Japanese-American Elder Care: Cultural Norms and Long-Term Care

Caregiving for Elderly Parents in Japan

Japan has witnessed significant growth in its elderly population. In 1950, 4.9% of the Japanese population was aged 65 years and above. This figure increased to 14.8% by 1995, and by 2025 it is estimated to reach 25.8% (Yamamoto & Wallhagen, 1997). Japan's "very old" population group — those aged 85 and above — is increasing rapidly. It has been projected that by 2025, the nation's "very old" population will account for 4.3% of its total population, a five-fold rise in three decades. Furthermore, it was projected that as many as 2.62 million Japanese would be suffering from senile dementia by 2015; the 1990 estimate for senile dementia was approximately one million individuals (11WSA, 1996).

Change in the proportion of Japan's aged population has brought with it a corresponding change in Japanese social norms pertaining to family matters. Historically, elder care in Japan was regarded as the predetermined duty of the successive generation in patrilineal extended families. Owing to this tradition, even in 1992, as many as 33.4% of aged, bedridden Japanese individuals who were not sent to institutions were cared for by their children's spouses (Yamamoto & Wallhagen, 1997). This moral tradition was financially reinforced through primogeniture, wherein the main family assets passed to the male heir upon his father's death. Following the Second World War, however, newly passed legislation on inheritance abolished the primogeniture tradition. Despite the time-honored moral imperative continuing to strongly influence those involved, the actual practice of this familial duty is now changing gradually. For instance, Japanese households containing three generations of the family decreased from 19.2% in 1970 to 12.5% in 1995. This shift in family configuration will likely significantly alter Japanese views on family caregiving for older persons.

Another key element of Japanese parental caregiving is women's role in the traditional Japanese family. Elderly and patient care was traditionally a role expected to be performed by the women of the household (Yamamoto & Wallhagen, 1997). According to traditional Japanese cultural expectations, the wife of the heir — the first son — is required to provide hands-on care for his aged parents, including changing diapers and feeding them, until the aged person is hospitalized due to a medical condition. However, this longstanding role expectation has become a source of conflict for Japan's growing number of working women. In 1975, roughly twelve million Japanese women held jobs; by 1993, this figure had increased to twenty million (Yamamoto & Wallhagen, 1997).

With broader recognition of the problem of a growing share of elderly individuals requiring assistance with their everyday activities, a number of formal services were introduced. In 1990, a "Gold Plan" — an exclusive ten-year initiative — was executed to improve support for elderly individuals and their families. This plan entailed the establishment of daycare facilities, homecare support facilities, and long-term patient care facilities. The Japanese Ministry of Health and Welfare planned a roughly tenfold increase in these services between 1990 and 2000 (Yamamoto & Wallhagen, 1997). However, family support for people with demented, elderly parents remains limited. Behavioral issues displayed by aged individuals diagnosed with dementia often exclude this group from services such as "short-stay" and daycare arrangements. Additionally, the services available fall far short of what is needed in Japan. As a result, aged persons and their family caregivers who need assistance face long waiting periods (Yamamoto & Wallhagen, 1997).

Despite their successes, Japan's long-term and health care systems face sustainability challenges similar to those encountered by their U.S. counterparts, including increasing demand and mounting expenditure. The government of Japan is weighing and pursuing numerous options, such as preventive services, increasing premiums, fees, or taxes, and promoting community-based healthcare services (Belli, 2013). In 2011, reform focused on a holistic model of community care was implemented. Similar in some respects to a responsible care institution, such a model would guarantee access to hospital, medical, or long-term patient care, preventive services, legal services or life support, and residential care services within elderly people's communities (Belli, 2013). Attention to service consolidation and prevention is intended to reduce reliance on more costly services by keeping the population in better health.

Japanese vs. American Elderly Care Systems

Professionals in the field often look to Japan as an example of a nation that effectively addresses the needs of its rapidly aging population. Its long-term and health care systems, while not without flaws, provide elderly Japanese with holistic and economical care. As the U.S. endeavors to reform healthcare in order to control costs and shift focus toward preventive and managed care, Japan's experience offers instructive comparisons (Belli, 2013). Rather than following an exclusively acute health model, American healthcare is gradually migrating toward chronic disease management, prevention, and long-term patient care. Beyond reducing costs, this kind of shift can help individuals live healthier for longer.

Some life expectancy disparities between Japan and the U.S. can be explained by health indicators. The U.S. obesity rate is among the world's highest at 35.7%, whereas Japan's rate is among the lowest at 3.1% (Belli, 2013). Obesity raises the risk for several chronic ailments, including diabetes, heart disease, and hypertension. America's diabetes incidence also exceeds that of Japan. Smoking constitutes another factor: while Japan's current smoking rate is higher than that of the U.S., historically the reverse was true. On account of the previously high smoking rate in the U.S., American life expectancy is now approximately two years lower (Belli, 2013). Beyond health influences, cultural values also affect the aging population. Japan's working population is among the longest-working globally, meaning older adults are able to support themselves longer. Strong social and family networks also mean that families deliver much of elder care — though this trend is changing as Japanese society modernizes.

While Japan and the U.S. face similar challenges regarding an increasing aging population, the two nations have adopted different approaches to meeting this population's needs. Historically, the American healthcare system emphasized acute care and dealt with diseases as they arose, rather than concentrating on disease prevention or management. The rise in chronic disease incidence necessitates long-term social and medical services for more individuals, especially older adults. A large number of chronic ailments can be prevented through healthy lifestyle behaviors such as regular exercise and healthy eating (Belli, 2013). While U.S. healthcare insurance is still not universally available, nearly half a century ago the federal government recognized elderly people's unique needs and launched the Medicare initiative. Currently, Medicare covers nearly all adults aged 65 and older, and some supplement services not covered by Medicare through private insurance (Belli, 2013). Furthermore, almost 17% are entitled to Medicaid coverage. However, Medicare is neither comprehensive nor free, and this creates care gaps when patients are unable to find or afford appropriate services.

While Medicare covers nearly every elderly American adult, its focus is acute care. The means-tested Medicaid initiative for low-income individuals of all ages covers both long-term and acute care. Many elderly individuals also supplement Medicare with private insurance. Medicaid and Medicare are highly costly programs, totaling over 900 billion dollars in 2010. They require cost-sharing by all except the poorest beneficiaries, and out-of-pocket expenditures are rising (Belli, 2013). Beyond mounting healthcare spending, long-term and health care systems for the elderly are complex and fragmented. Patients may be unaware of what services are available, what they are entitled to, and who pays their hospital bills. Inadequate communication between service providers is common, though case managers can help mitigate this problem. Family caregivers may also lack adequate support. For elderly individuals suffering from chronic ailments and disabilities, this complex framework can hinder timely and appropriate care.

The Affordable Care Act offered some solutions, including enhanced care coordination through electronic medical records (EMR), financial incentives for healthcare professionals to deliver the right care the first time, and coverage for elderly persons' preventive services (Belli, 2013). In contrast, every citizen of Japan enjoys healthcare coverage. They are covered under a compulsory employment-based or community-based scheme — the latter insuring citizens and residents not covered by the former, administered by municipalities. Exceptions include individuals aged above 75 years, covered under a prefecture-funded system, and those in poverty, whose healthcare expenses are borne by the Public Assistance system (Belli, 2013). These schemes are financed through a pay-as-you-go structure with three financing streams: co-payments or user fees, insurance premiums, and general tax revenues. Insurers set insurance premiums on the basis of numerous factors, including healthcare services usage and average earnings.

Japan's national government establishes fee schedules for products and services — including equipment and medicines — which are largely consistent across the country. Earmarked tax proceeds cover some deficits in insurance covering comparatively lower-income populations such as small firm employees, elderly persons, self-employed individuals, and part-timers (Belli, 2013). User fees and premiums vary according to income level, making healthcare reasonably affordable for the majority of the population. Government-established rates control healthcare spending, which stands at roughly 9.3% of Japan's gross domestic product (GDP), compared to America's 17.9% (Belli, 2013).

Long-Term Care Use Among Japanese-Americans

Despite Japan's longstanding family caregiving tradition, Japanese families residing in Japan as well as the U.S. are now facing challenges similar to those encountered by other populations — fewer caregivers are available due to greater geographic mobility and workforce participation (Young, McCormick & Vitaliano, 2002). As a result, formal services have become an increasingly important alternative for Japanese families in both countries. Japan's national government is employing its long-term Gold Plan to promote the welfare and health of elderly patients, with increased participation among elderly individuals and family members in formal health services.

Japanese research has revealed the influence of cultural factors on formal service utilization. A qualitative study conducted in 1998 by Wallhagen and Yamamoto on family caregiving in Japan identified three dimensions that affect a family's decision to use formal services: service availability, whether the primary caregiver can justify her level of tolerance to other family members, and the caregiver's authority within the family. The first dimension encompassed elements of distance, service quality, potential sanctions, quantity, and knowledge of available services. The dimension of tolerance encompassed social caregiving customs, personal beliefs about how care ought to be delivered, and the nature of the bond with the patient. This research highlighted the complex interaction among influencing factors, as well as caregivers' careful negotiation in making service decisions (Hashizume, 2000). Hashizume's (2000) review of emerging gender-related issues for Japanese women considered the Japanese cultural value of privacy, their apprehension about having service providers in the home, their unwillingness to bear the associated embarrassment, strong cultural expectations for familial caregiving, and a sense of having failed in one's responsibilities by handing them over to others.

Prior work among Washington State's Nikkei, or Japanese-Americans, demonstrated that despite stereotypes about Japanese family caregiving, nursing homes generated a similar level of interest to that seen in the general U.S. population, suggesting changing attitudes among Japanese families toward this alternative. However, a family caregiver survey found that Asian-Americans were the lowest users of community supportive services — such as delivered meals, personal care, or adult daycare. Only about 15% of Asian households used nursing or personal services, representing approximately half the rate of other cultural and ethnic groups. Additionally, nearly half of participants (49%) stated they were unsure what kind of information or assistance would be valuable, compared to 38% overall (Young et al., 2002).

There is currently only one culture-specific U.S. social service organization — the Japanese-American Service Committee (JASC) — targeting the Nikkei elderly population in Chicago's urban communities, and a medical clinic — Nihon Clinic — located in a Chicago suburb serving Japanese expatriates (Lau, Machizawa & Doi, 2012). Having served American Nikkei for more than 65 years by responding to the community's evolving needs, JASC aims to better understand the use of formal and informal support among functionally independent elderly Nikkei, to maximize their chances of "aging in place" — that is, continuing to live at home and within one's community in old age (Lau, Machizawa & Doi, 2012, p. 151). JASC has partnered with two universities to carry out a participatory community-based study assessing the specific service needs of elderly Nikkei living alone in Chicagoland — suburban and urban Chicago (Lau et al., 2012).

Factors Influencing Long-Term Care Use

A substantial body of research exists on factors that influence nursing home usage. Various major variables have been identified, including care recipient and caregiver characteristics that predict intent to institutionalize and actual nursing home placement (Young et al., 2002). Combined with the growth of community-based non-institutional health services, increasing attention has been paid to predicting usage of formal service alternatives. Care recipient characteristics that predict formal home care use include living arrangements and increased need for assistance with activities of daily living (ADL); individuals from smaller families and those in senior housing employ paid assistance more frequently (Yamada, 2001). Additionally, those who are older, female, or hospitalized in the past year are expected to use these services more, while more family care hours reduce the likelihood of seeking paid assistance. Numerous caregiver-related variables also prove important in predicting formal service use, including the need to rearrange work hours, provision of bladder and bowel care, and difficulties navigating outside of the home.

Recognition of cultural influences in healthcare service patterns has prompted research examining usage among diverse ethnic groups. Elderly Latinos exhibit patterns consistent with those of the mainstream American population, including higher rates of visiting nurse use, medical care use in the previous year, Medicaid eligibility, low income, and use of home health assistants and homemakers for greater ADL needs (Yamada, 2001). In a group comparison, ethnicity emerged as a major predictor of utilization — elderly Hispanics used community-based health services more, while elderly Caucasians were associated with greater homecare service utilization (Young et al., 2002). Elderly African-Americans showed a greater preference for home health care compared to elderly Caucasians, which influenced discharge disposition patterns following acute hospitalization.

The decision to use formal services involves complex, multifactorial decision-making that unfolds over time. King, Collins, Given, and Stommel (1991) identified reasons why people do not use formal services, including: an obligation to provide total care; a preference for informal rather than formal patient support; cultural expectations; dislike of relinquishing control of one's home and family member to strangers; and concerns about community service quality. An instrument developed to measure attitudes toward formal community services encompassed five subscales: faith in the health service system; concern for others' opinions; acceptance of government services; faith in the caregiver's independence; and desire to continue informal care. The last of these proved the greatest predictor of service usage.

Attitudes Toward Long-Term Care Services

Since people with similar health and functional needs may be served in diverse settings, attitudes and feelings toward services likely constitute an additional factor in the decision-making process beyond situational caregiving characteristics. As applied in the theory of reasoned action, attitudes are variables related to salient beliefs a person holds regarding an action, which may result from direct experience, inference, or information received from others (AARP, 1984). Rural elderly individuals hold different attitudes toward health services compared to their urban counterparts, and these differences influence usage patterns. A large-scale AARP survey conducted in 1984 found that 80% of members preferred care at home over care in nursing homes (AARP, 1984). Three general observations emerged: elderly individuals prefer to avoid nursing home services if possible; they do not wish to disrupt their relatives' lives despite relatives being willing to help and considering it their duty; and they are willing to accept public assistance for paying long-term care bills (AARP, 1984). Nevertheless, little is known about ethnic subpopulations' attitudes toward individual program characteristics among different community long-term care options.

In 1993, the Nikkei Long-Term Care (LTC) initiative began examining healthy elderly Japanese-Americans' views toward long-term medical and social care (Ajzen & Fishbein, 1980). This study confirmed their willingness to consider home care as well as nursing homes, especially services offered within their own community. Over the preceding 25 years, local Nikkei had delivered formal services to their elderly members — including assisted living, meals, nursing home care, and adult daycare — and with voluntary community support within community boundaries, these services came to be seen as an extension of the family caregiving tradition rather than a departure from it (Ajzen & Fishbein, 1980). In addition to assessing longitudinal data on caregiver characteristics and cognitive and functional status, attitudes and preferences with regard to long-term care were assessed using Fishbein and Ajzen's (1980) model for understanding social behavior. The Nikkei study aimed to supplement existing quantitative data and explore in depth people's attitudes and preferences with regard to specific services in individual communities.

Service Needs for Foreign-Born Caregivers and Care Recipients

The absence of culturally sensitive and applicable services constitutes a significant barrier, particularly for foreign-born or immigrant care recipients and providers. Every year, new waves of immigrants arrive in the United States (Sato, 2015), and this group typically struggles with adapting to a new culture (McLaughlin, 2002). Specifically, foreign-born immigrants — regarded as the first generation of a particular lineage — tend to maintain their native culture's traditions, values, and beliefs even after migrating to America. For example, the Issei, or first-generation Japanese immigrants to America, typically followed their own ethnic practices rather than adopting Western ones. The Issei, particularly those on the U.S. mainland, commonly face linguistic barriers when seeking social services or information.

In response, Issei-focused nursing facilities and community long-term social and health care services were developed in the 1960s and 1970s in San Francisco, Seattle, and Los Angeles to cater to their needs (Keiro Senior HealthCare, n.d.). Second-generation Japanese-Americans and succeeding generations may have different needs from their predecessors, as they are more likely to reflect mainstream American culture. This applies to other ethnic and racial minority groups as well. Because most research on service utilization has been conducted in English, immigrant care recipients and providers face linguistic barriers that complicate the research landscape, and relatively little is known about their specific needs (Keiro Senior HealthCare, n.d.).

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