Introduction
Due to urbanisation in China, about 7.74 million older people have left their hometowns for urban centres, where their adult children reside and work, to care for grandchildren (National Health and Family Planning Commission, 2016). These older people migrating along with adult children are generally of retirement age, from 50 to over 70 years old, and live in cities for an indefinite period of time without changing their registration status from their hometown.
This group of older migrants is a population with particular experiences, motivations, challenges and needs. Their motivation for migration is mainly to take care of grandchildren without payment, and their migration pattern is in line with that of their adult children: from rural areas to urban areas, from small cities to large cities, and from economically undeveloped areas to economically developed areas (Zhang and Zhou, Reference Zhang and Zhou2013). To some extent, migration to care for grandchildren is attributed to insufficient resources for child care in Mainland China and seen as a kind of sacrifice of self-interest (Wang, Reference Wang2015) as older people bear the double burden of care-giving and adaptation to a new environment. Therefore, they are quite different from other younger migrants who experience migration at a younger age for better jobs and socio-economic promotion. They also differ from other older migrants in ‘developed’ countries and areas who move to better climate or lower-cost areas for a better retirement life (Zhang and Zhou, Reference Zhang and Zhou2013).
Given the cultural virtues of filial piety and familial care, the phenomenon of older people migrating along with adult children in China is often considered a positive manifestation of traditional support and values. These older migrants may be viewed as a happy group due to benefits associated with family reunion and reciprocal support from adult children. However, an increasing number of studies (Yao and Wang, Reference Yao and Wang2010; Chen, Reference Chen2014; Liu and Chen, Reference Liu and Chen2015b; Bao, Reference Bao2017; Xu, Reference Xu2017a) describe challenges facing these older migrants and resultant mental health impacts. This group's social adaptation difficulties have become an important area of focus for researchers, social workers and other social actors in Mainland China.
However, there is a lack of national-level surveys or systematic reviews about these older migrants’ mental health and systematic national or local government services and policies for them. Therefore, a systematic review of mental health outcomes and determinants and suggestions for interventions can encourage government and organisations to develop targeted policy and services to support this group of older people. This is an important issue given that the migration of older people to urban settings is a growing trend, given the increasing number of older people in Mainland China moving to urban centres and the prevailing familial culture of maintaining close connections within extended families, especially as a result of the one child policy in China (Wu, Reference Wu2013).
Previous research in China has predominantly focused on mental health problems and negative experiences of these older migrants (Liu and Chen, Reference Liu and Chen2015b; Guo, Reference Guo2016) and the different migration patterns from the perspective of demographic studies (Zhang and Zhou, Reference Zhang and Zhou2013; Dou and Liu, Reference Dou and Liu2017; Liang and Guo, Reference Liang and Guo2018), or perspectives on social integration and social adaptation (Liu and Chen, Reference Liu and Chen2015a; Liu, Reference Liu2016). This systematic review aimed to enrich migration research on the ageing population in China by capturing both the positive and negative mental health outcomes reported in ageing migrants.
Conceptualisations of mental health
Mental health or mental wellbeing, reflecting the equilibrium between an individual and their environment in a broad sense (Dodge et al., Reference Dodge, Daly, Huyton and Sanders2012), is an important topic in social science research and policy making. The World Health Organization (WHO) defines mental health as a state of wellbeing in which an individual realises their own abilities, copes with life stresses, works productively and fruitfully, and contributes to community (Stenius, Reference Stenius2007; WHO, 2018). The WHO explains that mental health is an integral part of health and involves more than the absence of mental illness. Mental health can be understood in terms of either negative mental health or positive mental health, with the former encompassing mental disorders, symptoms and problems, and the latter considering mental health as a resource enabling individuals to experience life as meaningful and to be creative and productive members of society (Stenius, Reference Stenius2007).
As a broad concept, positive mental health is often considered to include emotional (affect/feeling), psychological (positive functioning), social (relations with others and society), physical (physical health) and spiritual (sense of meaning and purpose in life) aspects of wellbeing (Barry, Reference Barry2008). Keyes (Reference Keyes2013), for example, conceptualises positive mental health as including three dimensions of emotional, psychological and social wellbeing, which can be assessed according to three statuses: flourishing, moderate and languishing. Emotional wellbeing is defined in terms of perceptions of happiness and satisfaction with life and the balancing of positive and negative affect. Conceptualised as a primarily private phenomenon, psychological wellbeing focuses on challenges encountered by individuals in their personal lives, including self-acceptance (evaluation of oneself and one's past life), self-growth (sense of continued growth and development), purpose in life (belief that one's life is purposeful and meaningful), positive relations with others, environmental mastery (capacity to manage one's life and surrounding world effectively) and autonomy (sense of self-determination). As a more public experience, social wellbeing focuses on tasks encountered by individuals in their social structures and communities, including social integration, contribution, coherence, actualisation and acceptance (Keyes, Reference Keyes2013). Keyes (Reference Keyes2013) suggests that positive mental health and mental illness constitute distinct axes, rather than opposite ends of a single continuum.
In Chinese contexts, mental health is a ‘borrowed’ concept and often used to refer to the presence or absence of psychopathology (Yin et al., Reference Yin, He, Fu and Keyes2013). However, according to the WHO's definition and broader conceptualisations of mental health, mental health ought to be understood in terms of not only negative mental health but also holistic wellbeing that includes emotional, psychological and social dimensions. To review comprehensively the wellbeing of older people migrating along with adult children in China, this study adopted the WHO's perspective of mental health. It reviewed two aspects of mental health: positive mental health, based on indicators such as subjective happiness or wellbeing, life satisfaction and quality of life, and negative mental health, based on indicators such as depression or anxiety. In addition, literature on emotional, psychological and social wellbeing as main dimensions of positive mental health within Keyes’ framework was reviewed. An integrated conceptual framework of mental health and mental ill-health of Keyes (Reference Keyes2013) and Stenius (Reference Stenius2007) that guided this review is shown in Table 1.
Conceptual framework of mental health
Source: Stenius (Reference Stenius2007) and Keyes (Reference Keyes2013).
Review objectives and procedures
This paper reviews recent empirical research on the mental health of older people migrating along with adult children in China. It aims to: (a) review mental health and wellbeing outcomes associated with migration; (b) examine determinants related to the wellbeing of older people migrating along with adult children; and (c) identify social work interventions or strategies for addressing needs and challenges facing these older migrants.
Review strategies and processes
Literature search
Literature was identified from ten journal databases: CAJ Full-text Database (in Chinese), CINAHL Complete, Medline via EbscoHost, PsycInfo, Sociological Abstracts, Social Services Abstracts, Social Sciences Citation Index (SSCI), Science Direct, Scopus and Web of Science. Chinese key words sui qian lao ren (i.e. older people migrating along) and lao piao zu (i.e. a group of older people drifting along), which are the only two major Chinese terms referring to older people in China moving from place to place along with or due to their adult children, were used to search the CAJ database, and English key words (mental health or depression or depressive or anxiety or life satisfaction or life quality and ageing or older or elderly and migrant or migration and China) were used to search the other databases. Search-refining conditions included peer-reviewed English-language and Chinese-language articles published from 2008. In China, the first published paper using the term sui qian lao ren (i.e. older people migrating along) and lao piao zu (i.e. a group of older people drifting along) appeared in 2010 and 2011, respectively. As scholars might have published in non-Chinese journals earlier than 2010, the search for this current study covered the ten-year period from January 2008 to January 2018 when this study was completed. A total of 226 titles were identified through database searches and screened (Figure 1). Based on Stage 1 exclusion criteria (i.e. duplicate articles, articles not related to the mental health of older people migrating along with adult children in China), 201 articles were identified as potentially relevant after a brief review of titles and abstracts, a process adopted in other systematic reviews (Evans et al., Reference Evans, Andrew, Koffman, Harding, Higginson, Pool and Gysels2012; Peek et al., Reference Peek, Wouters, van Hoof, Luijkx, Boeije and Vrijhoef2014; Lai et al., Reference Lai, Li and Daoust2017; Xiao and Watson, Reference Xiao and Watson2017).
Literature search review diagram.
Note: SSCI: Social Sciences Citation Index.
Assessment of eligibility
After screening the abstracts and full texts of these 201 articles, 163 articles were excluded that did not meet Stage 2 inclusion criteria: (a) original empirical studies with research methods explicitly reported; (b) focus on older people migrating along with adult children and their wellbeing, including at least one research objective; (c) either qualitative or quantitative studies; and (d) full text was accessible. Thirty-eight articles were retained. Different Chinese and English names used for this older migrant group were noted. In addition to sui qian lao ren and lao piao zu, terms such as yi ju lao ren (‘migrating older people’) and liu dong lao ren (‘mobile older people’) were used in studies of elderly migration in Mainland China. A ‘forward and backward search’ was conducted to identify papers that may have been missed in Stage 1, by identifying references cited in the 38 reviewed papers (forward search) and papers citing these 38 publications (backward search). No new articles were found.
All strategies and processes conducted in this review complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., Reference Moher, Liberati, Tetzlaff and Altman2009).
Search results
Thirty-eight studies were reviewed, including three English and 35 Chinese articles (Table 2). Only nine studies directly examined mental health and influencing factors (based on key words such as depression, quality of life, subjective happiness, etc.) and 23 referred to at least one dimension of positive mental health (emotional wellbeing, psychological wellbeing or social wellbeing). The other six papers focused on general wellbeing or living status with reference to the mental status and surroundings of the studied group. Seventeen studies used quantitative methods and 20 used qualitative methods, with only one using mixed methods. Samples in these 38 studies were mainly from economically developed areas and large cities, reflecting labour migration trends in China: from rural areas to urban areas, from small cities to large cities, from economically undeveloped areas to economically developed areas (Zhang and Zhou, Reference Zhang and Zhou2013). For example, 26 studies were carried out in Beijing and south-east coastal areas (such as Shanghai, Jiangsu Province, Zhejiang Province, Fujian Province and Guangdong Province) and ten were conducted in western China and central China, primarily in major cities, as shown in Figure 2.
Distribution of the sampling areas.
General description of reviewed articles
Note: N = 38.
Results
Mental health and wellbeing outcomes
Negative mental health indicators
Depression was a frequently used indicator for mental health in previous literature. Three studies measured depression among older people migrating along with adult children (Liu and Chen, Reference Liu and Chen2015b; Li et al., Reference Li, Zhou, Ma, Jiang and Li2017; Tong et al., Reference Tong, Bai and Cao2017), using the Geriatric Depression Scale (GDS-30) or Hopkins Symptoms Check List. One survey of 61 older people migrating along with adult children in Hangzhou (Tong et al., Reference Tong, Bai and Cao2017) reported that 41 per cent of respondents experienced some degree of depression (as measured by the GDS-30). Another study of 2,570 respondents in the same city (Li et al., Reference Li, Zhou, Ma, Jiang and Li2017) found that older people migrating along with adult children reported higher depression than local elders (also measured by the GDS-30), while rural–urban migrants experienced higher depression than urban–urban migrants.
Positive mental health indicators
Unlike ‘Western’ studies that often use diverse indicators to assess positive mental health, quality of life and subjective happiness were the only two positive indicators identified among studies of mental health of older people migrating along with adult children in China. As with results from depression measures, two surveys (Hu et al., Reference Hu, Long and Yin2013; Deng and Wang, Reference Deng and Wang2016) in Hangzhou and Wuxi found that older people migrating along with adult children had low quality of life. However, a survey on subjective happiness in Beijing (Xu et al., Reference Xu, Mou, Xu and Zeng2014) showed different results, reporting significantly higher subjective happiness scores among older people migrating along with adult children compared with local elders, although no specific explanation for this finding was provided.
Emotional wellbeing
Qualitative and quantitative studies described negative emotions affecting older people migrating along with adult children, including feelings of rootlessness produced by drifting (Liu, Reference Liu2014; Guo, Reference Guo2016; Wen and He, Reference Wen and He2016; Li, Reference Li2017; Wang and Li, Reference Li2017), loneliness (Guo and Wei, Reference Guo and Wei2015; Liu, Reference Liu2016; Wang and Yin, Reference Wang and Yin2016; Zhang and Hu, Reference Zhang and Hu2016; Wang and Li, Reference Li2017; Zhang, Reference Zhang2017), depression (Chen, Reference Chen2015; Liu and Chen, Reference Liu and Chen2015b; Zhang, Reference Zhang2017), poor self-esteem and uselessness (Sun, Reference Sun2015; Zhang and Xi, Reference Zhang and Xi2015), frustration and anxiety (Xu, Reference Xu2017a), and helplessness and confusion (Liu and Chen, Reference Liu and Chen2015b). These may involve physical manifestations, such as insomnia, physical and mental exhaustion, or uncontrolled anger. In a survey of 912 older people migrating along with adult children in Shenzhen, more than 60 per cent reported at least one physical manifestation (Liu and Chen, Reference Liu and Chen2015b).
Psychological wellbeing
Poor self-acceptance was frequently mentioned in previous research. Five studies (He, Reference He2014; Sun, Reference Sun2015; Zhang and Xi, Reference Zhang and Xi2015; Xu, Reference Xu2017a, Reference Xu2017b) described how older people migrating along with adult children felt they were ageing and running out of time or that they could do nothing but housework in their new place of residence (Sun, Reference Sun2015). Others felt incompetent or valueless when they faced criticism or neglect by their adult children (He, Reference He2014; Zhang and Xi, Reference Zhang and Xi2015; Xu, Reference Xu2017a), or felt inferior when interacting with local older adults (Xu, Reference Xu2017a). In one survey of 452 older people migrating along with adult children in Jiangsu Province, only 12 per cent felt satisfied with their identity (Xu, Reference Xu2017b).
Another frequently mentioned issue among older people migrating along with adult children was difficulties in family and neighbourhood relationships. In one survey of 280 older people migrating along with adult children, 87 per cent of respondents reported that they rarely interacted with others in the community (Chen, Reference Chen2015). Poor interactions with adult children also created feelings of loneliness, rather than intimacy (He, Reference He2014). With respect to environment mastery, older people migrating along with adult children expressed that they could bear some kinds of inconvenience but encountered difficulties in dealing with modern household appliances and urban traffic (Xia and Xia, Reference Xia and Xia2015; Zhang and Hu, Reference Zhang and Hu2016). They viewed their migration as an unwilling action that undermined autonomy (Guo, Reference Guo2016). None of the 38 reviewed studies mentioned life growth or life purpose from the standpoint of older people migrating along with adult children, although these are two key dimensions of psychological wellbeing in Keyes’ (Reference Keyes2013) framework.
Social wellbeing
Twelve studies examined subjective feelings on social integration, although no studies referred to any of the four other dimensions of social wellbeing in Keyes’ (Reference Keyes2013) framework (social contribution, coherence, actualisation and acceptance). Eleven out of the 12 studies found that older people migrating along with adult children reported feeling no or little integration or belonging in their city of residence. Some felt exclusion and discrimination when interacting with local older adults (Yao and Wang, Reference Yao and Wang2010; Chen, Reference Chen2014, Reference Chen2015; Zhang, Reference Zhang2017) and others (especially rural–urban migrants) felt that they were ‘outsiders’ (Zhao, Reference Zhao2013; Liu, Reference Liu2014; Sun, Reference Sun2015; Wen and He, Reference Wen and He2016; Xu, Reference Xu2017b; Yi and Xue, Reference Yi and Xue2017; Zeng, Reference Zeng2017). Only one survey in Xi'an, north-west China, reported different results, with 81.6 per cent of respondents self-reporting that they had integrated into the city (Di and Fu, Reference Di and Fu2017).
Determinants of mental health
Drawing on multi-level determinants in previous studies, this review adopts a systems theory framework (Gupta, Reference Gupta2009) to understand the determinants related to older people's mental health. These determinants are classified into five categories: individual level, family system, social system, community and residential system, and government and policy system (Table 3).
Key findings on determinants of mental health and wellbeing
Individual-level determinants
Individual determinants included personal character, income and economic status, and physical health.
Personal character
Some qualitative studies (Liu, Reference Liu2016; Bao, Reference Bao2017; Zhang, Reference Zhang2017) suggested that older people migrating along with adult children who had an open mind and were optimistic were more likely to adapt and integrate into their new environments by attending social activities, making friends, and so on. In contrast, those who felt ‘inferior’ or pessimistic would be more likely to focus on their troubles and be unwilling to engage in social interaction (Zhang and Hu, Reference Zhang and Hu2016; Bao, Reference Bao2017). However, no further quantitative studies examining this topic were available.
Income and economic status
Older people migrating along with adult children with a higher income (including salaries, pension income or support from children) were more likely to feel happy (Wang, Reference Wang2017b). Those with independent income (mainly from pensions) were more likely to have harmonious relationships with co-residential adult children and report better adaptation and mental wellbeing (Zhang and Hu, Reference Zhang and Hu2016; Chen et al., Reference Chen, Liao and Li2017). However, perceptions of relative economic status can affect mental health (Liu and Chen, Reference Liu and Chen2015b). When older people migrating along with adult children perceived a gap between their economic status and the superior economic status of local elders, they felt a sense of non-belonging to their residential area.
Physical health
Qualitative studies (Liu, Reference Liu2016; Zhang and Hu, Reference Zhang and Hu2016; Chen et al., Reference Chen, Liao and Li2017) reported that older people migrating along with adult children with better physical health status were more socially adaptive and happier than those in poor health. Healthy migrants could cope better with housework and do more outside activities, which enhanced self-confidence, while those in poor health tended to feel guilty because they might be a burden to adult children.
Family system determinants
Family-level determinants included spousal relationships, intergenerational conflict, and family support and care-giving.
Spousal relationships
Studies of older people migrating along with adult children reported that marital partnerships influenced social adaptation (Chen, Reference Chen2015; Zhang and Hu, Reference Zhang and Hu2016) and integration (Liu, Reference Liu2016). Qualitative (Liu, Reference Liu2016) and quantitative (Chen, Reference Chen2015) studies found that older people migrating along with adult children and living with marital partners were more adaptive and happier than those without partners due to greater feelings of safety and belonging, and social engagement and fewer negative emotions (Chen, Reference Chen2015).
Intergenerational conflict
Qualitative (Chen, Reference Chen2014; He, Reference He2014; Bao, Reference Bao2017) and quantitative (Hu et al., Reference Hu, Long and Yin2013; Chen, Reference Chen2015) studies identified family conflict as the main source of stress for older people migrating along with adult children, hindering adaptation through negative impacts on self-esteem and withdrawal behaviours. Women tended to report conflicts with daughters-in-law over child care, educational styles and consumption behaviours (He, Reference He2014; Zhang and Hu, Reference Zhang and Hu2016; Xu, Reference Xu2017a).
Family support and care-giving
Due to reduced social support from friends and other relatives after migration, emotional support from adult children may become the main support source for these older people. This can have positive effects on social adaptation (He, Reference He2014; Chen, Reference Chen2015; Bao, Reference Bao2017), through economic support, care in daily life activities and spiritual comfort (He, Reference He2014). Relationships with grandchildren were also significant and meaningful for older people, providing emotional comfort and connection with adult children (Yi and Xue, Reference Yi and Xue2017).
Social system determinants
Social system determinants included social interactions and social activities.
Social interactions
A survey in Hangzhou (Li et al., Reference Li, Zhou, Ma, Jiang and Li2017) found that lower cognitive social capital (generalised trust and reciprocity) was associated with depression and that cognitive social capital mediated the relationship between migration and depression for older people migrating along with adult children. Another survey in Shenzhen (Liu and Chen, Reference Liu and Chen2015b) found that social capital affected mental health (notably depression) across three dimensions. While social engagement and trust contributed to mental health, more interactions with local older adults were associated with greater depression among older migrants due to perceptions of social inferiority and exclusion. Meanwhile, deeper interactions with other older migrants may be beneficial for adaptation (Bao, Reference Bao2017).
Social activities
Only one survey in Beijing (Xu et al., Reference Xu, Mou, Xu and Zeng2014) examined social engagement and reported that for older people migrating along with adult children, spending more time on enjoyable activities was associated with greater happiness, while spending more time on labour activities was associated with less happiness.
Community and residential determinants
Community-level determinants included community services, building design and facilities, and residential segregation.
Community services
A study in Nanjing (Zhao, Reference Zhao2013) reported that a lack of organisations and professional human resources hindered services for older people migrating along with adult children and restricted their social engagement. A survey in Suzhou (Song et al., Reference Song, Ye and Xie2017) indicated that the biggest barrier to social interaction was not language but a ‘lack of chances’ in community activities.
Building design and facilities
Only one study (Zou et al., Reference Zou, Zhang and Gen2013) in Beijing directly examined the effects of design on mental health, reporting that the needs of older people migrating along with adult children were ignored when outdoor spaces were designed. For example, a lack of marked buildings reduced their sense of direction, and insufficient facilities (e.g. public chairs and tables) hindered interactions among older migrants who needed to sit for a break.
Residential segregation
One study (Liu et al., Reference Liu, Dijst and Geertman2015) in Shanghai found that increased residential segregation between local and migrant older adults produced disparities in wellbeing between these two groups, although this study did not focus specifically on older migrants caring for grandchildren.
Government and policy determinants
Policy-level factors included medical insurance, hukou and pension systems.
Medical insurance system
One study (Wang and Li, Reference Li2017) found that, among all public policies, medical insurance was the most important factor influencing subjective happiness among older people migrating along with adult children as they may be afraid to get sick and go to hospital due to a lack of insurance and costly medical expenses. Even for those with medical insurance in their hometowns, complicated reimbursement procedures and costs of travel present significant difficulties. These institutional barriers affect the quality of life and mental health of older migrants (Yang and Zhang, Reference Yang and Zhang2015; Zhang and Xi, Reference Zhang and Xi2015; Wang, Reference Wang2017a; Zeng, Reference Zeng2017).
The hukou system
Due to the institutional constraints of the hukou (household registration) system, older migrants are not entitled to the benefits enjoyed by local older adults, such as free public transportation and free or preferential tourist attractions. These inequalities reflect social exclusion that can aggravate feelings of non-belonging and negatively affect integration (Xu, Reference Xu2017b).
Pension disparities
There are significant disparities in pension access in China, with older migrants from urban areas more likely to have pensions as their main source of income, and those from rural areas having no or limited pensions (Zhao et al., Reference Zhao, Brosig, Luo, Zhang, Yue and Rozelle2016). However, this was not explicitly discussed in studies of older people migrating along with adult children. One study (Zhang and Hu, Reference Zhang and Hu2016) reported that rural–urban migrants without pensions depend on adult children economically, aggravating older migrants’ stress and mental burden, while urban–urban migrants with fixed monthly pensions can maintain independence and be respected as parents. Another quantitative study (Wang and Li, Reference Li2017) confirmed that older migrants with pensions are more likely to be happy than those without pensions.
Interventions and suggestions
None of the reviewed studies introduced or assessed concrete mental health interventions for older people migrating along with adult children, although some emphasised the importance of social work interventions (Zhang and Xi, Reference Zhang and Xi2015; Chen et al., Reference Chen, Liao and Li2017; Xu, Reference Xu2017a). Xu (Reference Xu2017a), for example, discussed social work interventions for this group of older people at three levels: (a) case work focused on psychological adaptation, using lifecourse narrative treatment and family support, (b) group work such as learning groups for urban adaptation and peer support groups, and (c) community work linking community resources and supporting engagement in social activities.
While few studies examined specific interventions, some identified suggestions for improving mental health among older people migrating along with adult children. At the individual level, older migrants could actively engage in social interaction and community activities to adapt to urban life (Yao and Wang, Reference Yao and Wang2010; Li et al., Reference Li, Zhang and Zhang2011; Xia and Xia, Reference Xia and Xia2015; Di and Fu, Reference Di and Fu2017). At the family level, family members should offer more emotional support to older parents (Chen, Reference Chen2014; Xia and Xia, Reference Xia and Xia2015; Tong et al., Reference Tong, Bai and Cao2017; Zeng, Reference Zeng2017), encourage social activities, and teach older parents to use electronic devices to maintain connections with friends and relatives. At the community level, enhanced services should be established to enrich leisure time and social engagement, such as ‘acquaintance communities’ providing social support (Chen, Reference Chen2014), self-benefit activities to empower older people to join activities (Song et al., Reference Song, Ye and Xie2017) and self-aid organisations managed by older migrants themselves (Yao and Wang, Reference Yao and Wang2010; Zhao, Reference Zhao2013; Zhang and Hu, Reference Zhang and Hu2016). At the local government level, more resources (financial and human) should be allocated to communities, to provide professional services to help older migrants rebuild social capital and improve mental and social wellbeing (Zhao, Reference Zhao2013; Li et al., Reference Li, Zhou, Ma, Jiang and Li2017). At the national government level, efforts should be made to eliminate discriminatory policies and improve local economic status. Institutional barriers could be reduced by improving medical insurance and hukou policies, through local preferential policies for older people (Zhang and Xi, Reference Zhang and Xi2015; Zhang and Hu, Reference Zhang and Hu2016; Xu, Reference Xu2017b) and child-care policies, which support young families, prevent involuntary migration and relieve child-care duties imposed on older people (Li et al., Reference Li, Zhou, Ma, Jiang and Li2017).
Discussion
Mental health, a challenge for older people migrating along with adult children, has largely been overlooked by the public and in policy and research. Although no national-level survey data provide insight into the mental health of this group of older people, this systematic review showed that these older migrants face significant challenges. They reported high levels of depression, low quality of life, and negative experiences across dimensions of emotional, psychological and social wellbeing, including feelings of rootlessness, loneliness, poor self-acceptance, lack of quality family and neighbourhood relationships, and non-belonging to their place of residence.
It is noteworthy that only two comparison studies identified in our review compared the mental health of older migrants with local older adults. While one study (Li et al., Reference Li, Zhou, Ma, Jiang and Li2017) showed that higher prevalence of depressive symptoms was found in migrant elderly people (31.2%; Li et al., Reference Li, Zhou, Ma, Jiang and Li2017), another one showed that older migrants had higher levels of subjective happiness than their local counterparts (Xu et al., Reference Xu, Mou, Xu and Zeng2014). The contradictory results indicate that mental health should be measured by multiple indicators and consistent measurement tools. More comparison research is needed to understand better the relationship between mental health and older migrants with different socio-cultural and geographical backgrounds.
The challenges facing these older migrants have not earned sufficient attention from family members, the public, policy makers and researchers for several reasons. Firstly, older people migrating along with adult children may be labelled as a ‘happier’ group compared to other older groups in China (such as the ‘empty-nest’ elderly people, ‘left-behind’ elderly people who are taking care of grandchildren in rural China or older drifting workers who have to earn a living). Secondly, having no mental illness may be understood as being mentally healthy without the need for intervention. Thirdly, while most previous research has focused on adaptation or integration and the holistic status of older people migrating along with adult children, mental health as a concept is rarely mentioned and mental health problems facing these individuals are often overlooked in China. Therefore, more studies are needed to address mental health problems confronting this group of older people.
Determinants of mental health for older people migrating along with adult children require further research. Previous studies have identified positive determinants mainly at the individual and family levels: personal character, independent income, good physical health, social engagement, and familial economic and social support. Negative determinants included perceptions of inferior economic status compared with local elders, intergenerational conflict, and institutional or policy-level (medical insurance, hukou and pension) disparities. However, there is a need for further analysis of specific roles of key factors influencing mental health. Previous studies lack engagement with specific theoretical frameworks that could enable explanatory, rather than purely descriptive, analysis. Additionally, the lack of theoretical bases for explanatory analysis and insufficient comparative and regression analysis limit understanding of relationships and dynamics among determinants across different systems.
Strategies for addressing structural changes at community, societal and policy levels require more empirical evidence. Some studies identified recommendations to improve the wellbeing of older people migrating along with adult children: support for social engagement, community service provision (including peer support), provision of additional financial and human resources by local governments, and national efforts to eliminate discriminatory policies. These suggestions highlight the importance of older migrants’ mental health as a social issue which requires changes at community, societal and policy levels. They also reflect a widening perspective on support for older migrants beyond the traditional expectation of care responsibly borne by the family (Ngan and Kwan, Reference Ngan and Kwan2002). However, previous studies overlook the disparities in pension institutions, while rural–urban migrants tend to have limited pension and independent income. Additionally, the necessity and priority of suggestions is weakened by the lack of supporting evidence based on explanatory or comparative analysis.
Suggestions for future research
Empirical research indicates that older people migrating along with adult children face significant challenges in emotional, psychological and social wellbeing. However, this body of research is limited given the small number of published studies (with no studies on older people migrating along with adult children published in top journals in Mainland China during review period) and lack of diversity in conceptualisations of mental health and theoretical perspectives. Four directions for future research are identified based on this review.
First, most previous research has framed older people migrating along with adult children as passive study subjects. Despite identifying a series of challenges, it has largely ignored older migrants’ strength and resources. For example, as mentioned above, no reviewed studies explored how older migrants perceive their life purpose and meaning (e.g. how they value themselves for taking care of grandchildren) or successful cases or experiences of adaptation to a new environment in older age. Thus, future research should consider the strengths, agency and coping strategies of this group of older people.
Second, no specific research paradigms or frameworks were explicitly used in previous studies. While concepts of social integration and social capital were widely discussed, these are commonly used in studies on younger migrants. Older people migrating along with adult children have very different experiences as they are usually retired and closely bound with extended families, as discussed in overseas studies of immigrant grandparents (Chen and Lewis, Reference Chen and Lewis2015). Further conceptual work should examine how constructs of social integration and social capital are defined and applied in understanding older people migrating along with adult children in China, particularly given the growing phenomenon of migration and the government's aim for urbanisation covering 60 per cent of the Mainland Chinese population (Central Committee of the Communist Party of China and State Council, 2014).
Third, there is a lack of comparative analyses between sub-groups, such as rural–urban versus urban–urban migrants, migrant versus local elders and internal versus international older migrants who move for family reunion. More sub-group analyses could identify the uniqueness of different groups of older people migrating along with adult children and structural factors influencing mental health. This could inform more targeted policies and programmes to support older migrants better.
Finally, there is a lack of rigorous research on mental health interventions for older people migrating along with adult children and the evaluation of such intervention effects. Future research could explore the strengths and limitations of interventions for this group based on therapeutic theories (such as narrative theory, resilience theory, etc.) in order to understand the effects of interventions on older migrants’ mental health and empowerment.
Limitations
Older people migrating along with adult children are a special group that has emerged through the process of urbanisation in China. This review identified key findings from existing research on the mental health experiences of this group, gaps in previous studies and potential directions for future research, thereby informing a better understanding of this important topic. However, some limitations should be noted. First, the number of reviewed empirical studies is relatively small, with only 38 indicating a focus specifically on the mental health of older people migrating along with adult children. Some studies lack robustness in terms of research methodologies and theoretical bases.
Another limitation concerns the different perceptions of mental health in Chinese and Western culture. The reviewed studies have not only focused on psychological health, but also extended the concept of mental health to consider individual adaptation to the new environment. Studies that focused on social adaptation, social integration and mental health of older people migrating along with adult children were included in this review and analysed based on Keyes’ (Reference Keyes2013) framework of positive mental health, which was considered suitable for a Chinese holistic perspective on mental health. However, this review does not examine potential differences in perceptions of mental health in Chinese and Western culture. It is well documented that ethnic and cultural factors would affect psychopathology, prevalence, presentation and causes of symptoms in psychiatric disorders and cognitive disorders (Trinh et al., Reference Trinh, Bernard-Negron and Ahmed2019). Cultural beliefs also affect how illnesses are explained and conceptualised, making the Western biomedical models of health not necessarily relevant to people of diverse ethnicity and culture (Suzuki et al., Reference Suzuki, Goebert, Ahmed and Lu2015). Cultural values also dictate the attitudes towards various forms of mental health intervention and the stigma associated with the illness itself and the uptake of the interventions (Byers et al., Reference Byers, Lai, Arean, Nelson and Yaffe2016). Given the knowledge about the cultural variations in mental health, future research should be extended to examine further the across-group and within-group variations in how mental health issues are manifested, predicated and addressed in Chinese societies given the vast amount of diversity within this huge ethnocultural social entity.
Conclusions
Existing studies on older people migrating along with adult children reveal concerns about mental health outcomes and challenges in social adaption and integration. They have located older migrants’ wellbeing as a social issue which requires interventions beyond individuals and families. However, while services and policy measures are critically important to meet the specific mental health needs of this group of the population, there is a risk in labelling these older migrants as ‘needy’ or ‘vulnerable’, or overlooking the reality that care-giving roles may also be positively related to mental health (Sun, Reference Sun2012; Tang et al., Reference Tang, Xu, Chi and Dong2016; Zhou et al., Reference Zhou, Mao, Lee and Chi2017). While previous research has drawn attention to the issue of the mental health of older people migrating along with adult children, there are clear research gaps that should be addressed.
Author contributions
JJW was responsible for jointly designing the study, data collection, data analysis, drafting and finalising the article. DWLL was responsible for leading the design of the study, organising for data collection, data analysis, drafting and finalising the article.
Financial support
The authors received no financial support for the research, authorship and/or publication of this article.
Conflict of interest
The authors declare no conflicts of interest.
Ethical standards
This systematic review study made use of published data in public domains and therefore required no ethical approval.
