Rural-urban migration and depression in ageing family members left behind

Intergenerational Relationships and Their Impact on Social Resilience Amongst Arab Society Elderly Populations: A Qualitative Exploration

AIM

To explore the impact of intergenerational relationships on the social resilience of elderly populations in Arab societies. Additionally, the study aimed to identify the factors that influence the quality of these relationships and their role in enhancing or diminishing the resilience of older adults.

DESIGN

A qualitative study.

METHOD

Semi-structured interviews were conducted between June and July 2024 with 12 elderly participants from urban and semi-urban communities in Al-Ahsa, Saudi Arabia. Data were analysed using both deductive framework analysis, guided by social support theory, and inductive thematic analysis to identify key themes related to intergenerational relationships and social resilience.

RESULTS

The study involved 12 participants aged 61-85 years (average age of 72 years), with a mix of educational backgrounds and living arrangements. Strong intergenerational ties were found to significantly enhance social resilience by providing emotional support and a sense of security. Participants in multi-generational households reported more positive outcomes compared to those with less frequent family contact. However, generational differences and modern-life pressures posed challenges to maintaining these relationships.

CONCLUSION

The findings underscore the importance of fostering strong intergenerational relationships to support the social resilience of elderly populations in Arab societies. Future research should explore interventions that bridge generational gaps and strengthen family ties, particularly in the context of evolving social structures.

IMPLICATION FOR THE PROFESSION AND/OR PATIENT CARE

Healthcare practitioners and policymakers should consider the role of intergenerational relationships when designing interventions aimed at improving the well-being and resilience of older adults in a culturally sensitive approaches.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research (COREQ).

PATIENT OR PUBLIC CONTRIBUTION

The engagement and interview data from elderly participants provided valuable insights into the dynamics of intergenerational relationships and their impact on social resilience.

Mental health effects of adult children's outmigration on older parents in Central and Eastern Europe

OBJECTIVE

To examine the association between adult children's migration and depression among older parents in Central and Eastern Europe (CEE) and explore the role of intergenerational support in contributing to their depression.

METHODS

Data are from the eighth wave of the Survey of Health, Ageing and Retirement in Europe (SHARE), pooling a study sample of 11 CEE countries, with a cross-sectional design. Analysis of covariance (ANCOVA) and hierarchical linear regression were conducted using a study sample of 9133 respondents.

RESULTS

Older adults whose children migrated over 500 km were more likely to experience depression compared to those with no migrant child or all children within 500 km. Among intergenerational support, frequent parent-child contact mitigated the effects of migration on depression in older parents with all their children who migrated over 500 km.

CONCLUSION

This study suggests that older parents with migrant children over 500 km away should be considered a vulnerable population at risk for mental health in CEE countries. It is crucial for local governments and policymakers to address these challenges through improving integrated mental health and social programs for better mental health outcomes among older adults in CEE countries.

Physical and mental health among older parents: Does offspring migration and living arrangement matter? Findings from Longitudinal Aging Survey in India (2017-18)

The migration of adult children can have beneficial and adverse effects on the health outcomes of elderly parents left behind. This study examines the effects of adult children's migration on self-rated health and depression among older parents using Longitudinal Ageing Study in India (LASI) 2017-18 with 19,401 individuals aged 60 years or older. Binary logistic regression models were performed to determine the association of self-rated health and depression with adult-child migration status while adjusting for living arrangements and socioeconomic factors. Results show that 36 percent of older parents have at least one migrant child, and 35 percent are empty nesters. Older adults living with their children experience positive impacts on their physical and mental health. Our study reveals that empty-nested elderly have a higher prevalence of poor self-rated health and depression. Irrespective of migrant children, the availability of children in the household matters most regarding parents' health care, as our study suggests no significant difference in physical and mental health among left-behind and non-left-behind older parents. This study aims to draw policymakers' attention to the impact of adult children or youth migration on older parents' physical and mental health. To address this issue, policies should prioritize raising awareness among migrant children of older adults about the importance of maintaining frequent contact and visiting their aging parents.

Migration status, physical limitations and associated self-rated health: a study of older Indian adults

BACKGROUND

Migrant status with mobility impairment becomes a double burden for health and wellbeing of older adults. This study examined the independent relationships and multitude effects between migrant status, functional and mobility impairments and poor self-rated health (SRH) among older Indian adults.

METHODS

This study utilised nationally representative Longitudinal Ageing Study in India wave-1 (LASI) data, including a sample of 30,736 individuals aged 60 years and above. The main explanatory variables were migrant status, difficulty in activities of daily living (ADL), difficulty in instrumental activities of daily living (IADL) and mobility impairments; and the outcome variable was poor-SRH. Multivariable logistic regression and stratified analyses were used to fulfil the study objectives.

RESULTS

Overall, about 23% of older adults reported poor-SRH. Reporting poor-SRH was more prevalent (28.03%) among recent migrants (less than ten years). The prevalence of reporting poor-SRH was significantly higher among older adults who had mobility impairment (28.65%), difficulty in ADL or IADL (40.82% & 32.57%). Migrant older adults (regardless of duration) who had mobility impairment had significantly greater odds of reporting poor-SRH compared with non-migrant older adults who did not have mobility impairment. Similarly, older respondents who had problems in ADL and IADL with migration status had higher odds of reporting poor-SRH than their non-migrant counterparts with no such problems.

CONCLUSIONS

The study revealed the vulnerability of migrant older adults with functional and mobility disability, as well as those with limited socioeconomic resources and suffering from multimorbidity on rating their perceived health. The findings can be utilised to target outreach programmes and provision of services for migrating older individuals with mobility impairments and enhance their perceived health and ensure active ageing.

Internal and International Migration and the Mental Health of “Left-Behind” Older Parents

Despite evidence of the impact of adult children's migration on left-behind older parents, the comparison of left-behind older parents’ mental health and psychological well-being between internal and international migration is limited. This article examines how the relationship between adult children's migration and parent's mental health differs according to the migrant's destination — only internal migration, only international migration, or hybrid migration (at least one child who migrated internally and at least one child who migrated internationally). Drawing on a 2019 cross-sectional population-based survey of 697 left-behind older adults (≥ 60 years) in Nepal, we assessed the mental health of older parents, using the 21-item Depression Anxiety Stress Scales and a range of socio-demographic, health, lifestyle, and child-related characteristics. Multilevel mixed-method linear regression was performed to examine the effect of adult children's migration on left-behind older parents’ depression, anxiety, and stress symptoms. Results showed that parents whose children had all migrated internationally were at higher risk of mental health problems, particularly anxiety and stress, compared to parents whose children had all migrated internally. Older parents from the hybrid group (having both internal and international migrant adult children) had higher levels of anxiety, compared to parents whose children had all migrated internally, with no significant difference in depression and stress symptoms. Further, mothers of internationally migrated children were at higher risk of mental health symptoms than fathers. Interventions aiming to improve left-behind older parents’ mental health and psychological well-being should specifically target parents whose children have migrated internationally.

The impact of adult children rural-urban migration on left-behind parents' health: Evidence from China

Population aging and rural-urban migration have posed challenges to the elderly support system in developing countries that lack social safety net and services. Given that there is no consistent conclusion in the literature on whether adult children's internal migration can improve or impair their left-behind parents' health, little is known about the effect mechanisms. This paper investigates the comprehensive impact of adult children's migration on the health of their parents in rural China by analyzing the income effect and time allocation effect. The empirical analysis uses the rural sample of the China Health and Retirement Longitudinal Study (CHARLS) in 2013, 2015, and 2018. We found that adult children migration can improve parents' physical health, mainly thanks to the income effect. The analysis of the mechanism found that although the income effect has a positive effect on parents' health, the time allocation effect has a negative effect on parents' health because of the lack of care and increased working hours of parents. Our findings suggest that providing social care services and enhancing intergenerational communication can be practical strategies to mitigate the negative effect of children's migration to rural left-behind elderly parents.

Migration of adult male children and associated depression among community-dwelling older parents: A cross-sectional gender analysis from Longitudinal Ageing Study in India, 2017-2018

OBJECTIVES

This study empirically examines the association of migration of an adult male child (ren) on the mental health of the older parents left behind. It also examines the interaction effects of sex of older parents and male child migration on major depression to explore whether there is a gender differential in the possible association.

METHODS

The data for this study were obtained from the first wave of the Longitudinal Ageing Study in India (LASI, 2017-2018). The total sample size for the present study was 27,248 older adults aged 60 years and above (male-12,624; female-14,624). Descriptive statistics along with cross-tabulation were presented. Proportion test was used to evaluate the significance level of differences in depression by sex. Additionally, binary logistic regression analysis was used to find out the associations. Major depression with symptoms of dysphoria, was calculated using the Short-Form Composite International Diagnostic Interview (CIDI-SF).

RESULTS

About 10.5% and 9.0% of older males and females had migrant sons. It was found that there was significant gender differential in depression in older age (male: 7.5% and female: 9.7%; p < 0.001). It was further found that the prevalence of depression was found among older men (9.3% vs. 7.3%) and women (12.5% vs. 9.4%) with migrant son. Older adults with migrant son had 26% significantly higher likelihood to be depressed in reference to older adults with non-migrant son (AOR: 1.26; CI: 1.02-1.56). Further, older women with a migrant son had 76% significantly higher likelihood to be depressed in reference to older men with migrant son (AOR: 1.76; CI: 1.32-2.39).

CONCLUSIONS

This study invites policymakers' attention towards migration of adult children and its potential effects on mental health of left-behind older parents in community-settings and in women in particular. Policies should focus on spreading awareness to migrant children of older adults on maintaining frequent contacts and visits to their ageing parents.

Impact of child's migration on health status and health care utilization of older parents with chronic diseases left behind in China

BACKGROUND

Adult child are used to taking the responsibility of taking care of their older parents in Chinese culture. However, the migration of adult child is not uncommon now in the context of urbanization in China. The purpose of this study is to explore the impact of child's migration on health status and health care utilization of older parents with chronic diseases left behind.

METHODS

The data of the 2015 nationally representative longitudinal survey of the aged population in China were used in this study. Binary logistic regression was used to evaluate the impact of adult child's migration on health status and health care utilization of older parents with chronic diseases left behind.

RESULTS

About a quarter of the respondents (25.5%) had at least one migrant child. Most of the respondents (86.6%) rated their health as poor, and 42.0% of them suffered from physical limitations. Nearly half of the respondents (45.0%) had depressive symptoms, but the vast majority (88.2%) were generally satisfied with their lives. Only a quarter of the respondents received outpatient treatment in the past month while only one fifth of them received inpatient visits in the past year. After controlling for other demographic and socioeconomic variables, it was found in this study that those who with migrant child were more likely to report poor self-rated health (OR = 1.26; 95% CI 1.01-1.58), not satisfied with general life (OR = 1.28; 95% CI 1.03-1.59) and seek outpatient visits (OR = 1.22; 95% CI 1.03-1.43) than those who without migrant child.

CONCLUSION

Our study found that there is a negative association between migration of adult child and physical health, mental health and health care utilization of older parents with chronic diseases left behind, which means a comprehensive effect on their health status. Further health policies should focus on improving the well-being of older parents with chronic diseases left behind.

The effect of peer group education on anxiety, stress, and depression in older adults living in nursing homes

Background:

The effects of peer education have been addressed in different populations, but this method of education has not been applied in the elderly population of Iran, and its effect has not been studied. The present study investigated the effects of peer group education on anxiety, stress, and depression of the older adults living in nursing homes.

Materials and Methods:

This research is a quasi-experimental study with an intervention and control group and it was conducted on 70 elderly citizens living in Qom nursing homes in July 2017. For the intervention group, a relaxation and stress reduction program was trained through the peer group. The control group received routine care. Data were collected using a Demographic information questionnaire and Depression Anxiety Stress Scale-21 (DASS-21). Data were collected at the beginning, 10 and 30 days after the intervention. Data analysis was performed using SPSS 19, descriptive statistics, and repeated measure analysis of variance.

Results:

The results of the study showed no significant difference between any of the demographic variables at the beginning of the study (p > 0.05). The statistical test showed that the effects of time (p < 0.001) and group (p < 0.011) were significant on anxiety, stress, and depression.

Conclusions:

The results of this study showed that peer education could decrease anxiety, stress, and depression in the elderly. Therefore, this educational method can be used by nurses to promote various health education programs, e.g., to health promotion and prevent disease especially in the elderly community.

Offspring migration and nutritional status of left-behind older adults in rural China

Improvements in nutritional status is a principal pathway to good health. This study examines the effect of migration of adult children on the nutrient intake of left-behind older adults in rural China. We use data from four waves (2004-2011) of the China Health and Nutrition Survey and utilize individual fixed effects methods to panel data. Results show that the migration of offspring is associated with significantly higher nutritional status of their left-behind parents, especially higher intake of proteins, carbohydrates, vitamins B1-B3, phosphorus, magnesium, iron, selenium, and copper. The intake of some of these nutrients is below recommended levels. The magnitude of the estimated effects vary between 4% and 24 %. Older adults who live with their grandchildren in rural households or have a low income benefit more from having adult child migrants in the household. The improvement of nutrition outcomes of left-behind older adults is mainly due to increased consumption of cereals, meat, eggs, and fish.

Association of Time since Migration from Rural to Urban Slums and Maternal and Child Outcomes: Dhaka (North and South) and Gazipur City Corporations

This study analyzes data from a new Urban Health and Demographic Surveillance (UHDSS) in five slums in Dhaka (North and South) and Gazipur City Corporations to examine the relationship between migration status and maternal and child health service utilization. Migration status was determined by duration in urban slums (<= 9.99 years, 10-19.99 years, 20+ years, and urban-born). Compared to those born in the city, migrants were characterized by significant disadvantages in every maternal, neonatal, and child health (MNCH) indicator under study, including antenatal care, facility-based delivery, doctor-assisted delivery, child immunization, caesarean-section delivery, and use of modern contraceptives. We found that the level of service coverage among migrants gradually converged-but did not fully converge-to that of the urban-born with increasing duration in the city. We observed a strong positive association between wealth and total MNCH coverage, with a more modest association with higher levels of schooling attainment. Women who were engaged in market employment were less likely to receive adequate coverage, suggesting a tradeoff between livelihood attainment and mother-and-child health. After controlling for these socioeconomic and neighborhood variations in coverage, the duration gradient was diminished but still significant. In line with existing studies of healthcare access, this study highlights the persistent and widespread burden of unequal access to maternal and child health care facing migrants to slum areas, even relative to the overall disadvantages experienced in informal settlements.

Adult Children's Migration and Well-being of Left Behind Nepalese Elderly Parents

The objective of this study is to assess whether adult children's migration is associated with overall well-being of left-behind elderly parents in Nepal. A cross-sectional house-to-house survey was conducted among 260 community-dwelling elderly residents of Krishnapur municipality, Nepal. Binary logistic regression was used to identify whether migration of adult children was associated with elderly parent's self-reported chronic diseases, depressive symptoms, perceived loneliness and social support. More than half of the study household (51.2%) had at least one adult migrant child. Compared to participants without a migrant child, participants with a migrant child had higher odds of self-reported chronic diseases (OR = 1.79, 95%CI: 0.91-3.54), presence of depressive symptoms (OR = 1.07, 95%CI: 0.64-1.77), and self-perceived loneliness (OR = 1.23, 95%CI: 1.06-1.42) but except for loneliness, the odds ratio for other indicators of well-being were not statistically significant. Although the literature posits an inverse relationship between adult children's migration and the overall well-being of the elderly parents, in our study, adult children's migration was not associated with inverse health outcomes among study participants. However, from a policy perspective, it should be understood that these observations may be transient since the family structure of Nepalese society is rapidly changing.

The Impact of Rural Labor Migration on Elderly Health from the Perspective of Gender Structure: A Case Study in Western China

Aging and rural labor migration have become two major demographic features in China. Using data of 400 rural households in Sichuan, China in 2015, this study constructs an ordered probit model containing instrumental variables to analyze the effect of rural labor migration on the health of the elderly in the family, from the perspective of the gender structure of migrant labor. The results indicate that the overall impact of labor migration on the elderly’s health is positive, and labor migration in the family has different effects on the health of the elderly by gender. Specifically, the results indicate the following: (1) the joint migration of both male and female labor or the migration of only male labor in a household can have a positive impact; (2) if only female labor migrates, the impact is negative; and (3) although the effect is negative, the migration of only female labor has a more prominent impact on the elderly’s self-rated health, whereas the migration of only male labor has a more significant effect on the elderly’s activities of daily living. Our findings suggest that the differential influence of labor migration by gender on rural elderly health should be considered to ensure the welfare of the elderly.

The association between family members' migration and Epstein-Barr virus antibody titers among people left behind in rural Fujian, China

OBJECTIVES

In contrast to the health of migrants, which has been extensively studied, little attention has been paid to the health of adults left behind by family members who out-migrated to other locations. This study was performed to investigate the association between being left behind and the Epstein-Barr virus (EBV) antibody titer, which is an indicator of cellular immune functioning previously shown to be associated with psychological stress.

METHODS

A cross-sectional survey was conducted in rural communities in Fujian, China, in 2015. Questionnaire data and dried blood spot samples were collected from 748 adults. A mixed effect regression analysis was conducted to investigate the association.

RESULTS

Results indicated that the EBV antibody titers were higher among people who had been left behind compared with those who had not.

CONCLUSIONS

Our findings suggest that, in rural Fujian, China, family separation following the out-migration of family members is an important determinant of psychological stress.

Migration patterns & their associations with health and human rights in eastern Myanmar after political transition: results of a population-based survey using multistaged household cluster sampling

Background

Myanmar transitioned to a nominally civilian government in March 2011. It is unclear how, if at all, this political change has impacted migration at the household level.

Methods

We present household-level in- and out-migration data gathered during the Eastern Burma Retrospective Mortality Survey (EBRMS) conducted in 2013. Household level in-and out-migration information within the previous year was gathered via a cross-sectional, retrospective, multi-stage population-based cluster randomized survey conducted in eastern Myanmar. Univariate, bivariate and regression analyses were conducted.

Results

We conducted a cross-sectional survey of 6620 households across Eastern Myanmar between July and September of 2013. Out-migration outstripped in-migration more than 6:1 overall during the year prior to the survey - for international migration this ratio was 29:1. Most in-migrants had moved to their present location in the study area from other areas in Myanmar (87%). Only 11.3% (27 individuals) had returned from another country (Thailand). Those who migrated out of eastern Myanmar during the previous year were more likely to be male (55.2%), and three times more likely to be between the ages of 15-25 (49.5%) than non-migrants. The primary reason cited for a return to the household was family (26.3%) followed by work (23.2%). The primary reason cited for migrating out of the household was for education (46.4%) followed by work (40.2%). Respondents from households that reported out-migration in the past year were more likely to screen positive for depressive symptoms than households with no migration (PR 1.85; 95% CI 1.16, 2.97). Women in households with in-migration were more likely to be malnourished and had a higher unmet need for contraception. Forced labor, one subset of human rights violations experienced by this population, was reported by more in-migrant (8%) than out-migrant households (2.2%), though this finding did not reach statistical significance.

Conclusions

These analyses suggest that opportunities for employment and education are the primary drivers of migration out of the household, despite an overall improvement in stability and decrease in prevalence of human rights violations found by EBRMS 2013. Additionally, migration into and out of households in eastern Myanmar is associated with changes in health outcomes.

Self-reported Symptoms of Depression Among Chinese Rural-to-Urban Migrants and Left-Behind Family Members

IMPORTANCE

There were an estimated 247 million rural-to-urban migrant workers in China in 2016, yet at a national level, there is scant evidence on the association of migration with mental health among migrants and their left-behind family members.

OBJECTIVE

To examine the association of rural-to-urban migration with symptoms of depression among migrants and left-behind family members aged 45 years and older.

DESIGN, SETTING, AND PARTICIPANTS

Using representative cross-sectional data of 14 332 middle-aged and older adults from the 2015 China Health and Retirement Longitudinal Survey, regression analyses were conducted to examine the association of depressive symptoms with rural-to-urban migration status in urban areas and the association of depressive symptoms with left-behind status in rural areas. The statistical analysis was performed from January to August 2018.

EXPOSURES

Migration status (defined as having a rural hukou [household registration record]) in urban areas and left-behind status (defined as having a spouse or child living in another area) in rural areas.

MAIN OUTCOMES AND MEASURES

Depressive symptoms measured on the 10-item Center for Epidemiological Studies Depression (CES-D-10) scale.

RESULTS

A total of 14 332 middle-aged and elderly participants (mean [SD] age, 59.84 [9.51] years; 7394 [51.6%] women) were included, of whom 4404 (30.7%) lived in urban areas and 9928 (69.3%) lived in rural areas. In urban areas, 1607 participants (36.2%) were rural-to-urban migrants, and the remaining 2797 participants (72.8%) were local residents. In rural areas, 3405 participants (34.3%) were left-behind family members, and the remaining 6523 participants (65.7%) were not. Compared with urban residents, rural-to-urban migrants had higher CES-D-10 scores after adjustment for covariates (β = 0.74; 95% CI, 0.08-1.40; P = .03; standard errors clustered at the household level henceforth). Compared with intact-family rural residents, left-behind spouses had higher CES-D-10 scores after adjustment for covariates (β = 0.54; 95% CI, 0.05-1.03; P = .03).

CONCLUSIONS AND RELEVANCE

Rural-to-urban migration in China was associated with poor mental health for migrants and their left-behind spouses. Short-term policies, such as building community social facilities, may prove effective, but long-term solutions should address issues related to economic and social exclusions and the lack of a social security system in rural China.

Mapping heat-related health risks of elderly citizens in mountainous area: A case study of Chongqing, China

Heat wave becomes a leading cause of weather-related illness and death across the world under the background of climate change, urban heat island, and population ageing. Heat health risk assessment is an important starting point for heat-related morbidity and mortality reduction within the risk governance framework. Chongqing, a mountainous municipality with a fast rate of population ageing in China, was selected as a case study for mapping the heat health risk of the elderly population at a raster scale. The results indicated that the high heat hazard and human exposure areas were mainly distributed in the metropolitan areas, which largely resulted in high heat health risk in the urban areas. However, the high heat vulnerability pixels were mainly concentrated at the remote mountainous regions which have broken terrains and low socioeconomic statuses. Compared with traditional general heat risk indicator, this new model can provide more targeted spatial information to decision makers, and is helpful to improve the flexibility and comparability of heat risk assessment tool. Furthermore, this new model is particularly valuable for quantifying heat health risk in developing countries with limited open access data.

Being left-behind, mental disorder, and elderly suicide in rural China: a case-control psychological autopsy study

BACKGROUND

Suicide rate among rural elderly is the highest among all age groups in China, yet little is known about the suicide risks in this rapidly growing vulnerable population.

METHODS

This matched case-control psychological autopsy study was conducted during June 2014 to September 2015. Consecutive samples of suicides aged 60 or above were identified in three provinces (Shandong, Hunan, and Guangxi) in China. Living comparisons were 1:1 matched with the suicides in age (±3 years old), gender, and living location. Risk factors included demographic characteristics, being left-behind, mental disorder, depressive symptoms, stressful life events, and social support.

RESULTS

A total of 242 suicides and 242 comparisons were enrolled: 135 (55.8%) were male, mean (s.d.) age was 74 (8) years. The most frequently used suicide means were pesticides (125, 51.7%) and hanging (95, 39.3%). Independent risks of suicide included unstable marital status [odds ratio (OR) 4.19, 95% confidence interval (CI) 1.61-10.92], unemployed (compared with employed, OR 4.43, 95% CI 1.09-17.95), depressive symptoms (OR 1.34, 95% CI 1.21-1.48), and mental disorder (OR 6.28, 95% CI 1.75-22.54). Structural equation model indicated that the association between being left-behind and suicide was mediated by mental disorder, depressive symptoms, stressful life events, and social support.

CONCLUSIONS

Unstable marital status, unemployed, depressive symptoms, and mental disorder are independent risk factors for suicide in rural elderly. Being left-behind can elevate the suicide risk through increasing life stresses, depressive symptoms, mental disorder, and decreasing social support. Elderly suicide may be prevented by restricting pesticides, training rural physicians, treating mental disorders, mitigating life stress, and enhancing social connection.

Migration of adult children and mental health of older parents 'left behind': An integrative review

Background

Although a number of studies have examined the effect of the out-migration of children on the mental health of ‘left behind’ elderly parents, research on the consequences of children’s migration on the mental health and well-being of elderly parents left behind is inconclusive and a systematic review is warranted.

Objectives

To identify the association between the left behind or empty nest status and the mental health of older parents, and to identify common risk factors for poor mental health among those left behind.

Methods

Online databases CINAHL, PsycINFO, PubMed, Scopus and ProQuest were searched for research (2000-September 2017) that focused on the relationship between the migration of adult children and the mental health of the older parents (≥50 years) left behind. The JBI Checklist for Analytical Cross Sectional Studies was used to assess the methodological quality of the articles.

Results

25 articles met the inclusion criteria. The studies identified that left behind older parents had higher levels of mental health problems compared to non-left behind. Left behind parents had higher depressive symptoms, higher levels of loneliness, lower life satisfaction, lower cognitive ability and poorer psychological health. A number of risk factors were identified for mental health disorders among the left behind parents, which included living arrangements, gender, education, income, physical health status, physical activity, family and social support, age, rural residence and frequency of children’s visit.

Conclusions

This review synthesised the various studies related to the mental health of left behind parents, advancing the theoretical and empirical understanding of the implications of out-migration of adult children on the psychological health and well-being of older parents. More responsive preventive measures and effective management approaches are required for this vulnerable cohort.

Emigration, remittances, and the subjective well-being of those staying behind

We offer the first global perspective on the well-being consequences of emigration for those staying behind using several subjective well-being measures (evaluations of best possible life, positive affect, stress, and depression). Using the Gallup World Poll data for 114 countries during 2009-2011, we find that having family members abroad is associated with greater evaluative well-being and positive affect, and receiving remittances is linked with further increases in evaluative well-being, especially in poorer contexts-both across and within countries. We also document that having household members abroad is linked with increased stress and depression, which are not offset by remittances. The out-migration of family members appears less traumatic in countries where migration is more common, indicating that people in such contexts might be able to cope better with separation. Overall, subjective well-being measures, which reflect both material and non-material aspects of life, furnish additional insights and a well-rounded picture of the consequences of emigration on migrant family members staying behind relative to standard outcomes employed in the literature, such as the left-behind's consumption, income, or labor market outcomes.

Offspring Migration and Parents' Emotional and Psychological Well-being in Mexico

In Mexico, offspring migration disrupts familial norms of coresidence and geographic proximity. This paper examines how offspring migration, both domestically and to the United States, affects the emotional and psychological well-being of parents who remain in the place of origin. Using nationally-representative longitudinal data from the Mexican Family Life Survey (N=4,718), we found limited evidence that parents whose offspring emigrated to the United States experience worse outcomes than parents of offspring who do not migrate. Although we found that offspring U.S. migration was not associated with changes in parents' overall depressive syndrome, a child's U.S. migration increased the likelihood of experiencing loneliness, and lead to a lower likelihood of recovery from parental sadness over time. Children's domestic migration did not affect parental well-being. These findings add to a growing body of literature that should be considered when assessing the broader impact of migration on family members who remain behind.

Children's migration and lifestyle-related chronic disease among older parents 'left behind' in india

Lifestyle-related chronic diseases such as cardiovascular diseases and diabetes are now the leading causes of death and disability in India. Interestingly, those Indian states with the highest prevalence of lifestyle-related chronic disease among older adults are also found to have the highest rates of international or internal out-migration. This paper investigates the association between having migrant (adult) children and older parents’ lifestyle-related chronic disease in India. Bi-variate and multivariate analysis are conducted using data from a representative sample of 9507 adults aged 60 and older in seven Indian states from the UNFPA project ‘Building Knowledge Base on Ageing in India’. The results show that for any of the diagnosed conditions of hypertension, diabetes and heart disease, the prevalence among older people with a migrant son is higher than among those without. More specifically, the odds ratio of reporting a lifestyle-related chronic disease is higher among older adults with at least one adult son living in another district, State or outside India than those with their children living closer. This study contributes empirical evidence to the academic and policy debate about the consequences of globalization and urbanization for older people's health status generally, and particularly their risk for reporting chronic diseases that relate to changes in their lifestyle.

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The prevalence of chronic disease is high among ‘left behind’ older parents in India.

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Children's out-migration and (or) migration within different states and (or) different districts are risk factors.

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Selected chronic diseases include diagnosed hypertension, diabetes and heart disease.

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More research is required on the health consequences of globalization and urbanization.

Non-kin ties as a source of support amongst older adults ‘left behind’ in Poland: a quantitative study on the role of geographic distance

In the transition to democracy and a market economy, the Central and Eastern European countries experienced rapid and fundamental changes. Large-scale emigration flows and pronounced reductions in previously universal welfare systems increased the phenomenon of ‘left behind’ older adults. We examine this phenomenon in the case of Poland, a rather family-oriented society which in recent years sent most emigrants to Western Europe in absolute terms. Employing a support system framework and representative survey data, we enquire into older adults’ support patterns. Our results suggest that older adults in Poland rely predominantly on family support, although this varies greatly across living arrangements. We also find a positive association between distance separating parents and their closest child, and support from at least one non-kin. Yet, our findings reveal differences between practical and emotional support, with the latter being more likely to be provided by non-kin, but with distance mattering to a lesser degree. Parents with very distant child(ren) are few and differ only from parents with very proximate child(ren), a finding prompting the question as to what is the difference between being ‘left behind’ by international and by internal migration. We conclude that the phenomenon of ‘left behind’ in Poland, at least in terms of support, is less a matter of children's migration and more an issue of household and regional context.

Children's migration and chronic illness among older parents 'left behind' in China

The relationship between adult children's migration and the health of their older parents 'left behind' is an emerging research area and existing studies reflect mixed findings. This study aims to investigate the association between having migrant (adult) children and older parents' chronic illness in China, using chronic stomach or other digestive diseases as a proxy. Secondary analysis of the national baseline survey of the 2011 China Health and Retirement Longitudinal Study (CHARLS) was conducted. Analyses were conducted in a total of sample of 6495 individuals aged 60 years and above from 28 out of 31 provinces in China, who had at least one child at the baseline survey. Binary logistic regression was used. The prevalence of any of the diagnosed conditions of chronic stomach or other digestive diseases was higher among older people with a migrant son than among those without (27 percent vs 21 percent, p < 0.001). More specifically, the odds ratio of reporting a disease was higher among older adults with at least one adult son living in another county or province than among those with all their sons living closer (OR = 1.29, 95% CI = 1.10-1.51). The results from this large sample of older adults support the hypothesis that migration of sons significantly increases the risk of chronic stomach and other digestive diseases among 'left behind' elderly parents in contemporary China.

Determinants of internal migrant health and the healthy migrant effect in South India: a mixed methods study

Background

Internal labour migration is an important and necessary livelihood strategy for millions of individuals and households in India. However, the precarious position of migrant workers within Indian society may have consequences for the health of these individuals. Previous research on the connections between health and labour mobility within India have primarily focused on the negative health outcomes associated with this practice. Thus, there is a need to better identify the determinants of internal migrant health and how these determinants shape migrant health outcomes.

Methods

An exploratory mixed methods study was conducted in 26 villages in the Krishnagiri district of Tamil Nadu. Sixty-six semi-structured interviews were completed using snowball sampling, followed by 300 household surveys using multi-stage random sampling. For qualitative data, an analysis of themes and content was completed. For quantitative data, information on current participation in internal labour migration, in addition to self-reported morbidity and determinants of internal migrant health, was collected. Morbidity categories were compared between migrant and non-migrant adults (age 14–65 years) using a Fisher’s exact test.

Results

Of the 300 households surveyed, 137 households (45.7%) had at least one current migrant member, with 205 migrant and 1012 non-migrant adults (age 14–65 years) included in this study.

The health profile of migrant and non-migrants was similar in this setting, with 53 migrants (25.9%) currently suffering from a health problem compared to 273 non-migrants (27.0%). Migrant households identified both occupational and livelihood factors that contributed to changes in the health of their migrant members. These determinants of internal migrant health were corroborated and further expanded on through the semi-structured interviews.

Conclusions

Internal labour migration in and of itself is not a determinant of health, as participation in labour mobility can contribute to an improvement in health, a decline in health, or no change in health among migrant workers. Targeted public health interventions should focus on addressing the determinants of internal migrant health to enhance the contributions these individuals can make to their households and villages of origin.

A randomized study on the effect of modified behavioral activation treatment for depressive symptoms in rural left-behind elderly

OBJECTIVE

To evaluate the effectiveness of a modified behavioral activation treatment (MBAT) intervention on reducing depressive symptoms in rural left-behind elderly.

METHOD

This is a randomized study registered in Chinese Clinical Trial Registry (ChiCTR-IOR-17011289). Eighty rural left-behind elderly people who had a Geriatric Depression Scale (GDS) score between 11 and 25 were randomly assigned to the intervention (n = 40) and control group (n = 40). The intervention group received both MBAT and regular treatment for 8 weeks while the control group received regular treatment. Both groups were assessed with the GDS, Beck Anxiety Inventory (BAI), and Oxford Happiness Questionnaire (OHQ) at baseline, immediately post-intervention, and at 3 months post-intervention.

RESULTS

There were a total of 73 participants that completed the intervention. The scores of GDS and BAI decreased significantly, but the scores of OHQ increased significantly in the intervention group after 8 sessions of MBAT (P < .01). The reduction in depression symptoms after the intervention was maintained at the 3-month follow-up. Significant differences in GDS, BAI, and OHQ scores were observed between the intervention group and the control group (P < .01).

CONCLUSION

MBAT produced a significantly greater reduction in depressive symptoms than regular care in rural left-behind elderly. Clinical or methodological significance of this article: A modified behavioral activation (BA) psychotherapy can significantly reduce the recurrence and seriousness of depression symptoms in the left-behind elderly with mild to moderate depression. This study also suggests that further study of the MBAT as an intervention will provide a direction for the management of mental health in rural left-behind elders.

Adult Child Migration and Elderly Multidimensional Well-Being: Comparative Analysis Between Moldova and Georgia

Despite growing concern over the potential consequences of migration for the "left behind," few systematic attempts have been made to document the relationship between the migration of an adult child and the well-being of his or her elderly parent(s) remaining in the country of origin. This article proposes a multidimensional elderly well-being index that enables the identification and comparison of outcomes between elderly individuals with and without adult migrant children in Moldova and Georgia, two former Soviet states that are both experiencing demographic and mobility transitions. The outcomes of elderly individuals with and without children living abroad are compared to illustrate in what domains child absence through migration corresponds to differing well-being outcomes. The findings suggest that the migration of an adult child is not as significant a factor in shaping well-being outcomes as would be expected based on past literature; other factors may play much stronger roles in shaping of well-being.

Pathways to grandparents’ provision of care in skipped-generation households in Thailand

In many parts of the world, grandparents live with their grandchildren in ‘skipped-generation households’ in which no parent resides. In Thailand, this living arrangement is more common in rural areas where parents often migrate to find employment. The focus of this article is on how grandparents make the decision to live in skipped-generation households. Our study is based upon open-ended interviews with 48 grandparents who lived in three rural areas of Thailand. Using an interpretative phenomenological approach, the analysis uncovers several factors that contribute to grandparents’ decisions about their living arrangements. These factors include: norms about care-giving and family obligation, inadequate child-care options, the need for financial support, problematic relationships within the family and a desire for companionship. We also identify three different decision-making patterns: grandparents initiating the decision to provide grandchild care, adult children asking grandparents to assume this role and adult children abandoning grandchildren to the grandparents. Based upon these findings, we provide implications for practice that address the conditions of grandparents and their family members.

Migration and the Multi-Dimensional Well-Being of Elderly Persons in Georgia

High rates of migration coupled with low formal social protection provisions may place many members of the elderly Georgian population in precarious living conditions that promote vulnerability and limit well-being achievement. This potential connection has been poorly explored in past literature, however, suggesting a need to better assess how the migration of an adult child may influence the multidimensional well-being of the elderly in Georgia. Using a novel dataset comprising 2202 elderly individuals across all regions of Georgia (excepting the territories of Abkhazia and South Ossetia), this paper proposes a multidimensional well-being index that has been specifically designed to encompass the unique resources and constraints faced by elderly individuals in different age cohorts. Following the construction of a multidimensional well-being index-comprised of domains including physical health and independence, housing well-being, social well-being, and emotional well-being-the outcomes of elderly individuals are compared by age and the presence/absence of adult children due to migration. Findings suggest that the migration status of an elderly person's adult children is related to the attainment of well-being. Elderly individuals with a migrant child are more likely to attain well-being in physical health as well as in the overall multidimensional well-being index.

Facing “Double Jeopardy”? Depressive Symptoms in Left-Behind Elderly in Rural China

Objective: When examining the depressive symptoms of left-behind elderly, this article goes beyond a focus on disruption to traditional patterns of living arrangements and investigates the heterogeneities in the patterns of migration distance, as well as the role of community contexts in buffering the loss of migrant children’s support. Method: This study uses the first wave of the China Health and Retirement Longitudinal Survey, and employs random effects multi-level modeling. Results: Having migrant children is associated with increased depressive symptoms among older adults, above and beyond living arrangements. Having their migrant children all live outside the province further puts older adults in disadvantaged mental conditions. This disadvantage can be further compounded by residence in impoverished communities. Discussion: In assessing depression among rural older adults in China, examination of living arrangements may be insufficient. It may be necessary to reference to children’s migration status as well as community poverty levels.

Does it matter where the children are? The wellbeing of elderly people ‘left behind’ by migrant children in Moldova

This paper empirically evaluates the wellbeing of elderly individuals ‘left behind’ by their adult migrant children in Moldova. Using data from a nationally representative household survey conducted in 2011–12 in Moldova, the wellbeing outcomes of elderly individuals aged 60 and older with and without adult children living abroad are compared (N = 1,322). A multi-dimensional wellbeing index is constructed on the basis of seven indicators within four dimensions of wellbeing: physical health, housing, social wellbeing and emotional wellbeing. Probit regressions are used to predict the probability of an elderly individual being considered well in each indicator and then on total index level. The results reveal that elderly persons with an adult migrant child have a higher probability of being well in one physical health indicator. Following correction for the selectivity of migration using an instrumental variable approach, however, the migration of an adult child is no longer found to predict significantly the wellbeing of their elderly parents in any dimension, suggesting that migration bears limited consequences for elderly wellbeing.

Transnational ties and past-year major depressive episodes among Latino immigrants

Latino immigrants live in an increasingly global world in which maintaining contact with kin in the home country is easier than ever. We examined (a) the annual distribution of remittances burden (percentage of remittances/household income) and visits to the home country, (b) the association of these transnational ties with a past-year major depressive episode (MDE), and (c) moderation by Latino subethnicity or gender. We conducted weighted logistic regression analyses with the Latino immigrant subsample (N = 1,614) of the National Latino and Asian American Study. Mexican and Other Latino immigrants had greater remittances burden than Puerto Rican migrants. Cuban immigrants made the fewest visits back home. After adjustment for sociodemographics and premigration psychiatric history, remittances burden decreased odds of MDE (odds ratio [OR] = 0.80, 95% confidence interval [CI] [0.67, .0.98]), whereas visits back home increased odds of MDE (OR = 1.04, 95% CI [1.01, 1.06]). Latino subethnicity was not a significant moderator. Visits back home were more strongly linked to depression among women than men. The distribution of transnational ties differs by Latino subgroup, although its association with depression is similar across groups. Monetary giving through remittances might promote a greater sense of self-efficacy, and caregiving for relatives back home that positively affect mental health. Visits back home, especially for women, might signal social stress from strained relationships with kin, spouses, or children left behind, or increased caregiving demands that negatively affect mental health. Clinical practice with immigrants should routinely assess the social resources and strains that fall outside national borders.

Common mental disorders among adult members of 'left-behind' international migrant worker families in Sri Lanka

BACKGROUND

Nearly one-in-ten Sri Lankans are employed abroad as International migrant workers (IMW). Very little is known about the mental health of adult members in families left-behind. This study aimed to explore the impact of economic migration on mental health (common mental disorders) of left-behind families in Sri Lanka.

METHODS

A cross-sectional survey using multistage sampling was conducted in six districts (representing 62% of outbound IMW population) of Sri Lanka. Spouses and non-spouse caregivers (those providing substantial care for children) from families of economic migrants were recruited. Adult mental health was measured using the Patient Health Questionnaire. Demographic, socio-economic, migration-specific and health utilization information were gathered.

RESULTS

A total of 410 IMW families were recruited (response rate: 95.1%). Both spouse and a non-spouse caregiver were recruited for 55 families with a total of 277 spouses and 188 caregivers included. Poor general health, current diagnosed illness and healthcare visit frequency was higher in the non-spouse caregiver group. Overall prevalence of common mental disorder (CMD; Depression, somatoform disorder, anxiety) was 20.7% (95%CI 16.9-24.3) with 14.4% (95%CI 10.3-18.6) among spouses and 29.8% (95%CI 23.2-36.4) among non-spouse caregivers. Prevalence of depression (25.5%; 95%CI 19.2-31.8) and somatoform disorder 11.7% (95%CI 7.0-16.3) was higher in non-spouse caregiver group. When adjusted for age and gender, non-returning IMW in family, primary education and low in-bound remittance frequency was associated with CMD for spouses while no education, poor general health and increased healthcare visits was significantly associated in the non-spouse caregiver group.

CONCLUSIONS

To our knowledge, this is one of the first studies to explore specific mental health outcomes among adult left-behind family members of IMW through standardized diagnostic instruments in Sri Lanka and in South Asian region. Negative impact of economic migration is highlighted by the considerably high prevalence of CMD among adults in left-behind families. A policy framework that enables health protection whilst promoting migration for development remains a key challenge for labour-sending nations.

Alone but better off? Adult child migration and health of elderly parents in Moldova

Increasing labor migration and simultaneous aging of societies are two important demographic developments many poor countries face. Elderly people who are left behind may experience a decrease in welfare when their children migrate. This paper investigates the effect of migration on various dimensions of elderly health using unique data from Moldova, which has one of the highest emigration rates in the world. We find positive migration effects on body mass index (BMI), mobility and self-reported health. No effects are found on depression and cognitive capacity. We find evidence that these positive outcomes are linked to an income effect which leads to improvements in diet and identify a reallocation of time use from subsistence farming to leisure and sleep which may have further beneficial effects. These positive effects seem to compensate the elderly for decreasing social contact with their migrant family members.

The effect of asset-based wealth inequality on problem drinking among rural Thai elders: a prospective population-based cohort study

Evidence on the link between income inequality and alcohol-related problems is scarce, inconclusive and dominated by studies from the developed world. The use of income as a proxy measure for wealth is also questionable, particularly in developing countries. The goal of the present study is to explore the contextual influence of asset-based wealth inequality on problem drinking among Thai older adults. A population-based cohort study with a one-year follow-up was nested in a Demographic Surveillance System (DSS) of 100 villages in western Thailand. Data were drawn from a random sample of 1104 older residents, aged 60 or over (one per household) drawn from all 100 villages, of whom 982 (89%) provided problem drinking data at follow-up. The primary outcome measure was a validated Thai version of the Alcohol-Used Disorder Identification Test for problem drinking. Living in areas of high wealth inequality was prospectively associated with a greater risk for problem drinking among older people (adjusted odds ratio 2.30, 95% confidence intervals 1.02–5.22), after adjusting for individual-level and village-level factors. A rise in wealth inequality over the year was also independently associated with an increased risk of problem drinking (adjusted odds ratio 2.89, 95% confidence intervals 1.24–6.65). The associations were not explained by the social capital, status anxiety or psychosocial stress variables. The data suggest that wealth inequality and an increase in inequality across time lead to a greater risk of problem drinking. Efforts should be directed towards reducing gaps and preventing large jumps in inequality in the communities. Further research should investigate the effect of asset-based inequality on various health risk behaviors and its specific mediating pathways.

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Evidence on inequality and alcohol-related outcomes is inconclusive.

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Assets may be more reliable for measuring inequality in developing countries.

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The findings suggested that wealth disparity increased the risk of problem drinking.

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Widening disparity across time also increased the risk.

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To address problem drinking may need to target areas with high wealth inequalities.

Health of China's rural-urban migrants and their families: a review of literature from 2000 to 2012

BACKGROUND

Socioeconomic transformation in China at the beginning of the twenty-first century has led to rapid urbanization and accelerated rural-urban migration. As a result, the concerns about public health problems triggered by increasing internal population mobility have been more widely studied in recent years.

SOURCES OF DATA

Published data in Chinese and English on health of migrants and their families in mainland China from 2000 to 2012.

AREAS OF AGREEMENT

The shifting patterns of disease distribution due to rural-urban migration, health equity and health reform strategies that cater for this specific yet substantial subpopulation are outstanding concerns. Infectious diseases, mental health, occupational health and women's health are emerging public health priorities related to migration.

AREAS OF CONTROVERSY

The high mobility and large numbers of Chinese rural-urban migrants pose challenges to research methods and the reliability of evidence gained.

GROWING POINTS

While the theme of working migrants is common in the literature, there have also been some studies of health of those left behind but who often remain unregistered. Migration within China is not a single entity and understanding the dynamics of new and emerging societies will need further study.

AREAS TIMELY FOR DEVELOPING RESEARCH

Social, economic, emotional, environmental and behavioural risk factors that impact on health of migrants and their families call for more attention from health policy-makers and researchers in contemporary China.

Those easily forgotten: the impact of emigration on those left behind

Much has been written about the experiences and stresses of those who emigrate. By contrast, little attention has been paid to the experiences of those who stay behind-family members and friends who for various reasons do not to join their loved ones in the destination country. In this article, I describe the experiences of some South Africans whose families and friends have emigrated. This study forms part of a larger research project focusing on the impact of emigration on South African family life. Twenty-one participants were interviewed by means of a semistructured interview at least 6 months after one or more family member(s) and/or friend(s) left South Africa, to explore participants' experiences around their loved ones' emigration. A thematic analysis of the data reveals that those left behind experience various emotions, ranging from emotional ambivalence to anger and distress. Emigration is mostly experienced as a vast loss, almost akin to a "death," bringing about significant changes in social networks and relationships. The therapeutic significance of the findings for those working with emigrant families is also explored.

Migration and health: a framework for 21st century policy-making

In the introductory article to a six-part PLoS Medicine series on Migration & Health, series guest editors Cathy Zimmerman, Mazeda Hossain, and Ligia Kiss outline a migratory process framework that involves five phases: pre-departure, travel, destination, interception, and return.

Mexican migration experiences to the US and risk for anxiety and depressive symptoms

BACKGROUND

Scant and contradictory information prevails on the risk for common psychiatric disorders in Mexican immigrants to the United States (US). Extension of these results in larger samples is needed to better address treatment needs. This study investigates the association between migration to the US and development of depressive and anxiety symptoms in four urban areas of Mexico.

METHODS

A cross-sectional survey in 2005 of individuals ages 12-65 from four cities formed a representative sample. Immigration-related experiences and prevalence of depressive and anxiety symptoms were recorded. Respondents were classified into three groups: (i) 'return migrants', (ii) 'relatives of migrants' and (iii) 'non-migrants' in the general population. Depression symptoms were assessed with the Center for Epidemiologic Studies Depression Scale (CES-D) and anxiety was determined using the Beck Anxiety Inventory (BAI). Prevalence of depressive and anxiety symptoms were estimated as the proportion of the entire sample reporting the outcome. Crude and adjusted OR's were estimated in logistic regression models.

RESULTS

A total of 1630 respondents, represent a 70.5% response rate. Overall prevalence of depressive and anxiety symptoms were both approximately 16%. Increased risk for depressive symptoms (OR=1.49 CI 95%=1.01-2.20) among return migrants and depressive (OR=1.48, CI 95%=1.07-2.05) and anxiety symptoms (OR=1.38, CI 95%=1.08-1.78) in relatives of migrants was found in comparison to those without a migration experience.

LIMITATIONS

Specific age and timing of migration experiences were not recorded.

CONCLUSIONS

Migration experiences produce important levels of anxiety and depressive symptoms that could be linked to psychopathology.

Impact of children's migration on health and health care-seeking behavior of elderly left behind

BACKGROUND

Many countries are facing the burden of accelerated population aging and a lack of institutional support to meet the needs of older individuals. In developing countries, adult children are primarily responsible for the care of their elderly parents. However, out-migration of adult children is common in these countries. This study aims to explore the impact of migration on the health of the elderly left behind and their health care-seeking behavior.

METHODS

This paper uses data from a national survey of older persons in Thailand conducted in 2007. The analysis is confined to those who were aged 60 years or above and who had at least one child (biological or step/adopted) (n = 28,677). Logistic regression was used to assess the net effect of migration of adult children on the health of the elderly left behind and their health care-seeking behavior, after controlling for other socio-demographic and economic variables.

RESULTS

More than two-thirds of the elderly (67%) had at least one migrant child. About three-fifths (58%) reported that they had at least one symptom of poor mental health. Almost three in five elderly (56%) rated their health as poor, and 44% had experienced at least one chronic disease. About two-thirds of the elderly (65%) got sick during the 5 years preceding the survey. An overwhelming majority of elderly (88%) who got sick during the five years preceding the survey had sought treatment for their last illness.After controlling for socio-demographic and economic variables, our study found that those elderly who had a migrant child were more likely (OR = 1.10; 95% CI 1.05-1.17) to have symptoms of poor mental health than those whose children had not migrated. However, no significant association was observed among physical health, such as experience of chronic disease, perceived poor health, and illness of the elderly left behind. Interestingly, however, out-migration of adult children was independently associated with higher utilization of health services. The elderly who had migrant children were more likely (odds ratio = 1.22, CI 1.11-1.33) than those whose children had not migrated to seek treatment for their most recent illness, after controlling for socio-demographic and economic variables.

CONCLUSION

Our study provides novel evidence on an issue of special importance to countries affected by heavy out-migration of adult children, an issue that has received little attention. Out-migration of adult children was highly associated with poor mental health but it was not associated with the physical health of the elderly left behind. Out-migration of children was also highly associated with higher utilization of health facilities by the elderly. Thus, in order to decrease morbidity among the elderly as well as to maintain and enhance the well-being of families, programs should focus on alleviating the symptoms of poor mental health among the elderly left behind and aim to reduce the differences in utilization of health care-seeking behavior among elderly with children present in the community and elderly left behind.