Introduction

Successful aging research offers a paradigm from which to understand the components and predictors of health in later life. Findings can be used to inform aging policy and support services targeted at elders. Better understanding of the values and contexts that inform elders’ definitions of successful aging can be used to inform clinical care and preventive programs in more meaningful ways (Ng et al. 2009).

A range of definitions for successful aging can be found in the literature but, in a broad sense, it refers to the factors that promote a healthier old age (Bowling and Dieppe 2005). Phelan and Larson (2002) conducted a review of over four decades of successful aging literature in order to summarize the varying definitions that have been proposed by researchers. Out of the 11 seminal studies identified, the definition of successful aging included seven major elements: 1) life satisfaction, 2) longevity, 3) freedom from disability, 4) mastery/growth, 5) active engagement with life, 6) high/independent functioning, and 7) positive adaptation. These seven major domains illustrate an individual-centered approach to the definition of successful aging. Notably missing are domains that embody psychological health and the importance of interpersonal relationships. In a follow-up survey, the authors assessed older adults’ opinions of the successful aging definitions found in the literature and reported that only about two-thirds of the attributes deemed as important by researchers were ranked as important by older adults signaling a discrepancy between the researcher and individual perceptions (Phelan et al. 2004).

In a literature review citing 170 papers on the topic, Bowling and Dieppe (2005) found that the main themes which emerged from the successful aging literature reflected mainly psychosocial or biomedical approaches. The MacArthur funded studies of successful aging, out of which Rowe and Kahn’s (1987) model was developed, are the most well-known and cited. This approach to successful aging emphasizes the absence of disease and factors contributing to disease as a predictor of successful aging. Rowe and Kahn’s model is based on a functionally-oriented biomedical model and emphasizes three main principles: 1) the maintenance of high levels of physical and mental functioning, 2) the absence of disease and disability and factors leading to disease and disability, and 3) positive involvements with other people.

The focus on the biomedical processes of successful aging has been criticized for being parochial in its definition (Scheidt et al. 1999). Some researchers have expanded the biomedical model to incorporate other dimensions of health. Bowling and Iliffe (2006) found that a model which incorporates dimensions of biomedicine, social functioning, and psychological resources more strongly predicted self-rated quality of life than did models which were one-dimensional. The role of spirituality in influencing perceptions of successful aging has been highlighted (Iwamasa and Iwasaki 2011; McCann Mortimer et al. 2008). Cho et al. (2012) found that the oldest-old (age 80 and older) were more likely to satisfy the definitions for successful aging based on criteria focused on psychosocial domains including subjective health, perceived economic status, and happiness. Other studies focused on the significance of self-rated functioning as opposed to objective measures of health and functioning (Pruchno et al. 2010; Vahia et al. 2011).

The study of successful aging has expanded over the years, building upon the work of researchers from multiple disciplines. However, there remains a need for more research among minority elderly populations to address the needs of specific groups (Dillaway and Byrnes 2009; Lewis 2010). Studies from diverse Asian ethnic population groups are particularly lacking. Because the concept of successful aging is value-laden, findings generated from other racial and ethnic groups may not be culturally appropriate or generalizable to Asian groups. Asian populations are culturally heterogeneous and different subgroups may approach successful aging in different ways. In addition, immigrant elders may express different values from those who live in their country of nativity as they face unique issues related to cultural differences between normative practices of elder care in the U.S. versus the traditions from their native homeland. For example, Zimmer and Lin (1996) found that participation in leisurely activities had a negative impact on the emotional well-being of elderly Taiwanese women and not a positive impact as expected. This suggests that enrichment activities developed in western cultures may operate within paradigms that are not applicable across cultures. Since the cultural environment has an influence on the way in which people approach aging, there is value for exploration of the topic of successful aging as it applies to Asian elders living in the United States.

Current Research on Successful Aging in Chinese and Hmong Populations

To date, no studies have explored Hmong successful aging but empirical studies on successful aging in Chinese elders provide information applicable to that population. Ng et al. (2009) conducted a cross-sectional survey on Chinese elders living in Singapore using a composite score for successful aging based on overall and physical health, functioning, cognition, emotional well-being, social functioning, life engagement, and life satisfaction. They found education, better housing, social network and support, spirituality, and nutrition to be salient factors associated with successful aging. A study using a similar definition of successful aging in a community-based sample of Chinese elders in Shanghai, China found gender, age, marital status, and engagement in leisurely activities to be associated with successful aging (Li et al. 2006). Using a confirmatory factor analysis, Ng et al. (2011) found caring and productive forms of engagement to be better predictors than illness avoidance and functioning of successful aging. These studies include multi-dimensional constructs of successful aging in their definitions but are limited in that there is no consensus on how to operationalize the term (Ng et al. 2009).

Traditional East Asian cultural constructs, such as filial piety, are not well delineated in current definitions of successful aging. Filial piety refers to the obligation of younger generations to provide for and honor their elders. This tradition stems from Confucian belief systems and has been embedded in the Chinese cultural framework for centuries. The concept of filial piety guides the rules of interpersonal relationships between generations. Chinese perspectives on aging are still being influenced by traditional values though traditions are on the decline with younger generations (Mjelde-Mossey et al. 2009). For older Chinese, satisfaction with family relations is associated with higher self-rated health as well as lower rates of depression (Mjelde-Mossey et al. 2009). Among Hong Kong Chinese elders, those with greater interdependence on family members had greater levels of self-esteem (Leung et al. 2005). Leung et al. (2005) also found that optimism, self-esteem, and relationship harmony predicted satisfaction with life.

Though studies have been generated from Chinese populations living in Asian countries, these findings may be of limited relevance to Chinese Americans. Asian Americans may hold different values due to exposure and acculturation to American values and social norms (Phinney et al. 2000). A study conducted in Australia found that Chinese Australians and Anglo Australians hold similar values toward aging such as the importance of maintaining good physical and mental health (Tan et al. 2010). The authors note that Chinese Australians’ preference to be financially independent from their children differs from the traditional aspects of filial piety in which children acquire financial responsibility for their aging parents. In a similar cross-cultural comparison of successful aging between Japanese and Japanese Americans, Matsubayashi et al. (2006) found Japanese Americans rather than Japanese elders to be more concordant with White American definitions of successful aging. They suggest that Japanese Americans may be acculturated to western values.

The purpose of this study was to elicit the definitions of successful aging according to Chinese and Hmong elders living in a Midwestern city in the United States. This study aimed to address the aforementioned gaps in gerontological research and inform the design of geriatric service provision by exploring the specific needs of Asian American elders. The knowledge generated from this study can help service providers understand elder issues and concerns beyond generalized or stereotypical notions. As such, this study aimed to deliver translational value by providing culturally relevant information to the delivery of support services for older adults, such as those found in community senior centers, geriatric clinics, assisted living facilities, and local departments on aging.

Methods

In order to discover the definitions through the language of the participants themselves, we used qualitative methods for exploratory inquiry. Specifically, Chinese and Hmong elders residing in Milwaukee, Wisconsin were recruited for one-on-one semi-structured interviews.

The interview method is a research tool that allows for the elucidation of values and meaning through in-depth probes to explore personal explanations to phenomenon and allows participants to share their perspectives in their own words (Patton 2002). Interview questions were loosely structured to allow participants the freedom to guide their narratives in a way that makes sense to them. Giving a personal narrative allows the participant to reveal their worldview and construction of reality by telling their story and defining terms in their own words (Kaufman 1986). Narrative inquiry has been used to explore self-constructions and reflections on the aging identity (Dossa 1999; Moore 2010; Terrill and Gullifer 2010). All research activities were approved by the Medical College of Wisconsin Institutional Review Board.

Study Population

The Chinese and Hmong represent two historical patterns of immigration in the U.S. While the Chinese have had a long presence in the U.S., the Hmong are relatively new arrivals, with the majority of immigrants arriving at the end of the Vietnam War. According to the 2010 US Census (www.census.gov) there are roughly 3.8 million Chinese Americans, comprising the largest Asian subgroup in the U.S. It is estimated that there are 260,000 Hmong Americans with the majority residing in California and the Midwestern states of Minnesota, Wisconsin, and Michigan (Pfeifer et al. 2012).

Milwaukee, the recruitment site for this study, is the largest county by population in the state of Wisconsin. Data from the 2010 U.S. Census show that Milwaukee metro has an overall population size of about 948,000 people and over 32,000 people identified as Asian. Among those who identified as Asian, roughly 10 % were Chinese and 37 % were Hmong. However, Hmong are likely undercounted in the U.S. Census due to language and cultural barriers (Pfeifer et al. 2012).

Inclusion/Exclusion Criteria

In order to participate in this study, elders had to 1) self-identify as Hmong or Chinese, 2) be able to communicate verbally in English, Cantonese, or Hmong, 3) be age 60 or over, and 4) show no signs of cognitive impairment. Cognitive screening was included at the recommendation of research colleagues who work with older adults. Because upper age limits were not placed on the inclusion criteria, cognitive screening ensured that participants were cognitively able to answer complex questions at length and consistently. Cognitive impairment was assessed using a six-item screener (Callahan et al. 2002).

The screener was designed with the intent of providing researchers with a brief, validated, tool that is easy to administer and score. For this study, it was also necessary to obtain an instrument that was easy to translate to Hmong and Cantonese. The questions in the screener include a three-object recall (apple, table, penny) and three-item temporal orientation (day of the week, month, year). The screener has been shown to be have 83.8 % diagnostic accuracy for Alzheimer’s Disease in a Chinese population (Chen et al. 2010). A resource sheet with a list of dementia diagnostic clinics in the region was prepared to be given to the elder if the need arose. However, no one was excluded due to cognitive impairment.

Participant Recruitment

Targeted recruitment was employed in order to gain sufficient sample sizes for meaningful subgroup analyses. Snowball sampling was also employed. Recruitment was performed mainly through referrals from community partners. Chinese participants were recruited primarily from a local Chinese senior center and through the network of a local Chinese organization. Recruitment in the Hmong community was facilitated by local Hmong leaders through their extensive network. Our sample size is consistent with recommendations for this type of methodological assessment (Morse 1994), and facilitated meaningful between group differences across our two ethnic groups. Participants were not compensated for participation but snacks and tea were provided at the time of interview.

Data Collection

Face-to-face sessions were scheduled at a location chosen by the elders, including coffee shops, homes, and a private room in the Chinese senior center. English consent forms, and translated Chinese and Hmong consents, were available. Permission was obtained prior to audiorecording. Only two participants (1 Hmong 1 Chinese) declined to be recorded and notes were taken by hand for those interviews. All interviews were conducted by the primary author, who is bilingual in Cantonese and English, under the supervision of her co-author, who has considerable expertise in qualitative methods. All but one interview with Hmong elders were conducted with the help of one of three community partners who served as an interpreter. The community partners involved on this project were all native Hmong speakers who have worked formally as interpreters. All Chinese participants chose to complete the interview in English. Some only spoke English while some were bilingual in a Chinese dialect other than Cantonese. Some Cantonese speakers only used Cantonese to describe specific words, concepts, or phrases that do not translate well into English. The high level of English fluency in this sample may be an indication that this was a highly acculturated group. This issue is addressed further in the “Discussion” section.

After consent was obtained and before the interview started, demographic data (i.e., gender, ethnicity, age, education, religious affiliation, marital status, household size, country of nativity, length of time living in the U.S.) were collected using a standardized form. Self-reported health status and life satisfaction using the Satisfaction with Life scale (Diener et al. 1985) were also collected. Subjective health status and life satisfaction have been used as quantitative measures of successful aging in other studies on Chinese elders (Li et al. 2006; Ng et al. 2009). These two variables are included in this study in order to identify variations in responses between the Hmong and Chinese samples and assess the comparability of the two groups.

The Satisfaction with Life scale is a five-item instrument designed to measure the judgmental or cognitive component of subjective well-being and has been validated against the Life Satisfaction Index-A and the Philadelphia Geriatric Center Morale Scale (rs of 0.82 and 0.65) (Pavot et al. 1991). High internal consistency and strong partial invariance across groups has also been shown in a community sample of Chinese participants (Bai et al. 2011). Questions assess the respondent’s level of agreement with statements such as “I am satisfied with my life” and “In most ways my life is close to my ideal”. Responses fall within a seven-point scale ranging from “extremely dissatisfied” to “extremely satisfied.” Self-reported health status is a one-item measure that asks respondents to rank their health as “poor”, “fair”, “good”, “very good”, or “excellent”. Similar to the cognitive screener, these measures were chosen in close consultation with community partners to ensure that words and concepts would be translatable to Hmong and Cantonese.

The primary goal of the qualitative interview was to allow elders, through their own words, to give an oral account of the things they view as important to their aging process. Participants were asked to share their views on what it means to be healthy in old age using prompts such as “describe someone you know who you consider to be aging well.” Participants were also asked to talk about what it means to be happy in old age using prompts such as “describe some things or people who make you happy.”

Data Analyses

Descriptive statistics of demographic variables were conducted using Statistical Analysis Software (SAS). Bivariate analyses of demographic variables were also performed to determine homogeneity of the sample. For continuous variables (i.e., age, years in the US, years of education, and household size), Wilcoxon signed rank sum test, a non-parametric variation of the t-test, was used. Chi-squared tests were performed on categorical variables (i.e. sex, marital status, religion, country of birth, self-reported health status).

Password-protected Atlas.Ti software (v6, 2009) was used for management and analyses of interview data. Interview transcripts were analyzed using the principles of grounded theory analysis (Corbin and Strauss 1990; Strauss and Corbin 1994) whereby the code book is not created a priori but rather, through a process of analyzing the transcripts for emergent themes. First, several transcripts were examined by the primary author to identify primary coding categories. Open coding was used to capture the range of themes present within each category. The list of extracted themes was then discussed with the second author to ensure concordance with the information presented in the transcripts. All identified coding categories and themes were organized into a formal code book through a process of relating codes to one another called axial coding. Illustrative quotes relevant to these themes were extracted. Next, all transcripts were formally content coded using the emergent coding scheme. When suggested by associations, overlap, or diversions in the data, thematic categories were refined, merged, or subdivided. For example, the theme “absence of illness” under the category “physical fitness” was subdivided into two codes, “absence of major illness” and “absence of everyday aches and pains” when it became apparent that these were two distinct concepts. All modifications to the codebook were discussed by both authors.

Results

Participant Characteristics

A total of 44 elders (23 Chinese and 21 Hmong; 17 males and 27 females) were interviewed for this study. Continuous demographic variables are presented in Table 1. The average age for both groups was about 71 years old with a range of 60–100 years for Chinese elders and 61–95 years for Hmong elders. All Hmong elders emigrated from Laos while the Chinese cohort represented a mix of immigrants mostly from China or Hong Kong as well as those who were born in the U.S. The average number of years living in the U.S. was 53.2 years for the Chinese cohort and 26.9 years for the Hmong cohort. Hmong elders lived in households of larger sizes (5.7) than Chinese elders (1.9).

Table 1 Participant demographics: continuous variables (N = 44)
Full size table

Categorical demographic variables are presented in Table 2. The majority of Chinese elders were married while the majority of Hmong elders were separated, divorced, or widowed. About half of Hmong elders practiced traditional Shamanism while half practiced Christianity or Catholicism. The majority of Chinese elders practiced Christianity or Catholicism (65 %) with the rest reporting Buddhism, Daoism/Confucianism or none for religious practice. Over 75 % of Chinese elders reported their health status to be “excellent” or “very good” compared to 20 % of Hmong elders. Seventy percent of Hmong elders reported their health to be “good” or “fair.” Both groups scored on the higher end of the Satisfaction with Life Scale. None of the responses from the Chinese cohort fell below “slightly satisfied” with about 48 % scoring as “extremely satisfied.” Hmong responses covered the spectrum but over 65 % fell between “slightly satisfied” to “extremely satisfied.”

Table 2 Participant demographics: categorical variables (N = 44)
Full size table

Tests of homogeneity reveal variation in the demographic characteristics between the Chinese and Hmong cohorts. Therefore, results of the content analysis are presented below by ethnic group in order to allow the comparison of similarities and differences between the two groups.

Chinese Elders

Domain 1: Health and Wellness

The majority of all elders were able to articulate a response when asked to describe what they thought it meant to age well and to be healthy in old age reflecting an understanding of these concepts. However, some younger elders (under 65 years old) stated that healthy aging is not something they had thought about because they did not consider themselves as being old.

Physical Health and Mobility

Not becoming sedentary and having good physical health, strength, and energy were considered an important key part of successful aging. For many, the absence of diseases and illness was important only in terms of the absence of major debilitating illnesses, such as blindness or total loss of hearing, which would significantly impede upon their mobility and ability to interact with others. Most elders felt that the key to maintaining physical wellness was to take steps to prevent serious health problems like stroke or serious falls that would require a lengthy hospitalization and recovery. Most elders said that it was unrealistic to expect a total absence of any disease or other physical ailment. As such, muscle aches and joint pains and additional, for some, chronic diseases like diabetes and hypertension were seen as a normal part of old age:

I know as you’re older you always have ache and pain but you don’t have major illness. That’s good. Lots of people say they want perfect health but what’s the definition of perfect? (Chinese male, age 77)

Good mobility for some younger elders included participating in physical activities, such as going on hikes and enjoying the outdoors. Older elders emphasized daily self-care abilities, such as feeding oneself and going to the bathroom without assistance. Having mobility and being able to perform self-care activities allowed elders to maintain a sense of independence. Even for those who needed assistance from a wheelchair or walker for mobility, not being bed-bound gave them a sense of independence:

I don’t want to be dependent on people. I’m so independent and if I have to depend on anybody that would be the end of me…If you can’t take care of yourself. I see people having to have someone feed them and bathe them and all that. That’s like a vegetable, I think. (Chinese female, 90+)

Some elders wished to remain mobile and self-sufficient in order to continue the lifestyle that they were accustomed to in middle age and many wished to remain self-sufficient to avoid becoming a burden on society or family members. US-born as well as foreign-born Chinese elders described not wanting to live with their children even if their health failed. A few indicated that they would rather hire a home health worker or move into a nursing home facility than burden their children with caring for their needs.

Mental Health

None of the elders spoke about mental wellness in terms of psychological disorders or illness. They indicated that mental wellness meant remaining alert, retaining mental acuity, and having decent memory. Many said that they feared Alzheimer’s disease and feared losing awareness of surroundings and the ability to carry on meaningful conversations with others. Some elders also said that they wanted to be able to keep exercising knowledge and to keep their brain active and engaged.

Positive Attitudes

Outside of physical and mental wellness, many elders spoke about successful aging in terms of the philosophies and outlook toward life that one ought to have developed by the time one reaches an older age. Many echoed the sentiment expressed in this quote: “Feel at peace with your age and your condition that you’re in, whatever your condition may be.” (Chinese male, age 73). Many spoke of having gratitude for life, being alive, and seeing as blessings things such as positive and supportive relationships. Many also spoke of the importance of not hanging on to “pride” and being able to “let go” and accept certain physical limitations and changes in the physical body:

Even as I was showering the other day I was thinking, ok, there are two more rolls and I have always been really spry and slender. I don’t consider myself spry and slender now. Just a few too many loose skin here and it’s not because I had 5 kids and it’s not because I don’t do Pilates and all that. It’s just because that’s the way the body ages. (Chinese female, age 66)

Maintaining a positive attitude was a way for some elders to get past grievances and stressful matters that may cause anger or sadness:

Whatever is dealt to me is dealt to me. I handle it the best I can. There’s no sense in getting real depressed. I mean there are people I think that would get real depressed and let it bother them but that’s why some people think like they do. They think- why go on if it’s going to be like this it’s such a hardship. There’s never anything that you can’t handle. (Chinese female, age 76)

Some elders were defiant toward aging suggesting that it was important to maintain youthful thinking. This meant not acting like an “old and senile” person, not thinking of oneself as an “old man,” and still being able to engage in sports with younger people. This sentiment only emerged among younger elders (<70 years old).

Domain 2: Happiness in Old Age

Elders were asked to speak about happiness in old age in order to explore the concept of life satisfaction within the context of aging. For many, the ideas of health and happiness were related because it is difficult to have one without the other. Chinese elders emphasized personal satisfaction and individual factors of happiness.

Shedding Responsibilities

Many Chinese elders expressed that one of the benefits of old age was having the freedom to pursue finally the things that they really wanted to do. For many, reaching old age meant shedding the roles and responsibilities of middle age and was a time of reward for enduring the sacrifices and hard work they endured earlier in life. This meant they no longer needed to provide for their children, could retire from employment, and even earned the right to opt out of certain social expectations or etiquette, such as being overly polite. One woman said, “The nicest thing about retirement is I can pick and choose and I don’t have to give people a reason. I can just say I’m not available and that’s it… Socially we tend to think we have to give somebody a reason.” (Chinese female, age 66). However, at her current stage in life, she no longer felt she had to justify her decisions to other people.

For both men and women, not having to answer to someone else, such as a boss or supervisor, and not having to answer to the clock were examples of having freedom in old age. Particularly for women, reaching old age also meant no longer having to put the needs of their children and their husband before their own needs and not having to “wait on anybody.” This shedding of responsibilities allowed them to have more time to themselves:

I’m really enjoying my freedom right now. I can do what I want, sleep when I want to, however late I want to, eat whenever I want to and also, I don’t have to please anybody… I’ve been pleasing people all my life and I don’t have to do that anymore in my senior years. (Chinese female, age 90+)

One of the consequences of shedding the responsibilities of middle age was having more time for leisurely activities such as traveling, going on cruises or other outings with friends, going to the movies, bowling, or working on home improvement projects.

Positive Family Relationships

Elders spoke of the desire to be loved by family members and that there needed to be harmony and respect amongst all members of the family. For Chinese elders, having disrespectful children was seen as a source of unhappiness because being surrounded by loving children and grandchildren was a sign of prosperity. They also spoke about the importance of having reliable and dependable children so that if “something comes up, they’re just there.” (Chinese female, age 83). Children were a source of parental pride and elders were proud to see their children in happy marriages, loving relationships, and successful professions.

Chinese elders appreciated keeping in constant contact with their children and grandchildren but most preferred not to live with their children. As one elder said, “Parents always want to see their children…but not in the same house.” (Chinese female, age 67). Another said, “The parents’ job is just to launch their kids. Like a kite. Once they can be free, just let them go.” (Chinese female, age 63). While they enjoyed having a good relationship with their children, elders also enjoyed their privacy. They did not want to interfere with their children’s lives but also did not want their children to interfere with their lives. One elder called the idea of multiple generations under one roof as “the old way of thinking.” (Chinese female, 90+). Many of the Chinese elders interviewed have children who live in different states and a few said that it gave them an excuse to travel. Some said that if they were to live with their children, they would have to move out of Wisconsin and that it was not something they were willing to do. Two quotes illustrate Chinese elders’ view on this topic:

I definitely do not want them to live with me. They have different habits and different routines…. I like to see them but I don’t want to live with them. No way. I have my own interests and own routine and…they can interrupt my routine. (Chinese male, age 69)

I read a study saying and I agree with that, a 300 mile separation between yourself and your daughters or son, that is an ideal distance…I think when it’s too close you may burden them or they may burden you. Let’s say automatically, you may be end up babysitting more often then you like. (Chinese male, age 64)

Only two Chinese participants in this study resided with their children and in both cases, the children were not married. Both elders expressed enjoyment over their current living situation but said that their children were not obligated to live with them.

Financial Stability, Social Engagement, Religious Faith

While the possession of material things was not a priority in old age, having financial security was important. Participants said it was important to be able to afford the things that they wanted and to be comfortable without having to worry about failing to meet expenses. Being socially engaged by having companionship outside of family members and spouses was cited as an important component of being happy in old age. Having friends with whom to share activities such as meals, social visits, and outings helped to ward off feelings of boredom or loneliness. Being able to have meaningful conversations with friends was cited as something that kept life stimulating.

Having religious faith provided some Chinese elders with a sense of security and hope. For some, belief in a greater power helped them to forget about their stresses and worries. A few said that faith becomes a more important part of happiness as a person gets older because faith can provide a sense of security that “there’s somebody out there, to watch over me.” (Chinese female, age 69).

Accomplishments and Volunteer Work

Accomplishments outside of raising “good” and “obedient” children referred to completing an aim or goal, no matter how simple or complex (e.g. cooking a specific dish, completing a photo book, home video project). Accomplishments also referred to reflecting on the past and feeling a sense of pride over their life achievements because they followed desires without regrets and reached career goals. For some, engaging in volunteer work created a feeling of accomplishment in old age. Elders referred to volunteer work as a way to help others and to give back, as something that was rewarding and uplifting, and which gave them a positive outlook and sense of belonging. A few elders also said that they felt “lucky” in life and that volunteering to help others was a way of “sharing.”

Hmong Elders

Domain 1: Health and Wellness

The majority of Hmong elders were also able to articulate a response when asked to describe what they thought it meant to be healthy in old age. However, a few Hmong elders were unable to conceptualize the idea of being healthy in old age because the prevalence of sickness and disability was so high among their peer group that they are unable to describe a healthy older person.

Physical Health and Mobility

Hmong elders were also concerned about having good physical health, strength, and energy. Many also said that having some form of chronic illness was a natural part of getting older. For conditions such as diabetes or hypertension, maintaining glucose and blood pressure values within normal values through things such as diet and lifestyle modification, medication, and doctor visits was an important part of maintaining a sense of wellness. For Hmong elders, being at a healthy weight meant not being underweight. Particularly for women, there were concerns about becoming too thin. Some recently widowed elders said that the grief of losing a partner had caused them to lose weight and that gaining weight was something they were trying to do in order to regain strength and energy.

Good mobility and maintaining physical independence were also important to Hmong elders. Like the oldest Chinese elders, Hmong elders also said that performing self-care activities without assistance was a way to maintain a sense of independence:

When I think about other people who are my age, most of them are probably in bed. They can’t even move around but I am still able to move around so I think that’s a good thing. I am very thankful I can still move around, that nobody has to give me bedpans. I can use the bathroom by myself, on my own. (Hmong female, age 90+)

Hmong elders wanted to remain mobile self-sufficient in order to avoid becoming a burden on their family members but Hmong elders still expected to reside in the same household as their children and other kin.

Mental Health

Hmong elders also did not speak of mental health in terms of psychological disorders or illness. Hmong elders wanted to remain alert, have good memory, and maintain the ability to interact meaningfully with the people around them.

Harmonious Relationships

Having harmonious family relationships was particularly important for Hmong elders. Elders felt that being and feeling loved was an important part of healthy aging. For some, this may be the most important part of health:

I want to say that no matter how much money you have, it will eventually be used up. But as a human being, if you have love then it makes you happy then that is more than what money can buy. It’s better than having a jar full of wealth. (Hmong female, age 67).

Another elder stated that, “If there isn’t anyone to say nice things to you, then you won’t have good health.” (Hmong female, age 74).

Domain 2: Happiness in Old Age

The idea of happiness being akin to healthiness was extremely salient across the narratives though the sources of happiness differed between Hmong and Chinese elders. Hmong elders placed more emphasis on interpersonal relationships and family dynamics as opposed to individual factors. The few Hmong elders who described having poor family relationships often stated that there was nothing to be happy about in old age with statements such as, “None of my family can make me happy so I am just waiting for the time for God to call me to go home.” (Hmong male, age 78). Another said, “There’s not anything at all in this lifetime that will make me happy at all. Because I have to live, I live day by day, but there is nothing at all.” (Hmong female, age 74). Having poor family relationships was a source of emotional distress for these elders.

Positive Family Relationships

Hmong elders said that in general, having children as opposed to being childless was a source of happiness in old age. Particularly for those who have lost a spouse or have separated from a spouse, having children and grandchildren was important because, “They’re all that’s left.” (Hmong female, age 74). Elders said that it would be lonely without their children because it meant having no one with whom to share life’s joys and sorrows. They said that children should show love and respect for their parents in a variety of different ways but the most frequently mentioned act was visiting or calling parents on a consistent basis and without prompting.

Many spoke about the importance of having loving relationships with brothers and sisters and even extended relatives such as cousins or members of their clan. Referring to the importance of being invited to extended family gatherings, one elder stated:

When they have a party, they have a feast, a get together, they call me. And they call me and that makes me happy because [it means] they still count you in, they still respect you, they still invite you. That makes me happy. If they have something, an event, they don’t invite you anymore then that makes you depressed. (Hmong female, age 90+)

Only Hmong women spoke of the ways in which a good partnership in marriage and good spousal relationships could be a source of happiness. One woman said that having a reliable husband who “stays with you” (Hmong female, age 66) is a positive thing. It was important to women that their husbands don’t “start looking for trouble or create problems for the relationship so that both can have a strong and healthy relationship.” (Hmong female, age 67).

One method cited by Hmong elders as a strategy for maintaining harmony between the generations in order to avoid conflicts was to maintain balance in responsibilities between family members. Though it was seen as parental responsibility to teach children to respect their elders, some elders relented that there are times when they ought to relinquish control and decision-making to their adult children because they are more formally educated:

Right now the role is reverse… when the educated come back and say something and you listen to them. Then they understand that even though you are older but you still lower your status to listen to them… in our times we learn from the elders and we didn’t have formal education. But for them, they have formal training so we have to validate their education and respect them too. (Hmong female, age 68)

This elder’s statement highlights the ways that immigration has shifted the hierarchical ordering and structure of the household. In Laos, where completing formal education may not have been the norm, it was important for younger generations to learn from the knowledge of elders. However, in the United States, Hmong children may be more formally educated than their parents. This elder spoke of willingly lowering her “status,” indicating a conscious negotiation of rank for the sake of harmony.

Tangible Support from Family Members

Hmong elders expected their children to provide tangible forms of support. Some elders desired daily help with buying groceries, paying bills, and household chores. For many Hmong elders, relying on their children helped to alleviate daily financial stresses. For others, the reliance was crucial because limited English skills and lack of transportation created barriers to activities such as grocery shopping.

Hmong elders preferred to live with their children. For Hmong elders, this was true even if they were physically able to live independently. Living in the same household facilitated ease of care provision and children could “step in and care for” elders when they lose the ability to care for themselves. Hmong elders also expected younger members of the family to take up responsibility for their care should the need arise:

As I age, if I should have limitations, the children should care for my needs. Yes, it is important that kids live with their parents do that as they age and have some loss of abilities, the kids can step in and care for them. (Hmong male, age 64)

Elders would be able to transfer the responsibilities of housework to their children and grandchildren. One elder said, “When the time comes and we are unable to do household chores, then it is not our responsibility, so it is the children’s responsibility to do it.” (Hmong female, age 67).

Some elders indicated that they did not have the financial means to live alone. Additionally, a few elders spoke positively of the reciprocal help that is possible when multiple generations live under one roof:

Both my son and daughter-in-law have to go to work so they have to pay a babysitter and that’s not fair… They did not ask us [to provide childcare]. This is our choice and we help them because they are our son and daughter-in-law. Let’s say we do not help them then one of the person’s salary goes toward babysitting and that is not good. (Hmong male, age 67)

Financial Stability, Social Engagement, Religious Faith

Having stable finances was an important component of aging for Hmong elders. Having the financial means to travel to Laos was important. While some elders spoke about the desire to have the financial freedom to travel, most focused on the desire to have stable monthly finances in order to support expenses like food and rent.

Many elders stated that engaging socially with others provided them with an outlet for stressful emotions. One elder stated, “You get to express your frustrations and you talk to people and you forget about your own frustrations.” (Hmong male, age 74). Another said:

I’m not sure if other people have stress like I do but to be around others my age and to see how they are doing, to see that they have more health issues and it makes me think of the negatives and the positives in my life. (Hmong female, age 64)

For some Hmong elders, social engagement and companionship with family and clan members was preferable to companionships with those outside of the clan or family. Most elders also expressed preference for engaging with others their age as opposed to younger people.

Religious faith was only mentioned in Hmong elders who identified as a Christian or Catholic. Mainly, the practice of attending church on a weekly basis was something that allowed some elders to feel hopeful despite adversities.

Discussion

Cross-cultural comparisons between findings from Chinese and Hmong elders highlight the similarities as well as differences between the two groups and offer insight into the unique cultural perspectives that contribute to the culturally heterogeneity between these two groups. Good physical and mental wellness were important components of successful aging for Chinese and Hmong elders but none of the elders interviewed expected to experience a complete absence of disease or illness. Many participants acknowledged that physical limitations and the presence of some chronic diseases are a reality of the aging body. Moreover, some elders stated that self-perceived poor aging was sometimes the result of having unrealistic expectations about the body and then failing to meet that ideal. Many elders reported having various forms of chronic diseases such as diabetes and hypertension or having suffered from major medical events such as heart attack or stroke. These findings suggest that lay definitions of successful aging take into account self-evaluations of health status in relation to aging-related expectations for the body and support the need to include subjective measures of health in evaluations of successful aging. Other researchers also have found subjective evaluations of health to be a significant way in which people think about successful aging (Pruchno et al. 2010; Vahia et al. 2011). Additionally, Chinese elders in this study emphasized the importance of positive attitudes, which suggests that attitudes toward aging may factor into subjective measures of successful aging.

Good management of chronic conditions gave elders a sense of control over their health status. Other physical characteristics such as mobility, strength, and energy contributed to a sense of wellness because these characteristics enabled individuals to engage in self-care activities. Having good mental capacities allowed elders to maintain the ability to engage with others and to interact with their surroundings. The prevailing narrative suggests that the absence of debilitating illnesses or other severe physical and mental limitations served as a basic requirement for elders to exercise independence and interact with the world in a meaningful way. Therefore, maintaining good physical and mental capacities were mechanisms through which elders operationalized their value for independence and meaningful engagement with others.

This has important implications for clinical practice and ancillary care for older adults. Healthcare providers should focus patient education efforts on disease management techniques to boost patient sense of control. Incorporating ancillary services such as physical therapy, occupational therapy, nutrition counseling, weight management, and diabetes education into routine health management or physical health checkups may help elders improve their self-efficacy and connect them to the resources that will increase their ability to maintain control over changes in their health status. Senior social support services might also emphasize education or counseling on lifestyle and home environment modifications to optimize functionality, dexterity, and mobility for elders who experience disabilities, decreases in muscular strength, or limitations in range of motions. On a social level, modifications to public infrastructures such as the addition of escalators, wheelchair ramps, handrails, non-slip flooring, wide doorways and passages, and adequate signage may help create public environments that are age-friendly (World Health Organization 2007) and help older adults adapt to changes in physical mobility.

For Chinese and Hmong elders, successful aging also involved spiritual well-being, and financial stability. The importance of financial security and religiosity in successful aging are supported by other studies (Iwamasa and Iwasaki 2011; McCann Mortimer et al. 2008; Ng et al. 2009) and highlight the need for social services to offer a range of options for older adults from financial planning to spiritual support. While Chinese elders wished to remain financially independent from their children, Hmong elders depended on their children for financial support and was seen as an exercise of filial piety. This suggests that services for Hmong elders should not necessarily focus on financial independence but rather on the financial health of the extended family. Findings also suggests that the faith community may play an important role in promoting health and wellness for older adults. Partnerships between faith-based communities and senior programs to address multiple domains of wellness may be effective in promoting health. Faith-based organizations can play an important role in the health promotion of older adults given the interest among leaders in the faith community (Hale and Bennett 2003). Faith-based organizations are also often uniquely positioned to reach underserved populations (Patel et al. 2013).

Chinese and Hmong elders highlighted the importance of positive family relationships and the ways in which family roles were negotiated. Disharmony in family relationships was a cause of unhappiness and poor aging for many elders. The values of group harmony, family interdependence, and filial piety were prevalent in both sets of narratives. Through the negotiation of family roles and expectations, elders navigated inter-personal relationships in a way that best expressed their interpretation of the value for family harmony. Differences in interpretations demonstrate the ways in which these values translate into real practice and behavior. All elders viewed the negotiation of living arrangements as part of negotiating family roles and expectations. However, Hmong elders expected to live in the same household as their children and expected to share household as well as financial responsibilities. Hmong elders’ heavy emphasis on the importance of having harmonious and interdependent relationships within the family reflected the family-centeredness of traditional Hmong social structures. In traditional Hmong culture, clan societies dictate social structures and the roles within them. For example, providing childcare for grandchildren was a practical way to contribute to and play a role in household duties, as well as fulfill an expected role of being a Hmong grandparent. Healthcare professionals, social workers, and others who work with Hmong older adults should maintain awareness of the cultural importance of the involvement of family and clan members in the older adults’ lives. Those who adhere to traditional relationship structures may have specific expectations for interactions between generations and between members in terms of money, support, and living arrangement.

Chinese elders interpreted their roles in ways that differed from Hmong elders. Most Chinese elders did not wish to rely on their children for financial support or care and wished to live independently from their children. These findings demonstrate a shift from traditional interpretations of filial piety in regards to the interdependent roles between parent and child to an emphasis on personal independence. Other researchers have found this shift in elders in China as well, particularly in developed, urban areas (Li et al. 2012; Mjelde-Mossey et al. 2009; Pang et al. 2003). The emphasis on personal independence and individualism was further reflected in the way Chinese elders spoke about shedding responsibilities to family members and to others in order to pursue personal desires. This deviation from traditional values may partly be a result of adaptation to available structures of support. Most of the Chinese elders in this study obtained at least a college education. Since level of education is a salient measure of socioeconomic status (Lynch and Kaplan 2000; Marmot et al. 1997), Chinese elders were likely to be in the higher end of the socioeconomic gradient. Chinese elders with greater access to financial resources may prefer paid structures of support (e.g. home aide, assisted living, etc.) as a solution to retain independence to reliance on filial support. Because Chinese Americans have a diverse immigration history, professionals who work with Chinese older adults should consider the ways in which length of time living in the U.S. may affect adherence to traditional cultural values.

Limitations

This was an exploratory study and the results are a starting point from which to investigate successful aging among different Asian populations, particularly Hmong elders as little has been explored from their perspective. The themes and patterns presented in the results should be interpreted with care as they may not be generalizable to Chinese and Hmong elders living in very different social or environmental contexts, for example, large ethnic enclaves like Chinatowns where social norms and adherence to traditional values may be preserved in different ways. Furthermore, results may not be generalizable to Chinese and Hmong elders living in different geographical regions as regional effects may account for some of the findings including the role of acculturation in Chinese elders. Although acculturation was not formally measured, the long average length of time living in the US and strong English language proficiency of Chinese elders point to high levels of acculturation. Acculturation may account for some the shift away from traditional values for Chinese elders. Future studies should delineate the role of acculturation in influencing aging narratives. However, these findings are still relevant to Chinese and Hmong older adults living outside of ethnic enclaves in the Midwest. Outside of ethnic enclaves, minority populations may be harder to reach and this study demonstrates the value of partnering with local community leaders in order to discover the specific needs of minority elderly populations.

Differences in narratives between Chinese and Hmong elders may reflect demographic differences in addition to cultural differences. For example, Chinese elders’ preference for living independently may reflect not only a cultural shift from traditional values but also their financial ability to live alone. Further investigation should examine the role of socioeconomic status in attitudes toward successful aging and ways in which it interacts with culture. Finally, the Satisfaction with Life Scale and the six-item screener have not been validated within Hmong samples. This study relied on several interpreters to translate the instruments and interview questions. Therefore, there may be subtle individual interpreter differences in translation of words and concepts.

Conclusion

Despite the limitations, our data collected from the subjective narrative perspective of Hmong and Chinese elders support a broader conceptualization of successful aging and present unique cultural perspectives relevant to these two groups. This study contributes to the scholarly conversation around the construction of successful aging. There are unique meaningful cultural perspectives that shape Chinese and Hmong individual’s expectations for successful aging. Although it is important to consider the influence of cultural values in shaping individual expectations for successful aging, individual adherence to cultural values can shift because of adaptations to changing life circumstances and immigration experiences. Further work needs to explore the role of socioeconomic status and acculturation in influencing definitions of successful aging. Caution needs to be taken to avoid generalizing culture-specific values broadly across ethnic or cultural cohorts given the heterogeneity across ethnic groups as well as within ethnic groups themselves. Professionals who work with older adults can use findings from this study to inform the development of programs and policies designed to promote the health, well-being, and successful aging for Chinese or Hmong older adults by taking into account the cultural and normative practices of Chinese and Hmong elders and their families.