Unpaid caregiving and mental health during the COVID-19 pandemic-A systematic review of the quantitative literature.

The COVID-19 pandemic imposed additional and specific challenges on the lives and wellbeing of informal unpaid carers. Addressing an important gap in the existing literature, this systematic review (prospectively registered with PROSPERO CRD42022376012) synthesises and evaluates the quantitative evidence examining the association between unpaid caregiving and mental health (compared to non-caring), during the pandemic. Five databases were searched (Medline, PsycInfo, EMBASE, Scopus, Web of Science) from Jan 1, 2020, to March 1, 2023. Population-based, peer-reviewed quantitative studies using any observational design were included, with screening, data extraction and quality assessment (amended NOS) independently conducted by two reviewers. Of the 3,073 records screened, 20 eligible studies (113,151 participants) were included. Overall quality of evidence was moderate. Narrative synthesis was complemented by Effect-direction and Albatross plots (given significant between-study heterogeneity precluded meta-analysis). Results indicate that the mental health of informal carers, already poorer pre-COVID compared to non-caregivers, was disproportionally impacted as a result of the pandemic and its associated public health containment measures. This review highlights the vulnerability of this group and should motivate political will and commensurate policies to ensure unpaid caregivers are better supported now, in the medium term, and crucially if, and when, another global public health emergency emerges.

The effect of informal caring on mental health among adolescents and young adults in Australia: a population-based longitudinal study.

BACKGROUND: Young carers are people aged up to 25 years who provide unpaid care to a relative or a friend living with a long-term condition or a disability. Providing informal care is associated with poor mental health. Longitudinal evidence on this relationship among young people is scarce. To address this gap, we assessed the mental health of people aged 15-25 years when providing informal care compared with when not providing informal care. METHODS: We conducted a population-based longitudinal study using 20 years of data between 2001 and 2020 from the Household Income and Labour Dynamics in Australia (HILDA) survey. We included observations of participants aged 15-25 years with at least two observations across 20 waves of HILDA. Informal care was categorised as 0 h per week, 1-19 h per week, and 20 or more h per week. Mental health was measured using the Mental Health Inventory (MHI-5) from the 36-Item Short Form Survey (SF-36). Multivariate linear fixed-effects regression models were fitted to assess within-person changes in mental health when providing different levels of informal care. FINDINGS: Of 44 663 people with 410 658 observations who participated in HILDA waves 1 to 20, 32 726 were excluded with 351 445 observations. 11 937 young people (with 59 213 observations) were deemed eligible for this study and, of these, 8996 participants with 43 231 observations were included in the complete case analytical sample. When caring for 1-19 h per week, young carers had an MHI-5 score of -1·98 points (95% CI -3·06 to -0·89) compared with when caring for 0 h per week. Mental health was worse when caring for 20 or more h per week, with participants displaying an MHI-5 score of -3·47 points (95% CI -6·02 to -0·92) compared with when caring for 0 h per week. Our findings were consistent across sensitivity tests. INTERPRETATION: Our findings suggest potential mental health effects of informal care in young people, particularly when providing an intense amount of caregiving. Reducing young caring loads could be a possible avenue for intervention. FUNDING: Melbourne Disability Institute Scholarship, University of Melbourne Research Training Program Scholarship, Australian Research Council Discovery Early Career Researcher Award, National Health and Medical Research Council of Australia funded Centre of Research Excellence in Disability and Health.

Impact of informal care on the mental health of caregivers during the COVID-19 pandemic.

BACKGROUND: Informal care can affect the mental health of caregivers. The COVID-19 pandemic precipitated many people into informal care. Little is known about the longitudinal effect of informal care throughout the pandemic. We investigate changes in mental health in relation to changes in informal care between July 2020 and September 2021. METHODS: Using data from Understanding Society, we applied fixed-effects modelling to assess mental health variations associated with changes in caregiving among 13 557 participants (50 430 observations). Hours of weekly care were categorized as 0, 1-19, ≥20. Mental health was measured using the General Health Questionnaire (GHQ-12) as a continuous score and a binary indicator. Main analyses were stratified by gender. RESULTS: Compared to when delivering 0 hours care/week, the GHQ-12 scores of women providing care for 1-19 hours/week were 0.46 points higher (95%CI: -0.11, 1.09), while their mental health scores were 0.99 higher (95%: 0.08, 1.90) when caring for ≥20 hours/week. Changes on the binary GHQ-12 measure were only evident for women when providing ≥20 hours of weekly care. These changes were not substantial among men. CONCLUSION: Informal care adversely impacted the mental health of women carers during the COVID-19 pandemic. Support programmes for informal carers should focus on alleviating caregiving loads in women.

Gender and care: Does gender modify the mental health impact of adolescent care?

Young carers are people aged 25 years or less who deliver unpaid informal care to a family or a friend living with a physical or mental illness, a disability, problems related to alcohol/substance use or an elderly relative. Young caring has negative impacts on the mental health of adolescents. Gender patterns underpinning this association have not been explored. We examined gender differences in the mental health effect of informal care among Australian adolescents. We used data from the Longitudinal Study of Australian Children (LSAC). Participants were categorised as non-carers or young carers at 14/15 years old. Although we acknowledge that gender is non-binary, information about gender identity was not collected in LSAC during adolescence. We used the study child's sex as reported at age 14/15 years to categorise adolescents as boys or girls. Mental health was measured using the Kessler Psychological Distress scale (K10) at ages 18/19. We conducted multivariable linear regression models and assessed effect modification by fitting an interaction term between gender and informal care. Informal care was associated with poorer mental health among boys (ß: 0.97, 95%CI: -0.01, 1.95), and girls (ß: 1.66, 95%CI: 0.63, 2.69). Overall, in comparison to boy non-carers, girl carers had the highest level of distress (ß: 4.47; 95%CI: 3.44, 5.51), yielding high predicted scores of K10. While the mental health effects of young care were stronger for girls, there was limited evidence of effect modification as the difference in mental health disparities due to informal care between girls and boys was small (ß: 0.69) with high uncertainty levels (95%CI: -0.72, 2.11). Psychological distress scores were higher for girls than boys in both caring categories. Support strategies should focus on identifying and supporting boy and girl carers to reduce the adverse mental health impact of young informal care.

A blended face-to-face and smartphone intervention to improve suicide prevention literacy and help-seeking intentions among construction workers: a randomised controlled trial.

PURPOSE: In Australia and elsewhere, suicide rates among construction workers remain high. Construction workplaces are thus an important setting for targeted suicide prevention programs. This study aimed to compare suicide prevention literacy and help-seeking intentions among participants receiving face-to-face suicide prevention training, with those receiving face-to-face training augmented by a smartphone application. METHODS: A two-arm randomised controlled trial of a smartphone suicide prevention intervention was conducted among construction workers in four Australian states (trial registration number: ACTRN12619000625178). All participants received face-to-face training and were randomised to the control condition (face-to-face only, n = 575), or MATESmobile condition (face-to-face + smartphone application, n = 509). Surveys administered at baseline and 3-month follow-up measured suicide prevention literacy and help-seeking intentions for personal/emotional problems and suicidal thoughts. A mixed-model repeated measures (MMRM) analysis included all 1084 randomised participants. RESULTS: Outcomes did not differ significantly for suicide prevention literacy, nor help-seeking intentions from formal sources, informal sources outside the workplace, or no one (did not intend to seek help from anyone). However, relative to those in the control condition, those in the MATESmobile group showed greater increase in help-seeking intentions for emotional problems from a MATES worker/Connector (mean difference 0.54, 95% CI 0.22-0.87) and help-seeking intentions for suicidal thoughts from a workmate (mean difference 0.47, 95% CI 0.10-0.83) or MATES worker/Connector (mean difference 0.47, 95% CI 0.09-0.85). CONCLUSION: Results indicate that the MATESmobile application, together with face-to-face training, is beneficial in enhancing help-seeking intentions from MATES workers/Connectors and workmates to a greater extent than face-to-face training only. While this research provides some evidence that smartphone applications may support suicide prevention training, further research is needed.

Longitudinal association between informal unpaid caregiving and mental health amongst working age adults in high-income OECD countries: A systematic review.

Background: Informal unpaid caregivers provide most of the world's care needs, experiencing numerous health and wealth penalties as a result. As the COVID-19 pandemic has highlighted, informal care is highly gendered. Longitudinal evidence is needed to assess the causal effect of caregiving on mental health. This review addresses a gap by summarising and appraising the longitudinal evidence examining the association between unpaid caregiving and mental health among working age adults in high-income Organisation for Economic Co-operation and Development (OECD) countries and examining gender differences. Methods: Six databases were searched (Medline, PsycInfo, EMBASE, Scopus, Web of Science, Econlit) from Jan 1, 2000 to April 1, 2022. Population-based, peer-reviewed quantitative studies using any observational design were included. Population of interest was working age adults. Exposure was any unpaid caregiving, and studies must have had a non-caregiving comparator for inclusion. Mental health outcomes (depression, anxiety, psychological distress/wellbeing) were measurable by validated self-report tools or professional diagnosis. Screening, data extraction and quality assessment (ROBINS-E) were conducted by two reviewers. The study was prospectively registered with PROSPERO (CRD42022312401). Findings: Of the 4536 records screened; 13 eligible studies (133,426 participants) were included. Overall quality of evidence was moderate. Significant between-study heterogeneity precluded meta-analysis, so albatross and effect-direction plots complement the narrative synthesis. Results indicate a negative association between informal unpaid care and mental health in adults of working age. Importantly, all included studies were longitudinal in design. Where studies were stratified by gender, caregiving had a consistently negative impact on the mental health of women. Few studies examined men but revealed a negative effect where an association was found. Interpretation: Our review highlights the need to mitigate the mental health risks of caregiving in working age adults. Whilst men need to be included in further scholarship, reducing the disproportionate caregiving load on women is a crucial requirement for policy development. Funding: Melbourne School of Population and Global Health, Targeted Research Support Grant.

Mental health of young informal carers: a systematic review.

PURPOSE: This systematic review aims to assess and evaluate quantitative evidence on the association between informal caregiving and mental health in young people. METHODS: This review was registered in PROSPERO (CRD42021251666). We conducted our search in the following four databases: Medline (PubMed and OVID), EMBASE, PsycInfo and Web of Science. The last search was performed on the 17th of March of 2021. Quantitative studies that focused on carers aged 25 years or less and compared the mental health status of carers and non-carers were eligible for inclusion. Two reviewers independently assessed articles for eligibility and performed the quality assessment using the Risk of Bias tool in Non-Randomised Studies of Exposures (ROBINS-E). RESULTS: We identified a total of ten eligible articles. Mental health outcomes included depression, anxiety and other mental or emotional problems. Nine out of the ten studies showed that being a young carer was consistently associated with poor mental health. However, the overall quality of evidence was low, and longitudinal data were limited to three articles. The primary sources of bias were confounding and outcome measurement. CONCLUSION: Young carers experience poorer mental health outcomes than their non-caring peers. However, we identified an overall lack of quantitative evidence of high methodological rigour. To establish if young caring leads to poor mental health, future research should focus on addressing the identified methodological limitations and understanding the mechanisms explaining these associations. Addressing these gaps can better inform the allocation of appropriate support and resources to optimise the mental health of young carers.

Estimating cardiovascular health gains from eradicating indoor cold in Australia.

BACKGROUND: Exposure to cold indoor temperature (< 18 degrees Celsius) increases cardiovascular disease (CVD) risk and has been identified by the WHO as a source of unhealthy housing. While warming homes has the potential to reduce CVD risk, the reduction in disease burden is not known. We simulated the population health gains from reduced CVD burden if the temperature in all Australian cold homes was permanently raised from their assumed average temperature of 16 degrees Celsius to 20 degrees Celsius. METHODS: The health effect of eradicating cold housing through reductions in CVD was simulated using proportional multistate lifetable model. The model sourced CVD burden and epidemiological data from Australian and Global Burden of Disease studies. The prevalence of cold housing in Australia was estimated from the Australian Housing Conditions Survey. The effect of cold indoor temperature on blood pressure (and in turn stroke and coronary heart disease) was estimated from published research. RESULTS: Eradication of exposure to indoor cold could achieve a gain of undiscounted one and a half weeks of additional health life per person alive in 2016 (base-year) in cold housing through CVD alone. This equates to 0.447 (uncertainty interval: 0.064, 1.34; 3% discount rate) HALYs per 1,000 persons over remainder of their lives through CVD reduction. Eight percent of the total health gains are achievable between 2016 and 2035. Although seemingly modest, the gains outperform currently recommended CVD interventions including persistent dietary advice for adults 5-9% 5 yr CVD risk (0.017 per 1000 people, UI: 0.01, 0.027) and persistent lifestyle program for adults 5-9% 5 yr CVD risk (0.024, UI: 0.01, 0.027). CONCLUSION: Cardiovascular health gains alone achievable through eradication of cold housing are comparable with real-life lifestyle and dietary interventions. The potential health gains are even greater given cold housing eradication will also improve respiratory and mental health in addition to cardiovascular disease.

Theoretical explanations for socioeconomic inequalities in multimorbidity: a scoping review.

OBJECTIVE: To document socioepidemiological theories used to explain the relationship between socioeconomic disadvantage and multimorbidity. DESIGN: Scoping review. METHODS: A search strategy was developed and then applied to multiple electronic databases including Medline, Embase, PsychInfo, Web of Science, Scielo, Applied Social Sciences, ERIC, Humanities Index and Sociological Abstracts. After the selection of studies, data were extracted using a data charting plan. The last search was performed on the 28 September 2021. Extracted data included: study design, country, population subgroups, measures of socioeconomic inequality, assessment of multimorbidity and conclusion on the association between socioeconomic variables and multimorbidity. Included studies were further assessed on their use of theory, type of theories used and context of application. Finally, we conducted a meta-narrative synthesis to summarise the results. RESULTS: A total of 64 studies were included in the review. Of these, 33 papers included theories as explanations for the association between socioeconomic position and multimorbidity. Within this group, 16 explicitly stated those theories and five tested at least one theory. Behavioural theories (health behaviours) were the most frequently used, followed by materialist (access to health resources) and psychosocial (stress pathways) theories. Most studies used theories as post hoc explanations for their findings or for study rationale. Supportive evidence was found for the role of material, behavioural and life course theories in explaining the relationship between social inequalities and multimorbidity. CONCLUSION: Given the widely reported social inequalities in multimorbidity and its increasing public health burden, there is a critical gap in evidence on pathways from socioeconomic disadvantage to multimorbidity. Generating evidence of these pathways will guide the development of intervention and public policies to prevent multimorbidity among people living in social disadvantage. Material, behavioural and life course pathways can be targeted to reduce the negative effect of low socioeconomic position on multimorbidity.

Home ownership, income and oral health of children in Australia-A population-based study.

OBJECTIVE: Income inequalities in children's oral health have been well described. It is plausible that the security of tenure reflected by the ownership status of children's housing dynamically interacts with household income to shape these inequalities. We examined whether housing tenure modifies the known association between household income and oral health. METHODS: Data were analysed on 3344 10- to 11-year-old children from the Longitudinal Study of Australian Children. Multivariable regression models tested associations between household income and dental caries and tooth loss due to caries. Effect modification by home ownership (yes/no) was tested on the additive and multiplicative scales. Models were adjusted for sex, Indigenous status, main language spoken at home, area of residence, main carer education and family arrangement. RESULTS: Children in households in the low income group had worse oral health than children in the high group for caries and tooth loss. Models only weakly supported an additive interaction for tooth loss; that is, the relative excess risk due to interaction (RERI) for low household income was -0.903 (-2.38; 0.571) for tooth loss and -0.076 (-0.42; 0.271) for dental decay, although we note that the low proportion of children from low-income homeowning households (6%) reduces the power to detect interactions. Notably, our models suggest renters in both high- and low-income categories had the highest risk of tooth loss compared to owners (PR for high-income renters: 2.19 (95% CI: 1.25, 3.85); PR for low-income renters: 2.11 (95% CI: 1.42, 3.16)). CONCLUSION: Our study confirms that children in low-income households have poorer oral health outcomes than their high-income counterparts. Our findings additionally suggest that children in rental households may fare the worst of all housing and income combinations considered. Improving the security of housing for families privately renting may have wider health benefits that currently acknowledged.

Role of social support in the relationship between financial hardship and multimorbidity-a causal mediation analysis.

BACKGROUND: Social disadvantage is a key determinant of multimorbidity. Pathways through which social disadvantage leads to multimorbidity are yet undefined. In this study, we first examined the causal effect of moving into financial hardship on multimorbidity among Australian adults, and then the role of social support as a mediator of the relationship between financial hardship and multimorbidity. METHODS: Data were obtained from the Household, Income and Labour Dynamics in Australia (HILDA) Survey (2009-2013). We identified individuals who moved into financial hardship between 2010 and 2011 (n = 5775). Inverse probability treatment weighting with regression adjustment was used to examine the relationship between financial hardship and multimorbidity. Causal mediation analysis was applied to decompose the total effect of financial hardship on multimorbidity into the proportion attributable to social support and the proportion not occurring through measured pathways. We accounted for baseline covariates including age, sex, marital status, educational attainment, employment status, income, country of birth, multimorbidity and social support. Bootstrapping with 1000 replications was used to calculate 95% confidence intervals (CIs). RESULTS: The risk of multimorbidity was higher in those with financial hardship by 19% [relative risk 1.19 (95% CI: 1.02-1.37) and absolute risk difference 0.036 (95% CI: 0.004-0.067)] than those without financial hardship. Social support accounted for 30% of the total effect of financial hardship on multimorbidity, risk difference 0.009 (95% CI: 0.003-0.018). CONCLUSIONS: Financial hardship leads to increased risk of multimorbidity. Interventions directed at increasing social support among those in financial hardship may reduce their risk of multimorbidity.