Elderly care needs and factors influencing negative emotions among first-generation only child parents in a Chinese city

Abstract

BACKGROUND

China has recently encountered severe challenges associated with population aging. Parents of first-generation only children face significant challenges regarding elderly care needs and the associated negative emotions.

AIM

To analyze the elderly care needs of first-generation only child parents in China and identify factors that influence negative emotions.

METHODS

This study used a cross-sectional design. Convenience sampling was used to select 1580 elderly individuals who met the inclusion criteria in a Chinese city between June and September 2022. A questionnaire was administered to collect general information about participants. Depression and anxiety were assessed using the patient health questionnaire-9 and generalized anxiety disorder-7 scale, respectively. A logistic regression analysis was performed to evaluate the relevant correlations.

RESULTS

Among 1580 first-generation only child parents, 1120 (70.89%) preferred family based care, 324 (20.51%) opted for community care, and 136 (8.61%) chose institutional care, with 460 (29.11%) reporting negative emotions. Significant differences in the distribution of negative emotions among only child parents were observed based on age, marital status, living conditions, disability, type of chronic disease, frailty status, and family support (P < 0.05). The regression analysis indicated that disability, type of chronic disease, living environment, frailty status, and level of family support were independent risk factors for negative emotions among parents with only children (P < 0.05).

CONCLUSION

Elderly care for parents of only children is primarily family-based. Independent risk factors for negative emotions in this group include disability, chronic disease type, and living environment.

Key Words: Aging; First generation; Only child; Elderly care needs; Negative emotions; Influencing factors

Core Tip: The rapid aging of the Chinese population has created significant challenges for first-generation only child parents concerning their elderly care needs and associated negative emotions. This study therefore assessed the elderly care needs of first-generation parents of only children in a Chinese city, to identify factors that influence negative emotions. Our findings indicate that these parents primarily rely on family-based care, with only a small proportion opting for community or institutional care. The independent risk factors for negative emotions include disability, chronic disease, living environment, frailty status, and family support. Health managers should screen for these risk factors, implement early preventive strategies, and enhance family support to alleviate negative emotions.

INTRODUCTION

The global concern of population aging is particularly pronounced in China, the most populous country in the world[1]. According to United Nations aging standards, China officially became an aging society in 2000[2]. The latest data from the seventh national census indicate that the population aged ≥ 60 years has reached 264 million, accounting for 18.7% of the total population, with those aged ≥ 65 years reaching 190 million or 13.5%[3]. China has become the country with the largest global elderly population. Moreover, the elderly population is projected to approach 500 million by 2050, marking a transition into a phase of deep aging in which elderly care concerns will become even more pronounced[4]. Currently, the elderly care model of China relies primarily on family support. Approximately 90% of elderly individuals reportedly depend on their families for self-care, 7% benefit from community home care services, while only 3% receive care from institutions[5,6]. This indicates that despite the gradual development of community and institutional care, family based elderly care remains the core model within the elderly care system in China. However, as the elderly population and the degree of aging continue to increase, the burden of elderly care becomes increasingly heavy.

The implementation of the family planning policy has effectively controlled the growth of the population in China and improved the quality of life of its citizens; however, it has also elicited certain social issues. Only children must now take care of their own families and work while also taking care of their parents. Such overwhelming pressure often makes them feel helpless, which has emerged as a problem that parents of only children have to face in the pension system and will exist for an extended duration into the future.

Notably, parents of first-generation only children in urban areas are gradually entering old age. Because these only children have largely entered the workforce and established new families, the traditional “4-2-1” family structure (comprising 4 grandparents, 2 middle-age parents, and 1 child) has become more prevalent[7]. This unique family background has led to the gradual weakening of traditional elderly care resources and functions, resulting in increasingly prominent issues regarding elderly care for parents of first-generation only children[8]. Elderly parents in these families are at higher risk of depression[9,10]. The incidence of depressive symptoms among parents of only children can reportedly be as high as 20%-40%[11-13]. However, research investigating the factors that influence negative emotions (such as depression and anxiety) in this population remains relatively scarce.

To explore elderly care needs and factors influencing negative emotions among first-generation only child parents, this study focuses on a specific city in China. We used the generalized anxiety disorder-7 (GAD-7) scale[14] and the patient health questionnaire-9 (PHQ-9)[15] as assessment tools to identify the presence of negative emotions among the study participants. We aimed to analyze elderly care needs and factors influencing negative emotions among parents of the first generation of only children in the context of aging in a specific city in China. Our goal was to provide a theoretical basis and empirical support for the relevant policies formulated by the Civil Affairs and Social Security Departments of China.

MATERIALS AND METHODS

Study design and participants

This study used a cross-sectional design, with a self-designed questionnaire and existing scales, to conduct field visits between June and September, 2022. A stratified random cluster sampling method was used to select elderly individuals ≥ 60 years of age in XX City. In a certain city, stratified random sampling was planned based on administrative regions, using a reliable and valid questionnaire to analyze the basic conditions of the randomly selected communities' parents of first-generation only children, including sex, age, occupation, monthly income level, education level, health status, and living arrangements. We also analyzed the elderly care needs of the first generation only children, including their economic security, emotional support, daily care, medical care, and social interaction needs. A total of 1624 questionnaires were distributed and 1580 valid responses were collected, corresponding to a response rate of 97.3%.

Inclusion and exclusion criteria

Residents of XX city who were ≥ 60 years old and parents of only children were included. Individuals with severe acute or chronic illnesses and those who were unable to communicate effectively were excluded.

Ethics approval

This study was approved by the Research Ethics Committee, and participation was voluntary.

Demographic information and clinical data

Collection of general information: Information regarding sex, age, educational level, occupation before retirement, marital status, living situation, monthly income, disability status, medical payment methods, and types of chronic diseases was collected.

Negative emotions (anxiety/depression): The presence of negative emotions was defined as having ≥ 1 of either anxiety or depression. Depression was assessed using the PHQ-9, which consists of nine items rated on a four-point Likert scale ranging from 0 (never) to 3 (every day). Scores can range from 0 to 27, with a score ≥ 10 indicating the presence of depression. The Chinese version of the PHQ-9 has demonstrated strong reliability and validity, with a Cronbach’s alpha coefficient of 0.834 in our previous study[15].

The GAD-7 scale was used to evaluate anxiety levels. This scale comprises seven symptom items aimed at measuring the severity and functional impact of anxiety symptoms experienced over the previous 2 weeks. Responses were rated on a four-point Likert scale, ranging from 0 (never) to 3 (every day), resulting in a total score from zero to 21. A score ≥ 10 indicated the presence of anxiety. The Chinese version of GAD-7 is commonly used to evaluate anxiety severity in the Chinese population, with a Cronbach’s alpha coefficient of 0.938 in a previous study[14].

Fried frailty phenotype[16]: The frailty status of the participants was assessed using a combination of self-reporting and objective measurements, including fatigue, decreased walking speed, reduced grip strength, and decreased physical activity. Each of the above criteria counted as 1 point, with a scoring range of 0 to 5, as follows: 0 points, indicated health; 1-2 points, indicated pre-frailty; and ≥ 3 points indicated frailty. Higher scores indicated greater frailty, with an internal consistency coefficient of 0.818.

Family Apgar index scale[17]: This scale assesses adaptability, partnership, growth, affection, and intimacy. Each item was scored from 0 to 2, resulting in a total score ranging from 0 to 10. Scores of 0-3 indicated severe family dysfunction, 4-6 indicated mild-to-moderate dysfunction, and 7-10 indicated good family support. Higher scores reflected greater family support, with an internal consistency coefficient of 0.872.

Statistical analysis

Data entry was performed using Epidata version 3.1 (www.epidata.dk), which enables efficient and accurate data management through double entry by two individuals, to minimize data entry errors. Statistical analyses were performed using SPSS (version 22.0; IBM Corp., Armonk, NY, United States), a widely used statistical analysis software that offers robust tools for data management and a variety of statistical tests, making it suitable for the comprehensive analyses of complex datasets. Continuous variables reported as descriptive statistics are expressed as means and standard deviations, and categorical variables are expressed as counts and percentages. Pearson’s χ² test was used to compare categorical variables. Owing to the non-normal distribution of the dependent variable and collinearity issues, a binary logistic regression (using the stepwise likelihood ratio method) was employed for the multi-factor analysis. The odds ratio (OR) was employed to determine the ratio of the odds and the 95% confidence interval (CI) for an event occurring in the negative emotion group compared to its occurrence in the group without negative emotions. Negative emotions were defined as the outcome variable, categorizing participants into two groups: Those who experienced negative emotions and those who did not. Two-sided statistical tests were used in the regression model, and differences with P < 0.05 were considered significant.

RESULTS

Demographic and clinical characteristics

The demographic and clinical information of the participants is summarized in Table 1. Among the 1580 parents of only children, 781 (49.43%) were men and 799 (50.57%) were women. Age distribution among the cohort was as follows: 60-69 years [48.35% (n = 764)]; 70-79 [n = 566 (35.82%)]; 80-89 [n = 220 (13.92%)]; and ≥ 90 [n = 30 (1.90%)]. The educational levels of the cohort were as follows: Illiterate [n = 541 (34.24%)], primary [n = 601 (38.04%)], junior high school [n = 296 (18.73%)], vocational/high school [n = 106 (6.71%)], and college education or above [n = 36 (2.28%)]. Regarding preferred living arrangements, 1120 participants chose family care (70.89%), and 324 (20.51%) and 136 (8.61%) chose community and institutional care, respectively. A total of 460 (29.11%) participants reported experiencing negative emotions. The distribution of elderly care needs among parents of only children is illustrated in Figure 1A and a comparison of negative emotions among parents is presented in Figure 1B.

Figure 1 The needs and negative emotion distribution of parents with only child. A: Distribution of the demand for old-age care of parents with only child; B: Distribution of the negative emotions of parents with only child.

Table 1 Demographic and clinical characteristics of people.

Variable	People (n = 1580)	Percentage (%)
Sex
Male	781	49.43
Female	799	50.57
Age (year)
60-69	764	48.35
70-79	566	35.82
80-89	220	13.92
≥ 90	30	1.90
Education
Illiteracy	541	34.24
Primary	601	38.04
Secondary	296	18.73
Technical secondary school/high school	106	6.71
College and above	36	2.28
Distribution of pension needs
Home care	1120	70.89
Community care	324	20.51
Institutional care	136	8.61
Negative emotions
Yes	460	29.11
No	1120	70.89

Univariate analysis of negative emotions

Significant differences exist in negative emotions among parents of only children based on age, marital status, living situation, disability, chronic disease type, frailty status, and family support (P < 0.05). Compared with patients with negative emotions, those without were younger, and a higher proportion were married, living with a spouse, and not disabled. However, no significant differences were found in the choice of elderly care method based on sex, pre-retirement occupation, education level, monthly income, or medical payment method (P > 0.05) (Table 2).

Table 2 Univariate analysis of negative emotions, n (%).

Variable	Without negative emotions (n = 1120)	Negative emotions (n = 460)	P value
Gender			0.181
Male	537 (47.95)	244 (53.04)
Female	583 (52.05)	216 (46.96)
Age (years)			0.033
60-69	565 (50.45)	199 (43.26)
70-79	390 (34.82)	176 (38.26)
80-89	140 (12.5)	80 (17.39)
≥ 90	25 (2.23)	5 (1.09)
Education			0.363
Illiterate	369 (32.95)	165 (35.87)
Primary school	427 (38.13)	174 (37.83)
Junior high	222 (19.82)	81 (17.61)
Vocational/high school	80 (7.14)	26 (5.65)
College and above	22 (1.96)	14 (3.04)
Occupation before retirement			0.341
None	338 (30.18)	123 (26.74)
Some	782 (69.82)	337 (73.26)
Marital status			< 0.001
Unmarried	22 (1.96)	23 (5)
Married	862 (76.96)	319 (69.35)
Widowed	223 (19.91)	110 (23.91)
Divorced	13 (1.16)	8 (1.74)
Living situation			< 0.001
Living alone	88 (7.86)	67 (14.57)
Living with spouse	664 (59.29)	237 (51.52)
Living with children	350 (31.25)	101 (21.96)
Other	18 (1.61)	55 (11.96)
Monthly income (yuan)			0.759
< 1000	755 (67.41)	291 (63.26)
1000-2000	241 (21.52)	108 (23.48)
2001-3000	88 (7.86)	45 (9.78)
> 3000	36 (3.21)	16 (3.48)
Disability			0.022
None	984 (87.86)	389 (84.57)
Yes	136 (12.14)	71 (15.43)
Medical payment method			0.721
Urban employee basic	532 (47.5)	225 (48.91)
Urban resident basic	67 (5.98)	23 (5)
New rural cooperative	481 (42.95)	186 (40.43)
Commercial health insurance	2 (0.18)	1 (0.22)
Other	38 (3.39)	25 (5.43)
Chronic diseases			< 0.001
None	561 (50.09)	195 (42.39)
1 type	367 (32.77)	163 (35.43)
2 types	132 (11.79)	76 (16.52)
≥ 3 types	60 (5.36)	26 (5.65)
Frailty status			< 0.001
Healthy	660 (58.93)	130 (28.26)
Pre-frail	343 (30.63)	180 (39.13)
Frail	117 (10.45)	150 (32.61)
Family support			< 0.001
Good	612 (54.64)	160 (34.78)
Mild to moderate impairment	330 (29.46)	162 (35.22)
Severe impairment	178 (15.89)	138 (30)

Multivariate analysis of negative emotions

Using negative emotions as the dependent variable (0 = no, 1 = yes), statistically significant variables from the univariate analysis (Table 2) were incorporated as independent variables. Binary logistic regression analysis was performed to identify the independent factors influencing negative emotions. The regression model and variable assignments are summarized in Table 3. Results of analysis indicated that disability (OR = 2.408, 95%CI: 1.109-1.832), chronic disease type (OR = 2.187, 95%CI: 1.103-1.748), frailty status (OR = 2.343, 95%CI: 1.274-1.923), family support/care level (OR = 3.622, 95%CI: 1.315-5.397), frailty status (OR = 2.343, 95%CI: 1.274-1.923), and living arrangement (OR = 2.315, 95%CI: 1.165-1.871) were significant factors that influenced negative emotions. These findings are summarized in Table 4 and illustrated in Figure 2.

Figure 2 Forest map of independent influencing factors of negative emotions of parents with only child.

Table 3 Description of assignment.

Item	Assignment
Age	60-69 years = 1, 70-79 years = 2, 80-89 years = 3, ≥ 90 years = 4
Marital status	Single = 1, married = 2, widowed = 3, divorced = 4
Living situation	Living alone = 1, living with spouse = 2, living with children = 3, other = 4
Disability	No = 0, yes = 1
Chronic disease types	None = 0, 1 type = 1, 2 types = 2, ≥ 3 types = 3
Frailty status	Healthy period = 1, pre-frailty = 2, frailty period = 3
Family support	Good = 1, mild to moderate impairment = 2, severe impairment = 3

Table 4 Binary logistic regression analysis of negative emotions.

Variable	OR	95%CI	P value
Disability	2.408	1.109-1.832	0.043
Living situation	2.315	1.165-1.871	0.036
Age	2.536	1.107-3.336	0.917
Chronic diseases	2.187	1.103-1.748	< 0.001
Marital status	2.951	1.756-2.219	0.876
Frailty status	2.343	1.274-1.923	0.025
Family support	3.622	1.315-5.397	< 0.001

OR: Odds ratio; CI: Confidence interval.

DISCUSSION

This study provides a comprehensive analysis of the demographic and clinical characteristics of parents of only children, highlighting the independent risk factors associated with negative emotions in this population. Our results revealed that 29.11% of the 1580 participants reported experiencing negative emotions. This high prevalence underscores the psychological health challenges faced by older adults, particularly the parents of only children. This is consistent with the results of a previous study[10].

Demographic data revealed a balanced sex distribution, with 49.43% of participants being men and 50.57% being women. The age distribution indicated that the majority of participants were in the 60-69 years age group (48.35%), followed by the 70-79 years age group (35.82%). This suggests that most parents of only children are in the early stages of old age, a critical period when the risk for psychological health issues exists due to declining health and increased social isolation[18]. The educational level of the participants was relatively low, with a significant proportion being illiterate (34.24%) or having completed only primary education (38.04%). Liang et al[19] reported that in China, the education level of the elderly is relatively low and that they experience memory loss and poor comprehension ability, which is consistent with the results of this study. Low educational attainment may contribute to lack of awareness of mental health resources and coping strategies, potentially exacerbating feelings of helplessness and depression.

The distribution of elderly care needs among parents of only children presented a predominance of family (70.89%), community (20.51%), and institutional (8.61%) care. Reliance on family care may impose greater emotional burden on parents, particularly when family members are unable to provide adequate support[20]. A considerable proportion of the participants lived alone or in environments with poor support, which could further exacerbate feelings of loneliness and depression. This finding aligns with previous research and highlights the importance of social support networks in mitigating psychological distress in older adults.

Univariate analysis revealed significant differences in negative emotional status among participants based on age, marital status, living situation, disability, type of chronic disease, frailty status, and family care level (P < 0.05). Multivariate logistic regression analysis identified disability, chronic disease, frailty status, and family care level as independent risk factors for negative emotions. Specifically, the OR were as follows: Disability OR, 2.408 (1.109-1.832); living situation OR, 2.315 (1.165-1.871); chronic disease type OR, 2.187 (1.103-1.748); frailty status OR, 2.343 (1.274-1.923); and family care level OR, 3.622 (1.315-5.397). Frailty, deformities, and disabilities reportedly lead to negative emotions and discrimination, consistent with the findings of this study[21,22]. These findings are consistent with existing literature highlighting the impact of physical health on psychological health outcomes in older adults.

Compared to previous studies, our findings are consistent with the observed prevalence of negative emotions in older adults, which suggests that a large portion of this demographic faces similar psychological challenges. However, our study uniquely highlights the specific role played by educational attainment as a factor for promoting mental health awareness, which differs from previous studies that focused primarily on health status.

Therefore, an urgent need exists for targeted mental health interventions for parents of children who experience negative emotions, and future research should implement early prevention strategies that target the risk factors identified in this study. These strategies include community-based programs, family education regarding mental health resources, workshops to improve coping skills, and initiatives to promote social engagement and reduce isolation. In addition, the incorporation of mental health screening into the routine medical care of older adults will facilitate the early identification and intervention of those at risk.

Limitations

This study has several limitations that should be noted when interpreting our findings, the first of which is its cross-sectional design and data collection at a single time point. This restricts our ability to make causal inferences about the relationships between demographic and clinical factors and negative emotions. Future longitudinal studies are needed to better understand the evolution of these relationships. Second, the assessment of negative emotions, frailty, and family care levels relied on self-administered questionnaires. This may have introduced bias because participants may have underestimated or overestimated their emotional states or health conditions due to social desirability or lack of self-awareness. Future research should combine objective measures with self-reporting to enhance the validity of findings. Additionally, although this study used stratified random sampling, the results may not be generalizable to all parents of only children from different regions or cultural contexts. This study was conducted in a specific urban area and the unique sociocultural dynamics of this region may have influenced the results. Further studies conducted in diverse settings are required to validate these findings. Future studies should consider a broader range of variables to provide a deeper understanding of independent factors affecting negative emotions in this population.

CONCLUSION

In summary, in the context of ageing, parents of only children rely primarily on family care, with only a small proportion opting for community or institutional care. Disability, chronic disease, living environment, frailty status, and family care level were independent risk factors for negative emotions among parents. Therefore, health managers should screen for these risk factors, implement early prevention strategies, and enhance family care to mitigate negative emotions.