When Dyadic Recruitment Fails: Lessons from a Chinese American Older Parent-Adult Child Study of End-of-Life Care Decision-Making

Background: End-of-life decision-making is typically a shared process, especially in allocentric cultures like the Chinese community, which prioritize consensus, filial piety, and familial harmony over individual autonomy. Dyadic studies examining both older parents’ and adult children’s perspectives are therefore essential but methodologically challenging. Understanding the characteristics of families who participate and those who decline is critical for developing recruitment strategies that are effective and aligned with the community's values. Using data from an older parent–adult child dyadic study on end-of-life decision-making, we identified recruitment challenges and directions for future research. To enhance practical relevance and interpretive rigor, community partners involved in recruitment joined the study team, providing expertise to contextualize findings. This collaborative approach aims to inform targeted, culturally responsive strategies for future dyadic social work research in end-of-life care.

Methods: We interviewed 238 older Chinese Americans about end-of-life preferences; 109 identified a focal child who completed an “adult child” survey. For the remaining 129 without dyadic matches, brief follow-ups documented reasons for unsuccessful recruitment. Field notes were categorized as: (1) child declined, (2) parent as protective gatekeeper (e.g., “don’t bother them,” “they are too busy,” “not safe to involve child”), or (3) perceived relational vulnerability (e.g., “child would blame me,” “child would think it’s another scam and be upset”). Hierarchical stepwise logistic regressions examined sociodemographic factors, including acculturation and immigration background, and value measures (e.g., Big Five personality traits, filial piety) as correlates of dyadic matching status and primary concerns.

Results: Older adults without a focal child were more likely to be non-religious, better educated, living in the U.S. longer, have no recent hospitalizations, report higher extraversion, and have discussed end-of-life care with children. Dyads were also more likely if the child was female. Reasons for unmatched dyads were children’s refusal (29.46%) and older adults’ unwillingness to involve children (70.54%) for reasons of “protective gatekeeping” and “perceived relational vulnerability.” Being from mainland China, lower English proficiency, and Medicare coverage were associated with protective gatekeeping, and shorter U.S. residency was associated with relational vulnerability.

Discussions: Our findings have important implications for social work dyadic studies among Chinese Americans. Dyadic recruitment was least successful when parents declined to involve their children, rather than when children refused participation. This finding is consistent with community partners’ observations that, when adult children were present at senior centers, they often facilitated their parents’ participation. These results suggest that future studies may benefit from initiating recruitment through adult children while framing the study around the dyad to preserve autonomy and choice for both members. Our results also suggest that distinct strategies are needed for older adults with different concerns for such a dyadic study. For higher socioeconomic status, more acculturated older Chinese Americans, trust-building with both generations is critical, requiring time and visibility before recruitment. For later-life immigrants experiencing relational vulnerability, family-centered, empowerment-based approaches that acknowledge intergenerational dynamics may be more effective, because older adults often express low self-efficacy and internalized ageism, as reported by our community partner.