Gender, Health, and Aging in China

Jeanne SheaAssociate Professor

University of Vermont

Jeanne.Shea@uvm.edu

Outline

Basic demographic and public health situation

My related research on midlife Chinese women

Demographic and Public Health Situation

China’s Population

• Overall population– Mid 2008 1,324,708,000 – Mid 2025 (projected) 1,476,000,000 – Mid 2050 (projected) 1,437,000,000

• Decline in fertility and mortality– Birth Rate   12/1000 (16,029,000 per year) – TFR 1.6– Death Rate 7/1000 (9,180,000 per year) – Natural Increase 0.5% (6,849,000 per year)

(Population Reference Bureau 2008)

An Aging Population

• More than 10% of population is now age 60 or older– Age <15 256,993,000 (19%)– Age 15-64 967,036,840 (73%)– Age 65+ 107,301,000 (8%)

• Life Expectancy at Birth– Both Sexes  73 years – Males  71 years – Females   75 years

(Population Reference Bureau 2008)

Percentage Age 65+, 1950-2050

Toshiko Kaneda 2008, www.prb.org/Articles/2006/ChinasConcernOverPopulationAgingand Health.aspx, Source: World Population Prospects: The 2004 Revision (2005).

Population Pyramids

2000 2050

Toshiko Kaneda 2008, www.prb.org/Articles/2006/ChinasConcernOverPopulationAgingand Health.aspx, Source: World Population Prospects: The 2004 Revision (2005).

Social Concerns• Proportion of working-age (age 15-64) per elderly adults (age 65+) projected

to decline from 9 to 2.5 persons by 2050. • Support and care of frail or senile elderly• Increase in long-term chronic disease and disability

– Chronic diseases almost 80 percent of all deaths in China in 2005– Death major causes- cardiovascular disease, cancer, chronic respiratory dis.– Over past decade adult obesity doubled to 7%– And adult hypertension increased by one-third to 19%

• Large burden on singletons and other adult children: 4-2-1 problem• High male to female sex ratio -> deficit of daughters-in-law • Erosion of children’s moral drive to take care of elderly parents• Higher and longer labor force participation by women -> less informal care• Fear of caregiving burden reducing productivity of younger adults• Strain on pension, public welfare, and health care systems

– Rise in health care costs > growth of national economy and individual earnings – Health care access difficult for rural populations (many rural elderly)

• Fear -> slowing of economic growth due to less investment & productivity

China Population Devel. & Research Center, www.cpirc.org.cn/en/enews20020329.htm, Toshiko Kaneda 2008, www.prb.org/Articles/2006/ChinasConcernOverPopulationAgingand Health.aspx

Rural/Urban Divide• Rural dwellers ages 50+ 30% higher death rate than urban

– Lower wages– Fewer amenities, e.g., communication and transportation– Fewer short term health care facilities– Fewer long term care options – e.g., community care,

assisted living, nursing home– Despite recent expansion of coverage, at least half of rural

health care expenses still out of pocket– Little disposable income to pay for non-kin based care– Mass migration of rural youth to urban areas– Fewer kin available to provide care

(www.prb.org/Articles/2008/olderchinese.aspx)

Public health situation• Limited public funding for long term elder care• Social welfare reform, 1990s - decentralization, less govt. finance, more privatization• Locally funded public and private elder homes now accepting elderly with children

and some means of support; Increase in number of private elder homes• Elder homes very few, quality varies, too expensive for most, and few in rural areas • Community-based long-term care services emerging – checking in, daily care,

housekeeping, information, referral – but still very few• Some local govt. agencies and depts. of health - short-term training of laid-off

workers in basic care-giving – but still very limited • Govt. plans to develop undergrad. geriatric medical training and more geriatric units• MOH est. Natl. Ctr. for Chronic & Non-Communicable Disease Control & Prevention

and Disease Surveillance Points System (2002)• Working with WHO on 1st long-term (2005-2015) comprehensive national plan for

chronic disease control & prevention. Priorities - smoking, hypertension, obesity• Management of hypertension, diabetes (Beijing, Shanghai, Changsha, 1991-2000)• Program of Cancer Prevention and Control established • Ratification of WHO Framework Convention of Tobacco Control• Primary school nutrition education to prevent obesity

Toshiko Kaneda 2008, www.prb.org/Articles/2006/ChinasConcernOverPopulation Agingand Health.aspx

Research on Midlife Chinese Women in Beijing, 1992-present

Jeanne L. Shea

Associate Professor

University of Vermont

Chinese Women: Gender, Culture, Health, and Aging

• Community-based field research conducted in Beijing Municipality, 1992-2008

• Reading clinical and popular education materials published in China

• Examining scholarly literature on gender, aging, modernity, and experience/discourse

Fieldsites

Urban and rural communities in Beijing Municipality, China

Research Methods

• Quantitative community research (1994)– Over 400 Chinese women age 40-65 – Face-to-face interview using a questionnaire– Half in a rural village and half in an urban neighborhood in

Beijing Municipality– Total sample of village & block of neighborhood

• Qualitative community research (1993-94 and summers of 1992, 1996, 2000, 2007, 2008)– Conversations/participant observation: hundreds of women

in numerous rural and urban communities in Beijing– Tape-recorded interviews - dozens of women age 40-85, half

in rural and half in urban communities in Beijing

• Media studies (1992-2007)– Review of relevant local health education literature

Initial Research Questions: Experiences of Aging

• How view and experience their health, menopause, aging, middle age, and old age?

• What kinds of symptoms do they report, if any?

• How does this compare with cross-cultural research done in Japan and North America?

Core Symptom Profiles of Women Ages 45-55, Percent Reporting Symptom

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Core Symptoms

Japan

Canada

U.S.

China

Cross-Cultural Comparison of Symptom-Reporting

Chinese Women’s Views

Positive perspective end of menstruation

-end of mess, bother, expense

-not have to worry about birth control

NOT focused on:

-hormonal decline

-loss of physical attractiveness, reproductive ability, empty nest, etc.

Some Potential Explanations

• Local reproductive endocrinology and soy consumption only to hot flashes (NIH 2005)

• Confucian values instantiated differently in Japan versus China

• Extent, severity, and rapidity of social change

• Cultural acceptability of monitoring symptoms

• Cultural construction of dominant concept of female midlife (gengnianqi vs. konenki)

Chinese Women’s Experiences

In accounting for midlife symptoms and suffering, they tend to focus on:

-experience of social history

-suffering and loss of opportunity due to “feudalism,” Japanese occupation, civil war, anti-Rightist campaign, GLF, Cultural Revolution

-mother-in-law/daughter-in-law issues

-not prepared for change to market economy

Inspired Questions About:

Chinese Women’s Experiences of Romance, Sex, and Marriage

in Later Life

Chinese Media Advocating Romance, Sex, and (Re)marriage

In Later Life

• Doctors, psychologists, cadres, and educators

• Clinical/popular education

• Books, booklets, magazines, newspapers

• Some television shows, videos, posters

Campaign against

traditional views

“feudal superstition”

Confucian conservatism

Daoist alchemy

Campaign for

modern perspectives

communist ethics

scientific knowledge

cosmopolitan views

Media Representations

• Tradition and the Chinese past

• Chinese people in later life

• Middle-aged and old women– Prime victims– Prime perpetrators

Enlightenment Liberation of Behavior

• Educate the public on what is normal, natural, healthy, and socially respectable,

• And thus modernize behavior of older Chinese and promote their well-being.

Superstition Unhealthy Constraint

Enlightenment View of Knowledge

Why the campaign?

• Western enlightenment beliefs of some clinicians and popular educators

• Globalization and increasing pressure across the lifecycle to live like Westerners are believed to live

• Utility for nation to stress later-life conjugality at this time– Economic reforms– Changes in kinship obligations– Increased proportion of elderly in population

Women’s Views and Behaviors

Chinese Women, Age 40-65, N=399 40-49 (n=196)

n1 (%) 50-59 (n=126)

n1 (%) 60-65 (n=77)

n1 (%) Total (N=399)

n1 (%) Marital Status Married, living together 189 (96.4) 110 (87.3) 61 (79.2) 360 (90.2) Married, living apart 4 (2.0) 3 (2.4) 4 (5.2) 11 (2.8) Widow 1 (0.5) 10 (7.9) 12 (15.6) 23 (5.8) Divorced 0 (0.0) 2 (1.6) 0 (0.0) 2 (0.5)1 Never married 2 (1.0) 1 (0.8) 0 (0.0) 3 (0.8) Times Married Twice 6 (3.1) 3 (2.4) 5 (6.5) 14 (3.5) Once 188 (95.9) 122 (96.8) 72 (93.5) 382 (95.7) Zero 2 (1.0) 1 (0.8) 0 (0.0) 3 (0.8) Menopausal Status Premenopausal 111 (56.6) 4 (3.2) 0 (0.0) 115 (28.8) Perimenopausal 77 (39.3) 20 (15.9) 1 (1.3) 98 (24.6) Postmenopausal 8 (4.1) 102 (81.0) 76 (98.7) 186 (46.6) Residence Urban 112 (57.1) 57 (45.2) 31 (40.3) 200 (50.1) Rural 84 (42.9) 69 (54.8) 46 (59.7) 199 (49.9) Education 0-3 years 11 (5.6) 37 (29.4) 51 (66.2) 99 (24.8)

illiterate 1 (0.5) 8 (6.3) 26 (33.8) 35 (8.8) 4-9 years 142 (72.4) 62 (49.2) 10 (13.0) 214 (53.6) 10+ years 43 (21.9) 27 (21.4) 16 (20.8) 86 (21.6) Household Composition 1 generation 6 (3.1) 12 (9.5) 23 (29.9) 41 (10.3) 2 generations 153 (78.1) 59 (46.8) 20 (26.0) 232 (58.1) 3 generations 37 (18.9) 51 (40.5) 34 (44.2) 122 (30.6) 4 generations 0 (0.0) 4 (3.2) 0 (0.0) 4 (1.0)

Not so “feudal”

• 75% of 399 women age 40-65 sexually active

• Sexual attitudes not as conservative as media depicts

• Urban women - expressed more liberal views on sex

• Rural women - higher incidence of sexual activity

• Sexual attitudes and behavior often not consistent

Sexual Activity, Older Chinese Women

40-49 50-59 60-65 Total Total sample 184 of 196

(93.9%) 76 of 126

(60.3%) 28 of 77 (36.4%)

288 of 399 (72.2%)

Currently married 184 of 193 (95.3%)

76 of 113 (67.3%)

28 of 65 (43.1%)

288 of 371 (77.6%)

Currently married and living together

180 of 189 (95.2%)

74 of 110 (67.3%)

26 of 61 (42.6%)

280 of 360 (77.8%)

Sexual Attitudes

• Only 20.6% agreed that women should abstain from sex after menopause.– Rural 22.5%, Urban 18.6%– Low ed. 30%, Mod ed. 22.1%, High ed. 14.1%

• Although 80%/86% felt that husbands’/wive’s interest in sex declined some by middle age

Attitudes/Behavior

• Best to stop sex after menopause– Disagree: 76.6% sexually active– Agree: 56.1% sexually active

• Agree and postmenopausal: 32% sexually active

• Midlife decline in sexual interest in women and/or in men– Over 75% of sexually active women agreed

Sexual Activity and Menopause/Aging Info. Exposure

40-49 (n=189) x/ya (%)

50-59 (n=110) x/y (%)

60-65 (n=61) x/y (%)

Total (N=360) x/y (%)

Gossip or hearsay 140/149 (94.3) 71/102 (69.6) 20/52 (38.5) 240/312 (76.9) TV or film 129/135 (95.6) 58/82 (70.7) 14/40 (35.0) 201/257 (78.2) Newspaper, magazine 102/109 (93.6) 33/46 (71.7) 6/19 (31.6) 141/174 (81.0) Radio 79/80 (98.8) 29/40 (72.5) 9/20 (45.0) 117/140 (83.6) Book or booklet 60/64 (93.8) 22/31 (71.0) 4/14 (28.6) 86/109 (78.9) Advertisement, poster 23/23 (100.0) 9/11 (81.8) 2/3 (66.6) 34/37 (91.9) Medical text 14/14 (100.0) 4/7 (57.1) 2/8 (25.0) 20/29 (69.0) Expert lecture 13/14 (92.9) 2/6 (33.3) 2/4 (50.0) 18/24 (75.0)

Sexual Activity and Rural/Urban Residency (Married Women Living With Spouse)

40-49 (n=189) x/ya (%)

50-59 (n=110) x/y (%)

60-65 (n=61) x/y (%)

Total (N=360) x/y (%)

Rural 106/108 (98.1) 38/53 (71.7) 10/21 (47.6) 154/182 (84.6) Urban 74/81 (91.4) 36/57 (63.2) 16/40 (40.0) 126/178 (70.8) TOTAL ACTIVE 180 (95.2) 74 (67.3) 26 (42.6) 280 (77.8)

Sexual Activity and Education

(Married Women Living With Spouse)

Years of Education

40-49 (n=189) x/ya (%)

50-59 (n=110) x/y (%)

60-65 (n=61) x/y (%)

Total (N=360) x/y (%)

0-3 11/11 (100.0) 19/31 (61.3) 20/41 (48.8) 50/83 (60.2) 4-9 134/137 (97.8) 36/56 (64.3) 1/6 (16.7) 171/199 (85.9) 10+ 35/41 (85.4) 19/23 (82.6) 5/14 (35.7) 59/78 (75.6)

Sexual Activity and Household Composition(Married Women Living With Spouse)

40-49 (n=189) x/ya (%)

50-59 (n=110) x/y (%)

60-65 (n=61) x/y (%)

Total (N=360) x/y (%)

One generation 4/6 (66.7) 6/8 (75.0) 7/19 (36.8) 17/33 (51.5) Two generations 140/147 (95.2) 36/51 (70.6) 4/17 (23.5) 180/215 (83.7) Three generations 36/36 (100.0) 30/47 (63.8) 15/25 (60.0) 81/108 (75.0) Four generations n.a./0 (--) 2/4 (50.0) n.a./0 (--) 2/4 (50.0)

Ideology/Practice

• General ideals distinguished from own situation

• Practicality emphasized more than ideology– His/her health– Basic subsistence– Spatial convenience– Quality of relationship – equality, respect, trust

• Second honeymoon vs. Release from duty

Women vs. Campaign

• Few women wish to remarry

• But mostly unrelated to conservative views

• Instead: Different view of liberation/burden– Many see husbands as wet leaves– Flatbread story about helpless husbands– Some had difficult marriage, disrespectful husbands– Differential costs and benefits of remarriage

• Household division of labor for these cohorts• Gendered age differentials, mate choice, and caretaking

Caregiving Burden for Older Women

• Survey data from my 1994 Beijing survey, Chinese women, ages 40-65 (N=399)

• Although only half were formally employed, most did a great deal of informal domestic labor

• Interview and participant observation with Beijing women from 1992-2008 showed large amount of domestic labor among many women into their late seventies

• Informal domestic labor of older women often not accounted for in standard demographic representations of population ageing

Housework• Average about 28 hours of housework per week.

• The older women spent more time doing housework than the younger ones (women in their forties 23.5 hours per week, women in their fifties and sixties 33 hours per week).

• While two thirds said their housework load had decreased over time, over a third said it had increased or stayed the same. Decreases mainly due to increases in appliances, ready-made items, and other conveniences and money to spend on them.

• A fifth of the women said they got no help whatsoever with the housework from other members of the household, and four out of five women said that they did most of the housework. In that half were still employed, this translates into a large volume of labor on their shoulders.

Taking Care of Their Children• Although four out of five women said the amount of time they

spent taking care of their children had declined from when they were younger, two thirds still spent some time therein.

• For the numerous women with adult children, this meant tasks such as cooking their meals, washing their clothes, buying groceries, and running errands. Overall, the 393 women with children reported spending an average of 10 hours per week doing things for their offspring.

• The women in their forties and fifties spent more time on this than the women in their sixties, but those oldest women were still spending six hours per week caring for their children.

Taking Care of Their Grandchildren

• About one third of the women surveyed spent some time taking care of grandchildren.

• Only about five percent of the women in their forties had grandchildren, but sixty percent of the women in their fifties and seventy-seven percent of the sixty-year olds had grandchildren.

• • Among the 168 women who had grandchildren, they spent an

average of 27.5 hours per week taking care of them.

• About a third of the women in their fifties and sixties said that the amount of time spent in grandchild care had stayed the same or increased.

Elder Care• About three in ten of the women spent some time taking care of

elderly family members, most of whom were parents-in-law or parents, but some of whom were elderly husbands.

• Overall, women in their forties spent more time doing eldercare than women in their fifties or sixties.

• Of the 111 women who did some elder care, they averaged 11 hours per week.

• The 247 women with living parents-in-law or parents did an average of 5 hours per week of elder care.

• Time spent taking care of elders increased or stayed the same for two out of every ten woman surveyed, with this figure nearing a third for the women in their forties.

A Different Kind of Daughter-in-Law

While Western popular media posits Chinese daughters-in-law as sweeping in to save their mothers-in-law from housework and care-giving from about age 50:

• In those few households in which someone else did most of the housework, it was actually slightly more likely to be a male household member than another female, usually the woman’s husband.

• Fewer and fewer daughters-in-law live with their mothers-in-law and those who do only do so for a short period of time.

• Increasingly, mothers-in-law are doing housework and childcare for their daughters-in-law (and in some cases, daughters) into their seventies or later.

Ma Fengxiang, age 61, urban,retired garment factory worker

• “In the past, it was the daughter-in-law who served her father-in-law and mother-in-law. Now it’s reversed. Now the mother-in-law takes care of the daughter-in-law. Because the daughter in law goes out to work. The mother-in-law has time. So the mother-in-law should cater to her. Now it’s reversed. Now it’s all like this. It’s all like this. You babysit your grandson. You serve your son.”

• “In the old society as a daughter-in-law, women suffered once, and then after Liberation, things were reversed, and they suffered another time as a mother-in-law. But the kind of suffering of today’s mothers-in-law is different from the suffering of daughters-in-law in the past. What mothers-in-law do today for their daughters-in-law is because they want to do it.”

Ning Guiqin, age 60, rural,retired schoolteacher

• Since her sons and daughters-in-law all have to work, she does most of the housework, cooking, sewing, eldercare, and childcare by herself. In addition to taking care of her five year old granddaughter and ten year old grandson, she also feeds, washes, and dresses her husband who is bed-bound due to severe heart disease and stroke complications.

• “I don’t feel like I’ve gotten old. I’m still capable of everything. I still don’t want to ask other people to look after us. If someone else does things for me, then soon I won’t be able to do it myself any more. As long as I can still do things, I’ll do them. I don’t need someone else to take care of me. When I do things now, I still have energy left over when I’m done. I still feel like doing things.

Women vs. Campaign

• Generation realism vs. Enlightenment idealism

• Gender-sensitive vs. Gender-blind

• Local context vs. Universalism

A Different Kind of Later-Life Liberation

Envisioned by most,

though not all,

of the women studied

Not This

Primary Notions of Later Life Romance

• Enjoying being freed from domestic burdens

• Playing, often in local parks

• Traveling, even if only to new parts of Beijing

• Cultivating one’s own health

完