LUCYC. YU AND MINQIWANG
SOCIAL STATUS, PHYSICAL, MENTAL HEALTH, WELL-BEING A N D S E L F E V A L U A T I O N OF E L D E R L Y 1N C H I N A
ABSTRACT. This study examined self perceived physical and mental health, general well-being, social status and self evaluation among a group of Chinese elderly (N = 240, age range 65-94) who visited a geriatric outpatient clinic in Beijing, People's Republic of China. The instrument measured five areas of interest: (1) disease patterns; (2) perceived physical and mental health; (3) general well-being; (4) social-economic status and (5) self evaluation. The results showed that the illiterate elderly reported lower self-evaluation scores than all other groups (p < 0.05). In general, men gave themselves higher selfevaluation scores than women (p < 0.05). The blue-collar group had lower general wellbeing scores (p < 0.05) than the other occupational groups. These findings were discussed within social, cultural, political and historical contexts in China. Key Words:
social status, self evaluation, mental health, health status
Advancing age is associated with substantial adverse changes in physiologic functions (Milne & Lauder 1974; Leon, Jacobs, Denbacker & Taylor 1981; Whelton 1985; Globus & Melamed 1985; Bender 1985; Corbin & Eastwood 1986; Kane, Kiersch, Yates, Benton, Solomon, Satz & Beck I986), increased morbidity (Butler 1985; National Center for Health Statistics 1986) and mortality (National Center for Health Statistics 1986), and a decrease in the capacity for self-care (Nagi 1976). For many people, old age and the prospect of dying trigger a type of retrospective evaluation of life (Butler 1975). Life satisfaction has been a central construct in social and psychological theories of aging (Neugarten, Havighurst & Tobin 1961; Edwards & Klemmack 1973; Palmore & Kivett 1977; Markides & Martin 1979; George 1979; Lohman 1980; Liang 1982; Collette 1984; Dillard, Campbell & Chisholm 1984; Okun, Stock, Haring & Witter 1984; Sanders & Walters 1985). The proliferation of research has produced many contradictory findings on the correlates of life satisfaction fwm which few general statements can be made (Larson 1978; Lohman 1980; Caspi & Elder 1986). Most gerontologists define this construct as an appraisal of the overall condition of one's life. Put in this context, life satisfaction reflects a comparison of one's aspirations with actual achievements and a sense of progress toward the attainment of desired goals (Caspi & Elder 1986). Life satisfaction has also been viewed as the way "in which a balance between the individual and social system is attained." (Thomae 1976). However, Butler's psycho-developmental explanations of life review have been challenged by the Social Constructionists (Bertaux 1981; Bruner 1986; Wallace 1992) and the life satisfaction construct has been examined, challenged, and redefined. The present investigators wish to modify these definitions of life review and satisfaction and explore self evaluation of elderly in a society. We hypothesize that life review and life satisfaction require self evaluation which is affected not only by diminished functioning and multiple diseases in old age, but also by the Journal of Cross-Cultural Gerontology 8: 147-159, 1993. 9 1993Kluwer Academic PubIishers. Printed in the Netherlands.
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elderly's social status, mental health, well-being, and life satisfaction within social, cultural, political, and historical contexts. This paper presents an analytical study of the elderly's self evaluation in a Communist society by using a Self Evaluation Scale to examine the salient features of life review and satisfaction among a group of Chinese elderly who visited a geriatric outpatient clinic in Beijing, People's Republic of China (PRC). The central thesis of this study is that self appraisal and well-being in old age are shaped by an individual's current and past experiences within cultural, social and political boundaries. These experiences include the individual's occupation and education, which are related to disease patterns, and physical and mental health. They also include living through historical events that alter lives in unanticipated ways, and living in a political system that curtails or provides opportunities in the PRC. Traditionally, Chinese bestowed upon the elderly such titles as sage, patriarch, venerable counselor, and seer; the elderly were valued as transmitters of tradition and guardians of societal values and ancestral homes (Hsu 1971; Wu 1974; Yu 1980; Yu 1983). In the contemporary PRC, policies are established by gerontocrats, and the country is governed by them. It is interesting for gerontologists in the PRC and the West to study how the elderly evaluate themselves in different societies. International interest notwithstanding, for nearly thirty years after the Communists took over China (1949-1978), fewer Chinese and American scholars could carry out social science research (New York Times 1980, 1984, 1985) in the PRC than in America. After the Cultural Revolution, the Chinese government allowed more formal and informal exchanges, making it possible for interested scholars to study subjects that were once forbidden (Gui, Li, Shen, Di, Gu, Chen & Fang 1987). This paper provides a glimpse of how Chinese elderly evaluated themselves in the mid 1980s. METHOD
Sample The data for this study was collected in Beijing in 1985 but we did not receive permission to take the data out until five years later. A group of elderly who visited the Beijing Geriatric Outpatient Clinic were invited to participate in the study. The first 60 volunteers in four different age groups were retained for this study (ages 65-69, 70-74, 75-79, 80-94). The final sample consists of 240 men and women. Although the sample was not a truly random sample, the sequence of individual visits to the Clinic was not determined by any systematic process, thus making the sample less biased than would have been the case if a particular characteristic had been singled out for inclusion. In addition, since the Clinic was open to all citizens in Beijing, subjects with a variety of socioeconomic backgrounds were included.
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~s~umen~
The instruments measured five areas of interest: (1) disease patterns; (2) perceived physical and mental health; (3) general well-being; (4) socialeconomic status and (5) self-evaluation. A physician at the clinic determined the presence and absence of diseases and provided the diagnoses for each patient. The diseases were grouped into six categories: (1) cardiovascular; (2) respiratory; (3) digestive; (4) genital/urinary; (5) psychosomatic symptoms; (6) tumors. When there was a difference of opinion regarding diagnoses, a consensus was reached among the physicians involved. Perceived physical health and mental health had two single items: 1) how do you rate your physical health and 2) how do you rate your mental health. A 5point Likert scale was adopted to indicate self-perception from excellent health to poor health with a score of 5 being extremely healthy and a score of 1 being extremely unhealthy. There is evidence that a single one-item self-report of health status (i.e., Would you say your health is excellent, very good, good, fair, or poor?) is as powerful a predictor of health risks and mortality as more detailed health status indicators (Mossey & Shapiro 1982; Kaplan & Camacho 1983; Idler, Kasl & Lemke 1990; Cockerham, Sharp & Wilcox 1983). A 10item psychological general well-being schedule was adopted from Duprey (1978). Each item had a 0-5 point scale, with higher scores indicating more positive well-being. We translated this instrument into Chinese and back translated into English with ease. Pre-tests indicated that it was culturally relevant in the PRC. The alpha reliability coefficent of the scale was 0.93 for Duprey's study and 0.86 for this study. The ten items of well-being from Duprey are as follows: 1) how have you been feeling in general; 2) have you been bothered by any illness, bodily disorders, pains, or fears about your health; 3) have you been downhearted and blue; 4) have you been in firm control of your behaviors, thoughts, emotions, or feelings; 5) have you been anxious, worried or upset; 6) has your daily life been full of things that were interesting to you; 7) have you felt tired, worn out, used-up, or exhausted; 8) have you been under or felt you were under any strain, stress or pressure; 9) have you been waking up fresh and rested; and 10) how concerned or worried about your health have you been? The search for and subsequent development of the Self-Evaluation Scale was an interesting and didactic experience. It illustrates some of the challenges investigators face when carrying out cross cultural research. Its development was more complicated and time consuming than we anticipated. First, we scanned available gerontological literature in the United States for possible items to include in the measurement instrument. Since self evaluation as we defined it included the construct of life satisfaction, we began by translating Neugarten, Havighurst and Tobin's Life Satisfaction Index (LSI) into Chinese, and then back into English to ensure the original intent of Neugarten et al. was not lost in translation. However, when we pretested the Chinese version on
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newly arrived PRC exchange scholars in the United States, we realized that American based concepts of life satisfaction did not have the same meaning for people in the PRC. Also these exchange scholars stated that respondents who had lived through the Cultural Revolution may not be willing to respond to a self evaluation scale which included life satisfaction questions. Even if they were willing to answer these questions, the investigators may have trouble interpreting the true meaning of their answers. We decided not to use the LSI. Instead, we asked the Chinese scholars to help devise culturally relevant and politically neutral items to measure life satisfaction in the PRC. Secondly, we sent the completed questionnaire to our colleagues in the PRC for modification and approval. Finally, we decided on a four-item scale which included l) how does one perceive oneself in old age compared with others in one's age cohort; 2) looking back at one's life opportunities, is he/she satisfied with what life has brought; 3) evaluating one's contribution to society through occupational contribution, is he/she satisfied; and 4) looking back at one's personal life, is he/she satisfied. We named this instrument the Self Evaluation Scale. This instrument used a 5-point scale for scoring. The scores ranged from 5-20; higher scores indicated a more positive self evaluation. The scale is totally different from the one Neugarten and her colleagues developed. Socio-economic status included respondents' education and occupation. Under the Communist system, political correctness and party loyalty are essential to advancing one's education and career; a person's political background is intimately tied to his/her opportunity for higher education, better jobs~ and a better living standard. Education was categorized into five levels: (1) illiterate, (2) elementary, (3) junior high, (4) senior high, and (5) college. Since the Communists took over China, all jobs were controlled and assigned by the government and private business was not allowed. The major government job categories were blue collar and white collar workers, cadres, and intellectuals. However, the government did allow some unemployed individuals in the city who were not well educated or skilled to engage in "self-reliance business" in the private sector (the private sector had been reauthorized for several years by the time these patients were surveyed). The majority of these individuals were street peddlers or seasonal workers (e.g., people who sell ice-cream during summer months); most of them bad lower income and social status than the government employees; these respondents were grouped into the "Other" category. Thus, occupation was also categorized into five areas: (1) intellectuals who do not have much political power, but are respected in a society that traditionally values education; they include professors, physicians, engineers, other technical personnel, teachers, etc. Some cadres are intellectuals and some intellectuals are cadres; (2) cadres who may or may not be well educated; many of them hold positions of power because of their past contribution to the liberation or because of their political correctness. They are political appointees loyal to the Communist party, and have more power and opportunity than other occupational groups; (3) white collar (mostly office staff); (4) blue collar (labor), and (5) the unemployed who never worked, those who were home
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makers and never worked, and those in self-reliance business.
Procedure The study and data collection protocol were designed in the United States. Data were collected in the People's Republic of China. Each patient who visited the Beijing Geriatric Clinic was informed of the study and invited to participate. They were told that participation was voluntary and that they could withdraw at any time. Every effort was made to maintain confidentiality. The volunteers were given the questionnaire to complete in the clinic. Resident physicians and nurses at the clinic passed out the questionnaires and collected them. A member of the research team answered questions concerning the questionnaire, the illiterate had the questions read to them by a nurse in the hospital. Disease patterns were completed by physicians working in the clinic. The raw data were sent to the United States to be coded, processed, and analyzed.
Analyses The dependent variables in the study were disease pattern, perceived physical health, perceived mental health, general well-being, and self evaluation. The independent variables were occupation, education, and gender. Descriptive statistics, including one-way analysis of variance (ANOVA) tests, were used to examine the differences of each dependent variable with each individual independent variable. When a significant difference was found, multiple classification analysis (MCA) controlling for gender was performed. MCA is useful in examining the net effect of the independent variable (such as occupation and education) on dependent variables, when the effect of the other independent variable (i.e. gender) is controlled. However, if there is strong interaction between two factors, the MCA scores become meaningless. Therefore, the significance of interaction effects between two factors (i.e. occupation and gender) was checked before examining the MCA results. Moreover, MCA makes it possible to compare the original eta (which is equivalent to a simple beta from bivariate linear regression) with the adjusted eta (after controlling for other factors). FINDINGS
Education and previous occupation. Out of 240 elderly, 44 percent (n=107) were men and 56 percent (n=133) were women. Seven percent went to college (including two-year associate degree and bachelor's degree); 12 percent finished junior high; 12 percent finished high school; 30 percent finished elementary school; 39 percent were illiterate. Educational opportunities have expanded greatly over the past 40 years. Seven percent of the elderly having a postsecondary education is unusually high for this cohort as a whole, although perhaps not for Beijing. In the PRC, 3 to 5 percent of the population go to
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college (China Statistical Abstract 1985). This sample does not seem to possess educational characteristics similar to the general population. The sample may be more characteristic of large urban centers than rural areas. Eleven percent classified themselves as intellectuals, 11 percent as cadres, 5 percent held white-collar jobs, 35 percent had blue collar jobs, 37 percent put themselves in the category we called "other". Unfortunately, many individuals in this last category did not give us enough specific information for us to determine what their employment status was. We suspect that these included retired men and women or older cohorts who were either not employable or were never employed; it might also include very old women who were homemakers before the liberation and thus never worked outside the home.
Disease pattern. The prevalence of chronic disease is presented in Figure 1. Note that subjects could have multiple diseases so that the total number of diseases exceeded the number of patients. Results showed that cardiovascular diseases were most prevalent (58%, n=139), followed by respiratory disease (31%, n=75).
Cardiovascular
139
Respiratory Digestive Genital/Urinary Psychosomatic Tumor
14 I
0
I
I
50 100 150 Frequency of Diagnosis (N=240)
200
Fig. 1. Disease patterns
Gender effect. ANOVA was used in Table I to examine the gender difference on each of the dependent variables (see Table I). Results showed that self evaluation was significantly different for men and women, F(1,240) = 14.17, p < 0.001. Men viewed themselves more positively than women. Both perceived mental health and perceived physical health had borderline significance, p < 0.10. There was no significant difference in general well-being for men and women, p > 0.05.
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TABLE I. Means and analysis of variance of each dependent variable by gender Dependent Variable
Male (n= 105) Female (n=135) F p
Mental health
Physical health Well-being
Self-evaluation
3.86 3.65 3.45 0.06
3.82 3.61 3.16 0.07
13.39 12.75 14.~7 0.(}01
40.32 39.04 1.75 0.19
Self-perceived mental health. One-way A N O V A was performed to examine the differences in self-perceived mental health among elderly with different educational levels (illiterate, elementary, junior high, senior high, and college graduates). Results indicated a significant overall difference in self-perceived mental health scores among educational levels, F(4,217) = 2.48, p < 0.05 (see Table II).
TABLE II Means and analysis of variance of each dependent variable by education Dependent Variable
Illiterate (n=71) Elementary (n=71) Junior (n=20) Senior (n=29) College (n=17) F p
Mental health
Physical health
Well-being
Self-evaluation
3.64 3.83 3.93 3.93 3.29 2.48 0.04 a
3.60 3.85 3.79 3.83 3.35 1.70 0.15
38.73 39.70 39.69 42.24 39.35 1.43 0.22
11.73 13.04 13.52 13.83 13.18 6.68 0.001 b
Pairwise Comparison Results: College educated respondents reported lower mental health scores than other groups. b The illiterate group was more negative in their self-evaluation than any other groups. Pairwise comparison (not shown on Table II) found that the self-perceived mental health scores of college graduates were significantly lower than those of cadres, and blue- and white-collar groups, but they were not different from those of the illiterate group. A 2 x 2 (Education by Gender) MCA was employed (but not shown on Table II) examined the effects of education on self-perceived mental health, controlling for gender. The two-way interaction of education by gender was not significant, F(4,230) = 0.52, p > 0.05. The original eta (0.20) and adjusted eta (0.19) of the education factor showed that the difference in self-perceived
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mental health due to educational level was not influenced by gender. Table III used one-way A N O V A to examine self-perceived mental health by previous occupational categories. It showed a significant difference among occupational groups, F(4,230) = 3.15, p < 0.02. Pairwise comparisons of groups showed that intellectuals reported more negative mental health scores than white-collar workers and cadres. TABLE III Means and analysis of variance of each dependent variable by occupation Dependent variable
Blue collar (n=85) White collar (n=12) Intellectual (n=27) Cadre (n=27) Other (n=89) F p
Mental health
Physical health
Well-being
Self-evaluation
3.74 4.17 3.59 4.15 3.61 3.15 0.02a
3.69 4.00 3.59 4.04 3.61 1.68 0.16
38.11 43.75 41.59 40.89 39.48 2.49 0.048
13.18 13.17 13.74 13.04 11.74 5.34 0.001 c
Pairwise Comparison Results: a Intellectuals were lower in mental health scores than the white, blue, collar and the cadre groups. b The blue collar group and the other group had lower well-being scores than the white collar and the intellectuals. The other group was more negative in self-evaluation than any other groups. The intellectual group had the highest scores.
A 2 x 2 (Occupation by Gender) MCA was performed (but not shown on Table III) to examine the effects of occupation on self-perceived mental health, controlling for gender. The two-way interaction of occupation by gender was not significant, F(4,230) = 0.63, p > 0.05. After controlling for gender, the eta dropped slightly (original eta = 0.23, the adjusted eta = 0.21) suggesting gender factor did not strongly influence self-perceived mental health.
Self-perceived physical health. One-way A N O V A examining the differences in self-perceived physical health found no significant differences among educational groups F(4,217) = 1.70, p > 0.05 (see Table II). Nor were there significant differences among occupational categories, p > 0.05 (see Table III). Therefore, the M C A was not necessary.
General well-being. One-way A N O V A was used to examine the educational effect on general well-being. Results revealed no significant difference in general well-being scores among educational groups F(4,217) = 1.43, p > 0.05 (see Table II). However, one-way A N O V A showed a significant difference in general well-being among occupational categories, F(4,230) = 2.49, p < 0.05 (see Table III). Pairwise comparisons of different groups indicated that the blue-
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collar and the unemployed groups had significantly lower general well-being scores than the white-collar and the intellectual groups, p < 0.05. A 2 x 2 (Occupation by Gender) MCA (not shown in any of the tables) was adopted to examine the effects of occupation on general well-being scores controlling for gender. The two-way interaction of occupation by gender was not significant, F(4,230) = 0.93, p > 0.05. Gender did not change the effect of occupation on general well-being scores. The original eta (0.20) did not change.
Self evaluation.
One-way ANOVA showed significant differences in self evaluation scores among different educational groups F(4,217) = 6.28, p < 0.00I (see Table II). Pairwise comparisons (not shown in Table II) revealed that the illiterate group had the lowest self evaluation scores and was significantly different from any other group, p < 0.05. A 2 x 2 MCA (Education by Gender) was performed (again not shown in any of the tables). The results showed no two-way interaction of education by gender, F(4,228) = 1.81, p >0.05. In examining the self evaluation scores among different educational groups while controlling for gender, the original eta, 0.31, was reduced to 0.26, suggesting that self evaluation scores were influenced by both education and gender factors. The women in the illiterate group had the lowest self evaluation scores. One-way ANOVA also showed significant differences in self-evaluation scores among occupational categories, F(4,230) = 5.34, p < 0.001 (see Table III). The intellectuals reported the highest self-evaluation scores while the (grouped under other) unemployed reported significantly lower self-evaluation scores than any of the other groups, p < 0.05 (not shown in Table Ill). A 2 x 2 (Occupation by Gender) MCA was performed to examine the differences in self evaluation with occupational categories, controlling for gender. There was no two-way interaction of gender by occupation, F(4,228) = 0.76, p > 0.05. The results showed that the self evaluation scores were affected by both occupation and gender. The original eta between occupation and self evaluation scores was reduced from 0.29 to 0.23. Examining the cell means showed that women in the unemployed group reported the lowest self evaluation scores. DISCUSSION AND CONCLUSION This study found that the intellectuals' self-perceived mental health scores were lower than those of cadres, blue- and white-collar workers. The intellectuals were university professors, professional and technical staff, writers, etc. It is useful to put this outcome in context. When the Communists took over the Chinese mainland, the intellectuals in this study were about 25 years old; most of them went to college under the old system. They were the "cream of the crop"; many came from privileged backgrounds. Since the Communists took over, their lives have been eventful; many lived through purges and rehabilitations several times, the most recent being the Cultural Revolution, which began
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in 1966 and ended in 1976 after the death of Chairman Mao. During those ten years, many intellectuals suffered hardships unimaginable to the outside world; many went through years of political re-education, hard labor, and long separations from their families, either through imprisonment or exile to the countryside. In the 1980s, people were still talking about the hardship they suffered during that time. It is not surprising that their mental health scores are lower than the cadles and the workers who had higher status than the intellectuals during that period. However, there was no significant difference in the self-perceived physical health among all groups. This finding differs from American findings; in the United States education and occupation are associated with physical health and access to health care facilities. One possible explanation for the different findings could be that in the PRC, educational level and occupational categories are not related to ability to pay for medical care; when our data were collected, the Chinese government provided free medical care to civil servants and workers in state owned enterprises which covered large proportions of the workforce. For those who were not covered, medical care was provided by their work unit. However, the payment system is changing in the PRC. Since 1990, individuals have to pay for part of their medical care. Self evaluation: China was traditionally a Confucian society where women had been systematically oppressed and discriminated against (Yu & Carpenter 1991). Although the present Chinese government pays lip service to equality of the sexes, women's status is still, in reality, inferior at home, at work, and in society. However, in a country where education is highly valued, the illiterate have even fewer opportunities than women. Therefore it is not surprising that women and the illiterate reported lower self evaluation than other groups, and that women in the illiterate group reported the lowest self evaluation among all groups. On the other hand, although the intellectuals were persecuted and many were jailed or banished to the lowest social stratum during the Cultural Revolution, they were traditionally held in high esteem. While their mental health may have been affected by the political turmoil of recent past after the Cultural Revolution, many were told that they were wrongly accused. In fact, the government made efforts to reinstate and recall many intellectuals from banishment, because they were needed to help educate the next generation of young Chinese whose education had been interrupted by the Cultural Revolution. Those who were jailed became heros once more for their suffering and many were called back to help rebuild the country. Perhaps in reviewing their lives, many of them realize that they have survived the Revolution of 1911 to overthrow the Ching Dynasty, the Japanese occupation of the Chinese mainland during World War II, the Communist Revolution of 1949, and the Cultural Revolution from 1966-1976. They have survived all these intact, in spite of harsh living conditions, severe political criticism, and life-threatening situations. Perhaps these historical events, combined with the Chinese philosophy of passive endurance, tolerance, and acceptance of things beyond their control, enable them to achieve Erikson' s
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integrity (Erikson 1963, 1978, 1982) with the wisdom of age in the last stage of their lives. They may or may not be satisfied with their current situation, but in reviewing their lives, and in evaluating themselves, some of the intellectuals have survived hardships imposed on them by events beyond their control. Finally we wish to point out that the conventional Life Satisfaction Index developed by Neugarten et al. was not appropriate for use in the PRC. Instead, the Self Evaluation Scale developed for this study was culturally relevant in the Chinese societal context. In conclusion, gender and social status seem to affect urban Chinese elderly's self evaluation, but the effects need to be viewed within political, cultural, and historical contexts. ACKNOWLEDGEMENTS There is a third author, a co-principal investigator from The People's Republic of China, who has asked not to have her name appear because of the Tianamen Square incident. This research was jointly supported by the College of Health and Human Development and the Beijing Geriatric Institute. The authors also wish to acknowledge assistance in data collection by our Chinese colleagues. Please address requests for reprints to the first author. REFERENCES Bender, B.S. 1985 B Lymphocyte Function in Aging. Review of Biological Research in Aging. M. Rothstein, ed. Pp. 143-154. New York: Alan R. Liss. Bertaux, D. (ed.) 1981 Biography and Society. Beverly Hills: Sage. Brunet, J. 1986 Actual Minds, Possible Worlds. Cambridge, MA: Harvard University Press. Butler, R.N. 1975 Why Survive? New York: Harper & Row. Butler, R.N. 1985 Health, Productivity and Aging: An Overview. In Productive Aging. R.N. Butler and H.P. Gleason, eds. Pp. 1-14. New York: Springer Publishing Co. Inc. Caspi, A. and G.H. Elder 1986 Life Satisfaction in Old Age: Linking Social Psychology and History. Journal of Psychology and Aging 1(1): 18-26. China Statistical Abstract 1985 Beijing printing factory. Cockerham, W., K. Sharp, and L Wilcox 1983 Aging and Perceived Health Stares. Journal of Gerontology 38(3):349-355. Collette, J. I984 Sex Differences in Life Satisfaction: Australian Data. Journal of Gerontology 39(2):243-245. Corbin, S.L. and M.R. Eastwood 1986 Sensory Deficits and Mental Disorders of Old Age: Causal or Coincidental Associations? Psychological Medicine 16:251-256. Dillard, J., N. Campbell, and G. Chisholm 1984 Correlates of Life Satisfaction of Aged Persons. Psychological Reports 54:977-978. Duprey, H.L 1978 Self-representation of General Psychological Well-being of American Adults. Paper presented at American Public Health Association Conference. Los Angeles, October 17. Edwards, J. and D. Klemmack 1973 Correlates of Life Satisfaction: A Re-examination. Journal of Gerontology 28:497-502. Erikson, E. 1963 Childhood and Society (2nd ed.) New York: Norton. Erikson, E. 1982 The Life Cycle Completed: A Review. New York: Norton.
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Persons Aged 46-70. Journal of Gerontology 32(3):311-316. Sanders, G.S. and J. Waiters 1985 Life Satisfaction and Family Strength of Older Couples. Lifestyles 7(4): 194-206. Thomae, H. (ed.) 1976 Patterns of Aging. New York: S. Karger. P. 150. Wallace, J.B. 1992 Reconsidering the Life Review: The Social Construction of Talk about the Past. The Gerontologist 32(1): 120-125. Whelton, P.K. 1985 Blood Pressure in Adults and the Elderly. In C.J. Bulpitt, ed., Handbook of Hypertension, Vol. 6: Epidemiology of Hypertension. New York: Elsevier Science Publishers B.V. Pp. 51-69. Wu, F.F.T. 1974 Mandarin-speaking Aged Chinese in Los Angeles Area. Doctoral Dissertation. Los Angeles University of Southern California. Yu, L.C. 1980 Acculturational and Stress Among Chinese Americans in a University Town. International Journal of Group Tensions 10:99-119. Yu, L.C. 1983 Patterns of Filial Belief and Behavior within Contemporary Chinese American Family. International Journal of Sociology of the Family 13:17-36. Yu~ L.C. and L. Carpenter 1991 Women in China. In Women, in Cross-Cultural Perspective. L. Adler, ed. Pp. 188-203. New York: Praeger.
Lucy C. Yu Department of Health Policy and Administration 115 Henderson Building The Pennsylvania State University University Park, PA 16802, U.S.A. MinQi Wang Department of Health and Human Performance Studies University of Alabama at Tuscaloosa Tuscaloosa, AL 35487, U.S.A.
SOCIAL STATUS, PHYSICAL, MENTAL HEALTH, WELL-BEING A N D S E L F E V A L U A T I O N OF E L D E R L Y 1N C H I N A
ABSTRACT. This study examined self perceived physical and mental health, general well-being, social status and self evaluation among a group of Chinese elderly (N = 240, age range 65-94) who visited a geriatric outpatient clinic in Beijing, People's Republic of China. The instrument measured five areas of interest: (1) disease patterns; (2) perceived physical and mental health; (3) general well-being; (4) social-economic status and (5) self evaluation. The results showed that the illiterate elderly reported lower self-evaluation scores than all other groups (p < 0.05). In general, men gave themselves higher selfevaluation scores than women (p < 0.05). The blue-collar group had lower general wellbeing scores (p < 0.05) than the other occupational groups. These findings were discussed within social, cultural, political and historical contexts in China. Key Words:
social status, self evaluation, mental health, health status
Advancing age is associated with substantial adverse changes in physiologic functions (Milne & Lauder 1974; Leon, Jacobs, Denbacker & Taylor 1981; Whelton 1985; Globus & Melamed 1985; Bender 1985; Corbin & Eastwood 1986; Kane, Kiersch, Yates, Benton, Solomon, Satz & Beck I986), increased morbidity (Butler 1985; National Center for Health Statistics 1986) and mortality (National Center for Health Statistics 1986), and a decrease in the capacity for self-care (Nagi 1976). For many people, old age and the prospect of dying trigger a type of retrospective evaluation of life (Butler 1975). Life satisfaction has been a central construct in social and psychological theories of aging (Neugarten, Havighurst & Tobin 1961; Edwards & Klemmack 1973; Palmore & Kivett 1977; Markides & Martin 1979; George 1979; Lohman 1980; Liang 1982; Collette 1984; Dillard, Campbell & Chisholm 1984; Okun, Stock, Haring & Witter 1984; Sanders & Walters 1985). The proliferation of research has produced many contradictory findings on the correlates of life satisfaction fwm which few general statements can be made (Larson 1978; Lohman 1980; Caspi & Elder 1986). Most gerontologists define this construct as an appraisal of the overall condition of one's life. Put in this context, life satisfaction reflects a comparison of one's aspirations with actual achievements and a sense of progress toward the attainment of desired goals (Caspi & Elder 1986). Life satisfaction has also been viewed as the way "in which a balance between the individual and social system is attained." (Thomae 1976). However, Butler's psycho-developmental explanations of life review have been challenged by the Social Constructionists (Bertaux 1981; Bruner 1986; Wallace 1992) and the life satisfaction construct has been examined, challenged, and redefined. The present investigators wish to modify these definitions of life review and satisfaction and explore self evaluation of elderly in a society. We hypothesize that life review and life satisfaction require self evaluation which is affected not only by diminished functioning and multiple diseases in old age, but also by the Journal of Cross-Cultural Gerontology 8: 147-159, 1993. 9 1993Kluwer Academic PubIishers. Printed in the Netherlands.
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elderly's social status, mental health, well-being, and life satisfaction within social, cultural, political, and historical contexts. This paper presents an analytical study of the elderly's self evaluation in a Communist society by using a Self Evaluation Scale to examine the salient features of life review and satisfaction among a group of Chinese elderly who visited a geriatric outpatient clinic in Beijing, People's Republic of China (PRC). The central thesis of this study is that self appraisal and well-being in old age are shaped by an individual's current and past experiences within cultural, social and political boundaries. These experiences include the individual's occupation and education, which are related to disease patterns, and physical and mental health. They also include living through historical events that alter lives in unanticipated ways, and living in a political system that curtails or provides opportunities in the PRC. Traditionally, Chinese bestowed upon the elderly such titles as sage, patriarch, venerable counselor, and seer; the elderly were valued as transmitters of tradition and guardians of societal values and ancestral homes (Hsu 1971; Wu 1974; Yu 1980; Yu 1983). In the contemporary PRC, policies are established by gerontocrats, and the country is governed by them. It is interesting for gerontologists in the PRC and the West to study how the elderly evaluate themselves in different societies. International interest notwithstanding, for nearly thirty years after the Communists took over China (1949-1978), fewer Chinese and American scholars could carry out social science research (New York Times 1980, 1984, 1985) in the PRC than in America. After the Cultural Revolution, the Chinese government allowed more formal and informal exchanges, making it possible for interested scholars to study subjects that were once forbidden (Gui, Li, Shen, Di, Gu, Chen & Fang 1987). This paper provides a glimpse of how Chinese elderly evaluated themselves in the mid 1980s. METHOD
Sample The data for this study was collected in Beijing in 1985 but we did not receive permission to take the data out until five years later. A group of elderly who visited the Beijing Geriatric Outpatient Clinic were invited to participate in the study. The first 60 volunteers in four different age groups were retained for this study (ages 65-69, 70-74, 75-79, 80-94). The final sample consists of 240 men and women. Although the sample was not a truly random sample, the sequence of individual visits to the Clinic was not determined by any systematic process, thus making the sample less biased than would have been the case if a particular characteristic had been singled out for inclusion. In addition, since the Clinic was open to all citizens in Beijing, subjects with a variety of socioeconomic backgrounds were included.
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~s~umen~
The instruments measured five areas of interest: (1) disease patterns; (2) perceived physical and mental health; (3) general well-being; (4) socialeconomic status and (5) self-evaluation. A physician at the clinic determined the presence and absence of diseases and provided the diagnoses for each patient. The diseases were grouped into six categories: (1) cardiovascular; (2) respiratory; (3) digestive; (4) genital/urinary; (5) psychosomatic symptoms; (6) tumors. When there was a difference of opinion regarding diagnoses, a consensus was reached among the physicians involved. Perceived physical health and mental health had two single items: 1) how do you rate your physical health and 2) how do you rate your mental health. A 5point Likert scale was adopted to indicate self-perception from excellent health to poor health with a score of 5 being extremely healthy and a score of 1 being extremely unhealthy. There is evidence that a single one-item self-report of health status (i.e., Would you say your health is excellent, very good, good, fair, or poor?) is as powerful a predictor of health risks and mortality as more detailed health status indicators (Mossey & Shapiro 1982; Kaplan & Camacho 1983; Idler, Kasl & Lemke 1990; Cockerham, Sharp & Wilcox 1983). A 10item psychological general well-being schedule was adopted from Duprey (1978). Each item had a 0-5 point scale, with higher scores indicating more positive well-being. We translated this instrument into Chinese and back translated into English with ease. Pre-tests indicated that it was culturally relevant in the PRC. The alpha reliability coefficent of the scale was 0.93 for Duprey's study and 0.86 for this study. The ten items of well-being from Duprey are as follows: 1) how have you been feeling in general; 2) have you been bothered by any illness, bodily disorders, pains, or fears about your health; 3) have you been downhearted and blue; 4) have you been in firm control of your behaviors, thoughts, emotions, or feelings; 5) have you been anxious, worried or upset; 6) has your daily life been full of things that were interesting to you; 7) have you felt tired, worn out, used-up, or exhausted; 8) have you been under or felt you were under any strain, stress or pressure; 9) have you been waking up fresh and rested; and 10) how concerned or worried about your health have you been? The search for and subsequent development of the Self-Evaluation Scale was an interesting and didactic experience. It illustrates some of the challenges investigators face when carrying out cross cultural research. Its development was more complicated and time consuming than we anticipated. First, we scanned available gerontological literature in the United States for possible items to include in the measurement instrument. Since self evaluation as we defined it included the construct of life satisfaction, we began by translating Neugarten, Havighurst and Tobin's Life Satisfaction Index (LSI) into Chinese, and then back into English to ensure the original intent of Neugarten et al. was not lost in translation. However, when we pretested the Chinese version on
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newly arrived PRC exchange scholars in the United States, we realized that American based concepts of life satisfaction did not have the same meaning for people in the PRC. Also these exchange scholars stated that respondents who had lived through the Cultural Revolution may not be willing to respond to a self evaluation scale which included life satisfaction questions. Even if they were willing to answer these questions, the investigators may have trouble interpreting the true meaning of their answers. We decided not to use the LSI. Instead, we asked the Chinese scholars to help devise culturally relevant and politically neutral items to measure life satisfaction in the PRC. Secondly, we sent the completed questionnaire to our colleagues in the PRC for modification and approval. Finally, we decided on a four-item scale which included l) how does one perceive oneself in old age compared with others in one's age cohort; 2) looking back at one's life opportunities, is he/she satisfied with what life has brought; 3) evaluating one's contribution to society through occupational contribution, is he/she satisfied; and 4) looking back at one's personal life, is he/she satisfied. We named this instrument the Self Evaluation Scale. This instrument used a 5-point scale for scoring. The scores ranged from 5-20; higher scores indicated a more positive self evaluation. The scale is totally different from the one Neugarten and her colleagues developed. Socio-economic status included respondents' education and occupation. Under the Communist system, political correctness and party loyalty are essential to advancing one's education and career; a person's political background is intimately tied to his/her opportunity for higher education, better jobs~ and a better living standard. Education was categorized into five levels: (1) illiterate, (2) elementary, (3) junior high, (4) senior high, and (5) college. Since the Communists took over China, all jobs were controlled and assigned by the government and private business was not allowed. The major government job categories were blue collar and white collar workers, cadres, and intellectuals. However, the government did allow some unemployed individuals in the city who were not well educated or skilled to engage in "self-reliance business" in the private sector (the private sector had been reauthorized for several years by the time these patients were surveyed). The majority of these individuals were street peddlers or seasonal workers (e.g., people who sell ice-cream during summer months); most of them bad lower income and social status than the government employees; these respondents were grouped into the "Other" category. Thus, occupation was also categorized into five areas: (1) intellectuals who do not have much political power, but are respected in a society that traditionally values education; they include professors, physicians, engineers, other technical personnel, teachers, etc. Some cadres are intellectuals and some intellectuals are cadres; (2) cadres who may or may not be well educated; many of them hold positions of power because of their past contribution to the liberation or because of their political correctness. They are political appointees loyal to the Communist party, and have more power and opportunity than other occupational groups; (3) white collar (mostly office staff); (4) blue collar (labor), and (5) the unemployed who never worked, those who were home
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makers and never worked, and those in self-reliance business.
Procedure The study and data collection protocol were designed in the United States. Data were collected in the People's Republic of China. Each patient who visited the Beijing Geriatric Clinic was informed of the study and invited to participate. They were told that participation was voluntary and that they could withdraw at any time. Every effort was made to maintain confidentiality. The volunteers were given the questionnaire to complete in the clinic. Resident physicians and nurses at the clinic passed out the questionnaires and collected them. A member of the research team answered questions concerning the questionnaire, the illiterate had the questions read to them by a nurse in the hospital. Disease patterns were completed by physicians working in the clinic. The raw data were sent to the United States to be coded, processed, and analyzed.
Analyses The dependent variables in the study were disease pattern, perceived physical health, perceived mental health, general well-being, and self evaluation. The independent variables were occupation, education, and gender. Descriptive statistics, including one-way analysis of variance (ANOVA) tests, were used to examine the differences of each dependent variable with each individual independent variable. When a significant difference was found, multiple classification analysis (MCA) controlling for gender was performed. MCA is useful in examining the net effect of the independent variable (such as occupation and education) on dependent variables, when the effect of the other independent variable (i.e. gender) is controlled. However, if there is strong interaction between two factors, the MCA scores become meaningless. Therefore, the significance of interaction effects between two factors (i.e. occupation and gender) was checked before examining the MCA results. Moreover, MCA makes it possible to compare the original eta (which is equivalent to a simple beta from bivariate linear regression) with the adjusted eta (after controlling for other factors). FINDINGS
Education and previous occupation. Out of 240 elderly, 44 percent (n=107) were men and 56 percent (n=133) were women. Seven percent went to college (including two-year associate degree and bachelor's degree); 12 percent finished junior high; 12 percent finished high school; 30 percent finished elementary school; 39 percent were illiterate. Educational opportunities have expanded greatly over the past 40 years. Seven percent of the elderly having a postsecondary education is unusually high for this cohort as a whole, although perhaps not for Beijing. In the PRC, 3 to 5 percent of the population go to
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college (China Statistical Abstract 1985). This sample does not seem to possess educational characteristics similar to the general population. The sample may be more characteristic of large urban centers than rural areas. Eleven percent classified themselves as intellectuals, 11 percent as cadres, 5 percent held white-collar jobs, 35 percent had blue collar jobs, 37 percent put themselves in the category we called "other". Unfortunately, many individuals in this last category did not give us enough specific information for us to determine what their employment status was. We suspect that these included retired men and women or older cohorts who were either not employable or were never employed; it might also include very old women who were homemakers before the liberation and thus never worked outside the home.
Disease pattern. The prevalence of chronic disease is presented in Figure 1. Note that subjects could have multiple diseases so that the total number of diseases exceeded the number of patients. Results showed that cardiovascular diseases were most prevalent (58%, n=139), followed by respiratory disease (31%, n=75).
Cardiovascular
139
Respiratory Digestive Genital/Urinary Psychosomatic Tumor
14 I
0
I
I
50 100 150 Frequency of Diagnosis (N=240)
200
Fig. 1. Disease patterns
Gender effect. ANOVA was used in Table I to examine the gender difference on each of the dependent variables (see Table I). Results showed that self evaluation was significantly different for men and women, F(1,240) = 14.17, p < 0.001. Men viewed themselves more positively than women. Both perceived mental health and perceived physical health had borderline significance, p < 0.10. There was no significant difference in general well-being for men and women, p > 0.05.
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TABLE I. Means and analysis of variance of each dependent variable by gender Dependent Variable
Male (n= 105) Female (n=135) F p
Mental health
Physical health Well-being
Self-evaluation
3.86 3.65 3.45 0.06
3.82 3.61 3.16 0.07
13.39 12.75 14.~7 0.(}01
40.32 39.04 1.75 0.19
Self-perceived mental health. One-way A N O V A was performed to examine the differences in self-perceived mental health among elderly with different educational levels (illiterate, elementary, junior high, senior high, and college graduates). Results indicated a significant overall difference in self-perceived mental health scores among educational levels, F(4,217) = 2.48, p < 0.05 (see Table II).
TABLE II Means and analysis of variance of each dependent variable by education Dependent Variable
Illiterate (n=71) Elementary (n=71) Junior (n=20) Senior (n=29) College (n=17) F p
Mental health
Physical health
Well-being
Self-evaluation
3.64 3.83 3.93 3.93 3.29 2.48 0.04 a
3.60 3.85 3.79 3.83 3.35 1.70 0.15
38.73 39.70 39.69 42.24 39.35 1.43 0.22
11.73 13.04 13.52 13.83 13.18 6.68 0.001 b
Pairwise Comparison Results: College educated respondents reported lower mental health scores than other groups. b The illiterate group was more negative in their self-evaluation than any other groups. Pairwise comparison (not shown on Table II) found that the self-perceived mental health scores of college graduates were significantly lower than those of cadres, and blue- and white-collar groups, but they were not different from those of the illiterate group. A 2 x 2 (Education by Gender) MCA was employed (but not shown on Table II) examined the effects of education on self-perceived mental health, controlling for gender. The two-way interaction of education by gender was not significant, F(4,230) = 0.52, p > 0.05. The original eta (0.20) and adjusted eta (0.19) of the education factor showed that the difference in self-perceived
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mental health due to educational level was not influenced by gender. Table III used one-way A N O V A to examine self-perceived mental health by previous occupational categories. It showed a significant difference among occupational groups, F(4,230) = 3.15, p < 0.02. Pairwise comparisons of groups showed that intellectuals reported more negative mental health scores than white-collar workers and cadres. TABLE III Means and analysis of variance of each dependent variable by occupation Dependent variable
Blue collar (n=85) White collar (n=12) Intellectual (n=27) Cadre (n=27) Other (n=89) F p
Mental health
Physical health
Well-being
Self-evaluation
3.74 4.17 3.59 4.15 3.61 3.15 0.02a
3.69 4.00 3.59 4.04 3.61 1.68 0.16
38.11 43.75 41.59 40.89 39.48 2.49 0.048
13.18 13.17 13.74 13.04 11.74 5.34 0.001 c
Pairwise Comparison Results: a Intellectuals were lower in mental health scores than the white, blue, collar and the cadre groups. b The blue collar group and the other group had lower well-being scores than the white collar and the intellectuals. The other group was more negative in self-evaluation than any other groups. The intellectual group had the highest scores.
A 2 x 2 (Occupation by Gender) MCA was performed (but not shown on Table III) to examine the effects of occupation on self-perceived mental health, controlling for gender. The two-way interaction of occupation by gender was not significant, F(4,230) = 0.63, p > 0.05. After controlling for gender, the eta dropped slightly (original eta = 0.23, the adjusted eta = 0.21) suggesting gender factor did not strongly influence self-perceived mental health.
Self-perceived physical health. One-way A N O V A examining the differences in self-perceived physical health found no significant differences among educational groups F(4,217) = 1.70, p > 0.05 (see Table II). Nor were there significant differences among occupational categories, p > 0.05 (see Table III). Therefore, the M C A was not necessary.
General well-being. One-way A N O V A was used to examine the educational effect on general well-being. Results revealed no significant difference in general well-being scores among educational groups F(4,217) = 1.43, p > 0.05 (see Table II). However, one-way A N O V A showed a significant difference in general well-being among occupational categories, F(4,230) = 2.49, p < 0.05 (see Table III). Pairwise comparisons of different groups indicated that the blue-
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collar and the unemployed groups had significantly lower general well-being scores than the white-collar and the intellectual groups, p < 0.05. A 2 x 2 (Occupation by Gender) MCA (not shown in any of the tables) was adopted to examine the effects of occupation on general well-being scores controlling for gender. The two-way interaction of occupation by gender was not significant, F(4,230) = 0.93, p > 0.05. Gender did not change the effect of occupation on general well-being scores. The original eta (0.20) did not change.
Self evaluation.
One-way ANOVA showed significant differences in self evaluation scores among different educational groups F(4,217) = 6.28, p < 0.00I (see Table II). Pairwise comparisons (not shown in Table II) revealed that the illiterate group had the lowest self evaluation scores and was significantly different from any other group, p < 0.05. A 2 x 2 MCA (Education by Gender) was performed (again not shown in any of the tables). The results showed no two-way interaction of education by gender, F(4,228) = 1.81, p >0.05. In examining the self evaluation scores among different educational groups while controlling for gender, the original eta, 0.31, was reduced to 0.26, suggesting that self evaluation scores were influenced by both education and gender factors. The women in the illiterate group had the lowest self evaluation scores. One-way ANOVA also showed significant differences in self-evaluation scores among occupational categories, F(4,230) = 5.34, p < 0.001 (see Table III). The intellectuals reported the highest self-evaluation scores while the (grouped under other) unemployed reported significantly lower self-evaluation scores than any of the other groups, p < 0.05 (not shown in Table Ill). A 2 x 2 (Occupation by Gender) MCA was performed to examine the differences in self evaluation with occupational categories, controlling for gender. There was no two-way interaction of gender by occupation, F(4,228) = 0.76, p > 0.05. The results showed that the self evaluation scores were affected by both occupation and gender. The original eta between occupation and self evaluation scores was reduced from 0.29 to 0.23. Examining the cell means showed that women in the unemployed group reported the lowest self evaluation scores. DISCUSSION AND CONCLUSION This study found that the intellectuals' self-perceived mental health scores were lower than those of cadres, blue- and white-collar workers. The intellectuals were university professors, professional and technical staff, writers, etc. It is useful to put this outcome in context. When the Communists took over the Chinese mainland, the intellectuals in this study were about 25 years old; most of them went to college under the old system. They were the "cream of the crop"; many came from privileged backgrounds. Since the Communists took over, their lives have been eventful; many lived through purges and rehabilitations several times, the most recent being the Cultural Revolution, which began
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in 1966 and ended in 1976 after the death of Chairman Mao. During those ten years, many intellectuals suffered hardships unimaginable to the outside world; many went through years of political re-education, hard labor, and long separations from their families, either through imprisonment or exile to the countryside. In the 1980s, people were still talking about the hardship they suffered during that time. It is not surprising that their mental health scores are lower than the cadles and the workers who had higher status than the intellectuals during that period. However, there was no significant difference in the self-perceived physical health among all groups. This finding differs from American findings; in the United States education and occupation are associated with physical health and access to health care facilities. One possible explanation for the different findings could be that in the PRC, educational level and occupational categories are not related to ability to pay for medical care; when our data were collected, the Chinese government provided free medical care to civil servants and workers in state owned enterprises which covered large proportions of the workforce. For those who were not covered, medical care was provided by their work unit. However, the payment system is changing in the PRC. Since 1990, individuals have to pay for part of their medical care. Self evaluation: China was traditionally a Confucian society where women had been systematically oppressed and discriminated against (Yu & Carpenter 1991). Although the present Chinese government pays lip service to equality of the sexes, women's status is still, in reality, inferior at home, at work, and in society. However, in a country where education is highly valued, the illiterate have even fewer opportunities than women. Therefore it is not surprising that women and the illiterate reported lower self evaluation than other groups, and that women in the illiterate group reported the lowest self evaluation among all groups. On the other hand, although the intellectuals were persecuted and many were jailed or banished to the lowest social stratum during the Cultural Revolution, they were traditionally held in high esteem. While their mental health may have been affected by the political turmoil of recent past after the Cultural Revolution, many were told that they were wrongly accused. In fact, the government made efforts to reinstate and recall many intellectuals from banishment, because they were needed to help educate the next generation of young Chinese whose education had been interrupted by the Cultural Revolution. Those who were jailed became heros once more for their suffering and many were called back to help rebuild the country. Perhaps in reviewing their lives, many of them realize that they have survived the Revolution of 1911 to overthrow the Ching Dynasty, the Japanese occupation of the Chinese mainland during World War II, the Communist Revolution of 1949, and the Cultural Revolution from 1966-1976. They have survived all these intact, in spite of harsh living conditions, severe political criticism, and life-threatening situations. Perhaps these historical events, combined with the Chinese philosophy of passive endurance, tolerance, and acceptance of things beyond their control, enable them to achieve Erikson' s
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integrity (Erikson 1963, 1978, 1982) with the wisdom of age in the last stage of their lives. They may or may not be satisfied with their current situation, but in reviewing their lives, and in evaluating themselves, some of the intellectuals have survived hardships imposed on them by events beyond their control. Finally we wish to point out that the conventional Life Satisfaction Index developed by Neugarten et al. was not appropriate for use in the PRC. Instead, the Self Evaluation Scale developed for this study was culturally relevant in the Chinese societal context. In conclusion, gender and social status seem to affect urban Chinese elderly's self evaluation, but the effects need to be viewed within political, cultural, and historical contexts. ACKNOWLEDGEMENTS There is a third author, a co-principal investigator from The People's Republic of China, who has asked not to have her name appear because of the Tianamen Square incident. This research was jointly supported by the College of Health and Human Development and the Beijing Geriatric Institute. The authors also wish to acknowledge assistance in data collection by our Chinese colleagues. Please address requests for reprints to the first author. REFERENCES Bender, B.S. 1985 B Lymphocyte Function in Aging. Review of Biological Research in Aging. M. Rothstein, ed. Pp. 143-154. New York: Alan R. Liss. Bertaux, D. (ed.) 1981 Biography and Society. Beverly Hills: Sage. Brunet, J. 1986 Actual Minds, Possible Worlds. Cambridge, MA: Harvard University Press. Butler, R.N. 1975 Why Survive? New York: Harper & Row. Butler, R.N. 1985 Health, Productivity and Aging: An Overview. In Productive Aging. R.N. Butler and H.P. Gleason, eds. Pp. 1-14. New York: Springer Publishing Co. Inc. Caspi, A. and G.H. Elder 1986 Life Satisfaction in Old Age: Linking Social Psychology and History. Journal of Psychology and Aging 1(1): 18-26. China Statistical Abstract 1985 Beijing printing factory. Cockerham, W., K. Sharp, and L Wilcox 1983 Aging and Perceived Health Stares. Journal of Gerontology 38(3):349-355. Collette, J. I984 Sex Differences in Life Satisfaction: Australian Data. Journal of Gerontology 39(2):243-245. Corbin, S.L. and M.R. Eastwood 1986 Sensory Deficits and Mental Disorders of Old Age: Causal or Coincidental Associations? Psychological Medicine 16:251-256. Dillard, J., N. Campbell, and G. Chisholm 1984 Correlates of Life Satisfaction of Aged Persons. Psychological Reports 54:977-978. Duprey, H.L 1978 Self-representation of General Psychological Well-being of American Adults. Paper presented at American Public Health Association Conference. Los Angeles, October 17. Edwards, J. and D. Klemmack 1973 Correlates of Life Satisfaction: A Re-examination. Journal of Gerontology 28:497-502. Erikson, E. 1963 Childhood and Society (2nd ed.) New York: Norton. Erikson, E. 1982 The Life Cycle Completed: A Review. New York: Norton.
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Lucy C. Yu Department of Health Policy and Administration 115 Henderson Building The Pennsylvania State University University Park, PA 16802, U.S.A. MinQi Wang Department of Health and Human Performance Studies University of Alabama at Tuscaloosa Tuscaloosa, AL 35487, U.S.A.
