Sensing the Squeeze of Sandwich Generation Women in Jakarta, Indonesia

The majority of Indonesian women, known as "sandwich generations," have taken care of their young children and aging parents. Individual role-balancing challenges among these "sandwich" women have not yet, been fully investigated. This study aims to highlight Indonesian women's obstacles for being a sandwich generation. A qualitative descriptive case study through semi-structured interviews was carried out. A purposive sampling by key informants was conducted in June 2022 until saturation of the information was reached. This study involved six informants who live in Jakarta. Qualitative content analysis was carried out to generate codes and assign categories. From female respondent perspectives, males frequently provide financial support, whereas women are more likely to do so emotionally and assist with daily tasks like housework, grocery shopping, and personal cleanliness. Because of this, there was a significant conclusion that most sandwich-generation


Introduction
Many Indonesian women provide unpaid care for elderly parents and children simultaneously. Over the past 20 years, the Indonesian population's life expectancy has risen steadily until it averages 70.8 percent (Indonesia Subnational Collaborators, 2022). As the population ages, an increasing number of older persons are experiencing health issues (Sulityowati & Krisnatuti, 2019) and functional disability (Fong, 2019). The triple burden of the ageing population closely related to functional impairment are physical (Carmona-Torres et al., 2019), emotional (OʼSúilleabháin, Gallagher, & Steptoe, 2019), and mental (Turana et al., 2021), making elderly in Indonesia are vulnerable. The decline in cognitive function is the cause of the elderly's inability to perform routine daily tasks and is one of the factors that contribute to the elderly's dependency on others for self-care (Aziz & Krisnatuti, 2017).
The terms impairment, sickness, handicap, and limitation are directly related to the concept of physical disability (O'Young, Gosney, & Ahn, 2019). Activities including walking, squatting, and running are used to assess physical performance, which is related to the body's sensory and motor function (Carmona-Torres et al., 2019). The ability of an individual to adjust to varied life experiences serves as a gauge of their emotional performance (Rechenberg, Cousin, & Redwine, 2020). Tests that gauge a person's ability to think critically and intellectually are used to assess mental performance (Turana et al., 2021). The elderly's incapacity to conduct routine daily tasks and subsequent dependency on others to take care of themselves are both caused by the decline of physical, emotional, and mental function (Capeletto et al., 2021). Demand for elderly care in Indonesia is expected to increase in the future (Nursolehah & Krisnatuti, 2017).
Decreasing the average number of children, a woman would have throughout her lifetime by around two children from the period 2006 to 2017 has resulted in smaller households (Badan Kependudukan dan Keluarga Berencana Nasional, Badan Pusat Statistik, Kementerian Kesehatan, & ICF, 2018). As a result, three-generation coresidential families have been more common in Indonesia. Adioetomo and Mujahid (2014) found that 54.8 percent of elderly Indonesians in 2010 resided with their own children and with their grandchildren, reflecting three generations staying under one roof. These factors have increased the number of intergenerational coresident families and the growing variability in the connections and obligations entrenched within them, together with changes in longevity, fertility, and marriage that are redefining the definition of "family" (Mutchler & Roldán, 2022).
In Indonesian culture, the younger generation, which the elder generation has raised, must "pay back" the older generation by looking after them as they age, known as intergenerational responsibility (Khairunnisa & Hartini, 2022;Khalil & Santoso, 2022). More people have to deal with competing demands on their time and money from three-generation families, including minor children, parent(s), and grandparent(s), due to those recent demographic trends toward longer lifespans and young children (Nursolehah & Krisnatuti, 2017). Many Indonesians are squeezing their double roles as caregivers for both their young children and their elderly family members, reflected as a sandwich generation (Betancourt, 2019;Hämäläinen & Tanskanen, 2021). This will increase the care burden of middle-aged children, particularly young women, and thus the proportion of sandwich-generation women in society will tend to be increased (Elmhirst, 2012;Evans et al., 2016). There are social constructs; women from the working sandwich generation experience more diverse role-related to family care than males with the same role combination (Fu et al., 2023).
The sandwich generation's way of life may involve some financial, physical, and mental pressures. Since most Indonesian women are employed, they have to balance their employment issues and their traditional caring responsibilities to their children and their parents (Cameron et al., 2018). These sandwich generation women, either employed or unemployed, reported that increased caregiver burden to their children and their elderly parents/in-law led to time constraints (Marum, 2020), chronic fatigue (Reynaud & Bruneau, 2022), low social support (Hämäläinen & Tanskanen, 2021), negative emotional spillover (Gillett & Crisp, 2017), and poor health lifestyle (Steiner & Fletcher, 2017). The health issues of middle-aged women associated with high burdens of family care will become increasingly pronounced and may be considered a public health risk.
Additionally, those middle-aged sandwich-generation women frequently feel guilty for not providing their elderly families with more support since they also have another responsibility for their younger children. Strong feelings brought on by the conflict between the requirements of the older and younger generations may affect other aspects of life, causing mental suffering physically exhausted and exclusion from the formal labor force (Hämäläinen & Tanskanen, 2021;Lim, 2021;Luna, Rivera, & Ramos, 2021).
Previous studies have discovered the challenges of sandwich generation in Asia (Chen & Zhou, 2022;Estioko et al., 2022;Noor & Isa, 2020;Shin et al., 2015). However, studies that explored the pressures of sandwich-generation women in Jakarta, Indonesia, are limited. Therefore, the undiscovered burden of sandwich generation women in the capital city of Indonesia, Jakarta, is urged to be analyzed to help those women in tackling their physical, mental, and emotional burdens (Terkoǧlu & Memiş, 2022). Therefore, the aim of this study is to examine the physical, mental, and emotional issues challenged by the sandwich generation women in Jakarta, Indonesia.

Participants
This qualitative study was conducted in Jakarta city in Indonesia. Jakarta, the capital city of Indonesia, has experienced an increasing trend in its elderly population, from 1.48 percent in 1971 to 5.02 percent in 2020 (Badan Pusat Statistik, 2021). At the same time, the proportion of the population aged 0-14 years has decreased from 42.88 percent in 1971 to 23 percent in 2020 (Badan Pusat Statistik, 2021). Therefore, the productive population has been squeezed in caring for young children and the elderly. The informants in this study were selected using the snowball sampling technique (Kennedy-Shaffer, Qiu, & Hanage, 2021). Snowball sampling is a nonprobability approach to sampling design hard-to-reach and hidden populations such as sandwich-generation women because those women are busy caring for their young children and their elderly parents/in-laws (Rao et al., 2017). Six participants were recruited through snowball sampling using the following inclusion criteria: (1) motherhood is required, at least one child with less than 18 years of age; (2) remaining children also dependent on her; (3) providing care to at least one elderly parent/in-law, (4) three-generation living in one roof and (5) agree to be interviewed. The collecting qualitative data process through the telephone interviewing method in Bahasa was implemented during June and July 2022. Each interview took about 25 to 30 minutes.

Measurement
This study uses informant-based data collection techniques to collect primary data from interviews. This study evaluates the issues faced by those women. Semistructured interviews are conducted in the data collection of this study. Compared to structured interviews, semi-structured interviews are more flexible in practice by asking the informants for their opinions and ideas (Irawaty & Gayatri, 2021;Koetsenruijter et al., 2022). Semi-structured interviews use a question framework as a guideline during the interviews (Eltaybani et al., 2020). Five open-ended questions based on the three categories of sandwich-generations' burdens were utilized in the survey, as follows.
1. Do you have at least one child less than 18 years old and at least one elderly parent/in-law? How is your employment status currently? 2. How is the health condition of your young children and elderly parents/inlaws? 3. Can you afford to buy your family daily needs? How or why? 4. How does the activity in taking care of your young children and elderly parents/in-laws affect your time? Tell me. 5. What do you think about the current condition in caring for young children and elderly parents/in-laws at the same time? Does it make you exhausted and easily burnout?
Transcripts of the telephone interviews were recorded for the analysis. The transcripts of each interview question are classified into the thematic analysis: financial, physical, and mental burnout, coded with the participants' comments and justifications, and topics highlighted in the literature. Financial burnout has been defined as a substantial financial problem associated with high-cost health care for the child and the elderly rearing (Hämäläinen & Tanskanen, 2021). Physical burnout is the deterioration of physical health among sandwich generation caregivers, as they have to meet the care needs of two conflicting needs-their young children and their elderly parents/in-laws for 24 hours nonstop (Capeletto et al., 2021). Mental burnout is a stressful moment for sandwich generation caregivers since raising children produced more uplifting feelings while more unfavorable feelings were evoked by eldercare (Otto et al., 2021).

Analysis
The seven-step methodology for qualitative analysis was used to analyze the data. Those data analysis procedures were as follows: (1) manually sort and transcribe the participant's comments; (2) eliminate irrelevant and redundant information; (3) classify remaining information into themes; (4) validate the themes; (5) build a textual description based on participant's experiences; (6) create structural explanation by analyzing the textual descriptions, and (7) establish the final theme for the participant's experience (Castleberry & Nolen, 2018). Thematic qualitative analysis was carried out using NVivo 10 after interview transcription for coding (Dhakal, 2022). A decision help was created by compiling the themes.

Characteristics of the Sandwich Generation Women
Informants are productive women aged 43-57 years who have to take care of their young children and elderly parents/in-laws. To protect informant identification, pseudonyms are utilized. As shown in Table 1, out of the six informants, three are staying with their mother (informant C, informant E, informant F). At the same time, another three participants declared that they must care for their parents-in-law (informant A, informant B, informant D). The participants' educational backgrounds are senior high school (informant A, informant B), bachelor's (informant C, informant E), and diploma (informant D, informant F). The majority of participants are stay-at-home mothers (4 participants) (informant A, informant C, informant D, informant F) while only one participant is employed fully in the labor force market (informant B), and only one participant works part-time (informant E). Most participants have more than one child (informant A, informant B, informant C, informant D, informant E, informant F). The health issues of their elderly parents are common in those six participants, such as declining hearing (informant A), cancer (informant B), movement disorders (informant C), dementia (informant D), high blood sugar (informant E) and stroke (informant F).

Financial Challenges
Financial issues have been the main concern of sandwich-generation women. Both working and non-working women need an extra budget to pay out-of-pocket health expenditures for their elderly parents/in-laws and also to pay for their children's needs. Some informants mentioned having trouble paying their bills due to inadequate health insurance and medical conditions that prevent them from working. People with limited finances frequently base their management choices on which foods or medicines they can afford for their children or their elderly parents/in-laws. Due to insufficient family income, sandwich-generation women had difficulty making routine food and nutrition intake decisions. Most of the time, those women ignore their own food intake. Sample responses from informant D and informant E are as follow: "It is difficult for me to handle my mother-in-law, who is a dementia patient. Even  A story of a sandwich generation woman who had no siblings was documented: "I don't have any siblings, so I am the only child of my mother. Therefore, I have an obligation to take care of my mother. Of my three children, two are under five years old and enrolled in school, and the other is attending university. Currently, my family is going through a terrible financial crisis. In order to pay the bills, my husband works both full-and part-time jobs. I can only handle one job because I have to care for my mother and children. We make every effort to save money for our kids, but we might not be able to… (informant E, 46 years old)".

Time-Management Challenges
As a result of societal changes like postponed childbirth and an older population, more and more women are struggling to be a mother, caregivers for elderly parents, and employees. These three mixed roles can be harmful since they might lead to time constraints, unpleasant emotional spillover, and inflated expectations. There are gender differences, with women from the working sandwich generation facing more diverse role-related difficulties, using different personal role-balance solutions, and experiencing worse role-balance outcomes than males with the same role combination. Informants expressed how to manage their daily life. In doing so, those working women was building time management and self-discipline strictly: "I'm an employee, working in the private sector full-time. Even though we have a nurse for my mother-in-law, the situation is still tense for me because she is constantly ill and occasionally becomes so irate due The idea of feeling overwhelmed by doing so many things every day was also described by informant A:

Burnout
Based on the results of the interviews, sandwich generation women reported isolation caused by difficulties leaving their homes due to their heavy burden in taking care of their children and elderly parents/in-laws. Those women reported a range of feelings towards the heavy burden. Some reported strongly disliking being in the house because they felt anxiety, fear, stress, loneliness, depression, and burnout. Sample participant quotes: "Because I'm a stay-at-home mom and my mother has experienced stroke conditions, she has movement difficulty. Yes, managing her at times is quite difficult for me. We can't afford a nurse. I have to feed her daily while also caring for my two children. Most of the time, she acts normally, but suddenly she can express her anger due to some issues such as the food not being fit for her, nobody helping her change her clothes, etc. I know I have an obligation to take care of her but sometimes I feel physical and mentally burnout. I feel lonely. I don't have time to socialize and to do some exercise… (informant F, 52 years old)". "I don't work, I have three kids. My family life is seriously disrupted because my mother cannot move independently. She experiences knee osteoarthritis disease, leading to mobility disability in the aged due to alterations issue in knee mechanics. Her knee is splitting with excruciating pain. As a result, we almost have to travel to the hospital every other day. Although I make an effort to help her relax, I can no longer control her sickness. In the morning, I have to deliver my three kids to their school. After that, I delivered my mother to the doctor. I do those activities daily. I feel tired… (informant C, 48 years old)".

Discussion
The findings provide an in-depth contextual understanding of sandwich generation women's engagement in the family context of Jakarta. As mentioned by informant E, 46 years old, the respondent feels difficulties in financial management because she has no sibling to share the financial burden of taking care of her elderly parents. This is because as the educational level continues to rise, people continue to have fewer children and those children continue to be supported into older ages, and it's probable that multigenerational caregiving obligations will continue to increase for the offspring of baby boomers. The family context of the sandwich generation evaluated in this study highlights that the provision of elderly care nowadays is getting harder due to the decreasing number of siblings (Adioetomo & Mujahid, 2014). In the past, many siblings might help take care of elderly parents, but now the caregiving responsibility frequently rests with a single middle-aged child (Luna et al., 2021).
Informants also emphasized financial constraints, particularly those who have an elderly parent with catastrophic diseases. Informants code B, D, and F had declared that their parents experienced catastrophic diseases which were highly costly. Catastrophic diseases, elderly patients need more care from experienced professionals (Vermunt et al., 2017). At the same time, not all catastrophic diseases experienced by the elderly can be covered by health insurance Noda et al., 2021). Additionally, not all elderly persons in Indonesia have health insurance (Madyaningrum, Chuang, & Chuang, 2018;Rusdi, 2019). Therefore, most older people with chronic conditions cannot be properly cared for due to the out-ofpocket financial shortage (Iragorri et al., 2021;Noviani, 2021;Simeu, 2019). Sandwich generation carers' out-of-pocket medical expenses are 2.5 times higher than those of non-caregivers . This may be a result of the high costs of caring for elderly parents with chronic diseases in a home . Furthermore, the family cannot provide health treatment as needed because they lack the competence and full-time attention they require (Kent, Ornstein, & Dionne-Odom, 2020;Schulz et al., 2020).
Additionally, the result of this study revealed that the sandwich generation's carers face a time management challenge. Managing several responsibilities in working and caring for maturing children and aging parents simultaneously is difficult, multifaceted, and interrelated, as stated by informant B (43 years old) and informant A (53 years old). It was in line with previous studies sandwich generation caregivers, especially those who are caring for chronic disease patients at home, have a tough and time-consuming job (American Diabetes Association, 2018; Sibilska et al., 2020). The hectic daily schedule is increasing mental distress of the elderly care, which causes issues in both their personal and professional lives (Harrad & Sulla, 2018). Hence, time management is a problem to manage the demands of work and family, which might result in an anger and conflict (Molina et al., 2019).
In contemporary society, the requirements for raising children have greatly changed (Seltzer, 2019). People in their middle years may still have young children that require intensive care (Domond et al., 2020). Middle-generation individuals spend much more time than their parents spend on family care for both young children and aging parents/in-laws (Garcia et al., 2020). The shortcomings of current social institutions prevent formal care services from being provided for both young children and older parents. The tradition of informal obligations for looking after both their young children and aging parents could discourage middle-aged women from contributing for formal employment (Aziz & Krisnatuti, 2017;Mehri, Messkoub, & Kunkel, 2020). Some studies have found that involvement in double care has resulted in women dropping out of the labor force market (Aazami, Shamsuddin, & Akmal, 2017). Compared to other workers, sandwich-generation women are most likely to quit their jobs or have a shorter stay in employment (Decimo, 2019;Turgeman-Lupo et al., 2020).
Sandwich-generation women are likely to be "stuck in the middle" by the dual responsibility for elderly parents and their children. Informant F (52 years old) and informant C (48 years old) feel burnout and suffer from a lack of physical and mental well-being due to the continued obligations to their families, their jobs, and their own needs (Gillett & Crisp, 2017;Jang et al., 2021). The stress on caregivers is further increased by rearing young children and caring for an elderly parent/in-law at home without any professional help (Molina et al., 2019). The sandwich generation must adjust to all these changes by managing family resources, such as stress, time, and money, in order to reach the anticipated level of family life satisfaction (Sulityowati & Krisnatuti, 2019).
With regard to child care, being a sandwich generation caregiver is undoubtedly a difficult duty that women primarily fill. Sandwich-generation family women face multiple pressures in every case because of the enormous burden of duties that comes with taking care of the home, the kids, and elderly parents in addition to their jobs (Rai, Brown, & Ruwanpura, 2018). In spite of the fact that males are in some ways overworked from taking on additional tasks to pay the bills, families from the sandwich generation still face financial difficulties (Hannes, Rudolph, & Reinicke, 2017;Mandell & Kim, 2017). Studies have shown that the sandwich generation has greater rates of depression than the overall population, with women experiencing depression at higher rates than men (Hernandez, 2019). Women's psychological found are higher if they report having a lot of marital conflicts (Andrade & Neves, 2022). Health stress and financial stress were the two most intense stresses that those women felt when they were depressed (Terkoǧlu & Memiş, 2022). According to Ribeiro et al. (2018), depression can cause lower life satisfaction and mortality.
Caregiving crises that encompass both life and death are causing caregivers distress. According to numerous studies, employees with more than one caring responsibility (for both children and the elderly) are more stressed out and are more likely to miss work (Hannes et al., 2017;Mandell & Kim, 2017). Multiple generations of caregivers express less satisfaction with work-family balance and leave benefits (Patterson & Margolis, 2019). Women who perform various caring duties exhibit higher absenteeism than men (Turgeman-Lupo et al., 2020;Vlachantoni et al., 2020).
The following are some of these stressors such as too many crises involving numerous family members from one or more generations occurring at the same time (Mandell & Kim, 2017), decisions about placing an aging parent in professional aged care (Nursolehah & Krisnatuti, 2017), pressure on middle-aged parents free time (Noor & Isa, 2020), and acute strain on already limited financial resources (Mondal, 2021). Meanwhile, the sandwich generation women need extra time for leisure and selfdevelopment but find that their grown children are not quite independent, and their parents have shifted from autonomy to a degree of reliance (Gillett & Crisp, 2017).
The health conditions of the elderly are becoming incurable at home due to chronic illnesses, necessitating professional carers. Hence, caring for chronic disease patients at home is becoming nearly impossible due to patient needs and a lack of awareness about their unique care (Rizzuto et al., 2017). It has also been discovered that the number of hours mothers spend taking care of their elderly parents is positively associated with their psychological suffering, but not the fathers (Patterson, 2022).
The constant time pressure, stress, and mental fatigue caused by a high burden of care can force sandwich generation women less focus on their own well-being. The effect of a heavy load on sandwich-generation women might result in those women ignoring their nutrition intake, daily exercise, and subjective well-being (Aazami et al., 2017;Turgeman-Lupo et al., 2020). They are less concerned with their health and well-being (Ejem, Drentea, & Clay, 2015;Molina et al., 2019). Sandwich-generation women frequently lack sleep, which can raise the risk of sickness (Gehrman et al., 2018;Osorio et al., 2021). Sleep disturbance has been associated in several studies with early and greater mortality rates (Huyett, Siegel, & Bhattacharyya, 2021;McDermott, Brown, & Chervin, 2018;Owen-Smith et al., 2019).
Compared with non-sandwich generation women, the squeezing generation was found to be less likely to conduct an unhealthy lifestyle, avoid medical check-ups, consume leftover food, and exercise less. A possible explanation for sandwich generation women's poorer health behavior may affect their health conditions (Nair et al., 2021;Shrestha et al., 2021). In other words, people who care for multiple generations may value the health of others more than their own health (Steiner & Fletcher, 2017). It should be noted that health behavior of current life will affect not only current health status but also largely determines health later in their life (Nair et al., 2021). Coping mechanisms are methods utilized by sandwich-generation women to lessen stress (Lei, Leggett, & Maust, 2022;Ribeiro et al., 2018).
The positive effects on psychological health can offset the negative effects of sandwich care due to strengthening intergenerational relationships and strengthening families. Women who report being content with their work, content in their marriages, and feeling close to their families show less psychological suffering (Lendon, 2017). Grandparents could provide loving care for their grandchildren (Lau et al., 2019;Li et al., 2021). Thus, it would seem that having elderly parents/in-laws can support middleaged parents in taking care of young children (Joshi & Lebrun-Harris, 2022). At the same time, the opportunity of grandparents to care for their loved grandchildren is socially recognized and can be viewed by grandparents as meaningful and rewarding work that provides a sense of accomplishment that positively correlates with the health status of the elderly (Hayslip, Fruhauf, & Dolbin-MacNab, 2019;Komonpaisarn & Loichinger, 2019). Physical, psychological, and social functions will deteriorate in the elderly who are nearing the end of their lives (Clark et al., 2022;Zakari et al., 2022). The alterations in the neurological system and other systems throughout the body can cause reduced brain activity (Aziz & Krisnatuti, 2017).
The study has some limitations. Firstly, due to the limitation of resources, this study did not conduct triangulation. Secondly, the effects of the double burden of informal care on young children and elderly parents can vary depending on the intensity of care. The more intensive the care, the greater the negative effect on the sandwich generation caregiver's health and well-being. However, none of the data provide the intensity of those care.

Conclusion
The findings of this study showed that sandwich generation women are facing many issues because of their heavy burden in taking care of their children and elderly parents/in-laws, maintaining daily housework tasks, and their responsibilities in the workplace. Despite the fact that males are caring for more people than ever before, most caregivers are women. The type of care offered varies depending on gender. Men typically offer financial support, whereas women are more likely to offer emotional support and help with daily duties, including housework, shopping, and personal hygiene, which led to physical, emotional, and mental stress and financial challenges. Hence, sandwich-generation women tend to handle the double burden of taking care of their infants while taking care of their vulnerable elderly parents/in-laws.

Recommendation
Overall, sandwich generation families are under financial stress, struggling to manage their time, and dealing with work-family and family-work problems. Therefore, it is necessary to raise knowledge about the difficulties of caring for older people among the general public, family, friends, coworkers, and neighbors in order to address the emotional, physical, financial, and intellectual concerns faced by families from the sandwich generation. However, they do enjoy pleasant work-life balances thanks to a variety of government, workplace, and social support.
Based on the research findings, this study suggests the government should facilitate daycare centers for young children and elderly parents so that Indonesian women can fully participate in the formal labor force. As a result, it will boost the macro-economic of Indonesia. To facilitate the incredibly important and valued caring obligations of the "sandwich generation," policy and therapeutic support must be put in place.
Employees who are responsible for caring for young children and elderly parents at home must be given time off from work in order to support them in managing their work-life balance. By helping the sandwich generation manage their time, their workload, and their stress at work while also addressing the obligation of caring for their elderly parents, the senior management levels of the companies can play a part. Ongoing promotion and advocacy related to lifelong learning of elderly care should be conducted to increase the well-being of the elderly, families, and society in Indonesia. The community needs to learn about the abundance impact of the sandwich generation's duties, particularly on providing care, support, and well-being for the young children and elderly who live in their homes. Due to their noteworthy contributions to healthy aging, the sandwich generation ought to be recognized in this context.