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1 Factor Structure of the Chinese Version of the Meaning in Life Questionnaire among Hong Kong Chinese Caregivers Wallace Chi Ho Chan This study examines the factor structure of the Chinese version of the Meaning in Life Questionnaire (C-MLQ) in a sample of Hong Kong Chinese caregivers of patients with chronic illness (N = 223). Confirmatory factor analysis was performed to examine the factor structure. Findings confirm that, identical to the original version, C-MLQ showed the same two-factor structure: Presence and Search. Correlation between Presence and Search was found to be positive and moderate (r =.47). This study establishes empirically the same factor structure as the original version of MLQ among caregivers in Hong Kong. The relationship between Presence and Meaning is discussed in the contexts of Chinese culture and caregiving. Results suggest caregivers continuing need for meaning in life. Medical social workers may help caregivers to integrate their caregiving experience with their sense of meaning in life and search for meaning in life to sustain their caregiving role. KEY WORDS: caregiving; Chinese caregivers; factor structure; meaning in life Medical social workers often work with caregivers of patients with chronic illness, who may experience caregiving strain and burden (Chan & Chui, 2011; Chang, Chiou, & Chen, 2010; Kim & Spillers, 2010; Onega, 2008; Saunders, 2008; Zarit & Femia, 2008). Yet, consistent with the strengths perspective of social work, the emerging literature reveals that such caregivers may experience not only burden but also positive aspects of caregiving (Kramer, 1997; Peacock et al., 2010; Tarlow et al., 2004). Some scholars take an existential perspective and discuss positive aspects of caregiving in relation to the search for meaning in caregiving (Chan, 2012b; Farran, Keane-Hagerty, Salloway, & Kupferer, 1991; Farran, Miller, Kaufman, Donner, & Fogg, 1999). Some also discuss the contribution of finding meaning in caregiving to the well-being of caregivers (McLennon, Habermann, & Rice, 2011; Noonan & Tennstedt, 1997). In the literature, meaning in caregiving has been conceptualized as a coping mechanism, or a coping resource, which may mediate the stress of caregiving (Noonan & Tennstedt, 1997; Pearlin, Mullan, Semple, & Skaff, 1990), but the mechanism of meaning searching in caregiving has not been fully explored. One important discussion centers on what may facilitate caregivers search for meaning in caregiving (Quinn, Clare, & Woods, 2012) that is, the relationship between situational meaning (for example, meaning in caregiving) and global meaning (for example, meaning in life) (Park & Folkman, 1997). In proposing a meaning-making model, Park (2010) highlighted the role of global meaning in supporting situational meaning. For example, how caregivers consider their subjective sense of meaning in life (global meaning) may affect how they appraise their caregiving tasks. Caregivers of patients with chronic illness may better adjust to the caregiving role if their sense of meaning in life is not shattered by the stressful caregiving experience (Janoff-Bulman, 1992). Also, in Chinese culture, relationships with family members are highly important and often the source of meaning in life for people (Lin, 2001). Thus, Chinese caregivers meaning in life may also greatly depend on the caregiving relationship with their family care recipients. In this sense, meaning in life of caregivers may also reflect how well they have adjusted to the caregiving role; however, to our knowledge, very few studies have explored caregivers meaning in life. One exception is a study on Japanese caregivers of elderly people with disabilities (Steger, Kawabatta, Shimai, & Otake, 2008). In this study, the authors doi: /hsw/hlu National Association of Social Workers 135

2 explored a Japanese cultural concept called ikigai, translated as sense of life worth living (Okamoto, Momose, Fujino, & Osawa, 2009, p. 10). Findings showed that experiencing a sense of life worth living may help prevent caregiving burden. Still, it is surprising that previous empirical studies have not thoroughly investigated meaning in life among caregivers of patients with chronic illness, especially when we consider that meaning in life is one of the oldest constructs that has been examined by psychologists (Crumbaugh, 1968; Crumbaugh & Maholick, 1964; Frankl, 1970). The literature, both in the West and in the East, has supported the notion that meaning in life plays a key role in the physical and psychological wellbeing of humans (Chan & Chan, 2011; Melton & Schulenberg, 2008; Ryff, 2000; Shek, 1992; Zika & Chamberlain, 1992). The concept is also broadly examined in other areas, such as drug addiction, palliative and end-of-life care, suicide, and delinquency (Bliss, 2009; Chan, 1995; Heisel & Flett, 2004; Luptak, 2004; Tashman, Weist, Nobors, & Shafer, 1998). In the past, different scales of meaning in life have been developed to measure this construct for example, the Purpose in Life (PIL) test (Crumbaugh & Maholick, 1964), the Life Regard Index (LRI) (Battista & Almond, 1973), and the Sense of Coherence (SOC) Scale (Antonovsky, 1987). However, all of these scales have been criticized for their ambiguous conceptualization and lack of validity (Schnell, 2010; Steger, Frazier, Oishi, & Kaler, 2006; White, 2004). A more recent measurement, the Meaning in Life Questionnaire (MLQ), was developed by Steger et al. (2006).In a systematic and comprehensive review of 59 meaning-in-life instruments, starting in 1960, Brandstätter and colleagues (Brandstätter, Baumann, Borasio, & Fegg, 2012) rated MLQ the highest, with reference to the concept definition, sampling, item development, and forms of analysis. MLQ is considered one of the best measures of meaning in life. It consists of 10 items. The two-factor structure of this instrument Presence (MLQ-P) and Search (MLQ-S) was first explored by principal axis factor analysis and then confirmed by confirmatory factor analysis (CFA) among college students (Steger et al., 2006). Presence shows the level of experienced meaning in life, and Search indicates the desire to search for meaning in life. Each item is rated on a seven-point Likert-type scale ranging from 1 (absolutely untrue) to 7 (absolutely true). The original reported internal consistency of MLQ-P and MLQ-S was.81 and.84 at time 1 of the study and.70 and.73, respectively, at time 2 of the study (Steger et al., 2006). In view of the good psychometric properties of MLQ as well as its brevity, which may meet the need for rapid assessment in clinical practice (Springer, Abell, & Hudson, 2002) it was chosen for validation in Hong Kong. The Chinese version of the Meaning in Life Questionnaire (C-MLQ) was validated among college students in Hong Kong by Chan (2012a). However, when we translate and validate in non-western contexts a scale that was originally developed in Western cultures, one concern is whether the conceptualization of the construct being measured is universal and transcultural (Ng, Yau, Chan, Chan, & Ho, 2005). Some scholars suggest that meaning in life should be culture specific, as culture and ideology form the context in which people search for meaning (Baumeister, 1991; Yalom, 1980). For example, Chinese people may be influenced by the traditional beliefs of Confucianism, Taoism, and Buddhism, and may perceive self-cultivation, integration with nature, and nonattachment as important elements in a meaningful life (Ho, 1995; Yip, 2004). Moreover, Chinese people may emphasize interdependence and family relationships (Chan, Epstein, Reese, & Chan, 2009; Markus & Kitayama, 1991; Shek, 2006), and this may influence what they value. For instance, though caregivers of patients with chronic illness in Hong Kong often experience heavy caregiving burden and stress (Chan & Chui, 2011; Louie, Liu, & Man, 2009; Tang et al., 2011), the meaning in life of caregivers may be supported by traditional values, such as filial piety (Cheng & Chan, 2006; Lai, 2010; Yeh & Bedford, 2003). To examine the construct of meaning in life cross-culturally among Chinese, the factor structure of MLQ has been examined. As reported by Chan (2012a), the same two-factor structure of MLQ (Presence and Search) was replicated by CFA among Hong Kong Chinese college students. In two other studies, which were published in Chinese journals, the same factor structure of MLQ was reported among college students in mainland China (Liu & Gan, 2010; Wang & Dai, 2008). However, for both the original MLQ and C-MLQ, factor structure was examined only among college students in previous studies (Liu & Gan, 2010; Steger et al., 2006; Wang & Dai, 2008). Its factor structure 136 Health & Social Work Volume 39, Number 3 August 2014

3 has not been confirmed by other clinical samples that are further confronted by the issue of meaning in life, such as caregivers of patients with chronic illness. In addition, the relationship between the two factors of MLQ, Presence and Search, is an area that can be explored in different target populations and cultural contexts. CFA indicated that the Presence and Search factors were slightly but negatively intercorrelated in the original study (Steger et al., 2006). However, among Japanese college students, positive correlations were found between Presence and Search (Steger, Kawabatta, et al., 2008). One cultural explanation of the findings discrepancy between U.S. and Japan populations is that Japanese people may have a dialectical mode of thought and tend to believe that one should actively search for meaning in order to experience a meaningful life (presence of meaning should go with search for meaning) (Steger, Kawabatta, et al., 2008). If the cultural factor does play a role in this relationship, then it would be of interest to examine what relationship will be found culturally among Chinese people. In addition, since search for meaning is so crucial in caregiving, it will be important for us to explore the relationship between Presence and Search in this context. Exploring this relationship among caregivers may help social workers to better understand how their clients experience the presence of meaning in life and the search for meaning in life when facing stressful caregiving tasks. Therefore, this study attempts to investigate the factor structure of the Hong Kong Chinese version of MLQ among caregivers of patients with chronic illness in the Hong Kong Chinese context. The question is whether the same factor structure as the original version of MLQ can be replicated in this study. Another question is, if the same factor structure is replicated, what is the relationship between the two factors, Presence and Search, among Hong Kong Chinese caregivers? METHOD Study Sample and Procedures Caregivers of patients with chronic illness were recruited from 15 public hospitals in Hong Kong via the medical social work departments. The researcher and the medical social workers had a meeting. Caregivers of patients who receive medical follow-up from four major specialties palliative care, renal, stroke, and hip fracture were chosen to be the targets of this study. Inclusion criteria for recruiting these caregivers were: (1) primary caregivers identified by patients as the major person who takes care of them; (2) care of patients in a home setting; and (3) caregiving duration of at least two months. Exclusion criterion was caregivers who are in severe distress, as assessed by medical social workers. With reference to MacCallum, Widaman, Zhang, and Hong (1999, p. 84), the researcher estimated the required sample size to be about 200. After discussing the feasibility of data collection in each specialty with medical social workers, a quota of sampling was set as follows: 100 (palliative care), 40 (hip fracture), 40 (stroke), and 40 (renal). Medical social workers then identified suitable participants among patients with whom they were working. Though no exact number of caregivers who refused to participate in the research was recorded, involved medical social workers reported that the success rate of recruitment was high, as most caregivers maintained good working relationships with them. These participants were originally recruited to join a research project aimed to validate a Chinese version of an instrument that assesses caregivers strain. A set of questionnaires that records background information and includes various scales was completed by the caregivers themselves or with the assistance of medical social workers. C-MLQ was included in that set of questionnaires, and this study reports only the data of this measurement. Informed consent was obtained from each caregiver who joined the research. Ethics approval was granted by all ethics committees of the various hospitals. Measure The original version of MLQ was first translated into Chinese by a bilingual social work researcher and then back-translated by a bilingual social work student. Discrepancies between the back-translated and the original versions were discussed, and suggestions were made to slightly modify the wording to establish the final Chinese version of MLQ (Chan, 2012a). C-MLQ retained the same 10-item contents as the original MLQ. It was validated by 179 Hong Kong college students. The Presence subscale indicated convergent and discriminant validity by indicating a positive relationship with the Purpose in Life test (r =.59, p <.001) and negative relationships with the Anxiety subscale (r =.26, p <.001) and Depression subscale (r =.32, p <.001) of the Chan / Factor Structure of the Chinese Version of the Meaning in Life Questionnaire 137

4 Hospital Anxiety and Depression Scale. The Search subscale also indicated its validity by showing independent relationships with different scales, such as the Purpose in Life test and the Hospital Anxiety and Depression Scale, which was also suggested by the original MLQ validation study (Steger et al., 2006). The alpha coefficient of the Chinese version of Presence and Search subscales was found to be.85 and.75, respectively. Data Analysis Descriptive statistics was conducted using the Statistical Package for the Social Sciences (SPSS) Confirmatory Factor Analysis was conducted with Amos Software Version 17 to examine the factor structure and the relationship between C-MLQ factors. We used the chi-square statistic, the Incremental Fit Index (IFI) (Bollen, 1989), andthe Comparative Fit Index (CFI) (Bentler, 1990) to assess the overall fit of the model. In addition, the root mean square error of approximation (RMSEA) (Steiger, 1990) is reported to explore the errors of approximation. RESULTS Background Information of Participants A total of 223 caregivers of patients participated in this study. The majority were caregivers of palliative care patients (44.4 percent). Others were caregivers of renal patients (20.2 percent), stroke patients (17.9 percent), and hip fracture patients (17.5 percent). Most of the participants were female (70.4 percent). The mean of age was 54.7 (SD = 14.2, ranging from 18 to 87). Most were spouses (46.2 percent) or children (39.5 percent). The background information of the participants is shown in Table 1. Factor Structure and Relationship between Two Factors The CFA confirmed the same two-factor structure (Presence and Search) as reported by previous studies (Liu & Gan, 2010; Steger et al., 2006; Wang & Dai, 2008). As suggested by Hu and Bentler (1999) and Jöreskog and Sörbom (1981), the goodness-offit indices of the model were satisfactory [χ 2 (34) = 78.5, p <0.01;RMSEA=0.077,CFI=0.96,IFI= 0.96]. In addition, CFI and IFI with values greater than.95 are considered to be an acceptable model (O Connor, Lasgaard, Shevlin, & Guldin, 2010). Though the chi-square statistics were found to be significant, the model should not be rejected when Table 1: Background Information of Participants Item n % Gender Male Female Missing data M = 54.7 (SD = 14.2, Age Range = 18 87) Relationship with patients Spouse Children Children-in-law Siblings Relatives Friends Missing data Number of caregiving hours (per week) M = 67.7 (SD = 58.1) Education level No formal education Primary school or below Secondary school Tertiary education Missing data Religious affiliation No religious belief Christianity Buddhism Daoism Ancestor worship Other Missing data using a large sample that may increase the power of the test (Smyth & MacLachlan, 2005; Tanaka, 1987). All factor loadings were high (.54.86) (see Figure 1). Both Presence (α =.84) and Search (α =.88) demonstrated good reliability and were found to be positively and moderately intercorrelated (r =.47). DISCUSSION C-MLQ s two-factor structure was established in the present study. Similar to the original study by Steger et al. (2006), C-MLQ replicated the same factor structure among the Chinese caregivers, which includes the same five items in the factor of Presence and five items in the factor of Search. This study has provided further evidence for the universal structure of meaning in life across cultures (United States versus Hong Kong) and across 138 Health & Social Work Volume 39, Number 3 August 2014

5 Figure 1: Confirmatory Factor Analysis of the Chinese Version of the Meaning in Life Questionnaire among Chinese Caregivers of Patients Notes: MLQ = Meaning in Life Questionnaire; err = error. different samples (student samples versus caregivers samples). Several reasons may explain the uniformity of the MLQ factor structure across cultures and samples. One reason may be the brevity and simple wording of each item. This ensures MLQ can be better translated into Chinese. Previous studies may refer the similarity of the factor structure of a construct to the diminished influence of traditional culture among the participants. This is particularly true when studies involve young college students as participants, who may be less influenced by the traditional belief system of their culture (Wittkowski, Ho, & Chan, 2011).However, this study provides an alternative perspective by using a clinical sample caregivers of patients with chronic illness. Participants were much older Chinese caregivers (M = 54.7 years old), and one-fourth indicated traditional Chinese religious affiliation: Buddhism, Taoism, and ancestor worship. It is assumed that they may have cultural beliefs and may show cultural differences in understanding meaning in life; however, as shown in the findings, the same two-factor structure was replicated. This may lead us to reflect on the universality versus cultural and contextual specificity of meaning in life. Meaning in life may be influenced by the cultural context for example, Confucianism may emphasize self-cultivation as an important element in a meaningful life. However, our findings also suggest that the structure of meaning in life can transcend culture. One possibility is that structure of meaning in life may be universal across cultures, but its source will differ culturally between Chinese and Western people (Lin, 2001; Pan, Wong, Joubert, & Chan, 2008). Our findings may echo what Frankl (1984, 1988) mentioned as the will to meaning of all human beings, and give further support to apply MLQ in cross-cultural research studies that explore the meaning in life among people of different ethnicities. This study also reveals the positive and moderate correlation between Presence and Search, which is different from the negative and slight correlation that was found in the original study of Steger et al. (2006). Steger, Kashdan, Sullivan, and Lorentz (2008) discussed the competing views of the relationship between presence of meaning and search for meaning. They concluded that the Presenceto-Search Model which posits that people who experience little meaning or lose meaning may be more eager to search for meaning (an inverse relationship between presence and search) received greater research support. However, the findings of this study support an alternative perspective Search-to-Presence Model which indicates a positive relationship between search for meaning and presence of meaning. A possible explanation for the difference between the present findings and those of the original study of Steger et al. (2006) may be cultural and contextual in caregiving. Chinese people are believed to be action-oriented and pragmatic (Chan, 2000; Chan & Chow, 2006). At first glance, it seems that search for meaning may not be practical for them. Yet, when focusing on the wording of MLQ, it was revealed that the proactive role is often emphasized in the search for meaning, and search for meaning may be considered an action that Chinese people would like to engage in. For example, Chinese caregivers may believe that a meaningful life can be experienced if they show the desire to achieve it (therefore indicating a positive relationship between Presence and Search). They may engage in activities that reflect their effortful search for meaning in life. For example, specifically in the context of caregiving, Chinese caregivers may hope to do something for the family members they value, such as cooking for frail family members, which may support their sense of meaning in life. That may also explain why Chinese caregivers may experience a sense of Chan / Factor Structure of the Chinese Version of the Meaning in Life Questionnaire 139

6 powerlessness when they can no longer express their care and love to family members through cooking (Ma & Chan, 2004), especially when care recipients often lose their appetite at the end of life (Chan et al., 2009; McClement, 2005). Our findings also indicate a much stronger positive relationship between Presence and Meaning, compared with what was found among college students from Japan and mainland China (Liu & Gan, 2010; Steger, Kawabatta, et al., 2008; Wang & Dai, 2008). This difference may be attributed to the typesofparticipants(collegestudentsinprevious studies versus clinical samples of caregivers of patients in this study). Caregiving is a stressful task thatcallsforthesearchformeaning(okamoto, et al., 2009; Quinn et al., 2012). As indicated from the findings, participants of this study engaged in long hours of caregiving (M = 67.7 hours per week). According to Park (2010), global meaning and situational meaning are closely related; therefore, caregivers desire to search for meaning in life may reflect their urge to find meaning in life to sustain this intensive caregiving role. Alternatively, our findings may also reveal that caregivers who experience life as more meaningful are even more eager to search for meaning. This may reflect the fact that these caregivers are well aware of the importance of meaning in life; thus, they continue to actively engage in the search for meaning in life when they have already experienced the presence of meaning. The resource-congruence model suggests that the use of a coping strategy should be matched with the availability of appropriate personal resources to ensure positive outcomes (Chan, 2009; Wong, Reker, & Peacock, 2006). It is likely that people who possess meaning-focused personal resources, such as meaning in life, may be more willing to use the meaning-focused coping strategy (search for meaning). This may explain why participants of this study are more eager to search for meaning when they experience more meaning. IMPLICATIONS FOR SOCIAL WORK PRACTICE First, our findings may give additional evidence to the appropriateness of applying C-MLQ to Chinese caregivers in Hong Kong. With the same two-factor structure as the original MLQ, this instrument can help medical social workers to assess caregivers level of meaning in life and their desire for searching for meaning. C-MLQ can also be used to identify caregivers in different situations according to their ratings in the subscales of Presence and Search (for example, caregivers who show a low level of meaning in life but a high level of desire for meaning searching in life versus caregivers who show a high level of meaning in life but a low level of desire for meaning searching in life). In this way, medical social workers may better understand the needs of caregivers and provide appropriate interventions to them. Second, our findings may highlight the importance of continuous meaning searching among caregivers. Previous literature may suggest that people who lose meaning in life may be more eager to search for it, but our findings suggest that Hong Kong Chinese caregivers may search for meaning even more when they find life is meaningful. These data reflect caregivers continuing need for meaning in life. Although social workers may pay more attention to caregivers at risk, they may not overlook the importance of developing meaningfocused intervention to caregivers who seem to have experienced meaning in life. Frankl (1984) suggested three sources of meaning searching in life: (1) our creative work (for example, what we have accomplished), (2) experience (for example, the intimate relationships we experience), and (3) attitudes (for example, our positive attitudes toward suffering). Social workers may help caregivers explore their sources of meaning in life and search for meaning in life from different sources. Moreover, since meaning in life of Chinese caregivers may be closely related to the relationship with their family care recipients, medical social workers may help caregivers to integrate their caregiving experience as one of the important sources of meaning in life. For example, Chan (2012b) suggested that helping professionals may adopt a meaning-based model to work with caregivers losses and gains in caregiving. Medical social workers may broaden such a discussion of losses and gains to the whole life of caregivers and further facilitate caregivers search for meaning in their lives. LIMITATIONS AND FUTURE DIRECTIONS Limited by the cross-sectional nature of this study, we cannot understand the causal relationship between Presence and Search. Future longitudinal studies may help us to better understand the relationship found in this study, whether caregivers who experience more meaning in life may predict more search for meaning, or caregivers who search 140 Health & Social Work Volume 39, Number 3 August 2014

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9 Wong, P.T.P., Reker, G. T., & Peacock, E. J. (2006). A resource-congruence model of coping and the development of the coping schema inventory. In P.T.P. Wong & L.C.J. Wong (Eds.), Handbook of multicultural perspectives on stress and coping ( pp ). New York: Springer. Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books. Yeh, K.-H., & Bedford, O. (2003). A test of the dual filial piety model. Asian Journal of Social Psychology, 6, Yip, K.-S. (2004). Taoism and its impact on mental health of the Chinese communities. International Journal of Social Psychiatry, 50(1), Zarit, S., & Femia, E. (2008). Behavioral and psychosocial interventions for family caregivers. Journal of Social Work Education, 44(Suppl. 3), Zika, S., & Chamberlain, K. (1992). On the relation between meaning in life and psychological well-being. British Journal of Psychology, 83, Wallace Chi Ho Chan, PhD, RSW, FT, is assistant professor, Department of Social Work, The Chinese University of Hong Kong, Shatin, 852 h, Hong Kong; chchan@swk.cuhk.edu.hk. Original manuscript received June 13, 2012 Final revision received August 14, 2012 Accepted August 27, 2012 Advance Access Publication June 25, 2014 Chan / Factor Structure of the Chinese Version of the Meaning in Life Questionnaire 143

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