In this study, the mean SF-36 score of PCS was 64.83 ± 22.66 and the mean score of MCS was 59.36 ± 21.83. It was measured by the general population of 6 Chinese cities that the score on PCS was 77.54 ± 15.96 and on MCS was 71.29 ± 17.86 in 2011 [39]. Therefore, the QOL score of shidu parents was much lower than that of the general population in China. The loss of an only child often meant the loss of their primary source of health care, the end of family continuity, and a significant hazard to personal happiness [40]. For Chinese shidu parents, certain unique factors impacted their physical and mental health. The first was the cultural stigma associated with children’s death. Chinese culture regarding the death of a child as a symbol of bad luck and a taboo subject [17], communicating with shidu parents about the child’s death was often provoking and can be painful and insulting [2]. Another factor was that the one-child policy made shidu parents unique. Research indicated that one-child parents were more probable to rank their children as the most vital aspect of their lives compared with multiple-child parents [41]. Additionally, family care was a foundational way of caring in China. And as primary caretakers of the old people, adult children had the accountability to meet the mental health needs of parents [42]. Thus, the death of the only child meant not only the great sorrow and physical or mental damage, but also the termination of expected financial and social support both culturally and legally from the child for the parents.
Our results indicated that having chronic diseases was a risk factor for both PCS and MCS. Shidu parents had a higher incidence of chronic diseases, it was reported that more than 60% of those surveyed had chronic diseases in an investigation [7]. In addition, lower incomes and being in debt were found to be associated with a lower PCS score of the shidu parents. As they grow older, shidu parents face not only declining health but also financial difficulties. The income of some old parents was not stable, and the cost of aged care, medical care, funeral, and other expenses have been increased significantly [43]. When the only child died, the old parents virtually had no other reliable sources for aged care, and shidu parents’ rights to subsistence would be at risk without a stable source of income [14]. According to a survey in 2013, more than 60% of the shidu families examined said they had financial difficulties [44]. In the present study, we found that parents with debt had worse QOL than those without debt.
The results confirmed the conspicuous negative correlation between perceived stress and QOL, which was consistent with previous studies [45, 46]. Chinese shidu parents were burdened with stress both physically and mentally. On the one hand, "Raising a child for old age" is an inherent concept in Chinese traditional culture. The old parents need to live on their children, and it is a tradition of Chinese to support parents since ancient times. It was difficult to maintain families for shidu parents who were suffering from various difficulties including economic, spirit, pension, medical treatment of a serious disease [47]. But they did not have alimony given by their child, not to mention the other supports. On the other hand, Chinese culture is collectivist, regarding the interests of the family as the most important [18]. For Chinese parents who have lost their only child, “shidu” meant not only the loss of their only child but also the loss of the hope of having offspring and carrying on the family line, which was seen as the responsibility to ancestors in familism culture [17]. The unrealized and unfulfilled duty could cause the psychological pressure of shidu parents. And it was harmful to shidu parents’ QOL to face the stress both physically and mentally. The previous study has reported that there was a negative connection between stress with QOL [48], the more stress was related to lower levels of physical and mental health.
What's more, this study supported that social support was positively associated with QOL. It was shown that shidu parents received less social support from friends or families than they expected [49]. For bereaved parents, the loss of their child could lead to a decline in social status, which produced the loss of interest in social life [50]. After the children’s death, shidu parents not only suffered from social isolation but also designedly isolated themselves from social relationships [51]. There was a relationship between poor social support and lower levels of QOL. For example, the study in a sample of American women indicated that poor social support had a significant effect on poor functional statuses such as physical health problems and role limitations [52]. Previous studies have also found that lower social support was associated with increased blood pressure [53], hyperlipemia [54], and lower nutrient intake [55]. Previous research has suggested that social support was a pivotal factor in helping shidu parents solve their problems of adjustment and deal with the loss of children [56]. Thus, increasing social support is conducive to improving the QOL of shidu parents.
As expected, the effect of social support on mediating the relationship between perceived stress and QOL in 502 shidu parents was examined. Our results indicated that social support was positively associated with QOL and negatively associated with perceived stress, and as a mediator between perceived stress and QOL, this finding was in accord with previous studies [21, 46]. Previous researches had consistently shown that social support can offer a psychological buffer against life stress, anxiety, and depression [57]. And social support mediated stress and greater stress was associated with decreases in social support in an investigation [58]. The study among parents of disabled children supported that social support mediated parenting stress and QOL, with the higher the parenting stress, the lower social support, and the worse QOL [59]. Research of PLWHA has been proved that high stress had a negative impact on QOL directly, and then affected the QOL by decreasing the level of social support [60]. Therefore, it should be taken seriously to improve the QOL by reducing the perceived stress of shidu parents, because stress can directly affect QOL and indirectly through social support.
Overall, shidu was a particular social problem in Chinese society after the decades of implementation of the one-child policy. Children were the primary source of joy, hope, and well-being in life for all parents, and it would trigger the most devastating grief and a great deal of stress for parents to lose a beloved child [61]. Compared with parents who have not experienced this loss, shidu parents were at higher risk for developing mental health problems and physical health constraints. The death of a child led to a markedly higher level of unresolved grief, which could worsen physical and mental health based on the researches conducted with the bereaved parents. Therefore, the government and society would attach importance to improve the medical security service system for this unique group of shidu parents or provide shidu parents with home care within their means. Previous findings supported that furnishing shidu people with the strategies to cope with stress effectively may promote their QOL [6]. It was recommended that stress management would be incorporated into interventions to improve the QOL for shidu parents. The essential thing to shidu parents to provide them with systematic and culturally sensitive psychological assistance and mental health services [2]. For instance, it could be more conducive to reducing stress by providing exclusive psychological counseling channels and organizing activities to promote peer communication for shidu parents. And developing appropriate social support can be taken into account as a vital step of psychological intervention strategies to improve the QOL for bereaved parents. Besides economic support, social support in the manner of grief counseling is also needed to prevent a decline in mental health [62]. The researchers proposed that subjects with a certain occupation would have a larger social network and receive more social support from others [63]. Hence, the government can introduce corresponding policies to encourage shidu parents to get back jobs and participate in more social activities, which not only improve their economic situation but also reduce their social isolation and improve their QOL.
There were several limitations to the study. Firstly, the actual score of QOL may be lower than the results reported here, because the participants were selected by the certain criteria voluntarily and some shidu parents still cannot accept the fact that they choose not to take part in the survey, so the sampling method may not representative of all shidu parents in China. Secondly, this study concentrated mainly on the relationships among perceived stress, social support, and QOL, more studies are needed to explore the influence factors for the QOL of shidu parents. Thirdly, more investigations should be carried out to address the factors that make up the differences in shidu parents’ QOL between different cultural backgrounds. Finally, the present study was a cross-sectional study and our results cannot be used to build the causal relationships, and future researches using a longitude design care needed to validate the findings.