B10) How many neighbors do you feel close to such that you could call on them for help? (Please circle one number) None One Two Three or four Five thru eight Nine or more 0 1 2 3 4 5 B11) When one of your neighbors has an important decision to make, how often do they talk to you about it? (Please circle one number) Never Seldom Sometimes Often Very often Always 0 1 2 3 4 5 B12) How often is one of your neighbors available for you to talk to when you have an important decision to make? (Please circle one number) Never Seldom Sometimes Often Very often Always 0 1 2 3 4 5 FRIENDSHIPS: Considering your friends who do not live in your neighborhood.... B13) How many of your friends do you see or hear from at least once a month? (Please circle one number) None One Two Three or four Five thru eight Nine or more 0 1 2 3 4 5 B14) How often do you see or hear from the friend with whom you have the most contact? (Please circle one number) Less than monthly Monthly A few times a month Weekly A few times a week Daily 0 1 2 3 4 5 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 9 4 B15) How many friends do you feel at ease with that you can talk about private matters? (Please circle one number) None One Two Three or four Five thru eight Nine or more 0 1 2 3 4 5 B16) How many friends do you feel close to such that you could call on them for help? (Please circle one number) None One Two Three or four Five thru eight Nine or more 0 1 2 3 4 5 B17) When one of your friends has an important decision to make, how often do they talk to you about? (Please circle one number) Never Seldom Sometimes Often Very often Always 0 1 2 3 4 5 B18) How often is one of your friends available for you to talk to when you have an important decision to make? (Please circle one number) Never Seldom Sometimes Often Very often Always 0 1 2 3 4 5 LSNS -18 Score _(Please leave blank) B19) Do you live alone or with other people? (Please circle one number) Live alone Live with Live with Live with Live with unrelated relatives spouse spouse and persons relatives 0 1 2 3 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 195 PART C: SF-12 HEALTH SURVEY “ = — INSTRUCTIONS: This part of the questionnaire asks for your views about your health, how you feel and how well you are able to do your usual activities. 01) In general, would you say your health is; (Please circle one number) Excellent.....1 Very good....2 Good............3 Fair...............4 Poor............. 5 02) The following questions are about activities you might do during a typical day. Does vour health now limit vou in these activities? If so, how much? (Please circle one number on each line) 03) Yes, Yes, No, not limited at all AOTIVITIES limited a lot limited a little a. Moderate activities, such as moving a table. pushing a vacuum cleaner, bowling, or 1 2 3 playing golf 1 2 3 b. Olimbing several flights of stairs Durinq the past 4 weeks, have vou had any of the followino problems with vour work or other regular dailv activities as a result of vour ohvsical health? (Please circle one number on each line) All Most A good Some A little of the of the bit of of the of the time time the time time time a. Accomplished less than 1 2 3 4 5 you would like 1 2 3 4 5 b. Were limited in the kind of work or other activities Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 9 6 C4) During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? (Please circle one number on each line) All of the time Most of the time A good bit of the time Some of the time A little of the time a. Accomplished less 1 than you would like 2 3 4 5 b. Didn't do work or 1 other activities as carefully as usual 2 3 4 5 Durina the past 4 weeks, how much did pain interfere with vour normal work (including both work outside the home and housework)? (Please circle one number) Not at all A little bit Moderately Quite a bit Extremely 1 2 3 4 5 C6) These questions are about how you feel and how things have been with you durinc the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. (Please circle one number on each line) How much of the time during the past 4 weeks All of the Most of the A good bit of Some of the A little of the None of the time time the time time time time a. Have you felt calm 1 9 Q A C A and peaceful? O H O U b. Did you have a lot of energy? 1 2 3 4 5 6 c. Have you felt downhearted? 1 2 3 4 5 6 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 9 7 C7) During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? (Please circle one number) All of the time Most of the time A good bit of the time Some of the time A little of the time None of the time 1 2 3 4 5 6 C8) Are you satisfied with your residential choice? (Please circle one number) 1 .Yes 2. No 3. Mixed feeling 4. Other Please explain: Thank you for participating in this survey! Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 198 Appendix 8 QUESTIONNAIRE (Chinese Version) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 9 9 ii^ _______ m i m m m m m m n , m m i m ia m ih ^ rn n x i'f. PART A. BACKGROUND INFORMATION fE l A#:B:WI4 1 . 2, ^4 ^ i 4, A2) . A3) ( ¥ ) A4) 1 . B M 2. 3. 4. II $1 5. W-M 6. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. A5) S) l.UcW 2 . ^ w 3 .^ ^ ^ 200 ± tm & i 'ij (^ I^ W ) 2 . ^ # 4 . m % m 5.^ji]i 1 . / h ^ A7) 1. 2 . # i i —S^ 3.#11—a 4 5. # ii^ P B l A8) 1 .^ 6 ^ 2 . ^ # , A9) : 1) $15,000 2) $15,000 - $50,000 3) ®M$50,000 AlO) S : lo m n m m i m 2 . j m m i m 3o 4o m A ll) 1^: (:^ ) 60 M 64 65 S 69 70M 74 75M 79 8OM 84 85 M 89 90+ 1 2 3 4 5 6 7 A12)#6<J't4)3iJ: 1. M 2. A A13) W fflm—f i ^ ^ ) mm, 0 srp iM , ifu ^ , mnmmtmm, ik^m, m , m w ^ , =W'^, fi 1 ^ f t Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 201 PART B. LUBBEN SOCIAL NETWORK SCALE I. R M \ m ) ? . § i i i ± ”io ” ] B2) 0 . 1. 2 . 3. - m m n - K 4. 5. M - R B3) A{ 0 , lf±I±”io” ] IBIiAl r BI^AI B5) ^ ^ A ^ P E ^ W i Iff ? M A S S 5 4 3 2 1 0 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 202 u ± M 5 4 3 2 1 0 n. IMi B7) i j m i s . R M in 7 , i f ± i ± ”io ” ] t S i l A i ( B8) 6 l # S f i S ^ 6 ^ S ) S . A ? 0. 1. - \ m - ' - ( X 2 . 3. 4. 5. . l#±I±”io” ] . ii±I±”io” ] ISiiAl B ll) #1 M A B 5 4 3 2 1 0 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. B12) M ± S W 5 4 3 2 1 0 2 0 3 , ii±<±”io” ] IfiitAI B14) 0. A A - f @ i i - A 1. " - fiJ ? — 2. 3. - { @ S S i- A 4. 5. [$nm^3i+fi , if±I±”io” ] lfi$tAtS(__ Bi6) ? [$pm^M+{@ . li± I± ”io” ] l e i i A i B17) M A 5 4 3 2 1 s w 0 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 0 4 B18) 5 4 3 2 B 1 9 )# |i|= |[^ ft? MBJI E S S S '5 B ? S B B s w 0 _ Z 1 0 PART C. SF-12 HEALTH SURVEY Cl) 1. 2. u n 3. i f 4. - m 5. iU^-. (iiH H i- r n m m r n m . m ^xm M M W ^ m \ a. 't'^yS S fj, mtmM T, mm,U^ St34ciU c?T ;^» 1 2 3 b. ^ 1 2 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 0 5 n u t :k m m WB# m m a. 1 2 3 4 5 ?ijps$y 1 2 3 4 5 $njifc x m m m m . U W 1 2 3 4 5 i m r n i m r 1 2 3 4 5 \S/. 1. i 2 . % 3. 4. 5. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 0 6 C6) u , i t i t # - 'o"a' $njik m WB# m m W a. ^P? 1 2 3 4 5 b. 3 \ m x % ^f|J? 1 2 3 4 5 n , 1 2 3 4 5 i±5Syg®j c m n n m m m m m : ^ ) ? 1. 2. 3. ^ m i m w 4. 5. \rm C8) l.M M 2.75M M 3 .^ #, I f M W - T : Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 0 7 APPENDIX 9 SOURCES OF THE SAMPLE Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 208 VEN’TURA COUNTY [ K * < ^ ^ V "^\va . l i t # * 4 y v W # *r ‘ 5 '^ /-V ) ,> LOS ANGELES COUNTY ORANGE COUNTY < '> • 2 Each square rcprcicnta 100 Aiiani A, C hai^w orth, B, jSfortiuid^e C, Sfm fcTO Tido V a J } ^ )- D Q u ;i< v { o -.\a B, A Jih M ilp ra ' E M oi.tcjrcy P u rlc Q , 'Sao G a b E ^ I V a lj^ y H Tpn-dij^ I 'OrsqggCQW tY '1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

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Asset Metadata

Creator Pang, Elaine Chan (author)

Core Title Impact of housing arrangements on social support and health status among Chinese American elderly

School Graduate School

Degree Doctor of Philosophy

Degree Program Social Work

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Gerontology,health sciences, public health,OAI-PMH Harvest,Social work

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Flynn, Marilyn (committee chair), Aranda, Maria (committee member), Ell, Kathleen (committee member), Kung, Winnie (committee member), Silverstein, Merril (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-522687

Unique identifier UC11335996

Identifier 3140532.pdf (filename),usctheses-c16-522687 (legacy record id)

Legacy Identifier 3140532.pdf

Dmrecord 522687

Document Type Dissertation

Rights Pang, Elaine Chan

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA