Mental Health and Well-being of Empty-nesters: A Chinese Urban Case Study

The research examined the mental health and well-being of a sample of empty-nesters in Jinan City, Shandong Province. An in-depth individual interview approach, with document analysis and participant observation was performed on three types of interviewees (N = 33) recruited via purposive sampling. The empty-nesters faced many unique problems, especially a sense of being disjointed from the family, community and society. Inuencing factors included Chinese traditional lial piety culture, lagging implementation of relevant policies and development of community ageing services, as well as the loss of productive roles for the empty nesters. Implications for social work services are identied.

. Cross-cultural studies, which highlighted diversity in empty nest experiences by ethnic background and regional locale, pointed out that the empty nest applied mainly to white families rather than African American, Hispanic, or Asian families (Mitchell, 2016), thus existing literatures are mainly about the empty-nest experiences and responses in Western countries.
In the 21st century, China encountered rapid population ageing. The older population aged 60 years and above increased from 132 million ( Commission, 2015) shows that 10% of the older Chinese population are single empty nesters, and 41.9% are empty-nest couples. It is anticipated that there will be 118 million empty nesters in 2020, and the old-age dependency ratio will increase to 28% (The State Council, 2017). Thus recent sharp increases in the number of empty-nesters led to the advent of related social problems such as isolated elders without caregiver support and those who commit suicide (Xu & Yu, 2015).The current policies and services in China focus on material needs of empty-nesters, but studies show that they are often in need of support that addresses mental health and well-being in terms of psychological, emotional and social items (Bai, 2015;Lu & Guo, 2013;Mu, 2004).
Mental health and well-being is de ned in the current paper as a general state of being content with life as it is, and not feeling depressed or anxious about current circumstances. It exists when one perceives respect for individuality, feels emotional comfort, and a capacity for social achievements that contribute to the realization and ful llment of self-worth (Mu, 2004), in Chinese " " (jingshen yang lao). Respect for individuality is represented by items such as self-respect, desire for respect from others, and autonomy. Emotional comfort can be a positive affective state, and social achievements of the older people is linked with social participation. To improve the mental health and well-being of older people is a policy-relevant issue for more effective community-based care. What are the barriers to achieving mental health and well-being among empty-nesters in China? What kinds of social work services could be provided? This study offers some preliminary answers to these questions through a case study in Jinan, Shandong Province.

Literature Review and Theoretical Framework
Western studies on the empty nest started in the 1950s, mainly focused on the determinants of nest leaving and in uences of empty nest on marital quality, relationships with children, physical and psychological well-being of the parent(s), as well as gender differences (Bouchard, 2014 Zhai, 2015) identify that empty nesters with higher levels of education have better mental health than those with fewer years due to more social resources for adaption. Some empty nesters are entirely neglected by the children (Liu & Deng, 2012). A combination of home and community-based care may be needed, with institutionalized care likely for some needs (Liu, et al, 2015).
Role loss theory, which predicts a loss in sense of accomplishment as parental roles wane might lead to a decrease in well-being, as well as role relief theory, whichsuggests the empty-nest stage could lead to an improvement in parental well-being due to reduced exposure to stressors, provided two contradictory explanations of the empty-nest effect ( ,1990). Both theories emphasize the importance of social participation to the personal identity of empty-nesters. Social participation is the most pivotal character of positive ageing (Bowling, 2006 Guo & Shi, 2006). The positive ageing perspective proactively creates conditions that promote social engagement rather than social exclusion, so that people could feel a sense of joy and ful llment in old-age (Bass & Caro, 2001;Jiang, 2011). Positive ageing helps identify latent ability to selfadvocate and pursue hobbies and interests, as well as to access services and care and social bene ts in the process (Chen, 2015). Positive and adaptive meaning making helps empty nesters manage the transition more effectively, nding new meaning in life can extend their social relationships and roles outside the home (Mount & Moas, 2015). Social activities play a key role in maintaining life satisfaction for those in an empty nest, and it is critical for communities or local governments to assist empty nesters to maintain engagement in social environments (Chen, Yang, & Aagard, 2012).
Positive ageing theory will be adopted to analyze the current conditions of mental health and well-being of empty nesters in a Chinese urban community. This study focuses on two important factors affecting life quality of older adults in the empty nest: personality and level of social participation (Chen, Yang, & Aagard, 2012). Cultural and social policy perspectives are not often addressed in relation to outcomes of those in an empty nest, thus the causes of negative reports of mental health and sense of well-being will be explored.

Methods
This study was conducted in one community in Jinan city, Shandong Province. In 2018, the population above 60 years old in Shandong Province was 22.40 million, accounting for 22.29% of the total population in the province, of whom 58.36% were empty nesters (Health Commission of Shandong Province, 2019). The sample was drawn from a traditional community of Jinan City where there are 2,055 families and 3,200 permanent residents, among whom 20.2% were above the age of 60. There were 52 empty-nest families, de ned as all children having left home permanently for at least six months, in this community, and almost 70% lived alone and were thus classi ed as single empty nesters. The community was staffed with a liaison coordinator who collected information on the community residents, including empty-nest families, and then reported to the community cadres.

Sampling and Data Collection
The study employed an in-depth individual interview method, with document analysis and participant observation to add supplemental data. National and local policies on elderly care, study reports, working papers, and the records of the community cadres were reviewed during document analysis. For six months, our study team paid regular visits to this community, collecting facts on the community service development process, daily life, and participation of the older people in community activities through participant observation. These data were recorded as diary, photos and videos with the consent from the community residents. In the semi-structured individual interviews, 25 empty-nesters in the community were purposively screened and sampled to ensure their health status enabled them to participate in the interview process and they were willing to participate in the interviews. Four sections of questions were developed specially for them: (1)  The information concerning interviewed empty nesters in the community is presented in Table 1. The sample is representative in terms of empty-nest type. with 68% (N = 17) single empty nesters. Most participants were retired and only one person out of 25 had no pension. Moreover, all of them received some money from their children, so they were not without income. Some of the older people offered their own savings to subsidize their children. All participants were quali ed for the Basic Medical Insurance for Urban Employees. About 70% were able to take care of themselves, while the othera needed some assistance with activities of daily living. "number" in other columns refers to the number of the elderly. Further interviews were conducted among three community cadres and ve social workers. Five social workers from "Jicheng Community Service Centre" conducted a needs assessment of the residents in this community and all of them were invited to participate in the interviews. Suggestions were also sought with regard to their understanding of the mental health and well-being of empty nesters in this community. Examples of questions asked are: Do you have regular interaction with the empty nesters in this community? Do you have any special concerns about the mental health and well-being of this group of people? What kinds of community services (social work services) have you provided to the empty nesters? What problems have you encountered in providing these services? Do you know relevant social policies concerning the mental health and well-being of old people in China as well as in Shandong Province?
Interviews with community cadres and social workers were conducted in the community committee o ce and each interview lasted for about 1.5 hours.

Data Analysis
All the interviews were recorded with the consent of the interviewees, and the transcripts were analyzed via content analysis by the researcher. Regarding the phenomenon of unmet mental health and wellbeing, the macro, meso and micro levels of contextual conditions, causal conditions, and actions were identi ed as main themes. The macro level included social, cultural and policy dimensions (i.e., the Chinese traditional lial piety culture and relevant elderly-care policies), and the community dimension (community ageing services) constituted the meso level. The family and individual dimensions (the empty nesters and their family) were categorized into the micro level. The reports about the mental health and well-being of the empty nesters as well as the causal conditions will be presented in the next section at three levels.
The validity of the data analysis was rstly veri ed by checking the interview transcripts with the interviewees and discussing the analysis results for their feedback. After further clari cation from the participants, more detailed constructs were identi ed for individuals. Any coding result not veri ed by participants was revised integrating their clari cation and noting the old and new information. A second team of researchers experienced in qualitative study reviewed the content analysis process and results and suggested minor modi cations.

Findings
Research ndings are presented in two parts: The participants' current situation of mental health and well-being, and the barriers to achieving better mental health and well-being. In both parts, the family and individual dimensions, the community dimension and the social, cultural and policy dimensions are included.
The Mental Health and Well-being of Empty Nesters The empty nesters' generally negative attitude towards their own mental health and well-being demonstrated a low level of family, community and social participation as well as the potential for service interventions to address this issue.
Children's Company, Family Participation, and Mental Health and Well-being Older people tend to place signi cant value on their home as both their main living space and the source of emotional support. Social mobility has led to reduced family availability and disintegration of the traditional function of the family providing support for the aged. Table 1 shows that 70% of the children of these participants lived outside Jinan City, and 52% met their children less than twice a year. Some of the children called them only once a month or less. Conversations were often related to food, health and daily life, rarely about their psychological and spiritual life. Respondents reported a need for more communication and interaction with the children, but their children did not really understand their needs. Services, Community Participation, and Mental Health and Well-being Table 2 re ects the types of needs for community services, among which "provide company and chat" was the most common. The interviewees said that they hoped very much to interact with people in the community as well as people in the society so that they could gain mental support and emotional satisfaction. They looked forward to Fridays when the community cadres paid a visit to those who could not go out and talk with them. A community cadre shared her experience: Initially I thought that a brief visit to the empty nest households would be enough to understand their basic situation and keep a record for them. After the visit, I discovered that they were very eager to have someone to talk to, especially those who living alone with only TV as their companion. They can talk for 2 or 3 hours without realizing the time passes during our visit. In terms of entertainment activities, most participants watch TV, chat, play cards, plant owers, keep a pet and go to church. These activities were con ned to their own homes, former colleagues' homes or churches.. An interviewee explained: "There is little entertainment activity, just watching TV and reading newspapers to know what has happened outside. If I got very bored, I will go to see my former colleagues and chat with them. Before retirement, there was an activity room in my working place and we often went there for entertainment after work. Our life was quite ful lled through these activities. However, it is different in the community.
There are so few sports and tness facilities that whenever we go, they are occupied by someone else." (Case No. 4).
According to the participant observation and interviews with the community cadres, the community development lags behind expectations and it has just started to provide services for the aged. For example, home-based care services mainly covered a meal-delivery service. Other services were still being planned, e.g., handicraft groups, medical care seminars, psychological counseling, and more. The development of mental health and well-being services in other communities, even within those welldeveloped social services communities, did not make up for shrinking family support.

Meaning, Social Participation, and Mental Health and Well-being
Respondents noted retirement caused a lowering of their social status and less respect from working neighbors. Some felt that the way other people looked at them was different than before, and life had become gloomy after giving up their social life and reducing self-values and aspirations.
Most of the empty-nesters in this community participated in Christian activities as a major part of their social life. Their beliefs focused more on the spiritual aspects and social gatherings inspired by holidays of the religion than on any strict theological interpretation. For example, one older people respondent told us: One thing to note is that up to 87% of empty-nesters in this community have a high school diploma or above (about 68% have a college diploma). However, the more educated the respondents wereless likely to respond that they felt psychologically ful lled. This suggests that, at least in this community, highly educated people are more likely to have lower levels of psychological ful llment. In addition, the community cadres shared that these highly educated older people were more reluctant to seek outside help.

Barriers to Positive Mental Health and Wellbeing of Empty Nesters
This case study nds that the empty nesters' mental health and well-being may be affected by a variety of factors, including culture change, lack of effective policy implementation and community services, and loss of a role for the older people.

Culture Change
Chinese society values lial piety, which is especially evident in the cultural history of Shandong Province. Shandong is the home province of Confucius and Mencius, and is thus the original place of Chinese Confucianism and its core value of lial piety (Wang, 2012). Filial piety is a central element of Confucian philosophy, which demands respect and support for one's parents and family elders. It has been a core value fundamental to Chinese moral norms and value systems. As the society has become more industrialized, there has been a shift from family obligation to individual needs (Cheung & Kwan, 2009). Young people attach more importance to their career achievement as the basis of their self-value, while they show less lial duty to and respect for their parents (Sun & Zhou, 2013;Han, 2016). For example, one single empty-nester said: "The society has changed and the lial piety culture isn't valued. The way they (the younger generation) treat us is totally different from how we treated our parents. Their love for us has been commercialized. They are competitive in buying precious stuff for me, but I don't need them indeed. We have less respect, According to the community cadres' interviews, while assessing the old-age care needs of older people, the administrative departments focused on material and physical indicators. As a consequence, while community elderly services ourished, the mental health and well-being of residents had unmet needs. For instance, the Community-based Elder Care Public Service Platform of Shandong Province provided care services, health services, and life services, but little to address mental health and well-being issues.

Loss of A Role for The Older People
In the current old-age care policies and services covering urban communities, the self-identi ed needs are viewed as thoughts of passive recipients of the services and play little role in the actual provision of services. Among those who were interviewed, their sense of personal worth and recognition of their selfe cacy was lacking. The older people themselves also limited their roles in ageing services, which was especially noteworthy when it came to mental health and well-being.
Some older people found that it was di cult for them to adjust to the ageing process and the changes in their social roles. They chose to con ne themselves to their narrow living space, unwilling to take part in social activities. As a result, many reported that they suffered from feelings of psychological emptiness. Second, empty nesters cherished a deep-rooted notion of who they should rely on for caring, strongly believing the responsibility lied with their children, although they were aware their children had different notion of family support. Third, the older people did not normally spell out their psychological needs. The older respondents themselves told us: "How can I speak up my needs? I don't want to ask for their care and concerns.
What I want is their voluntary care" (Case No. 15).
The community cadres also mentioned that they were cooperating with social workers in conducting assessment on the psychological needs of the empty nesters. However, the problem was that the older people didn't want to articulate their needs or request help. Fourth, many older people were ashamed to ask for help. To them, getting help meant causing their children to lose face and simultaneously bringing trouble to the community. For example, one interviewee said: "The community cadres are very nice. They try to do everything for me. However, I don't think it's appropriate. They are busy people and they don't need to do what my children are supposed to do for me" (Case No. 17).

Discussion And Implication For Social Work Services
The active participation of older people in designing social support systems is critical to positive ageing. The results indicated many empty nesters feel a tension for the lack of family support and or comparable social services available, and very limited participation in family and community events leading to role loss. Even lower participation by highly educated older people calls for further study. There is untapped potential for positive ageing which social workers may address while diversifying the resources of care provided by adult children and developing social services that address mental health and well-being. The implication of positive ageing theory is that community services designed to support social participation play an irreplaceable role in promoting the value of mental health and well-being.
The sampled community represents urban communities across Jinan city which are in urgent need of community services due to rapid social, economic and demographic changes. Social workers could work together with the community and government departments to promote policy awareness and communitybased elderly services based on the Guide for Social Services among the Elderly, written by social work education and research institutions, social work agencies and social work associations in 2016.. It clearly states that social work services for older people should include psychological comfort services, community participation, and old-age education. Social workers should follow the Guide and help the communities and social work agencies address needs.
A focus on the development of community services designed with the active engagement of older adults in the region is a necessary step in the resolution of mental health and well-being problems of the empty nesters. Social workers could help the empty nesters to reframe their view of retirement and address issues that normally challenge those without support networks through casework and group services. This model could expand across China and similar areas which could bene t from implementing clientcentered elderly-care policies.
Finally, we should acknowledge the limitation of this research. A case study in one city based on 25 interviews is quite limited considering the diversity of contexts within China. However, this analysis of the various layers of factors which have created challenging conditions for those living without adequate support has identi ed some common mental health and well-being issues for Chinese empty nesters, and accordingly the implications for further improvement are valuable. In addition, this research mainly explores the common needs of empty nesters, and doesn't further address the differences between males and females which is worthwhile to tackle in future study.

Declarations
The study was partially funded by the Major Program of the National Natural Science Foundation of China Grant No. 71490733 and the Shanghai Municipal Education Commission Research and Innovation Project [Grant No. E00026]. The rst funding supported the team to collect the data and both funding partially supported the data analysis procedures of the paper.

Availability of data and materials
The data that support the ndings of this study but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the funding unit.

Ethics approval and consent to participate
The data were collected in accordance with the Declaration of Helsinki by The research team. The study was reviewed by the institutional Review Board at Fudan University, IRB approval number 2019SL1001.
All participants in the original survey voluntarily participated after being offered a written informed consent explanation.

Consent for publication
The research team and the funding grant encourages publication of results for scholars who have access to their data. Their website describes more than 150 papers published in China using their data, mostly in Chinese.