Impact of adult children's migration on the mental health and quality of life of older parents 'left behind' in Nepal

Population ageing and the migration of young and middle-aged people are the most significant socio-demographic trends of the 21st century. The migration of children may have both positive and negative impacts on the health and well-being of their left-behind older parents. Whilst money transferred by migrant children may increase the financial resources available to parents and enable better access to health and welfare services, the absence of a child can erode traditional intra-family care arrangements, and may adversely affect parents' physical and mental health. The two literature reviews for this thesis were a systematic review focused on the prevalence of mental health disorders in Nepal and an integrative review on the impact of adult children's migration on the mental health of left-behind older parents. The reviews found migration of children having a negative effect on parents' mental health. However, these studies were methodologically limited by the differing definitions of 'left-behind', by their not considering internal and international migration, their small-scale non-random samples, and their limited use of standard scales. In relation to Nepal, there are limited community-based studies on the mental health of older people, and no local study has assessed the impact of children's migration on parents' mental health and quality of life (QOL). A cross-sectional community-based survey aimed to identify the association of adult children's migration with the mental health and QOL of older parents. This study also estimated the prevalence of common mental health symptoms and identified potential risk and protective factors which may influence the mental health of left-behind older parents. The study was conducted during May‚Äö-July 2020 in two districts in Nepal among 794 randomly selected older adults aged 60 years or over who had at least one child aged 18 years or over. Mental health was assessed using the 21-item Depression Anxiety Stress Scales (DASS-21), which measures the mental health symptoms of depression, anxiety and stress. QOL was assessed using the World Health Organization Quality of Life-abbreviated scale (WHOQOL-BREF), which measures QOL in physical, psychological, social, and environmental domains. Older adults having an adult child not living in the same municipality were considered 'left-behind' parents. Migration of children was further classified into internal (to a different municipality within Nepal) and international. A wide range of socioeconomic, health-, lifestyle- and child-related characteristics were measured for adjustment. Data were collected through personal face-to-face interviews by trained interviewers. Socio demographic and study variables were presented, and compared using descriptive statistics (proportion, mean and standard deviation), chi-square test, Fisher's exact test, t-test, correlation, and analysis of variance (ANOVA). The risk factors of the symptoms of mental health disorders were assessed using multilevel logistic regression, while the association of migration of adult children with mental health symptoms and QOL was analysed using multilevel linear regression. The average age of the participants was 71.1 ¬¨¬± 8.2 years. A higher proportion of the participants were male (52.2%), married (61.0%), living with their spouse (62.9%), and currently working (55.0%), with agriculture the main source of household income (58.4%). The mean DASS-21 score was 12.6 ¬¨¬± 18.7, and the domain scores were 4.1 ¬¨¬± 7.6 for depression, 3.5 ¬¨¬± 5.0 for anxiety, and 5.0 ¬¨¬± 7.3 for stress, with prevalence, respectively, of 15.4, 18.1 and 12.1%. The study found several associated factors which were similar among both the general sample of older adults and the left-behind sub-group. The risk factors included being female, working in agriculture, perceived poor health, smoking, having chronic condition(s), having a child outside the country, and exposure to adverse life events. Perceived social support, functional ability, physical exercise, participation in social activities, and receiving an allowance were found to have protective effects. For left-behind parents, two additional variables‚ÄövÑvÆcloseness to a child and communication with children‚ÄövÑvÆshowed a negative association with mental health symptoms. Scores for QOL were 58.8 ¬¨¬± 19.8 for physical, 63.7 ¬¨¬± 18.0 for psychological, 60.7 ¬¨¬± 16.2 for social, and 61.8 ¬¨¬± 15.0 for environmental domains. Left-behind parents showed better well-being, scoring higher on QOL and lower on mental health symptoms compared to parents whose children did not migrate, but the differences were not statistically significant. Left-behind parents whose children migrated internally had higher scores for physical (b = 5.16, p = 0.017) and environmental (b = 3.19, p = 0.046) domains compared to parents whose child had not migrated. When internal and international migration were compared, parents with internationally migrated adult children were at higher risk of mental health symptoms, particularly anxiety (b = 1.39, p < 0.001) and stress (b = 1.08, p = 0.030). Left-behind older parents were not found to be at higher risk of mental health symptoms and they did not have lower QOL compared to non-left-behind parents. This finding contrasts with previous studies which reported adverse impacts on left-behind parents' well-being. Parents with internally migrated children were in a better position in terms of QOL and psychological well-being. Further longitudinal studies are required to determine the causal relationship between the migration of adult children and the QOL of left-behind parents, and to address selection bias associated with migration choice. This study provides important insights into the nature of the relationship of adult children's migration with their parents' mental health and QOL by providing an in-depth analysis of data from Nepal, a low-income country. Parents with internally migrated children showing better psychological health emphasises the importance of creating local employment opportunities and facilitating migration within national borders. Interventions aiming to improve the mental health of older adults should target the identified risk and protective factors. The results have contributed new knowledge about the well-being of left-behind older people, and can inform the development of public health social welfare policies and programmes more responsive to the needs of older people.