Filial piety expectations and loneliness among older people in Kuantan, Pahang

Background: Filial piety plays a vital role in combating loneliness among older people. Older adults have a high tendency to feel lonely when affection toward and from their children decreases. This study aimed to determine the association between filial piety expectations and loneliness among older people in Kuantan, Pahang. Methods: A cross-sectional study was conducted on 198 older people in Kuantan, Pahang. Filial piety expectation and loneliness were measured by the Filial Piety Expectation Scale and UCLA (University of California, Los Angeles) Loneliness Scale questionnaire. The data were analyzed by using SPSS version 22.0. Results: The results of this study indicate that the majority of respondents believe that adult children should care for their parents. A high level of filial piety expectations was associated with a low level of loneliness. Age and race were significantly associated with filial piety expectations among older people in Kuantan. Conclusion: The study showed an association between filial piety expectations and loneliness among older people. Thus, the influence of filial piety expectations on the level of loneliness among older people must be acknowledged to ensure the improvement of the health and well-being of older people.


Introduction
Malaysia has an aging population and an increasing number of older people. The older people account for 2.83 million (9.13 per cent) of Malaysia's total population of 31 million. 1,2 The country is forecast to be an aging nation by 2030 when 15% of the population is categorized as older people. 3,4 With the increase in age, people become at high risk of suffering from terminal illnesses and facing various disabilities.
In Malaysia, long-term support for older people is usually provided by family members, particularly adult children. Filial piety is still largely observed within Malaysian society. Filial piety typically refers to expectations for children to respect and care for their parents as part of their obligation. [5][6][7] Children are expected not only to respect their parents but to also devote themselves to and live together with their parents and care for them regardless of their condition. 8 Earlier studies mostly reported the influence of filial piety as a social norm in other East Asian countries, such as China and Japan. [8][9][10][11] Confucianism and Islam have the same views regarding filial piety concept, which hold that the young generation must respect and care for older people. 12 Confucianism and Islam also emphasize the role of a man in supporting the family and of young people to respect older ones. God says in the Quran that men have to carry out their role in the family. Other than that, Osman explained in their study that Confucianism and Islam focus on the love of the family given that children must remember and repay their parents by providing them food, clothing, and a place to stay; the authors also emphasized that the concept of filial piety has become a significant value in families. 13 From the Islamic perspective, children who neglect their parents are considered merciless and sinful. 14 Given that a mother deserves respect and pleasant words from her children, the children are not allowed to hurt her feelings. 13 However, the modernization of Malaysia has brought challenges for adult children fulfilling their traditional roles of providing support for parents. Social changes, such as migration from rural to urban areas, changes in the living arrangement, decline in family size, globalization, female participation in the labor force, and changes in family structure, can influence the cultural values related to the filial piety of children, 15,16 and these changes may often be associated with loneliness in older people. Therefore, family support is important in determining the quality of life and wellbeing of older persons. 17 Adult children's frequent contact, care, and affection lessen the loneliness among older people. 18 Nevertheless, high levels of support for A number of past studies have focused on the relationship between filial piety and loneliness. Dong assessed the association between loneliness and filial piety among Chinese older adults in the greater Chicago area and revealed that low levels of perceived filial piety receipt were associated with high severity of loneliness. 11 Another research on Chinese older adults in Mainland China reported that having children who are not filial is a risk factor of loneliness. 19 Although filial piety is the most essential value in Asian cultures, to date, the majority of studies focus on filial piety attitudes and expectations from the perspectives of young generations. To the researcher's best knowledge, to date, the data on the impact of filial piety expectations on loneliness among older people in Malaysia are still unavailable. Therefore, this study aimed to determine the association between filial piety expectations and loneliness among older people in Kuantan, Pahang.

Methods
This present study was a cross-sectional study conducted in Kuantan, Pahang, which is the most populous district in the east coast of Peninsular Malaysia. The study used the convenience sampling method, with an enrolment of 198 respondents. Inclusion criteria were age of 60 years old and above, residency in Kuantan; ability to read, write, and communicate; free from any mental or critical physical illness.
A total of 204 respondents were approached, but 198 completed the survey, yielding a response rate of 97%. A questionnaire, consisting of three sections, was developed to collect data from the participants. Section 1 contains demographic questions, including age, gender, races, level of education, monthly income, current marital status number of children, and living arrangements and health status. Section 2 consists of the Filial Piety Expectation Scale questionnaire used to measure the filial piety expectations. 20 Thirteen items were included in this questionnaire, which consists of two subscales, including expectation of filial piety. The respondents were asked to respond to each item on a five-point scale from 1 (strongly disagree) to 5 (strongly agree), whereby a high filial piety expectation is indicated by a high score in the scale. Four experts in the nursing profession field assisted in validating the instrument in Malaysian context. All four had a PhD in nursing. The results of validation agreed with the clarity and consistency of the items. Reliability was measured before data collection and achieved Cronbach's alpha coefficient of 0.712. Section 3 comprises the UCLA Loneliness Scale Version 3. This questionnaire consisted of a 20-item scale designed to measure older people's subjective feelings of loneliness. 21 The respondents were asked to respond to each item in this part on a four-point scale from 1 (never) to 4 (often), and the scores for each item were summed together. A high score indicates great severity of loneliness. According to Perry's loneliness classification scheme, scores of 20-34 were classified as a low level of loneliness experience, 35-49 as a moderate level of loneliness experience, and 50-64 as a high level of loneliness experience. 22 The Malay version of this instrument showed good reliability and validity. . Descriptive statistics, such as mean, standard deviation, frequency, and percentage, were used to describe the demographic characteristics, filial piety expectation, and loneliness scale. Mann-Whitney U and Kruskal-Wallis tests were employed to determine the significant difference in filial piety expectations between subgroups in each demographic category. Spearman's rank correlation was used for the association between filial piety expectations and loneliness scores. The conventional p of less than 0.05 was used to determine the level of significance. The association between filial piety expectation and loneliness shows a significant correlation (p = 0.047). Spearman's rank correlation coefficient was −0.141, which indicates a negative correlation between filial piety expectation and loneliness.  Table 2 shows the differences in demographic characteristics and filial piety expectation. Mann-Whitney U test indicated that the participants who were aged between 70-79 years old had significantly high filial piety expectation scale scores (p = 0.041). Kruskal-Wallis test with post hoc Bonferroni correction tests revealed that those of Indian ethnicity showed significantly higher scores than those who are not (p = 0.009).

Discussion
This study aimed to determine the association between filial piety expectation and loneliness among older people in Kuantan, Pahang. The results of this study indicate that older people in Kuantan generally hold an extremely high expectation of filial piety from their children. Meanwhile, these results were similar to those of most past studies with Asian samples, in which the authors reported filial piety belief as a significant tradition that is maintained by older people. [23][24][25] To the best of the researcher's knowledge, this research is the first study to examine the association of filial piety expectations and loneliness in Malaysia. Therefore, the results of this study cannot be used to generalize in a local context.
The majority of older people had a low to moderate degree of loneliness. In the current study, most of them stay with their family members. This result may explain why older people in the current study did not experience severe loneliness. Possibly, as older people stay with their adult children, they are more likely to feel less lonely because they receive additional support. The findings of the current study were consistent with those of Taube, who mentioned that 50% of older people who live in Sweden occasionally or often feel lonely; this finding shows that older people are associated with loneliness. 26 In addition, in the study conducted by Teh in Malaysia, 47% of older people reported that they never experienced loneliness, whereas 33% reported that they occasionally felt lonely; the rest of the respondents reported that they constantly experienced loneliness. 16 This study showed an association between filial piety expectations and loneliness. The significant negative correlation suggests that the higher filial piety expectations, the lower the loneliness among older people. A possible explanation for this result might be that the majority of the older people stay with their children, thus affecting the findings. This finding is also in line with the results from a previous study, 27 which indicated that older people feel less lonely when they expected their children to practice filial piety. This finding contradicts that of Dong, who revealed that filial piety expectation was not significantly associated with loneliness. This was because older people prevented themselves from getting disappointments with their adult children. 11 In contrast to other studies that found no association between age and filial piety expectation, 20,28 age is a factor that relates to how older people expect filial piety from their children. The increase in age is significantly associated with filial piety expectations.
Malaysia is a multicultural country constituting three major ethno-cultural groups, such as Malay, Bumiputera, and Chinese and Indian, which are deeply influenced by filial piety and other traditional family customs. Races have an effect on the expectation of filial piety among older people. Indian older people have a high expectation of filial piety. Indian culture, such as that of many other Asian cultures, emphasizes filial piety. Sons are considered to respect and care for their parents. 29,30 However, research observing the association between filial piety expectations and races is yet to be published as most of the studies on filial piety focused only on China and the United States. To the best of the researcher's knowledge, the current study was the first to examine the association of races with filial piety expectations. Therefore, this current research is needed to investigate the relationship between filial piety expectation and races among older people in the city of Kuantan, and further research is being conducted in Malaysia.
A limitation of this study was that it was conducted particularly in Kuantan, Pahang, and thus, the results cannot be generalized to all older patients in Malaysia. Another limitation of this study was the use of selfreported data to measure filial piety expectation and loneliness. Self-reported data may have introduced a social desirability bias, which could have led to overor under-reporting of filial piety expectation and loneliness. Additionally, the use of cross-sectional data has limitations when explaining causal relationships.
Based on the findings of this study, the following suggestions should be considered when carrying out future research. First, a qualitative study is recommended to explore more filial piety expectations and loneliness among older people who are over sixty years old. Second, additional research conducted in rural areas or other cities of Malaysia using the same measurement is recommended to examine the effect of filial piety expectation toward loneliness among older people. This step will improve the well-being of older people. Third, further research should be carried out to investigate the relationships between filial piety expectations and races among older people in Malaysia.

Conclusion
Overall, an association exists between filial piety expectations and loneliness among older people in Kuantan, Pahang. The outcomes of this study, which yielded a correlation between filial piety expectations and loneliness among older people, are expected to combat loneliness among older people through the practice of filial piety by children in the future. The influence of filial piety expectations toward the level of loneliness among older people must be acknowledged to improve the health and well-being of older people.