Abstract
The COVID-19 pandemic poses specific risks to vulnerable population groups. Informal carers for older adults are especially at risk of increased strain, as support from social networks and professional care services is no longer available or in short supply. Already before the pandemic, caring was unequally distributed within societies, with women and people in lower socio-economic status groups bearing a higher risk of caring strain. In this article, we propose a conceptual framework of (unequal) caring strain during the pandemic. We then summarise the state of empirical research, suggest questions for future studies and outline implications for social policy.
Introduction
The COVID-19 pandemic has caused historically unprecedented challenges for societies and individuals throughout the world, and has especially affected the situation of informal carers (hereafter, ‘carers’), that is, individuals who provide unpaid care to family members and friends. European countries are among the most advanced in their ageing trajectories, and the majority of older people rely on informal support and care from their relatives and friends (Colombo et al, 2011). Across Europe, 80 per cent of care for older people is provided by carers (Eurocarers, 2017). Caring can impose significant strain, especially if carers experience financial hardship or lack access to support from their social networks or professional care services. The COVID-19 pandemic and related mitigation measures restricted access to both formal and informal support resources, and carer strain has increased (Lorenz-Dant, 2020; Park, 2020).
Already before the pandemic, the prevalence of caring and the risk of care-related strain were unevenly distributed across population subgroups, with women and individuals with lower socio-economic status (SES) more likely to experience both (Tough et al, 2020). Carer strain also differs between countries, with higher burden in countries lacking public alternatives to family care (Verbakel, 2014). Empirical studies document decreases in carers’ well-being (Lorenz-Dant, 2020; Park, 2020; Brandt et al, 2021), but little is known about social inequalities in carer strain during the pandemic. We hypothesise that pre-pandemic gender and SES inequalities in caring obligations have increased, mainly due to reduced access to support from social networks, which, in turn, has widened social inequalities in carers’ well-being.
In this article, we draw on theories of caring strain and its relation to well-being, and empirical evidence about pre-pandemic inequalities in carer strain. We develop a conceptual framework of inequalities in carer strain during the COVID-19 pandemic. We then summarise the state of empirical research on carers’ health and well-being during the pandemic, paying particular attention to gender and SES inequalities, pre-pandemic country differences in caring, and national policies introduced during the pandemic to support carers. Finally, we identify gaps in existing empirical research that could be addressed in future studies, concluding with implications for social policy to enable carers to support their social network members without risk to their health and well-being during a public health crisis.
The stressful and unequal nature of caring
Caring and health
According to Pearlin and colleagues (1990) caring strain is a consequence of a process that comprises interrelated factors, including stressors related to the caring situation and resources available to the carer that can alleviate pressures on them. Caring can affect health and well-being in several ways. Carers may experience stress due to physical and time-consuming caring tasks (‘primary stressors’). They often sacrifice personal needs and have little time for respite and regeneration – especially when (professional) support is not available. These primary stressors, which are enduring and often intensify over time, can induce ‘secondary stressors’, such as intra-psychic strain and role strain. Secondary role strain results from conflicts in other parts of life, such as family conflicts or combining caring with paid work. Time-intensive caring can force carers to reduce their working hours, take a leave of absence or even give up their job (Moussa, 2019). Resultant financial hardship is an additional, secondary, stressor that may lead to long-term decline in carers’ health and well-being (Pearlin et al, 1990).
Previous research has shown a clear link between caring and poor (mental) health, especially among spousal carers (for example, Pinquart and Sörensen, 2011; Kaschowitz and Brandt, 2017). The extent to which caring is stressful, and thus harmful for health, depends on both the care recipient (their level of care need, medical condition and cognitive impairments) and the carer. For instance, strain may arise if carers need to fulfil other tasks (including paid work or care for other family members), have a restricted social life or experience financial hardship (Pearlin et al, 1990). In contrast, pressure on carers may be alleviated by ‘mediators’ – individual coping behaviours, instrumental and emotional support from other carers within the immediate social network, and professional care (Verbakel et al, 2018). Carers’ gender and socio-economic background, as well as the broader social organisation of care in their country, further influence the degree to which carers provide care and have access to resources to alleviate the strains of caring (Floridi et al, 2022).
Gender and SES inequalities in caring
Informal caring is a gendered task. In Europe, close to two thirds of those who provide informal help or personal care are women (Eurocarers, 2017). While men are more likely to share caring with others, women are more often solely responsible (Bertogg and Strauss, 2020). Caring has been shown to impact women’s labour market outcomes more negatively (Moussa, 2019), and women experience greater carer strain and more adverse health outcomes than men (Pinquart and Sörensen, 2006).
In addition, inequalities in informal caring by SES are evident. Individuals with lower income or education, or those who reside in socio-economically deprived communities, are more likely to provide informal care. Carers in lower SES groups have fewer opportunities to access privately paid professional care services (Broese van Groenou et al, 2006) and have smaller and more kin-based social networks (Broese van Groenou and van Tilburg, 2003) with whom to share the caring load. They are more likely to rely on informal care and to experience carer strain, and less likely to use professional care services than people in higher SES groups (Bertogg and Strauss, 2020; Tough et al, 2020; Quashie et al, 2022).
Cross-national variations in care inequalities in Europe
Cross-national differences in the magnitude of gender and SES inequalities in carers’ well-being may result from a mix of cultural and institutional factors that shape the availability and use of public alternatives to family care. Countries in Northern and Western Europe are characterised by the higher availability of publicly funded professional care services and support for family carers, whereas in countries in Southern and Eastern Europe, public formal care services and support for family carers are more limited (Lamura et al, 2008). Furthermore, countries differ in their expectations about how individuals should contribute financially to the costs of eldercare. In some Southern and Western European countries, publicly funded services are only provided if the person in need or their close relatives cannot independently afford the costs of care (Haberkern and Szydlik, 2010; Spasova et al, 2018).
Generally, when state-supported services are more readily available at the national and regional level, there seems to be less pressure on family members to provide a high level of care and the negative impacts of caring on well-being are less pronounced (Wagner and Brandt, 2018). In contexts with few formal alternatives to family care, women tend to adopt a larger share of family care responsibilities than men (Schmid et al, 2012) and experience lower well-being than men (Ruppanner and Bostean, 2014; Floridi et al, 2022). When considering SES inequality in access to, and utilisation of, formal care, Albertini and Pavolini (2017) show that in countries where long-term care (LTC) systems focus on care services (for example, Denmark and France), there is equal access to formal care across the socio-economic spectrum. In contrast, in countries where LTC systems focus on cash-for-care programmes (for example, Italy and Germany), income inequality in access to formal care is more pronounced.
Prior to the spread of COVID-19, then, researchers had documented gender and SES inequalities in carer strain, of varying magnitude, across Europe. Mitigation measures against the virus emphasised limiting physical interaction; this brought inevitable changes in care arrangements, potentially reinforcing gender- and SES-based inequalities in carer strain. In the following, we summarise these changes in care arrangements, develop a conceptual framework and describe how inequalities in stressors and coping resources have changed due to the pandemic.
Changes in care arrangements during COVID-19
The pandemic has affected many aspects of social life, including carers’ access to formal and informal care support. Across Europe, many carers receive support from formal care services, including, in some cases, care provided by migrant care workers (Anderson, 2012). At the peak of the pandemic, many live-in migrant care workers returned to their countries of origin. As many were working without a legal working contract, some were subsequently unable to cross European borders (Safuta and Noack, 2020). When borders later reopened, (affordable) public transport options were often unavailable, constraining some migrant care workers’ return.
In some cases (for example, in Germany), day-care and night-care centres were forcibly closed (Eggert et al, 2020), and rehabilitation centres and hospitals sent their patients home to create capacity for the expected COVID-19 patients. Closure of these services led to increased demand for informal care within the home. At the same time, many carers living separately from those they cared for became anxious about visiting older relatives and reduced their visits voluntarily to avoid transmission of the virus or the risk of infection (Eggert et al, 2020; UNDP and UNW, 2021), though social-distancing exceptions regarding care of dependent relatives were made in some countries, such as Finland and Sweden, where visits by family carers were also restricted (Forma et al, 2020). Overall, caring intensity and the pressures on carers increased during the pandemic (Lorenz-Dant, 2020; Park, 2020; Eggert et al, 2020), often due to the restricted availability of care support networks.
Conceptual framework: social inequalities in carer strain during the pandemic
According to the stress-process model (Pearlin et al, 1990), the degree to which caring affects health and well-being depends on the degree of exposure to primary and secondary stressors, as well as on resources to cope with these stressors (mediators). Our conceptual framework (see Figure 1) posits that the COVID-19 pandemic is likely to affect all dimensions of the stress process. Restrictions in social contacts (‘mediators’) could lead to lower social support for carers, which, in turn, may contribute to care overload (‘primary stressors’) and to reduced health and well-being among carers. Reductions in care support can also influence care conflicts, particularly among those who live with those they care for, and the psychosocial strain of managing care and work, especially for those who worked at home during the pandemic, experienced job loss or had to maintain regular employment (for example, if employed in essential services). These are ‘secondary stressors’, which may lower well-being. We further argue that the influence of the pandemic on primary and secondary stressors, as well as on social support resources (which can mediate or reduce carer strain), can differ by the individual carer’s gender and SES (‘micro-level context’) and help explain why carers in different subgroups may experience greater strain. Finally, national differences in care policies, especially the extent to which formal care services are available and utilised (‘macro-level context’), are expected to influence cross-national variation in carer strain caused by the pandemic.
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Caregiving strain in pandemic times
Citation: International Journal of Care and Caring 8, 2; 10.1332/239788221X16592761870899
Source: Own illustration based on Pearlin et al (1990).Several studies have documented decreases in carers’ well-being since the beginning of the pandemic (Lorenz-Dant, 2020; Park, 2020; Brandt et al, 2021). Based on our conceptual framework, we expect that some groups of carers will have been more affected than others. First, we expect gender differences. We expect female carers to have lower well-being than their male counterparts due to:
problems in balancing paid and unpaid work (reduced working hours will lead to more care load, causing greater carer strain) (‘secondary role strains’).
Male carers, however, may experience an increase in carer burden and a decline in well-being compared to before the pandemic due to:
a sudden decrease in social and formal support (‘mediators’) that makes it harder for them to combine full-time work and caring (‘secondary role strain’).
Similarly, the pandemic may have produced SES differences in carer strain. We hypothesise that for carers with lower (compared with higher) SES:
poorer health and greater need for medical services among their care recipients will lead to more primary stressors and thus greater decline in well-being (‘primary stressors’);
their higher probability of experiencing difficulty in the labour market will lead to greater financial strain and a sharper fall in well-being (‘secondary stressors’); and
their higher social support potential within the family, as well as the greater focus of professional care providers on more vulnerable segments of the population, will generate gentler declines in well-being (‘mediators’).
We also expect the macro context to affect carer strain and well-being. If COVID-19 mitigation measures lead to restrictions in access to formal care services, carers have to step in. We thus expect steeper well-being declines for carers in countries with stronger norms of using formal care services (such as countries in Northern Europe), as compared to carers in countries with stronger family care norms, because:
formal care services were less available in the pandemic and diverse care networks (formal–informal care mix) were reduced (‘macro-level context’).
In the following sections, we contrast our conceptual framework and the proposed hypotheses with ongoing research on carer strain during the pandemic. We also propose research questions for future studies.
State of research: inequalities in carer strain since the start of the pandemic
Gender inequalities in carer strain
Early evidence from research in Europe, North America, Africa and South-East Asia points to increased unpaid care and domestic work for women, including childcare, housework and care for ill family members (Bolis et al, 2020). Although men’s unpaid work has also increased, caring remains largely women’s responsibility and has been one of their primary concerns during the pandemic (Bolis et al, 2020; Czymara et al, 2020). The pandemic has also had significant impacts on gender inequality in paid work, as mitigation measures resulted in job losses, reductions in working hours or transitions to working at home, which, to date, have been far more prevalent for women than for men (Reichelt et al, 2020).
Bolis and colleagues (2020) show that increased caring loads are disproportionately affecting women’s well-being, with a higher proportion of women than men experiencing stress and anxiety. For Germany, Klaus and Ehrlich (2021) find that female carers report a sharper increase in depressive symptoms and loneliness, while male carers experience greater declines in self-reported general health. In the US, female carers exhibited more adverse declines in mental health, as measured by anxiety and depressive symptoms, than men (Beach et al, 2021). In Spain, female carers were more likely to experience increases in caring intensity and a reduction of social support than male carers, and this was associated with higher perceived burden and declines in self-rated health. Although, overall, male carers were less likely to experience reduced informal support, men who provided high-intensity care also reported a deterioration in health after the pandemic (Del Río-Lozano et al, 2022).
While most studies suggest that gender inequalities have increased, this does not seem to apply in all country contexts. For the Netherlands, Raiber and Verbakel (2021) show that women were more likely to have increased their care intensity during the pandemic yet, at the same time, were more likely than men to have stopped or decreased caring. The gender gap in subjective carer strain also narrowed due to decreased strain in women. A study conducted in Austria (Rodrigues et al, 2021) found that psychological well-being decreased, especially among male carers.
From existing studies, we can thus conclude that while the pandemic reinforced existing gender inequalities in carer strain in some countries, in others, the picture was not so clear. Future studies should address the following questions:
Which factors lead to increased gender inequalities in caring intensity and strain? Can changes be attributed to such characteristics as educational level or family structure, or to country-level factors?
What kinds of support (financial, emotional or practical) do carers need to cope with pandemic-related strains? Do support needs differ by gender?
SES inequalities in carer strain
In at least the early stages of the pandemic, mitigation measures disrupted individual access to healthcare, disproportionately affecting disadvantaged groups (Arnault et al, 2021). This suggests that carers in lower SES groups may experience greater increases in care needs among those they care for, as well as the need to manage their own health needs.
To date, little research has examined if the pandemic has affected pre-existing SES inequalities in carer strain, apart from the study by Beach et al (2021). These authors show that in the US, lower-income carers reported worse mental health (as measured by anxiety, depressive symptoms and fatigue) than non-carers. The study also identified several COVID-19-related changes as risk factors for carers’ deterioration in mental health, including: increased care duties; financial, emotional and physical strains related to caring; family conflicts; and greater difficulty in accessing healthcare during the pandemic. It nevertheless remains unclear which factors differentiate the well-being of lower- compared with higher-income carers. To better understand and address the underlying mechanisms that influence SES disparities in carers’ well-being during the pandemic, future studies should address the following questions:
Do lower SES carers (who often share their caring responsibilities with other carers in their social network) have limited support due to physical-distancing measures? Have changes in informal support increased their carer strain and lowered their well-being?
How have pandemic-related changes in formal care arrangements, such as the closure of day centres or the reduced availability of migrant care workers, affected the well-being of carers in higher SES groups?
How has the pandemic affected the financial resources of carers in different SES groups? What are the consequences of this for carers’ well-being?
National differences and policy changes
To date, research on cross-national differences in carers’ well-being due to the pandemic is sparse. Bergmann and Wagner (2021) show country differences in the effect of the pandemic on carers’ mental health. Carers in Southern Europe (especially) had a higher probability of anxiety than non-carers. Additionally, mental burden was (slightly) higher in the Baltic States and in Eastern European countries, though no such effects were observed in the Northern and Western European countries studied.
Policymakers in Europe adopted different approaches to enable the continued provision of care during the pandemic, providing varying degrees of support for carers (Lorenz-Dant, 2020; UNDP and UNW, 2021). In Spain, one of the countries hardest hit by the pandemic, female carers were allowed flexible working hours or a reduction of working hours in emergency situations (Instituto de la Mujer, 2020). Spain also established a national emergency fund to expand the provision of social services to support older adults and dependent persons, including home-care services, and to increase the number of beds in care centres (UNDP and UNW, 2021). In Bulgaria, the government increased funding to maintain and expand in-kind home services (for example, food delivery and medicine) to older adults and persons with disabilities (UNDP and UNW, 2021). COVID-19 policy responses in these countries have, in effect, served to encourage reliance on family support by default. Although measures are in place to expand in-kind support and care for older adults, the extent to which family carers, especially women, are relieved of strain has not yet been studied empirically.
Western European countries, such as Austria and Germany, provided financial support for family carers, which aligned with the cash-for-care organisation of their LTC systems. In Austria, employees could interrupt their employment to care for a care-dependent family member without reductions in salary (Altersberichtkommission, 2020). Germany provided financial support to carers and lowered bureaucratic boundaries for receiving support or taking unpaid leave (AOK, 2020). These measures maintained the centrality of families in providing support and probably incentivised caring among women, while potentially minimising the additional carer strain induced by financial insecurity.
Overall, since the beginning of the pandemic, few countries in Europe have enacted policies to strengthen care services for older adults and to support carers (UNDP and UNW, 2021). Where policies do exist, there are notable differences in countries’ approaches that potentially alleviate primary and secondary caring stressors and may influence cross-national differences in carers’ well-being, at least in the short term. Empirical studies addressing the implications of policies that support carers’ well-being are not yet available at this stage in the ongoing pandemic. To support the development of adequate policy measures to support carers, future studies should focus on the following questions:
Are there cross-national differences in changes to carers’ well-being due to the pandemic?
What has been the effect on gender and SES inequalities in carer strain in different national contexts? If there are national differences, what is the role of public alternatives to family care, the availability of paid family leave and financial support for carers?
Has professional care and public support for carers alleviated carer strain?
Discussion
Even before the COVID-19 pandemic, carer strain was unevenly distributed across population groups, being more burdensome for women than men and for carers in lower compared to higher SES groups. The pandemic has led to marked changes in informal and formal care arrangements: less support via social networks (due to social-distancing measures) and less support via formal care services (due to the closure of day-care facilities for older and disabled people).
In this article, we have developed a conceptual framework of (unequal) carer strain in the context of the COVID-19 pandemic. We argue that the pandemic and, specifically, measures introduced to mitigate its impact have affected the primary stressors (for example, care overload) related to caring, as well as the secondary stressors (for example, financial strain) and mediators (for example, lack of social support), leading to lower well-being. Based on this framework, we developed hypotheses about how pre-existing inequalities in carer strain relate to the carer’s gender, SES and country of residence, and how they are likely to have developed during the pandemic. We contrasted our hypotheses with existing empirical research and developed new questions to be addressed in future studies.
Existing studies on gender and SES inequalities show that carer strain was amplified for women during the COVID-19 pandemic due to increases in care load, negatively affecting their well-being in terms of depressive symptoms, perceived stress and anxiety. While male carers also experienced well-being declines during the pandemic, these effects were more pronounced in female carers.
With respect to SES inequalities and changes in strain due to COVID-19, empirical studies are rare. However, existing research suggests steeper decreases in well-being, as measured by anxiety, depressive symptoms and fatigue, for lower-income carers compared to carers with more financial resources. We do not know, however, which factors differentiate the well-being of lower- compared with higher-income carers.
Finally, we shed light on country differences in the organisation of care that can affect care arrangements and thus carer strain, especially in times of COVID-19. Here too, empirical evidence is scarce, though some country differences are discernible in the magnitude of well-being declines among carers during the pandemic, the strongest of which were observed in Southern European countries. To better address carers’ needs, future studies should address the impact on carers’ well-being of caring policies and of national mitigation measures against the virus.
Policy implications
Early research suggests that the COVID-19 pandemic has exacerbated gender and socio-economic inequalities in carer strain. Targeted social policy measures are needed to support the most vulnerable groups during the current pandemic and in planning for future crises:
Make carers less dependent on informal social support by improving the quality, affordability and accessibility of professional care services. This includes measures against shortages of care professionals (for example, higher salaries) and improved working conditions for migrant care workers.
Make carers less solely responsible by connecting carers and care recipients to home health services, and by filling gaps in accessing essential services and in meeting physical and mental health needs (for example, medication and counselling) when public health mitigation measures restrict mobility.
Value individuals who combine caring and paid work by implementing flexible working arrangements. This helps carers balance paid and unpaid work (for example, financial compensation for carers who give up work to care for older relatives), with a special focus on women.
Increase awareness of the gendered nature of caring. The redistribution of caring responsibilities between women and men, as well as between the family and the welfare state, should be at the core of social policy.
Ensure medical treatments are available for care recipients even during lockdowns to avoid a further deterioration of their health. Although the implementation of stay-at-home orders may be necessary, mitigation measures should aim to curtail the unmet health and care needs that may arise from limited access to therapeutic facilities or postponed medical care.
Conclusion
The COVID-19 pandemic poses specific risks not only to care-dependent older adults, but also to carers, who are especially impacted by the pandemic, as support from their social networks or professional care services is no longer available or in short supply. Based on prior research, it is likely that the pandemic will exacerbate pre-existing social inequalities in carer strain. There is an urgent need for targeted social policy measures that support carers, who are an important pillar of LTC provision in many European welfare states. This article is the first to point out important gaps in knowledge – for example, on gender and socio-economic inequalities in the carer stress process, as well as on country-level differences – which can be addressed in future studies. As internationally comparative representative data grow, it will be important to answer these questions and to identify the most vulnerable groups of carers and adequate measures to ensure that individuals can continue to care for their close ones without putting their own well-being and health at risk.
Funding
This work was supported by the German Research Foundation (DFG) within the Open Research Area for the Social Sciences (ORA) under Grant Number BR 3868/4-1 for the project ‘IN-Care: How Are Varying Care Systems Associated with Inequalities in Care and Wellbeing in Later Life?’ (see: http://in-care.fk12.tu-dortmund.de/).
Acknowledgements
We are grateful to Sarah E. Patterson for very helpful comments on an earlier draft that greatly improved the manuscript.
Conflict of interest
The authors declare that there is no conflict of interest.
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