Professor of Medicine, Nursing, and Behavioral Sciences, Rush University Medical Center; Director of Chinese Health, USA
Received: 13/01/2016 Accepted: 28/01/2016 Published: 15/02/2016
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Objective: This review aims to explore the perception of filial piety among the global Chinese adult children with respect to its endorsement level, risk factors, and consequences, as well as the perceptions of filial piety. Methods: The author searched the global literature in PubMed, EBSCO, JSTOR, ProQuest and PsycINFO. Search terms included adult children/ young/ student AND filial piety/ Xiao/ filial obligations/ respect/ attitudes/ beliefs/ practice/ behaviors AND Chinese/ Taiwan/ Hong Kong/ Chinese- American/ Chinese Immigrants. The author excluded studies that existed only as abstracts, case series, or case reports and non-English publications. Results: Evidence revealed that filial piety is common among the global Chinese adult children. Being only-child, married, with older age, higher education level, and more income are associated with higher endorsement of filial piety and more filial practice. Mixed findings are found regarding to gender, grade, living arrangements, place of origin as risk factors of filial piety. The adverse outcomes of filial piety included caregiving stress, worse self-rated health and role strain. Beneficial outcomes were found such as healthier family functioning, higher academic achievement and less caregiving burden. Conclusion: Filial piety is commonly endorsed among the global Chinese adult children. This review highlighted important knowledges gaps, such as a lack of standardized assessing instruments, insufficient longitudinal research in regards to risk factors, consequences of endorsing filial piety, intervention and education programs unified and coordinated efforts at global level should continue to be promoted in understanding and encouraging the value of filial piety.
Filial piety, Adult children, Global Chinese population.
Filial piety (Xiao) is defined as “a traditional Confucian virtue in Chinese culture, which refers to a prominent, family-centered cultural value that adjusts children’s attitudes and behaviors toward their parents to ensure parental well-being”. It has contributed toward keeping different generations connected and has led to an inherent sense of obligation for children to support their parents in various changing contexts [1-3]. In addition to provide adequate physical and financial care and support for their older parents, filial piety requires children to be respectful, caring and obedient to elders, family or otherwise , living with the parent (or staying close if co-residence is not possible), taking care of the parent whether healthy or sick, and avoiding injury to self because the body belongs to the parent, among others . Traditional concept of filial piety has meanings of the continuation of the family line, honoring or promoting the public prestige of the parent and the ancestors as well. Therefore, adult children’s perception and practice of filial piety shape the parent–child relationship and caregiving of the elders in Chinese communities. Filial piety played an important role in the daily life of older adults and their caregivers. Researchers had suggested that receiving more filial piety is associated with older adults’ better psychological well-being , self-rated health , lower risk of depression  and suicidal ideation . In addition, older adults who perceived their children as filial reported decreased utilization of health care services . However, recent studies suggested that traditional Confucian filial piety may be undergoing modification, perhaps erosion, implying ongoing changes in inter-generational relations in this modernizing Asian society . A qualitative study noted that there are existing disconnections between older adults’ conceptualizations of filial piety and the receipt of filial care in U.S. Chinese community . What the older adults are expecting in contemporary society might be different from what their adult children would like to offer. Meanwhile, adult children, as one of the main caregivers of older adults, are influenced by their perception of filial piety. Existing empirical evidence suggests that filial piety could adjust caregiving burden and indirectly affect depression for adult children . and yet, limited studies were conducted to explore filial piety from adult children’s perspectives and its influence upon their wellbeing, mental health and behaviors. What is less known is that how adult children cope with their sense of loss and powerlessness if they are incapable of providing home care to their ailing parents. In addition, little is known about the mechanisms that empower those who are capable to care for their parents in spite of a various resource and practical limitations [13-15].
The relationship between caregiving and filial piety among Chinese adult children warrants greater attention. China currently has 160 million people (11.9% of the total population) aged 60 . By 2030, this number will increase to about 347.1 million (23.8%) . Under the effect of China’s One-Child policy, the single child generations are now looking at a 1:2:4 paradigm: one (the child)-two (parents)-four (grandparents) family structure, calling for enormous responsibility of caregiving and burden. Facing such a rapid growth of the elder population, the Chinese government enacted a law in 2013 aimed at compelling adult children to take care of their aging parents physically, financially as well as spiritually. The law, called “Protection of the Rights and Interests of the Aged”  has nine clauses that lay out the duties of children and their obligation to tend to the needs of the elderly. One of the clauses requires the offspring of parents older than 60 to visit their parents frequently, occasionally send them greetings and make sure their needs are met. What’s more, companies and employers should give employees enough time off so they can make parental visits. It was amended by China’s legislature after a spate of reports of older parents being neglected by their adult children as well as through prior research reports [19-24]. It was believed that the need to make filial duty a legal matter is a reflection of the monumental changes taking place throughout Chinese society, and will encourage adult children to endorsement the value of filial piety and prevent older adults from experiencing loneliness, neglect and elder abuse. Globally by 2050, it is estimated that 25% of the world’s elderly population will be Chinese . Because of cultural and linguistic barriers, acculturation, and social isolation, Chinese older immigrants are found having a higher risk of neglect and elder abuse [26-29]. Meanwhile, they expected overall high level of filial piety, especially respect from their children [11,30-33]. For their children, caregiving is challenging when they struggle among unfamiliar systems of elder support and try to balance back and forth between western and eastern values. A study conducted in the greater Chicago area with 3,159 Chinese aged 60 years or older showed that older adults still highly expect filial piety from their adult children [27,30]. It is daunting for Chinese younger generation to support the elder population along with China’s developing economy and its fragmented old-age support system . In order to meet the challenges, and mitigate conflicts between westernization and traditional values expected from the older generation [11,35-38], we need national and international studies for in-depth information of the concept and perception of filial piety. The purpose of this systematic review is to enhance our understanding of the epidemiology of filial piety from the perspectives of adult children among global Chinese populations. This review will synthesize both qualitative and quantitative studies, presenting the level of endorsement, risk factors, consequences and perceptions of filial piety. Moreover, this review discusses the primary gaps on filial piety in the global Chinese population, and the key implications for practice and policy.
Studies eligible for this review were those investigating filial piety perceptions and practices among Chinese adult children in China, Hong Kong, Taiwan, overseas and cross-countries. Quantitative researches were first searched and analyzed. Due to limited intervention studies, qualitative researches were later included to further understanding of filial piety among Chinese adult children.
The process of the literature search was demonstrated in Figure 1. The authors conducted a search of global literature in PubMed, EBSCO, JSTOR, ProQuest and PsycINFO, and limited the search to studies published in English after 1995. Filial Piety is interchangeably used by other terms such as Xiao (in Chinese), filial obligations, filial respect, filial support, filial attitudes, filial beliefs, filial behaviors, filial obligation, and filial expectation. Searched keywords included the following: adult children/ young/ student and filial piety/ Xiao/ filial obligations/ respect/ attitudes/ beliefs/ practice/ behaviors and Chinese/ Taiwan/ Hong Kong/ Chinese-American/ Chinese Immigrants. The exclusion criteria were studies published only as abstracts, case reports, and non- English publications. Furthermore, the authors examined the reference lists of previously identified works for relevant articles.
Endorsement of Filial Piety
Filial piety is globally endorsed by Chinese adult children. Due to the scarcity of systematic studies, the endorsement of filial piety among Chinese adult children varies depending on the populations, settings, research methods, and measuring instruments (Appendix-Table 1). In mainland China, the mean score of the perception of filial expectation and obligation range from 3.18-4.86 on 5-point scales with a total range of 1 to 5 [39-42]. Other studies reported mean scores of 36.40-77.50 of attitudes and practice of filial piety with a larger score range (total score range 10-55; 0-100) [43,44]. In Hong Kong and Taiwan, more various instruments were used under different score range. Lam’s study  is the only one presented frequency along with mean scores of filial piety, which showed that 76.30% to 96.20% of the caregivers agreed or strongly agreed with the value of filial piety. Chinese immigrants in U.S., Canada, and New Zealand also showed endorsement of filial piety under acculturation [46-50]. Only three studies investigated practice of filial piety of Chinese adult children, two of which were conducted in Hong Kong, and one in mainland China [43,51,52]. A variety of instruments were applied to estimate the endorsement of filial piety. The majority of research utilized two scales: the Filial Piety Scale by Yang et al. , which presented high reliability with Cronbach’s α ranging from 0.73-0.90, and a various number of items from 6 to 41; and the Dual Filial Piety Scale  with α ranging from 0.48-0.90. Yang’s scale was later revised into the Revised Yang's Filial Beliefs Subscale (YFBS-R) and Yang's Filial Affection Subscale (YFAS-R) to assess filial beliefs and affections . Some used revised Ho’s  Filial Piety Scale with 6 or 12 items (α ranging from 0.68 to 0.88), Gallois’ Filial Piety Scale with 6 items ; or Liu and colleagues’ 6 or 12-item scale (α=0.80). Others chose self-developed instruments such as the 4-item filial norms scale [56,57].
Risk Factors Associated with Filial Piety: Perceptions and Practices
Detailed analyses of risk factors are presented in Appendix-Table 2. Single-child, married, with older age and more income are associated with higher endorsement of filial piety and filial practice [41,51,58,59]. Whereas, risk factors regarding gender, grade, living arrangements, place of origin yielded mixed findings. Women endorsed higher reciprocal filial piety than men while men had higher authoritarian filial piety than women . Zhan and Montgomery  confirmed the gender difference in their study in mainland China. Women seem to be more sensitive than males to emotional needs while men to material support . Other studies suggested the opposite . Besides gender difference, the relationship between education and filial piety was inconclusive. Adult children with higher education endorsed more filial piety and will practice more filial behaviors [41,43,51]. However, higher grade was associated with lower filial piety in younger students [58,60]. What’s more, living arrangement suggested distinctive attitude toward filial piety. Students co-reside with grandparents showed lower filial obligation toward older adults . While with 110 adult children caregivers, co-residence with parents was associated with a higher endorsement of filial responsibility [41,51]. Moreover, adult children from the different origin of places may have various levels of endorsement of filial piety. Lin and Yi  reported adult children in Taiwan endorsed higher filial norms than their Chinese counterparts. Mainland Chinese practiced more filial behaviors than adult children in Hong Kong . Interactions between adult children and their parents may impact children’s perception of filial piety. In Hong Kong, students perceived different types of parenting tended to value different types of filial piety under the Dual Filial Piety Model . Children are found more filial when they spent more time with their mother , and having less conflicts with parents .
Consequences of Endorsing Filial Piety
The consequences of endorsing filial piety raised another debate within researches, due to both adverse and beneficial outcomes were found (Appendix Table 3). Evidence showed that for those who are living with parents, filial piety was significantly associated with more caregiving stress , worse self-rated health , and more role strain .To the contrary, other studies showed that higher endorsement of filial piety leads to healthier family functioning , lower level of caregiving burden  and higher academic achievement motivation . Under the dual filial piety model, filial piety was associated with greater life satisfaction [58,61], better academic achievement , more social competence  and less deviant behaviors of adolescents . What’s more, endorsement of filial piety affects adult children’s care-taking behaviors. Adult children with a higher endorsement of filial piety practiced more financial assistant [40,46,56,57,67], tended to co-reside with older parents [57,68], had more face-to-face contact , spent more time on care tasks , had more frequent assistance in household chores  gave emotional aid more frequently to their parents [46,56] and practiced more filial behaviors . Greater filial belief may reduce the incidence of conflicts and incidence of inappropriate behaviors .
Qualitative research offered an in-depth discussion about filial piety and how it is experienced and undertaken by Chinese families of today (Appendix Table 4). Researches explored and developed a wide range of themes under this topic. With regard to the meaning and attributes of filial piety, studies concluded themes such as reciprocal relationship, mutual support, situationalreciprocal- filial caregivers, and parent-child relationships, which all lead to an interactive dynamics between the caregivers and recipients [13-15]. In contrary to the notion of authority relationships in the traditional sense of filial piety where children are to conform to their parents’ wishes without resistance [70,71], all adult-children caregivers expressed the importance of reciprocal relationships in the care and support of their aging parents. Other two themes mentioned regularly are gender difference and financial status. Daughters and daughters-in-law seemed to spend more time emphasizing their efforts in making their elderly relatives “happy comfortable”, or “feeling cared for” whereas sons generally talked more about financial matters . Speaking of financial status, it was a critical factor to consider when adult children should keep their parents under the same roof or place them in an institution. Some had to choose income-limited housing for their parents due to limited financial resource. Those who have sufficient financial resources had a more positive attitude toward providing for or managing care for their parents, or offering living arrangements or custodial support . When considering the Chinese immigrants, traditional filial beliefs provided motivation for family caregiving. Along with the process of acculturation and modernization, adult children were trying to adjust their way of practicing filial piety according to their own situations and accessible resources [14,15,44,73,74]. The qualitative studies affirmed that the younger Chinese generation all over the world still expressed a remarkable endorsement of filial piety in contemporary society .
The review indicates that adult children still endorse filial piety among contemporary global Chinese society. The endorsement of filial piety guides the caregiving behaviors and influences the relationships between adult children and their older parents. Various risk factors have been found associated with filial piety. Among the risk factors, being female, married, older, living with parents, higher educated, having more income, and having more interactions with parents are associated with higher endorsement of filial piety and more filial behaviors. As for consequences, filial piety may lead to adverse outcomes such as more stress, and worse self-rated health; and beneficial ones such as healthier family functioning, lower caregiving burden, and more caregiving behaviors.
Researchers raised the debate on the transformation of filial piety under certain circumstances. It seems plausible that the prevalence of filial piety and its accompanying authoritarian moralism in Chinese societies has diminished as a consequence of modernization and exposure to Western influence . Cheung and Kwan's study  found that filial piety was lower when the adult children were in a city with higher or more advanced modernization. Adherence to filial commitments among younger generations has found weakened due to modernization and social changes [77,78]. Many aging parents in China, as in other industrialized nations, complained about not seeing their children enough. Adult children say the stresses of life prevent them from carving time for their parents. To ensure the importance of filial piety, one of the most treasured of traditional virtues in Chinese society, the Chinese government even passed a law to compel children’s caregiving responsibilities and obligations toward their aging parents in 2013 . Yeh  argued that although in the last decade, the process of industrialization, urbanization and pluralization have weakened the authority of filial piety and exchange links between parents and children, filial concept relevant to affection between parents and children remain highly important. It is found the extents of endorsement differed widely in this review. Filial piety has components of authoritarian requiring children's absolute submission, duties to fulfill parents' needs, repay parent's sacrifices, preserve the family honor, and continue the ancestral line. While on the other hand, other components still exist, such as respect, protection, gratitude, and the notion of "tender-heartedness to parents", reflects the emotion and affection in the traditional Chinese filial piety . Studies emphasizing more on the authoritarian elements of filial piety could find a decreasing trend, since people valued more autonomy and less absolute obedience. Focusing on the emotions and elements of filial piety might lead to another conclusion. Another reason might be the age variance. Younger adult children who have not undertaken the caregiving responsibilities may be less exposed to parents' expectations of filial piety. And those who are older and already practicing filial piety showed that they might naturally endorse more filial piety than those not involved in filial practice. Since filial piety is a unique cultural norm rooted deeply in Confucian Ideology and developed geologically in East Asian areas, place of origin may affect how one perceive and practice filial piety. For example, in mainland China, the one-child policy introduced in 1979 drastically shifted the filial practice of the single child generation. The only children seemed to feel especially responsible for their parents’ happiness because of their singleton status . When the only child starts to undertake the main caregiving responsibilities for their parents and in-laws, each of them is facing a possible one (the child)-two (parents)-four (grandparents) family composition. If married, the numbers of the elders simply doubled. Along with the driving needs of the enormous and rapidly growing older population, there is the urge to support adult children in practicing filial piety with all sorts of resources. Meanwhile, in Hong Kong, exposed more to westernization, adult children valued their own autonomy and independence and were more willing to respect their parents and have emotional interactions with them . Despite the fact that Taiwan has a higher economic development level, people in Taiwan are not very differed from their counterparts in China and Hong Kong regarding filial values and practice . For Chinese immigrants, it could be more complicated due to acculturation, language barriers, education, and incomes, etc. Especially immigrants who were the first or second generation struggled to connect with whatever family and personal resources available to maintain the caregiving and survive. Meanwhile, they continuously adjust their values, expectations, goals, and activities to accommodate changing situations and demands . Assessments of filial piety adopted in the literature varied enormously regarding the scales selected, the number of items on each scale, and the range of reported scores. Four “schools” of measurements were mainly developed by different researchers, whose previous work were either cited or revised for various study goals. Even when utilizing the same instruments, the number of items used to measure filial piety varied. Filial piety scale (FPS) was structured by Yang and his colleagues in 1989  with fifty two items. Revised or extracted by other researchers, FPS contained various item numbers from 6 to 41. Based on Yang’s work, Yeh et al. [63,79,81] continued developing the FPS and proposed the Dual Filial piety Model and scale (DFPS) in his later work to capture filial piety in modern Chinese society . The scale contains each 8 items on reciprocal and authoritarian filial piety subscale. Ho’s FPS originally  had 22 items and was revised into 11 to 22 items in different studies. In addition, Gallios’  perceived filial expectation and obligation scale has six items assessing filial piety. Yeh and colleagues designed the Dual Filial Piety Model to integrate the conflicting findings over whether filial piety is beneficial or harmful to individual development [58,63,67,69,78]. Based on Yang’s  four distinct filial piety factors, Yeh  used confirmatory factor analysis to identify two higher order factors. The two factors were corresponding to two focal filial piety attributes: reciprocity and authoritarianism. Reciprocal filial piety means emotionally and spiritually attending to older parents due to gratitude for their efforts in raising their children, and physical and financial care for them as they age. It reflects the beneficial aspects of filial piety, such as enhanced interpersonal relationships. Authoritarian filial piety encompasses suppressing one’s own wishes and complying with parents’ wishes because of their seniority, as well as continuing the family lineage and maintaining parents’ reputation under the force of role requirements. Authoritarian filial piety reflects the generally negative findings on filial piety. The influence of filial piety on individual development can neither be labeled wholly beneficial nor harmful. Instead, reciprocity and authoritarianism form two intertwined aspects of filial piety grounded in the historical development of the concept. Yeh suggested that while there may be continuing support for reciprocal filial piety, authoritarian filial piety may be decreasing in relevance in modern Chinese societies. The Dual Filial Piety Model provided a new point of view in understanding filial piety and a prototype for future research on filial piety. There are various limitations in the field of filial piety that causing challenges to this systematic review. First of all, due to the inconsistency of instruments, results of studies are hard to compare and analyze systematically across studies. This current review used the mean score as indicators of the endorsement level of filial piety within different score ranges. Despite using the same instrument, the approach of defining endorsement of filial piety differed greatly across studies. Most studies reported the level of endorsement or attitudes according to adult children’s agreement to certain statements, some other studies use different categorizations of filial attitudes. In addition, different length of instruments raised some challenge to this review. The shortest version of the assessment used three items to measure norms of filial piety. Yet the longest had twenty five items. Moreover, culturally and linguistically appropriate instruments should be developed and implemented [31,32,36,82]. Second, this review excluded non-English published researches; therefore, we are lacking the view of other scholars’ perspectives and data in other languages. Finally, representation of Chinese adult children varied greatly by regions. The majority of studies on filial piety were conducted in Mainland China, Hong Kong, and Taiwan. Only three studies were carried out in U.S., one in Canada and one in New Zealand. A lack of representative studies in certain regions such as South America, U.K., and Austria will affect the understanding of filial piety among global Chinese adult children across continents.
Future Research Direction
In the future, psychometrically sound measures are critically needed  to get a deeper and more systemic understanding of filial piety, its risk factors and consequence. The inconsistent measurement created enormous barriers to understanding filial piety at a global level. Standardization of the core elements and the procedures of survey could a more representative result of endorsement of filial piety among global Chinese adult children [84-89].
Utilizing well-developed measuring instruments, it is likely to conduct longitudinal studies and provide invaluable information about the short-term and long-term effects of filial piety. Longitudinal studies are vital to further understand the changes of filial piety. The content of filial piety may change under different circumstances including modernization, westernization, improving financial status and immigration. Innovative approaches to explore the contemporary filial piety are necessary for improving support for older adults and potential interventions. Moreover, researches are needed to understand the causal mechanism for the consequences of filial piety. Moreover, filial piety described a form of parent-child relationship. Therefore, researches with regards to both parental and children’s characteristics, the cross-generational discrepancy of filial piety, as well as reciprocal interactions are needed [90-94]. This review included researches with adult children caregivers, who were looking after their parents and/or in-laws. However, few studies paid attention the discrepancy of different generations in terms of perception of filial piety [95-99]. Numerous Chinese older people held the belief that they don’t need to tell their children what they need, because if the children are filial enough, they will know for themselves. And yet, those untold needs may never get enough attention and fulfilled, and even cause family conflicts, if adult children are not aware of existing discrepant perceptions of filial piety [100-104]. Knowing more about it could help adult children improve the quality of support, meet more needs of their older parents, and fulfill the responsibility better. Plus, few studies discussed the differences between children’s filial piety and children in-laws, or even the extended family members [105-108]. Caregiving is not only limited to parent-child interaction, but also in-laws-child and grandchild-grandparent, etc. In order to build up a healthy support network, more understanding of filial piety among extended family members are important.
Implications and Interventions
This research has widespread implications for health care professionals, social workers, community organizations and policy makers. It is crucial for health care professionals to provide health services in a culturally sensitive approach in consideration of the expected role of children as caregivers in the Chinese families [109-113]. Special attention should be paid to several subgroups with higher risks of filial burden, including the low-income, single child, caregivers with poor health status, and poor mental status. Heath care profession should improve their understanding of important cultural norms when caring for the Chinese population. Moreover, adult children who were unable to fulfill filial piety may be involved with potential elder mistreatment. Health care professionals are in a critical position to screen for it as well . Support strategies and interventions provided for vulnerable population and subgroups  call for more notice to nourish intergenerational relationship through filial piety practice. For instance, helping adult children get connections with more community resources for caregiving could be very considerate. It is imperative to specifically design education program  of filial piety to build healthy parent-child relationship. Along with the changes of perception of filial piety, adult children valued more emotional interactions. Community education program targeted at improving intergenerational communications could help to increase emotional inputs such as respect and greet at the family and community level. In order to prevent caregiving burden or other mental health impacts from practicing filial piety, social workers and mental health providers could help adult children use self-support resources, such as meditation, self-awareness training, anger management, etc. Furthermore, policy makers and community organization should consider ways to foster the quality of inter-generational relationships as modernization continues and more adult children choose to live elsewhere away from the place of birth [85-89]. China has passed the law “Protection of the Rights and Interests of the Aged” in order to reinforce the importance of filial piety and ensure the responsibility of adult children in taking care of older parents . Nevertheless, the law does not identify elder abuse or neglect of older adults, or stipulate any punishments for people who neglect their parents. In future, more policies ensuring older adults’ benefit and care should be developed, so as policies supporting adult children who are undertaking the responsibility of caregiving of their parents. Given the association between filial piety and adult children’s caregiving burden, life satisfaction and motivation of filial behaviors, mental health policies and programs developed by Mental Health Service Administration and other relevant federal departments should rest on the keen appreciation of the cultural value and facilitate the ability of Chinese adult children to get adequate support from other family members, community resources and other professionals.
This review highlights the endorsement of filial piety as well as the complexities in research and practice. Standardized assessing instruments are needed to better capture the perception and attitudes toward filial piety. Longitudinal research is needed to better define filial piety, the risk factors, and consequences of endorsing filial piety in diverse settings among Chinese adult children. Health professionals and social workers should consider cultural sensitivity when providing support to adult children who are enduring caregiving burden. Support and education programs should be designed to help adult children fulfill their filial responsibility and take care of themselves. While vast gaps remain in the field of filial piety, unified and coordinated efforts at a global level should continue to understand the value of filial piety and the causal mechanism of the risk factors upon filial piety and its consequences.