This paper presents a general population-based multi-level mixed effects analysis of individual level self-assessed mental and general health status of Australians in relation to their informal caregiving status. The study investigated the moderating effects of social capital indicators on carer/non-carer health outcomes. Additionally, the study accounted for the small area level variation in the carer/non-carer health outcomes, by allowing for variation in the average values of the health component scores as well as variation in the type of relationship between carer status and health by SA1s. The analysis supports evidence that informal carers do suffer from worse health than non-carers both in terms of their general and mental health. There are statistically significant small area level variations in health status both in their overall mean values as well as in the extent to which carer status influences health outcomes. The study adds significant value to the caregiving and health literature for its findings on the moderating effects of individuals’ social capital on their health outcomes. Carers’ social capital proves to be important for counteracting the negative health effects of caregiving on health. Additionally, the study yields significant inferences for SA1 level policy perspective to improve overall general and mental health status of carers and reduce the impact of caregiving on health.
Carer and Non-carer Health
Carers in general suffered from worse health outcomes than non-carers, with values almost 5 points lower in magnitude in general health and 3.8 points lower in mental health. The inverse relationship between caregiving and health remained statistically significant as we introduced other confounding individual level characteristics such as their socio-demographic, economic and health behaviour, along with the social capital variables one-by-one in separate models. In the penultimate model (Model 6), the carer status continued to remain negatively significant with a much lower magnitude (coefficient of -1.1 in general health and -1.7 in mental health). These findings are aligned with previous studies which highlighted the extent to which caregiving was associated with poorer health status 1 19 34. Oshio and Kan (2016) 19 looked specifically into the effect of informal caregiving on caregivers’ mental health and confirmed the same adverse impact as found in previous studies (e.g., Cameron et al., 2008; Binder & Freytag, 2013) 35 36. Stacey et al. (2018) 37, revealed a similar negative effect of caregiving on other chronic conditions, such as asthma and diabetes, which may in turn impair an individual’s general and mental health.
However, in the fully adjusted model, the moderating effects of the social capital indicators were able to offset the negative influences of caregiving on health outcomes. More importantly, the research revealed how community level social capital such as community participation, social cohesion and trust realised by individual carers, potentially could mitigate the negative influence of caregiving on health outcomes. This could be driven by the positive and significant influence of social capital on both general and mental health outcomes 20 38 39. Similar to these findings, Oshio and Kan (2016) focussed on social activities involving individual interpersonal interactions with others mainly in their neighbourhood or community (e.g., hobbies or cultural activities, exercise or sports, community events, support for children and the elderly) and concluded that participation in such activities mitigated substantially the negative impact of caregiving on mental health 19.
Carer Health and Small Area Differences
The small area level variations accounted for almost 12% for the total variation in general health, and for almost 13% of the total variation in mental health status of individuals in Australia. In the fully adjusted models, these small area level variations remained statistically significant accounting for about 5% of the total variation in general health and for about 6% of variation in mental health. Additionally, there were statistically significant differences in the magnitude of impact that caregiving exerted on carers’ general and mental health across small areas in Australia. We found a negative association between the magnitude of impact that caregiving had on general health and the average value of general health across SA1s, but a direct positive association between caregiving effects on mental health and average values of mental health at SA1 level.
These findings have important implications for SA1 level policy perspectives with respect to both general and mental health outcomes. For general health, as the average value of general health increases across SA1s in Australia, the impact of caregiving on general health declines (Figure 2). Therefore, in order to reduce the negative impact of caregiving on general health, policies should be targeted at improving the average general health scores for SA1s. Furthermore, policies aimed at mitigating the negative influence of caregiving on carers’ general health would be more effective in SA1s in the top left quadrant of Figure 2 than the SA1s in the bottom left quadrant, whereas SA1s in the bottom left quadrant should be targeted for overall improvement in general health scores.
For mental health, as the average value of overall mental health increases across SA1s, the impact of caregiving on mental health increases (Figure 4). This contrasts with the policy implication for general health at SA1 level. Indeed, increasing the overall mental health scores at SA1 level is not helpful as it does not decrease the negative impact of caregiving on carer mental health. Therefore, policies should rather be targeted to reduce the impact of caregiving on individual carers’ mental health. Furthermore, policies to alleviate negative influence of caregiving on carers’ mental health should be directed to SA1s in the top right quadrant of Figure 4, whereas SA1s in the bottom left quadrant should be targeted with policies for overall improvement in mental health scores coupled with policies to disentangle the negative impact of caregiving on carer’s health.
These are important small-area level inferences that have not been revealed through any previous research examining the influence of caregiving on the general and mental health status of individuals in Australia. Identifying geographical variations in health and quantifying their magnitude is a rather new trend in research and policy perspectives. This research moved beyond previous research that looked at the effect of caregiving on carer health in regional and rural areas 2 3. While previous studies found that carers in regional and rural areas suffered worse health outcomes than their urban counterparts, due to remoteness and distances to services, this study shows SA1 level variations, irrespective of rurality, in the impact of caregiving on both general and mental health and drew policy implications. This is really a move forward in promoting policies to identify small area level variations and devise systemic policy changes that would have rather a bottom-up than a top-down approach to implementation.
Social Capital and Carer Health
An almost 7% decrease in the variations in both health component scores attributed to small areas were accounted for by the inclusion of individual level demographic, economic and health behaviour related contextual factors and social capital variables in the fully specified models. More importantly, the inclusion of social capital variables that represented societal level social capital - community participation, social cohesion and trust on the local community, realised or harnessed at individual level, considerably reduced the magnitude of negative impact of caregiving on carers’ health. Furthermore, these individual level societal social capital variables, once interacted with carer status in the fully adjusted models, the consequent significant moderation effects alleviated the negative impacts of caregiving on both health components scores. This is an indication that interventions to improve societal social capital components and encouraging carers to harness more of those resources, would deliver robust health outcomes for them.
Community participation included civic engagement, political participation and breadth of participation as one component and informal social connectedness as another component in this study 20 21. Overall, the civic engagement variable, which represented rather formal communication and involvement at community level, exerted no significant influence on individual level general health, and it had a very small in magnitude negative influence on carers’ general health in the fully adjusted model. However, civic engagement exerted a positively significant influence on individual level mental health but with no specifically significant moderation effect on carers’ mental health. On the contrary, informal social connectedness, which represented rather informal connection with family and friends, exerted a statistically significant influence on individuals’ general health with no specific moderating effect on carers’ health, though it exerted significant influence on non-carers’ general health. However, for mental health, this variable exerted significant positive influence on all individuals with significant moderating effect on carers’ mental health. It appeared that for carers informal community participation was helpful than somewhat formal commitments. This may be due to the circumstances that formal commitments may limit the time and resources available for their caregiving responsibility.
Previous studies examined the concept of social cohesion and investigated the relationship between social cohesion and individual health 40. The literature on social cohesion converges on the view that social cohesion is not a homogenous concept. It includes social justice, social relationships and social exclusion as different dimensions. Much of the debate on social cohesion, in recent days, focuses on social exclusion 40 41. Social cohesion was included in this study in a holistic sense as personal social cohesion and personal social exclusion are two separate components. This is based on the belief that these two components capture specific dimensions of social cohesion independently 42, rather than exerting mutually opposing influences on the individuals’ health. These two social cohesion variables exhibited significant influences (in the expected directions) on individual level general and mental health scores with even significant effect modifications. These variables represented the extent of social support and social isolation of the individual within the community and proved helpful in reducing the negative influence of caregiving on carer’s health.
Trust and Reciprocity
There is a growing literature with the view of trust as a foundation of social orders 43 44. Likewise, components of societal trust and reciprocity were included in this study as levels of trust and distrust on the community. This view is supported by literature that we need to understand both trust and distrust if we are to understand the different ways how trust works 43 45. They do not really exert opposing influences and distrust is not merely the absence of trust. Like trust, distrust has its own normative dimension 43 45. These two variables simultaneously represented levels of trust and distrust within relational framework based on assumptions of multidimensionality in relationships 44. These variables came up as significant influences (in the expected directions) for both general and mental health of individuals in this study, with specific moderating effects for carers 46. They were helpful in reducing the negative influence of caregiving on carers’ health. Since they reflect levels of trust and reciprocity in the community perceived at individual level, they may serve as the foundation of overall personal social capital.
Strengths and Limitations
To sum up, this study has added value to the literature by identifying the moderating impact of social capital in offsetting the negative impacts of caregiving on carers’ health outcomes. The study also highlighted that the negative impacts of caregiving significantly vary in nature and magnitude across small areas in Australia. It is evident that factors at the community level are important. So, policies targeting to improve social capital and carers’ health in terms of promoting community participation, social cohesion, trust and reciprocity need to have a small area, i.e. local, focus rather than taking a ‘one-size-fits-all-regions’ approach.
The strength of this study lies in the inclusion of a large set of nationally representative relevant and potentially influencing variables and using advanced multi-level mixed effects regression modelling to an existing cross-sectional data set (wave 14 of HILDA). While HILDA is longitudinal in nature, we have used the latest wave containing information on community participation, social cohesion, trust and reciprocity. The multi-level mixed effects technique allowed us to model the hierarchical structure of the data set where individual carers/non-carers were nested within small geographical areas where policies and more importantly social capital and area context might vary. Using multi-level mixed effects modelling, we have been able to tease out and quantify the small area level variations in average levels of health scores and in the effects of caregiving on health scores across Australia.
On the other hand, the first weakness of the study lies in using an observational data set as opposed to a data set from a controlled randomized design, and the nature of the cross-sectional data as opposed to the longitudinal data. Secondly, given the nature of HILDA surveys, certain groups of the Australian population such as immigrants, people from culturally and linguistically diverse (CALD) communities may have been inadequately covered in the survey. Thirdly, there may still be a significant portion of the variation in health outcomes associated with unobserved small area contextual variables independently of individual attributes or with unobserved individual level attributes independently of small area indicators that are not accounted for in this analysis. Furthermore, the manner in which this study investigated how the nature/attributes of the local community and community social capital experienced at the individual level moderated carer’s health it fails to account for the possibility that caregiving status and other individual attributes (e.g., personality traits) may in turn affect individuals’ perception of their community and the inherent social capital and other area-related attributes.