Background

The responsibility of caring for relatives with mental illness often falls on the family members. It has been reported that the reactions to or consequences of providing care are what rendered the role of a caregiver challenging and hence a source of distress. This present study thus aimed to identify socio-demographic correlates of caregiving experiences using the Caregiver Reaction Assessment (CRA) and to examine the associations between reactions to caregiving and psychological distress.Role of caregivers in promoting mental health.

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Methods

A total of 350 caregivers with relatives seeking outpatient care at a tertiary psychiatric hospital were recruited for this study. Distress among caregivers was assessed using the Patient Health Questionnaire (PHQ-9). The CRA was administered to measure reactions from caregiving in four domains including impact on schedule and health (ISH), impact on finance (IF), lack of family support (LFS) and caregiver esteem (CE). Participants also completed a questionnaire that asked for their socio-demographic information. Multivariable linear regression analysis was first used with domains of CRA as outcome variables and socio-demographic variables as predictors in the models. The next set of multivariable linear regression analysis tested for the association between CRA domains and distress with CRA domain scores as outcome variables and PHQ-9 score as predictor, controlling for socio-demographic variables.Role of caregivers in promoting mental health.

Results

Socio-demographic correlates of CRA domains identified were age, education, employment, income and ethnicity. Domain scores of CRA were significantly associated with PHQ-9 score even after controlling for socio-demographic variables. A higher distress score was associated with greater impact felt in the domain of ISH (β = 0.080, P < 0.001), IF (β = 0.064, P < 0.001), and LFS (β = 0.057, P < 0.001), and was associated with lower CE domain scores (β = −0.021, P < 0.05).

Conclusion

This study identified several socio-demographic correlates of caregiving reaction in the different domains. Each of these domains was found to be significantly associated with caregiver distress. Higher distress was associated with stronger impact on the negative domains and a lower impact in the positive domain of caregiving reaction. Interventions such as educational programs at the caregiver level, and also promoting wider social care support in these domains may help to address caregiver distress.Role of caregivers in promoting mental health.

The Present Study

The preceding review suggests a need to focus attention on the implications of the caregiver’s relationship to the care recipient and gender for understanding of the caregiving experience, including the mental health and well-being of caregivers. Despite extensive attention to the implications of caregiving for caregiver mental health and well-being, little is known regarding the impact of the relationship of the caregiver to care receiver. Role of caregivers in promoting mental health.Where studied, the focus tends to be on older adults as recipients of care, most often provided by adult children. Consequently, the implications of parental caregiving compared with those associated with caregiving to a spouse/partner, to children, or to others, remain unclear. Furthermore, although gender differences in caregiving outcomes are well-documented, little is known regarding whether and how the implications of the caregiver to care recipient relationship differ by gender. Thus, although research tends to report finding that female caregivers report more burden as well as greater stress and depression than do male caregivers (Kim et al., 2012; Li, Mak, & Loke, 2013; Litwin et al., 2014), the implications of intersections involving gender and relationship status are less clear.Role of caregivers in promoting mental health.

To address these gaps, this study drew on national survey data to examine the stress and overall mental health implications of spousal caregiving compared with those associated with providing care for children, parents, siblings, other family members, and nonfamily (friends, neighbors, coworkers). Two research questions were examined: (a) What impact does the relationship of the caregiver to the care receiver have on stress and mental health outcomes of caregivers? (b) Secondly, does this impact vary depending on caregivers’ gender? The analyses controlled for characteristics of the caregiver (age, marital status, living arrangements, education, employment, income, and health status) and care recipient (age, nature of problem requiring assistance, contact with caregiver, and length of care receipt) that have been previously shown to influence stress and mental health among caregivers (Pinquart & Sörensen, 2006, 2011).Role of caregivers in promoting mental health.

Data and Methods

Data

Data for the analyses came from the 2007 Canadian General Social Survey, Cycle 21 (GSS-21), conducted by Statistics Canada. The GSS program is an annual national survey that gathers individual- and household-level data to monitor changes in social conditions and the well-being of Canadians (Statistics Canada, 2009). In addition to collecting basic demographic and socioeconomic data, each GSS cycle has a specific thematic focus, such as family, time-use or victimization. The thematic focus of the GSS-21 was aging and social support. It collected detailed information on social support, family history, retirement planning and experience, informal care, and health.Role of caregivers in promoting mental health.

The GSS-21 target population included Canadians aged 45 and older living in all 10 provinces, excluding Canadians living in the northern territories (remote areas) and full-time residents of institutions. The survey was conducted through telephone interviews. As such, households without telephones were excluded, representing 0.9% of the target population (Statistics Canada, 2009). Households with cellular phone service only (6.4% of Canadian households) were also excluded. Although exclusion of cellular phone only households is a limitation, it is unlikely to significantly bias our regression estimates insofar as cellular phone only households are primarily young adult households (Blumberg & Luke, 2008). In 2008, less than 2% of Canadian adults aged 55 and older relied exclusively on cell phones (Statistics Canada, 2014). As well, our data were weighted to represent the entire target population (including cellular phone only households) in the analyses.Role of caregivers in promoting mental health.

The GSS-21 includes a nationally representative sample of 23,404 Canadians aged 45 and older, with an overall response rate of 57.7%. To study caregiving and health, our study population is limited to caregivers. The GSS-21 identified caregivers by the question, “During the past 12 months, did you provide any assistance to an individual because of a long-term health condition or physical limitation? Exclude paid assistance to clients or patients.” For those who answered affirmatively, more information was collected about the primary care recipient—the person to whom the respondent had dedicated the most time and resources (due to a long-term health condition or physical limitation, excluding paid assistance to clients or patients)—and various activities the respondent engaged in to help the primary care recipient. Our study sample included all respondents who had provided such assistance in the past 12 months (n = 6,140). Role of caregivers in promoting mental health.Cases with missing data for the dependent variables and the primary independent variables were minimal (n = 34) and thus were removed from the analyses. With the exception of household income, missing data for the control variables were generally insignificant (less than one-half percent) and were imputed using multiple imputation techniques (Rubin, 1987). For household income, missing data were nontrivial (18.4%). Thus, a dummy variable for missing household income was added to all regression models.Role of caregivers in promoting mental health.

Measures

The study considered two dependent variables tapping the psychological well-being of the caregivers. We measured self-rated stress on a 5-point Likert scale, using responses from the question: “Thinking of the amount of stress in your life, would you say that most days are: (a) not at all stressful, (b) not very stressful, (c) a bit stressful, (d) quite a bit stressful, or (e) extremely stressful?” (Lim, Williams, & Hagen, 2005; Littman, White, Satia, Bowen, & Kristal, 2006). Similarly, self-rated mental health was also measured on a 5-point scale, using the question: “In general would say your mental health is: (a) poor, (b) fair, (c) good, (d) very good, or (e) excellent?” (Mawani & Gilmour, 2010).Role of caregivers in promoting mental health.

Our main independent variable was the respondent’s relationship to the primary care recipient. As noted, all caregivers were asked to identify a primary care recipient (the person to whom the respondent had dedicated the most time and resources during the past 12 months) and information was collected about their relationship to the recipient. We measured this relationship as a six-level categorical variable: (a) respondent’s own child; (b) respondent’s own parent; (c) respondent’s sibling; (d) other family such as a grandchild, a grandparent, an in-law, a relative, or an ex-partner/spouse; (e) a friend, a neighbors, a coworker or someone else; and (f) respondent’s spouse or partner (the reference group).Role of caregivers in promoting mental health.

Various characteristics of the caregiving network, the caregiver, the care recipient, and care activities were also controlled for in the analyses. We included two variables to measure the caregiving network: whether the respondent was the primary caregiver (1 = yes, 0 = no), and the size of the caregiving network (i.e., the number of other people providing informal care to the care recipient). Caregiver characteristics included their age (measured in years), current marital status [measured in five mutually exclusive categories: (a) cohabiting, (b) widowed, (c) separated/divorced, (d) never married, and (e) married (the reference group)], coresidence (1 = living alone, 0 = otherwise), education (ranging from 1 = elementary school education or less to 10 = some post-graduate education or more), employment status [a three-level categorical variable: (a) currently working at a paid job/business, (b) other employment situations (e.g., working inside the home, looking for work), and c) retired (the reference group)], household income (a five-level categorical variable), and health status (assessed using two indicators: activity limitations—a dummy variable, indicating whether the respondent reported any amount/kind of limitation in regular activity at home, work, or in other activities due to a physical or mental condition, or health problem—and the presence of chronic conditions—a dummy variable, indicating the presence of any chronic condition—e.g., arthritis or rheumatism, back problems, diabetes, Alzheimer’s disease, heart disease, or cancer). Two variables reflected care recipient characteristics: age (in years) and the nature of the problem(s) that required assistance [a categorical variable with four categories: (a) mental, (b) both physical and mental, (c) something else, and (d) physical (the reference group)]. Finally, we included two measures of care activities: frequency of visiting/seeing the recipient [an ordinal variable: (a) less than once a month, (b) at least once a month, (c) at least once a week, and (d) daily (the reference group)] and length of time spent providing care (in years).Role of caregivers in promoting mental health.

Statistical Models

We used ordinary least squares (OLS) models for the regression analyses. Since both dependent variables were ordinal variables, we experimented with ordered logit models (Long, 1997). Comparing the two sets of the results, however, we found no substantive differences in either the nature or the magnitude of the parameter estimates. For ease of interpretation, we therefore report the OLS results in this article. In addition, we carefully assessed key model assumptions (e.g., multicollinearity, outliers) and did not detect any serious violations (results of the sensitivity analyses available upon request). Where models were run separately for male and female caregivers, we also tested for the significance of differences in the regression coefficients (unstandardized) associated with the relationship to the care recipient (results not reported but available upon request).Role of caregivers in promoting mental health.

Results

Overall, 26.2% of those in the overall sample reported that they provided care for someone with a long-term health condition or physical limitation during the past 12 months. Most (56.7% of the target population) of those who reported having provided such care were women. Among female as well as male caregivers, the most frequently reported primary care recipient was a parent (35.1%; Table 1). Over one-quarter (26.2%) provided care to nonfamily members (such as friends, neighbors, or coworkers).Role of caregivers in promoting mental health.The next most frequent category of primary care recipients included other family members (e.g., grandchildren, grandparents, in-laws—16.8%), followed by spouses (10.3%), siblings (5.8%), and children (5.7%). Female caregivers were somewhat more likely than male caregivers to report caring for children, parents, and siblings whereas male caregivers were somewhat more likely to report other family and nonfamily members as primary care recipients. However, when it came to spousal support, the gender gap was considerably reduced.Role of caregivers in promoting mental health.