The lived experience of family members of older people who have committed suicide in rural China

Background: China has the largest older population in the world. With the increasing trend of ageing, the problem of suicide among old people is increasing rapidly, especially in rural areas. The pressures and challenges faced by family members of loved ones who have committed suicide has been studied closely around the world. However, the impact of suicide on the lives of family members have not received enough attention in China. Therefore, it is very important to understand the lived experience of the family members of older people who have committed suicide. The study aims to understand the lived experiences of family members who have experienced their older family member’s suicide in a rural area based in Shaanxi Province, China. Methods: Interpretative phenomenological analysis (IPA) was used for this study. Semi-structured individual interviews with ve family members of older people who have committed suicide recruited from a rural area of Shaanxi Province, China. Results: Three main themes emerged from the study: (a) Initial reactions; (b) Continual effects; (c) Social attitudes. Conclusions: With the development of China’s economic, social and cultural changes, the suicide of the older people in rural China poses a challenge to the future living quality of their family members. It shows that it is necessary to pay attention to families of older people who have committed suicide. It also shows that more support is required to improve the quality of life of families of older people who have committed suicide in rural China.


Background
Suicide has become a serious public health and social problem worldwide, and imposes a heavy mental, medical and economic burden on individuals, families and society (1). Due to rapid ageing in some countries and regions, senior people committing suicide has become more of a public health issue One study has shown that China has one of the highest suicide rates in the world (2), especially amongst the older population. Another study also reported that the rate of suicide is increasing among the older population in recent years (3). Studies reported that about 38.2% to 44% of all suicidal deaths in mainland China were committed by people aged 65 years and older, of whom 79% were rural residents (4,5). Previous study has also reported that the suicide rates in rural and urban China are very different. The suicide rate in rural areas is usually much higher (2).
China has the largest older population in the world. Living with grown-up children is generally regarded as a form of family-based care (6). However, with the acceleration of urbanization and social development, the traditional form of family-based care has begun to decline in recent decades (7). Especially in rural areas, where older people do not have pensions and their family's income is relatively low compared to urban residents, thus, maintaining the quality of life and care becomes even more di cult (8, 9). In some cases, there are situations where children shirk the responsibility around each other and no one is willing to support the older people (10). Furthermore, with the acceleration of ageing and the increase of migrant workers, older parent has been left behind in rural areas are becoming more common which is inconsistent with the traditional co-residency culture (11). These factors may create psychological pressures for older people, which may lead to a higher suicidal rate among the older people in rural areas.
Compared with studies about older people who have commit suicide, the psychological experience of family members of older people who have committed suicide has received less attention. In addition, due to the fear of discrimination and stigmatization, their family members are less willing to share their feelings with others (12). Study indicated that family members of loved ones who have committed suicide more likely to experience sadness, guilt, abandonment, anger, shame and rejection (13). In addition, family members will be stigmatized by society, leading to a higher risk of suicidal thoughts and suicide attempts, which will affect their health and life (14). In Chinese norm, suicide of older people is usually regarded as the children being un lial, family con icts or bad luck, especially in rural areas (15). It will seriously affect the family's quality of life. Therefore, this study aims to understand the lived experience of the family members of those older people who have committed suicide and to discover the problems faced by family members after their loved one has passed away, in order to inform relevant health professionals and policy makers.

Study aim
The study aims to understand the lived experience of people with an older family member who has committed suicide in a rural area in Shaanxi Province, China.

Study design
Interpretative phenomenological analysis (IPA) approach was used in the study. IPA is rooted in philosophical traditions of phenomenology and symbolic interactionism, it explores lived experience and the way in which individuals make sense of their experience by focusing on the internal psychological meanings evident in their accounts (16). It aims to explore an individual's personal perception, or interpretation of an experience, in detail. It can also be used to explore the inner world of people in special situations or personal psychological feelings (17). Therefore, IPA is suitable for exploring people's lived experiences of their loved one's suicide.

Inclusion criteria and recruitment
The participants were recruited from a rural area in Shaanxi Province. Data were collected from November 2020 to February 2021 through a snow-balling approach. The rst participant was recruited from the same living area as the rst author (MC), the rest were introduced to the study one by one.
Participants who were interested in the research received an invitation letter and a research information sheet. Participant inclusion criteria were as follows: (a) has a family member aged ≥60 who has committed suicide.
(c) had the ability to participate in the interviews.

Study site
Shaanxi was selected as the recruitment site because it is one of the most important birthplaces of Chinese culture. In addition, Shaanxi is a less economically developed province in China. Healthcare and social support for older people is also less developed, but its culture is the most traditional compared to other places in China. With the emergence of immigration, most young and middle-aged people from rural areas seek jobs in cities. The residents who stay in the village are mostly frail and old, and there are hardly any social or recreational activities for them. Most older people live with their spouses and rarely with their children, but they receive various forms of support from their children.

Data collection
Semi-structured individual interviews were conducted. Semi-structured interview can make necessary adjustments exibly according to the actual situation during the interview (18), thus, have the advantage of gaining a deep and comprehensive understanding of the participants' life experience. Open-ended questions were designed to allow interviewees to talk about their lived experience after the older person's suicide in their own way. Before conducting the interview, the researchers ensured that all participants understood the potential risks that may emerge from the research and gave an opportunity for the participants to ask questions that they were concerned about at any time. Then, they informed them about their right to withdraw at any time. Interviews were conducted in the participants' own houses or in a place they preferred. The interviews lasted between 30 and 60 minutes. All interviews had been audiorecorded and transcribed into verbatim.
As this study involves sensitive topics which may cause an emotional reaction, interview questions have been carefully considered and designed in advance. The research team also prepared to deal with such emotional issues and responses during the interviews. For example, if the participants appear to have any emotional reactions, such as crying or being distressed, the research team was prepared to give them time to calm down and allow them to drop out from the interview if they so wish. The village clinic physician will be informed with the consent of the participant if further support was needed, and a contact number of a support group for suicide was provided. Field notes were used for taking down any issues as well as the re exivity of the researcher, such as their personal experience of involving of such sensitive questions, or their professional work in this area. It's surprise, most people who participated in the research carried on with the interviews well and found it helpful that their voices were heard. There may be less chances for them to openly talk their feelings. A counselling number was also available for the researcher if anyone needed it.

Data analysis
The process of data analysis was adapted from Smith's (2009) six steps of IPA: First of all, the research team read the transcript repeatedly and got familiar with the content. After this, individual transcripts were coded line by line in detail, preliminary notes were made in the left margin, the key code words were recorded in the right margin. Then, the codes were listed and grouped into the initial emerging themes. At this stage, the researchers looked for connections across the initial emerging themes and determined the patterns between them. The rest of the transcripts were analyzed in the same way. Finally, a master table was made to present the emerging themes in all transcripts, establish connections, and group the emerging themes of each transcript to identify and compile the main themes. During the process of analysis, in order to maintain accuracy and correctness, researchers reviewed and revised the themes with verbatim extracts and transcripts several times. The research team met regularly to discuss any issue raised from the data analysis. In addition, the rst author went back to the participants to discuss and con rm some unclear issues.

Results
The sample included ve family members of senior people who had committed suicide. The participants were sons, daughters or siblings of an older person who has committed suicide. Participants included three females and two males. Among them, two participants were unemployed without income and three participants were farmers with low incomes. All people had no religious beliefs.

Theme one: initial reactions
This theme re ects the initial reactions of the participants and their perceived experiences of grief. Words such as "heartbroken", "sad" and "unbelievable" were frequently used by the participants. Some participants expressed that they also had suicidal thoughts after their family members committed suicide. For example, participant Zhao says: "I didn't want to work. An important people in my life had been lost due to suicide and I wanted to go with her." (Zhao) Participant Cao has had a same feeling and similar thoughts (suicide) after her father committed suicide, she says: "I felt that we (children) were very useless. We didn't take care of our father well. If we had done so, he might not have died. I wanted to commit suicide too." (Cao) After the older family members committed suicide, family members will initially have emotional reactions. The degree of reaction is related to how close the relationship was with the suicidal person. In this study, participants have not only expressed thoughts of suicide (luckily, both the participants hadn't been planning for their death), but also experienced the psychological effects and expressed their feelings of heartbreak, grief and sadness. Hu described her miserable feelings after her mother committed a suicide.
" When I learnt that she had committed suicide, I was broken, I couldn't accept it, I felt panicked, I was very sad, tears streamed down my face." (Hu) Another participant, Li says: "Oops (dialect for shock), it made me tremble and shocked, I felt very sad. I felt restless every day. I didn't know what I was doing." (Li) Stress caused by bereavement can increase the likelihood of onset or worsening of one's physical or mental disorders. In addition, the medical and economic levels are more likely to be underdeveloped in rural areas, people living in such areas often ignore bereavement caused by suicide and worsen the condition; they hardly seek medical support. This shows that it is very important for the government and relevant departments to consider the impacts on the family members of the senior people who have committed suicide in rural areas.
The suicide of the older person could cause their family members to feel guilty as well.
"I regretted that I was busy with work every day and did not take good care of my mother. If I took good care of my mother, she would not commit suicide." (Hu) Similarly, Zhang says: "I really am a useless person (crying), I didn't have the ability to take care of her when she was alive, due to the hardship of our life. If my mother did not commit suicide, now that the living conditions are getting better, she would have had a better life… so I always feel very guilty." (Zhang) In rural China, where economic, social and cultural changes happen rapidly, young people leave to work and earn money to support their families and may not have time to take care of the older people. This causes the family members to perceive a feeling of regret after the older people have committed suicide, and they blame themselves for causing their loved ones' suicide.
Theme two: continual effects Continual effects described by the participants were more associated with long-term psychological impacts after their loved one committed suicide. It is more likely to include continual bereavement, worry and stress, and di culties with life arrangements after the event.
According to Hu, the suicide of her mother has caused continual bereavement which has been lasting for many years. She says: "Until now, when I wear the cloth shoes and embroidered insoles she made for me, I will think of her, and I feel very sad and want to cry." (Hu) Another participant, Zhang says: "When I see other people's mothers, I think of my mother, and I can't help crying and I'm sad." (Zhang) These continual psychological impacts have been present with most of the family members. In addition, the suicides of the elders brought huge nancial pressure to the family due to the funeral costs. All participants worried and stressed about the nancial issues. For example, both participants Cao and Zhao experienced the burden of funeral costs.
"I was worried about how to handle the funeral of my father, because the economy was relatively di cult, and the economic pressure in all aspects of burying my father was very high. Where should the funds come from?" (Cao) "I'm worried about how my sister's family lives, the family is very poor with no money, how can they afford to bury my sister?" (Zhao) In traditional Chinese culture, a more decent and costly funeral not only represents the family's reputation, but also means that more respect is being paid for towards their loved one who passed away. Therefore, most participants expressed that they were worried about funeral costs. Consequently, this has become a psychological burden for most participants. Especially, in rural China, most of the household incomes comes from their eld work and odd jobs, this extra cost has made a life-long impact on the participants and their families. The government should consider changing the cultural norm of holding an expensive funeral ceremony and supporting low-income families with funeral costs.
Furthermore, there is a speci c custom in the countryside about suicide: if an older female person has committed suicide, the family needs to report the tragedy to the person's maiden family (the woman's family before she was married). When the person's maiden family hear the news, they will become angry and perceive the suicide as the older person's children's fault, and they are more likely to ask for an expensive and decent funeral. There would be a con ict between the older female's maiden family and her married family if a deal cannot be made. Thus, the family is very worried and upset about this situation. This has not only caused lifelong pain to family members, but also led to a nancial burden to the family. It is more likely to cause large amounts of debt for the family members. Zhang says: "My brother and I are very scared. Hearing my father telling me how to report the funeral to my uncle's house, I still feel very scared and stressed when I think about it." (Zhang) Similarly, another participant Cao says: "My brother went to report the funeral. My uncle was very angry, he was out of control. I can still recall the scene now, I was very afraid." (Cao) Except from the nancial burden after the funeral expense, suicide of a loved one not only causes longlasting psychological impacts on most of the participants, but also effects the future living arrangements for the family members as well as the quality of their life.
"After my mother passed away, no one took care of my children. I can no longer go out to work and earn money. Life is very di cult." (Hu) "When I came back home, no one would cook for me. My family is in bad nancial condition and no one gave me money to support my education, so I stopped studying." (Zhang) In China, a reciprocal family relationship is a strong link for family members to support each other, especially between the older and younger generations. For example, it is more common in the rural areas for the grandparents to look after their grandchildren while their adult children go to work to earn the household income for the whole extended family. Apart from the miserable feelings brought on by the suicide, it can also be a nancial disaster for the whole family due to the breakdown of the reciprocal family relationship. It is suggested that the local support services should be available to support these families and intervene with the funeral arrangements and related issues.
As for the long-term psychological effects, time has helped heal participants. Participant Hu says: "It had already happened, and we must face it. I know that recovering will take a long time, and as time goes by, I would be better." (Hu) Another participant Zhao says: "I thought about it, the dead cannot be resurrected. After a period of time, I will gradually recover." (Zhao) In the study, some family members gradually overcome the suicide of their loved one, though there is still hardship. Health professionals should be taking steps to support them.
Theme three: Social attitude This theme illustrates the attitude of the public and society towards the families of the older people who have committed suicide, and how it creates a sense of social stigma and isolation. In Chinese traditional culture, it is shameful and indecent if an older family member commits suicide. In the eyes of others, it means that the children did not treat the older person well. This brought not only tremendous psychological pressure to the family, but also seriously affected the family's reputation. In this study, participants felt frustrated by villagers' gossip. For example, "I went out in the village, the villagers gossip that my mother died by drinking pesticide, I felt frustrated and I thought that it was disgraceful." (Zhang) Similarly, Cao says: "As a family member, my father's suicide made me 'lose face' in front of villagers. The villagers misunderstood me and said that I didn't respect my father, which caused him to commit suicide. Villagers in the village would laugh at me and say that I didn't even take care of my father, which had a great impact on my personal pride". (Cao) In rural areas where the economy and technology are underdeveloped, people gossip at the door as a means of entertainment. After the elders committed suicide, the villagers often gossiped about the suicide event as an indecent thing and blame the family as the cause of the suicide. Participant Hu perceived discrimination as well as feeling ashamed. She says: "The neighbors said that if we took good care of her, she would not commit suicide. It is the lack of attentive care that leads my mother to suicide". (Hu) Similarly, Li says: "The villagers said that I was not lial to my mother which is the reason why she committed suicide. My children and grandchildren felt that they have lost face in the village. What can I do? I feel very ashamed now." (Li) These excerpts illustrated the negative social attitudes and stigma presented in the study associated with the suicide event in a traditional, speci c, cultural setting. People mistakenly believed that the elder committed suicide because their family members were not lial to the older person or did not take good care of them. In this matter, the family perceived the experience of shame and helplessness. The phase 'what can I do?' has shown the participant's vulnerability to this stigmatizing label and situation. More importantly, it had serious impacts on her long-term mental health and quality of life. This suggests that the local government, health professionals and policy makers should think about suicide preventions and interventions in rural areas, as well as reconsidering the social perceptions of suicide.

Discussion
This study disclosed the lived experience of family members of senior people who had committed suicide. It re ects the process of the family members' grieving, continual long-term psychological effects as well as social attitudes towards them. The effects of suicide bereavement are wide-ranging, including high levels of stress, depression, and anxiety (19).
The suicide of older people can have serious psychological impact on their family members. All participants in this study have experienced grief and sadness, including the initial response to heartbroken and the process of psychological effects over time. Previous study indicates that grief is the universal, instinctual and adaptive reaction to the suicide of a family member (20). One study has also found that family members of people who have committed suicide have signi cantly higher levels of psychological distress two years after losing their loved ones (21). Family members of people who have committed suicide experience higher levels of sadness, depression, despair, post-traumatic stress disorder (PTSD) symptoms, anxiety, and suicidal behaviors compare to other causes of death (22). This study has also found that all the participants have experienced these psychological responses after their loved ones' suicide. Moreover, most participants expressed that after their parents committed suicide, they are more likely to blame themselves for causing their loved ones to commit suicide. Filial piety is the core and foundation of traditional Chinese ethics and culture, and it plays the role of supporting the senior family members in traditional Chinese social life (23). However, this family support model has become unavailable due to immigration and urbanization. For this reason, some participants believe that due to their own study and work, they did not take good care of the elders, and this made them feel that their being un lial was what caused the suicide of the elders. They often feel very guilty which causes them to have serious psychological problems. This gives us a warning, to pay attention to the mental health of family members of older people who have committed suicide, especially those who lived in rural areas, to prevent the tragedy from happening again. However, there lack the relevant support services in most of rural areas in China. This suggests that the government and the community must implement a series of interventions, to assess the suicide risks of the family members and support their psychological needs.
In addition, in China, most rural residents live without pensions (24), so the older residents are more likely to be nancially depend on their children. This family nancial de cit may also be a reason for suicide. In this study, two older people committed suicide due to care burden problems, two older people committed suicide due to personal health reasons, another one due to multiple reasons. Previous studies reported that older people living in rural areas with two or more chronic physical conditions have a signi cantly higher risk of suicidal ideation (25,26). In this study, three of the older people who have committed suicide had more than three chronic diseases. Studies have shown that the health status of residents in rural areas in China is not optimistic, many patients cannot afford expensive medical expenses (27). Therefore, the older people may choose to commit suicide in order to reduce the pressure of the medical and care costs on their children. Study indicates that people are more likely to fall into the vicious circle of poverty and poor healthy (27). This suggests that improving the level of medical care and income support, especially improving the accessibility and ability of rural residents to obtain medical care is very important.
Furthermore, social attitudes have a huge impact on the family members of suicidal older people. Studies have shown that family members of someone who has committed suicide are often stigmatized by society in rural areas (14). This study is consistent with previous studies, which identi ed that social stigma affects the quality of life of family members after other family members committed suicide. Filial piety is still widely advocated by society and is binding to children (28). In consequence, rural residents generally believe that the suicide of the older person is caused by the children being un lial. In the study, due to the villagers' gossip, all participants experienced distress and guilt. Previous studies have also shown that family members of suicidal elderly often feel ashamed, blamed, and judged and had higher perceived stigma levels. This was associated with psychological distress, depression, self-harm, and suicidality worldwide (29). The ndings of the study are similar to previous studies. In addition, due to the undeveloped economy in rural areas compared to cities, in order to reduce the burden on the younger generation, the older people will choose to commit suicide, such as in this study, two cases of suicide were caused by this reason according to the reports by their family. Therefore, the government should raise public awareness of the effects on the rest of the family members if one of the family members has committed suicide. Along with continuously improving the medical system, and establishing an effective social support system for both the old rural residents and their families. In addition, appropriate psychological interventions on family members after their loved one has committed suicide needs to be considered. This will help support the rest of the family members to live with a positive attitude, thereby improving their quality of life.

Implications for practice
This study highlights the lived experience of the family members of older people who have committed suicide in a rural area in Shaanxi Province. The research recommends that more care and attention should be paid to this group of people, this would be bene cial for their resilience and help them to go back to their routine life. In addition, it is important to detect their mental health problems, early intervention may reduce the further suicide accident happening and improve the quality of their life.

Limitations of the research
The study took place in just one rural area in Shaanxi Province and therefore there is no claim that ndings from this current study can be applied to other economic and political regions or other ethnic groups in China. Future research should study the psychological experience of family members of senior people who have committed suicide in other rural geographic areas across China. In addition, the nature of an IPA study is to investigate deep and detailed personal perspectives. However, the sample size is very small, it is not possible for the results of this study to be generalized to a wide population group, but it serves as a window into the real life of this group of people in a speci c rural setting.

Conclusion
The study adds to the understanding of the lived experience of family members of senior people who have committed suicide in less economically developed rural areas. It recommends that urgent consideration needs to be given to support families where one of the older family members has committed suicide in rural China. An appropriate care support package maybe needs to be developed to deal with this. The study also highlighted the speci c social attitude toward suicide in this area. This suggests that future research should focus on how to improve the understanding and awareness of the family members of older people who have committed suicide in rural communities and challenge the discriminatory attitudes towards family members in the unique culture of rural areas in China.

Declarations
Ethics approval and consent to participate This study was approved by the Ethics Committee of Lanzhou University. The informed consent form was signed by the participants and pseudonyms was used for reporting.

Consent for publication
Informed consent for publication was obtained from all participants together with consent to participate.

Availability of data and materials
The data that support the ndings of this study are available on request from the corresponding author [XZ]. The data is not publicly available due to them containing information that could compromise research participant privacy

Competing interests
All authors declare they have no competing interests.
Funding None Authors' contributions MC was responsible for the study concept and design, acquisition of data, analysis and interpretation of data, and drafting the manuscript. XZ contributed to the study concept and design, the acquisition of data, the analysis and interpretation of data, and the drafting of the manuscript.