This exploratory study adopted a metatheme approach using semi-structured interviews. Metatheme is a qualitative method for cross-cultural research, which provide an analytically significant pattern to describe those patterns in rich, contextually appropriate ways within cross-cultural data sets (25).

Participants were recruited from University A in Japan and university B in China. Inclusion criteria comprised enrolled Japanese and Chinese adult university students. The potential subjects were approached from the referral of the teachers in University A and B, who only introduced the purpose of the study and were blind to the study procedure for diminishing possible conflicts of interest. A snowball sampling method was used, whereby eligible participants were asked to link the researchers to other potential participants. Students who expressed an interest to participate received an information sheet. Students had at least 2 weeks to consider the participant after receiving the information sheet and being informed that their participation was entirely voluntary.

Twenty-one Japanese potential participants and 19 Chinese potential participants expressed interest. Two Japanese students declined for time constraints. As a result, 19 adult Japanese university students at University A in Japan and 19 adult Chinese university students from University B in China were recruited, which exceeded the minimum number needed for metathematic qualitative research saturation (26). The number of participants in each school year was also balanced to ensure accurate data representation. The participants were divided into four Japanese focus groups and two Chinese focus groups according to the participant's willingness and schedules.

Data were collected from December 2021 to July 2022. Before the interviews, the study participants were informed that their participation was entirely voluntary again. Two interviewers then conducted 80-min focus group interviews (FGI) that followed the consolidated criteria for reporting qualitative research (COREQ) guidelines (27). The interviews were digitally recorded. During the FGIs, two researchers participated in Japanese focus groups and three researchers participated in Chinese focus groups as observers. The observers record the data and non-verbal communication such as facial expressions and raising hands to maintain a heightened level of perspective (28). To identify and compare their perspectives, it isn't allowed researchers' beliefs and assumptions to shape the process of data collection (29). Interviewers and observers were fully trained in interview methods before the FGIs (30). During the FGIs, interviewers and observers paid attention to participants' wellbeing, if anyone shows or expressed signs of discomfort, the FGI would be paused immediately.

The FGIs, which were conducted at the participants' respective universities, focused on several main questions, namely, how do you feel about taking care of your parents? What is important to you when caring for your parents? Finally, what are your perceptions and opinions regarding the use of care services to care for your parents vs. taking care of them yourself?

All FGIs were recorded with the written informed consent of the participants, from which transcriptions were made. Metatheme analysis was then used to identify the broad cross-cultural metathemes and inter-relationships (25).

The data analysis was conducted as follows. First, each transcript was repeatedly read to ensure familiarization and gain an overall sense of the data. The materials were then categorized and separated into fundamental units for each country that were relevant to the study goals. After the thematic analysis was completed, a list of themes for each country was developed and the metathemes were identified. To ensure that the culturally situated meanings of the site-specific themes were not lost, all themes were translated into Japanese by researchers who could speak both Chinese and Japanese. After further comparison of the similarities and differences, sub-metathemes were then developed for the related or comparable codes, the classifications for which were developed by comparing and grouping the subcategories. After that, the metathemes were compared and distilled into a smaller set of metathemes. After multiple review rounds, further convergent metathemes and sub-metathemes were developed.

To ensure analytical rigor, Lincoln and Guba's four-dimensional criteria were used: (1) credibility, that is, checking the study participants who cooperated; (2) transferability, that is, describing in detail the phenomena obtained from the analysis; (3) dependability, that is, specifying the entire data collection and results acquisition process in a report; and, (4) confirmability, that is, conducting continuing discussions between the co-researchers and the research team to decide on the final themes with the assistance of two public health and qualitative research experts (31).

Approval from the Ethics Committee of the epidemiology research department at our university was obtained. All procedures were conducted in line with the Helsinki Declaration. An information sheet explaining the study's goals, procedures, and ethical considerations was given to each participant, which also explained that they could discontinue or withdraw from the study at any time, that the interview would be recorded and their anonymity would be preserved, and that the study may be published in journals or presented at conferences. Participant agreement was obtained by signature. On the day of the FGIs, the researchers repeated this information before the interview and received verbal agreement again from the participants.

Interview data were obtained from 19 Japanese university students and 19 Chinese university students. The participants were divided into four Japanese groups and two Chinese groups. The mean age of the Japanese students was 20.94 (SD = 3.05), and the mean age of the Chinese students was 20.84 (SD = 1.68). Table 1 gives the basic participant attributes.

Three metathemes were identified for parental care: distrust of leaving parental care to others, responsibility to care for parents, and the importance of parent-child interactions about parental care.

Both the Chinese and Japanese student groups had a mistrust of nursing homes because of news about the mistreatment of older adults. A Japanese Ministry of Health, Labor and Welfare (MHLW) publication, the “Act on the prevention of abuse on older adults and support for caregivers of older adults,” reported that in 2020, 2,097 abuse cases on older adults had been referred and 595 judgments had been made (32). Because of the public distrust in nursing homes, a system is being developed in Japan to prevent abuse on older adults in nursing care facilities, which is hoped will ease resistance to the system and improve how the public views nursing homes (33). In China, attitudes toward nursing homes have shifted from it being a stigma to recognizing that nursing homes can provide high-cost professional care; nonetheless, some negative attitudes remain (34). It has also been reported that Chinese nursing homes are of low quality and have a low capacity to accommodate the older adults in China (35). For these reasons, putting parents in a nursing home is seen as unfilial, and many parents resist moving there.

The results from this study indicated that increasing the number and professionalism of nursing home caregivers were required, which agreed with a previous study that found nursing home caregivers in China are often poorly educated older adults who lack expertise (36). Although great efforts have been made to improve care services in nursing homes and require that healthcare workers have formal occupational training, there is a shortage of healthcare workers in China (37). As a result, the lack of care skills and the poor quality of medical care have received widespread attention (38). Even though the Chinese government has published “basic specifications of service quality in senior care organization,” careworker in nursing homes was found underqualified for care work than other Western countries (35). Careworker job vacancies by prefecture in Japan are on average 3.97 times higher than the number of care workers employed in nursing homes (39). The MHLW estimated that 2.43 million care workers would be needed by 2025; however, the expected number is estimated at only 2.11 million, a potential shortage of 320,000 (40), which could lead to increased careworker workloads, which in turn could reduce the quality and safety of care.

In East Asian cultures, the firstborn is expected to live with their parents after marriage, and the firstborn and their partner are expected to take care of their parents (41). This study found that this was still the belief of most Japanese university students; however, the Chinese students felt that the responsibilities lay with all children regardless of their birth order. As Chinese caregivers are suffering from emotional and financial stress, sharing the care responsibilities would be easier (42). Nonetheless, although female work opportunities have increased in Japan and the expectations of care by the family have weakened, females were seen as being more likely to be the primary caregivers (43). However, the responsibilities are more equal in China because of its socialist system and legislation specifying (44). Further, because females have gained greater access to higher education in China, they are less likely to abandon their careers to take care of their aging parents and more likely to insist upon shared sibling responsibility (43).

Filial piety emphasizes dependence, obligation, and reciprocity in intergenerational relationships, all of which should strengthen intergenerational bonds (45). This study found that the Chinese participants were more likely to leave their jobs if they were unable to balance work and parental care, whereas the Japanese participants were more likely to place their parents in a nursing home. China has strengthened the social obligations of children to care for their aging parents (46); and in many Chinese families, older people continue to have strong bonds with their children and are involved in their daily lives, such as taking care of grandchildren and providing financial support, while they can also receive necessary care from their children as an exchange (47). Since the promulgation of Japan's long-term care insurance system, the family role has shifted from the direct provision of care to an organizational and administrative role and emotional support when using the available resources, which had led to a lower tendency for children to quit their jobs to take up parental care (48).

The Japanese and Chinese university student groups both stated that parent-child interactions were essential to strengthen parent-child connections and parental health. In China, Confucian filial piety was the guiding principle, which required children to ensure the emotional and physical wellbeing of their aging parents (49). Confucian culture means that older Chinese and their children have close emotional ties and high mutual emotional dependence (50). If their parents were resistant to entering a nursing home, both groups claimed that they would respect their parent's wishes (51). In Japan, however, because of the healthcare insurance scheme and economic growth, older parents tend to be more independent and less in need of their children's support; therefore, the participants said that they would seek to persuade their parents to enter a nursing home rather than compromise (52).

Based on the study's findings, several practical suggestions are given for improving healthcare systems in China and Japan. First, studies in Japan and the US found that the quality of long-caregiver services at nursing homes was poor (32, 53). Therefore, care service delivery and healthcare systems must be improved to build trust between healthcare professionals and the public. Second, because of cultural contexts such as filial piety, aging policies can have profound implications for both older adults and their children. Therefore, services and interventions must be developed to ensure the wellbeing and livelihoods of both the children and the parents. Third, caregiver gender equality, especially in Japan needs to be promoted (54). Fourth, similar to Japan, China needs formal policies such as nursing care leave in place to provide a better work and life balance for Chinese caregivers, and supports to mitigate the dissonance between their parental caregiver roles and their own lives.

This study had some limitations. First, because only university students were included in the study, it was difficult to extrapolate the results to all people in the younger generations. Further, as none of the participants had yet experienced the difficulties of balancing parental care and work obligations, the findings were related to the potential worries they may have in the future. Therefore, more studies are required to determine the reactions to these problems in the coming decades. While it was found that the university students were willing to help with parental care, more quantitative research is needed because of the small sample size and the qualitative research frame. Future research should explore the perspectives of all younger generations on parental care. It could also be useful to examine the attitudes of other generations to explore generational differences. On the other hand, exploring the socio-cultural reasons influencing parental care perspectives, or comparing the differences in institutional systems for older adults across different nations is important. Such research can assist policymakers in alleviating potential concerns.

This study examined the attitudes of Chinese and Japanese university students toward parental care. The findings suggested that both countries needed to improve their care service delivery and healthcare systems and build trust between healthcare professionals and the public. Support will also be needed to assist children to balance their care responsibilities with their work and family life. Culturally, it was found that healthcare policies had significant social implications for older adults and their children; therefore, future service delivery policies need to consider the wellbeing of both the children and the parents.