Health and Social Constraints for The Elder Chinese Women Who Lose Their Only Child and Spouse: A Perspective of Resilience
Ageing Chinese people who lose their only child are a newly developed vulnerable group as the result of the one child policy in China. As an integral part of this group, women who lost their only child and spouse are more vulnerable and have their own particularity. From the perspective of resilience, this study applies the qualitative methods to explore the resilience of women who have lost their only child and spouse from the interaction of risk factors and protective factors at individual and environment levels. From the perspective of resilience, this article examines the psychological suffering, health and social constraints experienced by elder women who lose their only child and spouse and who lack appropriate support from the government and society. It analyses that the internal protective factors of the resilience of women who lost their only child and spouse include being hard-working and being able to bear hardships, forbearance and good ability to seek social support, while the external protective factors include the care from relatives and the support from multiple social relationships. There are many forms of resilience of women who have lost their only child and spouse, including traditional positive resilience and recessive resilience, such as complaining and somatization, indicating profound health and social implications that require the development of appropriate policies in China.
Keywords: Social Care; Health care; Constraints; Resilience; The Elder Women; Child; Spouse; China
Although the One-Child Policy was replaced by the universal Two-Child Policy in China in 2016, it does not mean the repercussion of the One-Child policy should be ignored. The over three decades of the One-Child Policy has brought about a new vulnerable group of the elderly who lose their only child in China and this group is expanding rapidly. These over-fifty-year-old elderly ‘childless’ people are forced to endure psychological suffering and cope with health problems alone.
There are more than100 million families who lost their only child in China and the future figure will increase [1]. The flawed health and pension systems in China have forced elderly parents to become heavily reliant on their children. Traditionally, children provide not only a continuation of the bloodline, but also spiritual sustenance for Chinese parents, based on the ingrained ideas of ‘bringing up sons to support parents in old age’ and ‘carrying on the family line’ in Chinese society. When the only child dies because of social risks, accidents and illnesses, at the age when parents are unable to reproduce, this causes unbearable impairments on their physical health, psychological trauma, and social aspects, including poor economic conditions, lack of daily care, no one to take care of them, unstable family relations, difficulties in social integration [2]. Moreover, discrimination against this vulnerable group as a result of the long-standing superstition and ignorance persists.
Women who have lost their only child or spouse are more vulnerable. They not only lost their only child, but also their spouse because of illness and divorce. The loss of spouse will undoubtedly bring a series of psychological stress and difficulties in daily life. Previous studies summarized and classified the life crisis in human social life, among which the psychological stress caused by spouse death and divorce ranked the top two [3]. The impact of losing spouse on the health of widowed people mainly involves physical health, mental health and social relations. The proportion of widows and divorces of women who have lost their only child are much higher than that of mothers of only child of the same age [4]. After losing only child, it is very likely for them to become women who have lost their only child and their spouse. For this group, the loss of superposition aggravates their grief and predicament.
Resilience refers to the operation and effect of resistance by using external resources and interaction and adjustment of internal and external factors when an individual is in an adversity [5]. The resistance is very important for parents to accept, evaluate, develop and realize the integrity of individuals after they face the loss [6]. The study of resistance has experienced different stages of development, such as ‘trait theory’, ‘interaction theory’, ‘constructivism’ and ‘cultural ecology theory’. The trait theory emphasizes that the resilience to adversity is the characteristic of resistance to adversity that the individual has. The theory of interaction introduces the ecological perspective and pays attention to the interaction process between individuals and the environment [7]. Constructivism emphasizes that intervention measures should be taken to construct and enhance individual resistance. The theory of cultural ecology has begun to pay attention to the differences of cross-cultural factors on the impact of stress resistance [8]. In addition, there may be gender differences in resilience and stress resistance. It is found that when resilience is defined as a dynamic process, the level of female resilience is significantly higher than that of men [9].
Resilience is the result of mutual adaptation and interaction between internal and external protective factors of an individual. Internal protective factors are determined by individual psychological ability and personality traits, including mental, cognitive, social/behavioral, emotional and physical aspects [10]. It has been proved by empirical research that the personal characteristics with protective effect are: infant temperament that is easy to be taken care of, humor, self-esteem, sense of self-worth, high self-efficacy and problem-solving strategies [11]. External protective factors include family resources and social support system. Kumpfer’s environment individual interaction model discussed the starting point, process and result of resilience. It points out that stress source or challenge is the starting point of resilience, and the process of resilience is the result of interaction between environmental factors and risk factors and protective factors of an individual. Risk factors make individuals face greater pressure or challenge, Protective factors can cushion their negative effects. Stress resistance process can lead to three possible results: resilience reconstruction, adaptation and maladaptation reconstruction [11].
Aging parents who lose their only child are forced to endure psychological suffering and cope with health problems without support from government and society [2]. Although numerous aging and demographic specialists [12-19] have stressed the importance of studying the aging issues, very few studies focus on this vulnerable group of elder Chinese women who lose their only child and spouse. From the perspective of resilience, this study analyzes the coping process of women who have lost their only child and spouse when they are faced with the loss of superposition in their lives, including internal and external protective factors, operation process and manifestation of resilience, and discusses the policy implications to enhance the resilience of this group.
The study was conducted in Jinan of Shandong Province, which is the home of Confucianism. Jinan as one major city in China can represent the consequence of one child policy especially the one child policy has been implementing more strictly in urban China. Jinan is also a city with a rapidly paced aging society and a high density of childless older people. The number of native elderly in Jinan who have lost their only child reached 4200 in 2015 [20] and this group of people is currently expanding.
The study obtained informed consent from participants and interviews were carried out using a semi-structured interview. In total, 22 interviews with 22 participants were conducted with childless older women who lose their only child and spouse. Participant selection criteria include the following points: first, they had all lost their only child and spouse, and had no grandchildren; and second, they were divorced or widowed, and were sterile because of age.
All participants were over the age of 50. The average age of participants was 53. Of the participants, 14 were divorced and 8 were widowed. Of the 22 participants, 12 were still working and 10 had retired. They had all lost their only child and spouse over one year prior to their participation. Regarding their educational level, 11 participants had reached Junior high school level, 8 had reached senior high school level, and 3 had completed higher education. The reasons given by participants for the loss of their only child are diverse, e.g. personal accidents including traffic accidents, leukemia, cancers and suicide. And the reasons for the loss of their spouse include divorce and the death of their spouses The health statuses of participants are poor: 5 participants suffered from heart disease, 9 from hypertension, 2 participants had been diagnosed with cancer and 6 claimed melancholia and depression.
Interviews took place between July to September 2019. All interviews were conducted in a private space at the participant’s home or at a room in a teahouse. Each interview took from between one hour to one and a half hours to complete. Participants were left to answer questions uninterrupted and were allowed to elaborate on issues they found important. The participants were asked to answer questions including details about their living conditions and living difficulties. Questions about living difficulties were categorized into five sub-sections: reasons for losing the only child, reasons for losing their spouses, living condition and living difficulties financial stabilization, health problems, health needs, social networks, and access to health services. Given the potentially sensitive nature of the subject matter, the topic guide was designed to focus initially on attitudes, before exploring personal experience.
The snowball approach to sampling and access by means of neighborhood committees were utilized in gaining access to participants. A number of participants were obtained through contact with childless older people who were personal acquaintances. Other participants were obtained through groups set up as a method of seeking emotional comfort from others in similar situations. I also worked in collaboration with the local neighborhood committees of districts, to generate a purposive sample of the childless elderly aged over 50. Neighborhood committees hold information about the childless elderly, and their personnel visited selected people asking if they would be willing to participate in a research project that explored the health and social care for the childless elderly. They were offered a small payment for their participation.
Participants were fully informed of the study’s intent and requirements and informed consent was received from all participants without any inducement, coercion or perceived pressure. Confidentiality was also considered. Interviews were completed in anonymity to protect their identities and all data checked for anonymity to prevent any information being attributed to an individual participant. from an examination of material guided by and constructed from participants’ accounts [21]. Analysis included both coding data into categories and themes according to existing theoretical concepts and by drawing themes inductively from the data. Data analysis was accomplished through an elaborate set of coding processes. Data were broken down compared then allocated into appropriate categories. Similar data were placed in similar categories, and new categories were created for different data. Contextualizing strategies [22] were used to link themes from the multiple data sources to understand data within the context of study. Information about the discursive context of participant’s response was also considered and information about the background characteristics of participants that are visible to the participants and could influence the course of the interaction was taken into consideration. The data collected from semi-structured interviews were tape-recorded, with the participants’ consent, and notes were taken to enable the precision of statements. The interviews were transcribed verbatim into English.
The study demonstrates that the death of only child and loss of spouse bring an unbearable psychological trauma for ageing females, who display prominent clusters of symptoms. The elderly Chinese women also have great needs in health care, spiritual comfort and support, economic support, support and care for their daily life, and spiritual sustenance. Moreover, they frequently have to face discrimination in their lives, and they feel neglected by the government and society.
The one-child family is essentially a family at risk; if the parents are unable to produce other children, the whole family will fall into the dilemma of childlessness. Social risks and accidents include illnesses or traffic accidents and suicide. After losing their only child, there are two reasons leading to the emergence of childless women who lose their spouse. First, their husbands died from the diseases which became more serious after losing only child; and second, their husbands divorced them after losing the only child, The study found that 14 couples had broken up following the death of their child, because it is easier for male parent to remarry a younger wife and have another child, especially in China as many Chinese men see only the son can carry on the family line. So this leaves the divorced wives in very vulnerable and worse situation.
(Participant): My ex-husband divorced me after our only son died from a cancer five years ago; he got married again and now has a son. But I am 57 years old and very lonely; when I get serious health problems, I do not know who will send me to the hospital. When I was young, I got pregnant three times, but finally received induced labor three times for the sake of the one-child policy.
The participants lost their only child and spouse successively. In the past few years, the two closest people died successively. The continuous loss brought strong psychological impact and separation anxiety to the them. In this study, the participants expressed more sadness and worries about the future. For the death of her husband because of illnesses, some participants have certain psychological preparation, which also means the reduction of burden and psychological relief. However, the death of husband also made the participants lose the meaning of life and the only support.
The participants brought up their daughters and sons, and the sudden loss of only child was like a bolt from the blue. The only child instead reposes all the hope of the interviewee for the future. The sudden death of only daughter or son also means the complete collapse of hope. The impact of losing the only child of interviewees is multi-level, including cognition, emotion, motivation, and so on.
(Participant): My marriage with my husband was arranged under the pressure of her parents, and my husband was paralyzed in bed after losing our only son. My legs have been aching since he died, he died three years agon and I have been suffering from the pain of legs for more than two years.
The impact on cognition level after losing only child and spouse is that they think the tragic result is related with the one child policy; on emotional level, the impact shows that missing their children, lamenting their death, feeling depressed and lonely, and worrying about the future; the impact on motivation is that the participants tries to keep a secret about only child’s death; According to previous studies [23, 24, 25] the loss of relatives, children, or a spouse during the advanced years of life can result in loneliness, an increased sense of vulnerability, increased isolation, and other psychosocial dilemmas. The childless elderly might also try to avoid social life and normal communication with others because they do not want to be reminded of their painful memories in public and their social circles might become very limited as a result of this avoidance. This, in turn, causes further deterioration of their symptoms as they have no outlet for grieving and they lose their interest in life. And the loss of only child and spouse also brings negative impact on their health status, e.g. Pain (legs, arms, cervical spine, etc.) / possible somatic symptoms.
(Participant): I took my child’s casket home from the funeral and kept it at home and go to bed with it every day. I may be sick, maybe it’s a kind of morbid state. When any TV programme mentions who gets married and has children or babies, we don’t watch it, and we immediately change the channel.
After losing their only child and husband, the traditional family structure completely disintegrated, and the elder women lost the most stable support, and their lives encounter many difficulties.
Poverty is a prominent problem, the death of only child and losing spouse make the participants lose the financial support, they usually only rely on a small amount pension per month to maintain their living conditions. Clothes at home are presented by others, and they try to save money when buying food. The living conditions are crowded and poor.
Most participants suffer with depression for a long time. Because of this, their risk of heart disease and hypertension is high. Many cannot afford medical treatment. Although many of the regions provide basic health insurance, the insurance is limited and the costs of operation and medicine still cause concern for the elderly.
Because they have suffered with depression for a long time, most of the childless elderly who lose their spouse also suffer with emotional or physical health problems. Special care and reduction of medical costs are required to help them. A large number of medical and social workers and other volunteers are needed to help the elderly.
(Participant): When having operations, it is difficult to find family members to sign the agreement letter. In emergencies, we have no one to take care of us. When checking into rest homes, it’s hard to find a guarantee.
The participants began to live alone after divorce or their husbands died. Because of their difficulties in mobility, they spent most of their time at home. Because of staying at home for a long time, the interviewees said that they usually have a strong sense of loneliness and feel that time passes very slowly. And more than once expressed the worries that no one would know if he died at home. Eighteen participants said they gradually fell into autistic patterns. Their poor psychological conditions are also linked to their concerns and worries about a lonely old age with a limited pension and proper health care.
(Participant): I was seriously depressed by grief after losing my only daughter. I always get sleep disturbance and I found that it was serious by my hair loss. After my husband died from the heart attack because she could not bear the blow of our daughter’s death, life becomes more difficult to me. I have been suffering from long-term depression, loneliness and anxiety.
Hard working and forbearance is the first factor. The participants in this study are traditional Chinese women with virtues of hard working and forbearance. They worked hard and performed well in their work-units. After their husband got sick, they took care of their husbands alone and worked hard until her husband died. And after encountering the loss of only child and spouse, they can still bravely tenaciously face difficulties and challenges in their life. In this study, when the participants talked about many difficulties in life, the most common expressions were “just muddle along” and “if I can bear it, I will try my best”.
(Participant): During the period that my husband paralysed in bed, I often bathed him. In order to save money, I learned everything by myself, did everything by myself, such as, inserted a catheter, got a haircut for him and shaved him.
Self-esteem and strong personality characteristics are second internal protective factor. The participants have strong personality and strong self-esteem. For example, they do not want to tell others about their families as they worry that others will treat her differently. Some of their neighbors still don’t know about the loss of their only child and spouses. To some extent, this strong self-esteem can play a protective role and create a relatively safe and comfortable external environment for them. Most participants especially reject others saying that they have a bad fortune and they do not believe in fate, which can stimulate their potential to some extent and try to make some positive changes.
(Participant): In the past, when he was alive, sometimes he fell to the ground. I would drag him to bed alone. If the bed was too high, I would drag him to the low physiotherapy bed first, and then pull him up, I was afraid other people would hear this.
The ability of expressing feelings and emotions and to seek social support is the third internal protective factor of resilience. In this study, participants can well share their life experience and express viewpoints well in issues, they perceive the support in the environment well and make good use of it. Such as “bestie”, “master/former colleague”, and a neighbour who is a family of vegetable vendor. One example is the complementary interaction between the participant and one neighbour who is a family of vegetable vendor, which can make the participant feel their own value and enhance their sense of self-efficacy in the interaction with others
(Participant): I am a close friend of the family of vegetable vendor, they helped me a lot, few days ago, they gave me some vegetables when they felt that I need some, as return, I gave their son a bowl of stewed meat.
Altruism is also an internal protective factor of resilience. In the process of communication with friends and neighbours, the participants show a strong altruistic tendency, including providing material support, helping to take care of the stall, etc. this ability of having initiative to establish a relationship and make good use of this relationship, on the one hand, can improve the participants’ self-efficacy, on the other hand, some of their life needs could be satisfied through this kind of complementary communication. The participants also mentioned that they would consider everything for others first, and being forgiving. This is also a very important reason why their friends in the neighborhood are willing to communicate with her.
(Participant): This is two pillowcases and a bedspread, my gift to the family of vegetable vendor. I usually give them everything I don’t use. It’s nice to meet them. If there is anything I need help, they do everything to me without hesitation.
Care and support from relatives is the first external protective factor of resilience. For some participants, after their parents passed away, as some of their brothers and sisters are far away from home and so they mainly rely on their younger brothers to take care of them. When the only child died and they lost their husbands, the younger brothers worried that they would commit suicide and other extreme behaviours, so they were taken to homes and were looked after by their brothers. Later, when the participants moved back to live alone, the younger brother often came to visit them, always paid attention to their life and health status, and was able to give timely support and care when necessary.
(Participant): At that time, after I lost my only son and my husband divorced me, my younger brother was with me every day and took care of me.
The support from multiple social relations is the second external protective factor of resilience. In addition to the care from relatives, most participants also received support from the ‘bestie’, former colleagues, current colleagues, neighbours, and families of vegetable seller, which created a supportive external environment for the participants. For example, ‘bestie’ has been very helpful to them. The interviewees mentioned it a lot. ‘bestie’ and one participant grew up in the same alley. They are 60 years old. Although they are not sisters from same family, they are very close. ‘Bestie’ takes care of the participant in every aspect of clothing, food, housing and transportation, and knows the situation and living conditions of the participant best. The participant mentioned that ‘bestie’ would call her once a week, and would take the initiative to call the participant in view of the high telephone charges. The clothes of the participant were given by the ‘bestie’, the medicine was given by the ‘bestie’, a lot of food was given by her, and the saddest stage was accompanied by the ‘bestie’ all the way.
In this study, 16 participants said that the former and current colleagues became their friends of when they worked in the early years and are working in work-units, and their former and current colleagues were able to provide necessary life care. For example, one participant accidentally fell down on her bicycle, the colleague sent the plaster in time. Former colleagues often invite them to their homes for dinner, so that the participants can have more contact with others. Another example is that after the participant lost her bicycle, the neighbour gave her one bicycle in time, although it was an old one, it could also solve the current difficulties. Although the participants are facing many difficulties in life, they can also help others with their own meager strength. This kind of help is greatly recognized by others, and then they can give back as much help as they can.
In this study, the operation process of resilience of participants is the result of the interaction between risk factors and protective factors, which is reflected in the individual level and the environment level. At the individual level, the risk factors faced by the interviewees are a series of sad reactions after the loss of their only child and the inconvenience of life and movement caused by physical diseases. The protective factors are the unique positive personality characteristics of the participants, such as the virtues of Chinese traditional women’s hard-working and good ability to seek social support. There are many risk factors on the environmental level. Firstly, they are faced with many life difficulties, constraints for medical services and lack of community/government care. The protective factors in the environment are reflected in the support of family relations and multiple social relations.
There are different forms of resilience, including traditional positive resilience and some negative resilience, namely recessive resilience. In this study, the participants often express complaints about the government to the community. On the one hand, they complain that the government implemented the one child policy in those years, but when they lost their only child, they did not get enough support from the government and the community. On the other hand, they complain that the government staff did not implement the policies made by the higher authorities, it is a kind of recessive resistance. The reason behind it is that they want to get the attention of the government and the community. In addition, the symptoms of leg pain and general pain may be related to sadness and somatization. The participants felt more physical pain so that they could escape the psychological pain caused by loss.
Women will face multiple dilemmas, including psychological, daily life and other aspects, after they encountered the continuous loss of their only child and spouse. This study supports the previous research on the plight of the group of the lost only child and the group of the widowed.
However, compared with the single loss of one’s only child and the loss of one’s spouse, the women’s sad reaction and dilemma caused by the superposition of the loss of one’ only child and the loss of one’s spouse are special. To a greater extent, the impact is more intense and far-reaching, resulting in the complete disintegration of family structure and emotional, cognitive, behavioral, motivational, physical and other aspects of the grief response, which needs a longer time to deal with grief.
The resilience of women who lost their only child and spouse has a distinct cultural background. First of all, women who have lost their only child and spouse are over 50 years old and have experienced the alternation of the old and the new society. In the traditional society where men are superior to women, women are responsible for family affairs, serving their husbands and taking care of the old and young family members. In the communist society, the whole social trend of thought advocated women’s independence, “women can hold up half the sky”, and a large number of women got into work. And this group of people often experience harsh living environment before economic reforms. Growing up in such an era, they generally have the independence of the new society and retain the forbearance and hard work of the traditional society, which is particularly reflected in the participants. The good quality of hard work and forbearance is a very important manifestation of resilience in Chinese culture.
This cultural feature is reflected in the fact that for women who have lost their only child and spouse, in the face of many difficulties, the help and support from their brothers, sisters and parents are very important. After losing their only child and spouses, their parents and brothers and sisters become the most direct relatives. If parents are alive and brothers and sisters can provide good support, it is undoubtedly a great help and comfort for them. This is consistent with the traditional Chinese culture, which emphasizes the concept of kinship. No matter how good the relationship with neighbors and friends is, it is difficult to replace the position of family members.
The resilience of women who lost their only child and spouse has distinct female characteristics. Some studies have shown that women can better adapt to urban life than men, because women are significantly better than men in psychological complaints and seeking help [11]. This study supports the existing research, and this study also finds that women who lost their only child and spouse are often better at expressing and asking for help in coping with adversity, whether facing family members or other social relations, which is a very important advantage to help them better cope with difficulties. In addition, compared with men, women have more communication strategies and interaction media, it is more likely for them to establish relationships with young people, and more likely to get emotional support from the younger generation. The female characteristics of resilience of women who lost their only child and spouse also show that women usually take more housework in the family, so women have better self-care and management ability in life.
The operation process of resilience is the interaction process between different elements (risk, protective factors, individual and environment). In this study, due to the complexity of individual psychology and the diversity of events, it is difficult to define a specific point as a protective factor or a risk factor of resilience. The boundary between the two is not clear. In some cases, it varies from time to place. For example, forbearance among the participants’ personality characteristics can make them more tolerant of reality from the cognitive level. Forbearance has distinct traditional cultural characteristics, but at the same time, it will bring some psychological pressure.
It is necessary to affirm and carry forward the resilience (in the traditional sense) of women who have lost their only child and spouse in coping with difficulties, such as the good quality of hard work and the female characteristics of being more willing to express and take the initiative to ask for help. The most direct impact on women is reflected in the cognitive level and emotional level, and there is interaction between the two. In the process of intervention, it is necessary to help them establish a more rational and relatively positive cognition of the event, avoid falling into the two extremes of self-attribution and structural attribution, and rehabilitate. Emotional level should encourage appropriate patience and timely expression. At the behavioral level, women who have lost their only child or spouse should be encouraged to participate in and reintegrate into the society, to reconstruct the confidence of life.
Some behaviours (such as complaining, somatization, petition, etc.) of women who lost their only child and spouse also reflect the need to express some needs, such as the need to get attention, the need to be supported, and so on. It is necessary to listen to their needs, and then intervene from the individual and environmental levels to make them relieved.
The availability of timely help from family, social relations, government/community/ society would be crucial to improve the quality of life and reduce the health and social constraints of women who lost their only child and spouse. Family level interaction is the most intimate and frequent, and support is the most direct and needed. Therefore, family support is very important, whether from parents or siblings, including daily care and inclusive listening. When necessary, social workers need to be the coordinator of family relations. Social work institutions can actively help the childless elderly by providing emotional support. Social work is a relatively new area in China, and the government might consider encouraging training social workers to offer free psychological consultations and mental interventions [26]. A social worker can provide grief relief counseling, psychological counseling and treatment for the childless elderly without spouse, to assist in the release of negative emotions and to help them adjust to life without their children. At the community level, social workers can pursue urban community volunteer services, in collaboration with the local neighborhood committees, to strive for social resources to help the childless elderly establish social support. At the level of social relations, daily support from friends and neighbors, activity participation, emotional expression and experience sharing among groups could be encouraged. The government/community/society should adequately understand the needs of this group of childless women who lose their spouse, provide appropriate services, including economic support, basic life care, cultural and recreational activities, policy assistance, psychological intervention, etc., to provide opportune support to this vulnerable group.
