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   Table of Contents      
ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 5  |  Page : 432-438

Support received and provided by older adults who lost a child: A qualitative content analysis


Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran

Date of Submission25-Sep-2021
Date of Decision21-Dec-2021
Date of Acceptance14-Mar-2022
Date of Web Publication14-Sep-2022

Correspondence Address:
Mohsen Adib-Hajbaghery
Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.ijnmr_274_21

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  Abstract 


Background: Despite the vulnerability of older adults and the importance of social support following the death of a child, little research has been conducted on the Iranian older population. This study aimed to explore perceived support among older adults after the death of a child. Materials and Methods: This study was carried out in Iran in 2020-2021 using a qualitative content analysis method. Semi-structured interviews with older adults who had experienced child death were used to collect data. To ensure the data's trustworthiness, Guba and Lincoln's criteria were applied. The Graneheim and Lundman method was used to analyze the data. Results: The participants' mean age was 70.41 years. The findings were organized into one theme, two main categories, and five subcategories based on 352 initial codes. Two main categories emerged from the participants' experiences: “supporting networks” and “giving support to others” with the theme of “healing emotional pain.” Following the death of a child, the older parents perceived support as recuperation from their hurt feelings. Conclusions: Receiving support from family, entourages, and society, as well as providing support to the family and parents with the same experience were protective factors against the effects of child death among older parents. To reduce the consequences of child death, older parents' health should be monitored through home care provided by nurses.

Keywords: Aged, child, death, social support


How to cite this article:
Safa A, Adib-Hajbaghery M, Rezaei M. Support received and provided by older adults who lost a child: A qualitative content analysis. Iranian J Nursing Midwifery Res 2022;27:432-8

How to cite this URL:
Safa A, Adib-Hajbaghery M, Rezaei M. Support received and provided by older adults who lost a child: A qualitative content analysis. Iranian J Nursing Midwifery Res [serial online] 2022 [cited 2022 Oct 3];27:432-8. Available from: https://www.ijnmrjournal.net/text.asp?2022/27/5/432/356036




  Introduction Top


The world's older population is expected to grow from 9% in 2020 to 16% in 2050.[1] According to the most recent census in 2018, more than 10% of the Iranian population is older adults.[2] Aging is a natural stage of life that is characterized by reduced function, anatomical and physiological changes. Older adults may suffer from a variety of physical and psychological illnesses, including cardiovascular disease, dementia, depression, and various stresses, such as the death of family members.[3],[4] Among family member deaths, the death of a child can have the most negative effect on older parents and jeopardize their functional, psychological, and cognitive status.[3] Anxiety and depression, social dysfunction,[5] changes in health-related behaviors, hospitalization in psychiatric wards, and suicide attempts are just a few of the reactions to a child's death that can reduce their quality of life.[6] These reactions can disrupt a successful aging process and alter communication with others.[7] Therefore, older parents need help from their families, others, and society to meet their needs.

Social support refers to the establishment of an effective relationship with others that provides resources when a person is in need and protects him or her from the negative effects of stressful events.[8] Social support is a mutual relationship that can foster a positive self-concept, hope, and self-confidence, as well as provide an opportunity for self-fulfillment and growth.[9] Effective social support following bereavement reduces the severity of depressive symptoms, as well as the burden of mental illness.[10] A study showed lower emotional support predicted higher depressive symptoms.[11] Previous studies have also found that social support and communication with others can affect parents' mental health, resilience, and life satisfaction after mourning.[4],[12],[13]

The parents' relationships with the world around them may change after the death of a child. Parents may or may not receive support from others.[3] Due to increased physical problems, older parents may receive less social support or engage in behaviors that alienate others. Loneliness and isolation can be exacerbated by a lack of social support.[11] So far, research has concentrated on social support for young parents following the death of a child, rather than on social support for older adults.[11] According to one study, one of the challenges Chinese parents faced with child death was the poor social networks and interactions.[14] Another study found that after a child dies, parents experienced unstable family and disrupted social relationships,[15] which demonstrates the need for social support following the death of a child. Social relationships and support can vary in different communities and cultures. For example, post-mortem rituals and ceremonies that allow parents to communicate with others vary greatly across cultures.[16]

Although many studies have shown the improvement of parental adjustment to social support,[12],[17] some parents have also reported a lack of or ineffective support from others,[18] or support given to parents have not met their true needs.[19] Recognizing and strengthening effective sources of support helps the healthcare team, including nurses, to improve the physical and mental health and quality of life of older adults after losing a child. Because quantitative studies cannot identify the various dimensions of this issue, a qualitative approach was used in this study to deeply perceive parental support after a child's death. Regarding the vulnerability of older adults and the importance of their social support after the death of a child, few studies have been conducted on the Iranian older population. This study aimed to explore perceived support among older adults after the death of a child.


  Materials and Methods Top


This study is part of a greater qualitative study conducted using the grounded theory approach. Previously, the meaning of losing a child among older adults was explored.[20] The present study is a qualitative content analysis using a conventional approach (Oct 2020- Jul 2021). The purpose of qualitative content analysis is to explore individuals' perception of everyday life phenomena and to interpret their mental content.[21] Based on the experiences of the participants, the manifest and latent concepts in their minds were identified, coded, condensed, and classified, and themes were extracted from them.[22] Inclusion criteria were: a) people over the age of 60 years according to the definition of older adult's age in developing countries[23]; b) no cognitive problems based on the self-report of the participants and their families, because they could share their experiences with researchers; c) those who were at least one year after the death of a 16-year-old or older child, and d) those who were willing to participate in the study. Exclusion criterion was the participant's decision to withdraw from the study. Based on the statements of some participants, pointed out the lack of support from the healthcare team, two members of the healthcare team were also interviewed to complete the data.

The first researcher, a female, Ph.D. candidate with experience in qualitative research, conducted semi-structured and face-to-face interviews to collect data. Eligible older adults were selected purposefully. The researcher selected the first two participants through a search among her colleagues, and then selected the subsequent participants based on the data and codes obtained from these participants. Some of the participants with similar experiences were also introduced to the researcher by the previous participants. Telephone contacts were made with participants to arrange interviews. After introducing and explaining the purpose of the study, the researcher determined the time and place of the interviews based on the participants' preferences, and the interviews were conducted in a private, quiet, and comfortable location. In total, 22 interviews were conducted with 19 participants, 17 of whom were parents, and 2 of whom were healthcare providers. Three eligible older adults and two health care providers refused to participate in the study because they were busy. As a result, 18 interviews were conducted at the participants' homes, two in health centers, and two in a park. The interviews lasted from 39 to 70 min (50 min on average), depending on the participants' willingness and tolerance. To avoid fatigue and answer questions carefully, three participants were interviewed in two sessions in order to ensure the data's trustworthiness. All interviews were recorded on an MP3 recorder with the participants' permission. Participants were asked about their perceptions of support after the death of a child. Each interview began with a general question: “What happened after your child died?” and was followed by the following questions: “Would you please tell us about your experiences communicating with others after losing your child?” and “What support did you experience after your child died?” Additionally, probe and follow-up questions were used to elicit additional information from interviewees, such as “What do you mean?”, “Could you please explain more?” and “then?” Researchers tried not to lead participants to their predetermined mindsets in interviews. As a result, they recorded their initial thoughts about the study in a notebook and revisited it periodically throughout the research. Sampling was continued until the data were saturated. Saturation occurs when no new conceptual codes are discovered.[24]

Data were analyzed and collected simultaneously after the first interview. The analysis was a reciprocal process between the creation of concepts and the collection of data that helped to gather relevant information in the next interviews.[21] The Graneheim and Lundman (2004) method was used to analyze the data.[22] For this purpose, the text of the interview was transcribed verbatim after listening to it several times. MAXQDA software version 12 was used to manage data. The interview transcripts were read several times to gain a general perception. Then, the units of analysis were identified. In this study, the entire text of each interview was considered as a unit of analysis. Then, the paragraphs were considered as meaning units. According to their content, these units were put together and condensed meaning units were formed. Condensed meaning units were abstracted, labeled, and coded. Codes could be the participant's exact words or the researcher's interpretation of them. The codes were then compared in terms of similarities and differences and classified into five subcategories and two main categories. Finally, the data's latent content was presented under the theme “healing emotional pain.” All stages of data analysis were performed, corrected, and confirmed under the supervision of all research members.

Guba and Lincoln's criteria were used to ensure the trustworthiness of the data.[25] For data credibility, member-check and prolonged engagement were used. The participants were given the transcribed texts of five interviews, as well as the extracted codes, to review, approve, or correct them. Also, researchers were able to gain a better understanding of participants' real world after a ten-month engagement with them. A peer check was used to ensure dependability. Therefore, four analyzed interviews were presented to two qualitative researchers, whose opinions were taken into account during the analysis. The use of sufficient and appropriate samples with maximum variation in terms of demographic variables strengthened the confirmability of the data. The study process was reported in detail and representative quotations were provided from the transcript to improve transferability.

Ethical considerations

This research obtained the necessary permits from the ethics committee of this university (ethics No. IR.KAUMS.NUHEPM.REC.1399.049). First, the researcher explained the objectives of the research, the interview process, and the confidentiality of information to the participants, and obtained their written informed consent for their participation in the study and recording of the interviews. During the COVID-19 pandemic, all interviews were conducted following health protocols.


  Results Top


The study findings were based on 22 interviews with 19 participants, 17 of whom were parents, and 2 of whom were healthcare providers. Twelve (70.5 percent) participants were female. The participants' mean age was 70.41 years [Table 1]. The deceased children were between 17 and 62 years old, with 11 boys and 6 girls dying because of illness, accidents, martyrdom, drowning, burns, and drug abuse. In data analysis, two main categories of “supporting networks” and “giving support to others” with the theme of “healing emotional pain” were extracted [Table 2]. In general, the participants' experiences revealed that following the death of a child, support received by others, particularly family, and support given to loved ones and parents with the same experience were both important factors in achieving peace of mind, which could improve the physical and mental health of the older adults and allow them to return to life. According to the participants, a child's death was like a wound to their soul and body, and the support they received and provided alleviated their pain.
Table 1: Demographic characteristics of older parents

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Table 2: Categories extracted in terms of perceived support among older parents after the death of a child

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Supporting networks

According to the participants, support meant protection resulting from a relationship with another person or community. They would have been alone and isolated if they had lacked relationships with others and social support. After the death of a child, one of the most important needs of older parents was to receive emotional and functional support from family members, entourages, and community support systems.

Supporting by family members

This subcategory included support provided by the spouse and other children of participants. The role of the spouse in dealing with the death of a child was emphasized in the experiences of participants who were married at the time of their child's death. Because their spouses shared a common sorrow, they were better able to understand each other and deal with this painful event. Following the death of a child, many parents considered their spouses to be their best supporters, and they had peace of mind through their spouses' words and support. “Although my wife is sad, she consoles me through her words and actions.” (A 61-year-old father)

”My husband was very good. He did not leave me alone; he supported and assisted me in dealing with this painful event.” (A 75-year-old mother)

As all of the participants in this study had more than one child, they relied on the support of other children after their child died. Daughters were a better source of support, particularly when caring for older parents. ”I was so bored that I would not take a shower for two weeks. My daughter made me take a shower, and she was very gentle with me” (A 72-year-old mother).

Supporting by entourages

Participants mentioned the support of friends, neighbors, and coworkers on numerous occasions. There were contradictory interpretations of parental experiences in this subcategory. Some supports were effective and helpful from the perspectives of the parents, while others were ineffective and even harmful. “My good friends kept showing up at my house. They would not leave me alone. Some of my neighbors who came to see me expressed their sympathy in a negative way, which made me feel even worse” (A 64-year-old mother).

”After my son died, my landlord goes shopping for me. Some neighbors, on the other hand, annoyed me with their words. They inquired about my son's death, even though they were aware of what had occurred for him” (An 82-year-old mother whose son died because of a drug overdose).

Bereavement services provided an opportunity for parents to communicate with entourages, which may have relieved their grief over their child's death. ”It was encouraging when everyone came to see me in mourning customs; they rubbed and massaged my shoulders and kissed me. Their presence made me feel comfortable” (A 69-year-old father).

Community support systems

This subcategory included institutional and healthcare support for older parents. Only parents of martyrs were supported by public and private institutions in this study, which was few. During the interview, some participants also mentioned a lack of support from the healthcare team. ”We only look after the older adults who come to the center. A depressed person may not come to the center at all. Some older people are paralyzed or incapable of moving. This is a problem for us because we do not have home care” (A healthcare provider in a health center).

Lack of home care during the COVID-19 pandemic has become more important. ”As well as the older adults don't come to the center due to age-related problems such as knee and back pain, in the COVID-19 outbreak, older adults are afraid to seek healthcare services” (A nurse working in a health center).

The interview revealed that there have been no educational or recreational programs in the health centers for the older adults who have lost their family members.

Giving support to others

After their child died, older parents attempted to support their families more. This was especially important for those who were the most outstanding members of their families. They also tried to help parents who had the same experience as them.

Protection of family

Following the death of their child, the bereaved parents attempted to console their spouses and children. They tried harder than ever to take care of their families. They considered it as a replacement for their deceased child.

”My husband was very sad. My son's death was as a wound in his heart. I attempted not to leave him alone. I chose motivational sentences from my son's diary and wrote them on his palm every day.” (A 69-year-old mother)

”All I have, are my children. They must be fine because one of them died. Now I must concentrate on what I have” (A 63-year-old father).

Most older parents were in charge of taking care of the grandchild. They believed that taking care of and making the grandchild happy relieved their grief, made them feel younger, and made the deceased child pleased. ”She looks like her mother, and I adore her. I try to take care of her in the best possible way” (A 65-year-old mother).

Relieving of peers

Participants' experiences indicated that they felt good about assisting parents with similar experiences in a variety of ways. Several of them visited these parents and expressed their sympathies. Additionally, some books or films were introduced to them that could assist them in managing stress and accepting the event. “When I learned that someone had lost a child, I made a point of visiting them, speaking with them, and assisting them, because we understood one another better” (A 63-year-old mother).

When I learned that someone had lost a child, I made a point of visiting them, speaking with them, and assisting them, because we understood one another better.” (A 63-year-old mother)

I purchased a book that assisted me in regaining control of myself following the death of my child. Later, I bought the same book and gave it as a gift to parents who lost their children. In addition to helping them, it calmed me down” (A 65-year-old mother).


  Discussion Top


This study aimed to explore perceived support among older adults after the death of a child. Although previous studies focused on support received by parents,[12],[17] this study discovered that giving support to loved ones and peers could also be used to accept the death of a child and achieve peace of mind. These supports healed their emotional pain. Wang et al. (2021)[26] also demonstrated that social support played a protective role in parents, protecting them from mental and physical illnesses.

In the present study, receiving support from family as the most important source of protection as well as giving support to family and peers played an important role in preventing the negative consequences of child death. The spouses and children are the most important parts of older people's social networks. In general, older adults are more vulnerable to stress due to the effects of aging, decreased health, and the experience of multiple losses in their life[27] and are more likely to experience social isolation.[28] Receiving support from family and others can protect parents from the negative effects of child mortality.[27] Although it was expected that parental relationships would change after the death of a child, older parents reported romantic relationships based on empathy. Having a good relationship with the spouse in old age is a factor in preventing psychological illnesses, because it is associated with more attachment between the couples and spouses are the primary source of emotional support.[29],[30] Also, other children, particularly the daughters, were the best source of support for the older adults. Children play a key role in the family structure and are responsible for caring for their parents at their older age in Eastern societies. Sons are regarded as financial supporters, while daughters are regarded as emotional supporters.[31] This can alleviate the sense of loneliness and improve physical health in older adults.[32] As a result, having multiple children can be a protective factor in older parents following the death of a child.

Other sources of support in this study included entourages. Parents' experiences revealed contradictory supportive effects in this matter. The findings of a systematic review of Chinese older people also revealed the contradictory effects of friends' support.[32] This could be due to an inconsistency between the needs of the older adults and the social expectations of bereaved parents.[19] Mourning rituals differ from one culture to another;[33] many relationships were established during mourning rituals following a child's death. For the bereaved parents, they were a way to calm down and accept the death of a child.

One of the most important resources for supporting older adults is the health care system.[34] In this study, this system did not have adequacy for the vulnerability of the older adults following the death of a child. Iranian healthcare centers have not effectively integrated comprehensive geriatric care programs for mental health of older adults.[34] Despite the emphasis of experts on home care and its benefits for older adults, this program has not yet been implemented in Iran.[35] Inadequate home care was particularly salient during the COVID-19 pandemic and may increase the risk for poor outcomes.[36] The need for home care is strongly felt because of the older adults' physical and mental problems, particularly after the death of a child.

As support received by older parents can be beneficial to their health, giving support to family members can also be beneficial in this study. This factor had served as a substitute for the dead child. All of the parents were satisfied with looking after their grandchildren. Zhai et al. (2019)[7] showed that giving support to children played an important role in the mental health of the elderly. Another study found that intergenerational relationships could help older adults to cope with depression.[37] In addition, the results of this study showed that giving support to peers could also be useful. A study showed that bereaved survivors benefitted from peer support. Peer support was associated with a reduction in grief signs and an increase in individual well-being and development.[38] More care and attention to the family and peers had improved their physical and mental health.

The findings of this study indicated that receiving and giving support both are protective factors against the negative effects of child death in older parents. Older parents perceived support as recuperation from their hurt feelings following their child's death. Nurses' responsibilities are not limited to the patient's bedside and they should care for and support the older people to promote their health and prevent their diseases.[34] Effective communication with older adults, counseling with them, and physical and mental examinations to prevent diseases after losing a child are just a few of the actions nurses can take to help them. In this study, the healthcare team did not provide adequate care for the older people following the death of a child. Thus, it is suggested that the healthcare system design a follow-up program for these older adults. Home care programs can be provided and monitored through follow-up care. This study was the first study in Iran to examine the support of older adults after losing a child in Iran. The main limitation of this study was more than three-quarters of the participants were female. According to the differences in parental responsibilities in the family, it is suggested that future research focus more on fathers to determine whether there is a difference in perceived support after child death between older mothers and fathers.


  Conclusion Top


Receiving and providing support were protective factors against the effects of child death on older parents. Following the death of a child, the support received and provided by the older parents were like recuperation from their hurt feelings and led to better coping with this situation. To reduce the consequences of child death, it is recommended that older parents' health be monitored through home care provided by nurses.

Acknowledgements

The researchers express their gratitude to all elderly parents who shared their valuable experiences with us. This study is part of the PhD dissertation in nursing with the number 99121 in Kashan University of Medical Sciences. We also appreciate the university's Vice Chancellor for Research who was responsible for the financial support of this research.

Financial support and sponsorship

Kashan University of Medical Sciences

Conflicts of interest

Nothing to declare.



 
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