Inequality and heterogeneity of variables influencing parents' perceived worry before and during COVID-19 outbreak: evidence from a cross-sectional survey in Australia

doi:10.21203/rs.3.rs-2228367/v1

Background

Worry, in its general form, is an invisible disruptive force that, if ignored, may have adverse health outcomes. Understanding variables associated with worry among parents in abnormal events such as the recent COVID-19 outbreak and its variation compared to everyday life and across geography remained inadequately addressed.

Methods

Following an extensive literature review, we developed a conceptual framework outlining factors contributing to parents' worry. We undertook an anonymous online survey between (June – July 2020) involving parents (N = 332) and their primary school-aged children across Australia. Multilinear regressions, geographical weighted regression GWR and forest-based algorithms are used to identify significant variables, their spatial behaviour, and their importance in predicting parents' worry. The spatial association examines the geographical relationship between worried parents and children.

Results

There is a 13.8% increase in "very worried all the time" parents during the pandemic compared to before the outbreak. However, variables associated with parents' COVID-19-related worry were not directly related to physical health. Ethnic background (p < 0.05), neighbourhood safety (p < 0.05), parents with a history of distress symptoms (p < 0.05), excessive exposure to the news (p < 0.05 and p < 0.001), and income change (p < 0.05) were significant. Perceived neighbourhood safety was a paramount predictor of parents' worry before COVID-19, whereas the financial risk of income change was the leading variable in predicting parents' COVID-19-related worry. Spatial variations in the latter variable contributing to parents' worry is likely due to varying state policies and virus-reported cases rate. Worried children are found among distraught parents during COVID-19.

Conclusion

The analyses revealed inequality in the impact of the pandemic on parents' well-being and heterogeneity in variables contributing to modifying parents' worry across time and geography. The outcome has implications with international relevance in combating the invisible force of worry by advocating for parents-specific policies and ensuring access to appropriate mental health resources for those in need. There is also a need to forward research in geographical modelling for mental health to help devise much-needed location-targeted interventions that can aid in prioritising resources for high-risk areas.

Pre-and-during COVID-19

parents' worry

inequality

regression analyses

Australia

conceptual framework

GIS.

The World Health Organisation (WHO) defines human well-being as the integration of physical, social and mental health [1]. Public health crises are reported to cause various social, emotional, and mental distress among vulnerable populations [2]. Beyond ill health, an invisible disruptive force of worry may affect the well-being of households that are exposed to an array of stressors that may have originated outside their system [3]. These stressors may potentially promote population worry due to uncertainty about the future [4] Yet, the impact is not uniformly distributed, and parents' worry may vary in the degree of anticipating an event as stressful.

When Coronavirus (SARS-COV-2; COVID-19) landed in Australia, the nation was recovering from unprecedented bushfires [5–7]. The environmental and ecological damages were extensive [8], but the loss of property and life in affected states was substantial. During the COVID-19 outbreak (referred to by the pandemic hereafter), the Australian nation, owing to its geographical location and enforced border closure measures, compared to the rest of the world, has made up a small proportion of both cases and deaths from the virus outbreak. Also, 99.1% of Australians who contracted the virus reported mild to moderate symptoms, with only 0.17% of the confirmed cases being severely ill [9]. However, disruption of life behaviour in terms of social distancing and lockdowns to interrupt the virus transmission and economic hardship may have adverse outcomes threatening population well-being with commonalities across the world [10, 11]. Drawing attention to the disruptive impact of health crises beyond physical health is challenging because this effect is largely invisible. Nevertheless, research needs to systematically unpack key dimensions of settings most relevant to guide appropriate policy to mitigate the impact on well-being. Global uncertainty about the future is likely to generate feelings that may negatively affect people's thoughts, emotions and behaviour [12]. Examined population worry in past health crises like H1N1 and Ebola [13] or due to mass violence in the US [14] found that increased levels of anxiety have significant implications for general health and well-being that may impact the quality of people's life [15]. Increased prevalence of anxiety and distress [16] and a potential increase in vulnerability [17] and worry [10, 18] are detected during COVID-19 among adults.

Kean and Gesler (1998) have drawn attention to the importance of geographical modelling of mental health [19]. Recent advances in geographic information systems (GIS) have offered the possibility of modelling spatial relationships and explaining factors behind observed spatial patterns [20]. Research phenomenon questions of " where " and "why" employing spatial statistical regressions can be unfolded. Links between places and adverse effects on human health have been largely addressed [21]. However, relations between place and population worry are found in environmental hazard studies [4, 22]. The recent pandemic saw unprecedented use of dashboards to map COVID-19 cases spread worldwide [23–25] and the adoption of case tracing using digital solutions to support a safe society in many countries [26]. Yet, the lack of knowledge on the deleterious consequences of the recent COVID-19 or past pandemics beyond physical health among parents has given rise to calls for studies investigating how the pandemic affected parents' worry [16].

Literature expands on several dimensions of fear or worry, such as anxiety [27] or disorders with stress-related symptoms that may advance to depression [28]. This study followed past research by Prior et al. (2019) to address the general form of worry outside the consideration of any specific shape. Examining the relationship between parents' worry and its sources can provide evidence to mitigate the impact of the pervasive pathological worry among those who experience abnormal events [4]. Unlike past studies on people's worry that use a global static model of the variables examined [16, 29], addressing the spatial behaviour of variables in their local form may avoid potential bias in the outcome and policy implications. Research has yet to unfold variations of influences on parents' worry in everyday life from those triggered by an abnormal event such as a health crisis. Past studies indicate that parental levels of worry may vary with the age of the children they care for [30]. Thus, addressing parents' worries while focusing on one specific children's age group will likely help avoid over-generalisation in the outcomes.

Conceptualising parents worry during or before health crises

Epidemic diseases are a permanent threat to global health [31]. Given the scarcity of research, we build on a review of past literature on the intersection of health geography, worry and health crisis to outline a conceptual framework for parents' worry. We adapted Crichton's "risk triangle" technique, which examines perceived risks related to natural disasters [32]. The author summarises three main points for consideration: natural hazard, vulnerability, and elements at risk. Later, Chen H. modified the concept to examine the spatial associations of the three above points in the analysis but involved factors related to community resilience [33]. This study outlined factors affecting parents' resilience to worry during a health crisis and everyday life that were grouped and placed on each side of the triangle, Fig. 1. However, we argue that all elements are perpetuated over time and geography, which we put on one of the three triangle's corners. Proximity to high morbidity areas may adversely affect well-being, even if people are not at risk of contracting the virus. Also, factors influencing parents' worry are dynamic and likely to vary in regular times from those in abnormal times, such as health crises. Research also suggests that effect of parents increased worry, expand beyond their own well-being [34]to affect their ability to look after their children [35], straining the parent-child relationship (Brown et al., 2020) and increasing the risk of child abuse [36]. The red area shows the pandemic's anticipated impact on well-being extending to families, parents, and children. The circle inside the triangle represents the parents' resilience to worry. A larger circle represents higher resilience to worry, that more likely to elevate family, children, and the community's well-being. The varying effect among factors is represented in the arrows. For example, the link between sociodemographic characteristics and exposures, such as neighbourhood safety, penetrates through time and geography elements that may lead to inequality in the effect. Addressing this negative impact of worry on parents is critical for family well-being.

Parents' characteristics, socioeconomic status, and history of distress are found in past literature to modify levels of people's worry. However, some factors, such as perceived neighbourhood safety, trigger worry in everyday life. Others, such as media exposure, may play a more prominent role in its influence during abnormal events [14, 37]. Mental health experts suggested that increased mental health problems are likely due to fear of contracting the virus or uncertainty about the situation [38]. Thus, we addressed financial and health risks. Attributes for each factor are outlined in the next section.

To this end, we aim to fill a void in research by constructing knowledge of parents -who care for primary school-aged children (grade 4–6)- characteristics with heightened worry and examining stressors within or outside the event of the disease outbreak that may exacerbate their worry level. We also signify heterogeneity of exposures during abnormal events and everyday life across geography and its effect on health and well-being. The outcome knowledge is crucial for effectively mitigating the adverse impact of worry across the family structure and increasing public health resources' preparedness for future events. The following research questions are addressed: (RQ1) What factors exacerbate parents' worry during or before COVID-19? (RQ2) How does geography modify factors influencing parental worry in or before the pandemic? (RQ3) What variables are most important in predicting parents with heightened worry in the pandemic and everyday life? And finally (RQ4), do worried children reside with worried parents?

Sample characteristics

Among the 332 included respondents, parents were about 57% females. About 41% of the parents were under 35 years old. Using Australia's Bureau of Statistics (ABS) broad ethnic grouping [57], 48% of participants were Oceanian by birth. The countries that fall under this category are in Table 2, Additional file 1. Parents' qualifications varied from vocational or technical (8.4%), high school or less (15.6%), below bachelor's degree "undergraduates" 37.9%, at or above bachelor "Graduate degrees" 37.9%. Parents from the lowest income category of $3,499 monthly are 23.4%, 38.5% of the sample fall within the median yearly income (between $3,400 to less than $6,500 monthly), and 32.8% of the high income. The general Australian population, in the majority, were represented in the study sample. Yet, parents' qualification of undergraduates was slightly underrepresented compared to 48.6% according to ABS's latest survey in 2018. Most parents reported no direct exposure to COVID-19 cases (78%). Nearly 56% reported keeping their jobs, whereas 27.4% had their salary reduced due to the pandemic at the time of the survey. Remaining descriptive statistics are in Table 3 Additional file 1.

Bivariate relationships

Figure 4 shows a significant 13.8% increase in parents who reported "very worried all the time" during COVID-19 compared to pre-pandemic. Whereas parents who reported "not worried at all" declined by 26% in a similar comparison.

Parents' exposure to news soared in the category of 1-3 hours daily to 36% during the pandemic compared to 18% before that. The percentage of "more than four hours" daily exposure has trebled, reaching 12% during the pandemic compared to 4% before that. Parents that never followed any news decreased from 7% to 1% in pre-and-during the pandemic comparison.

Regressions results

Parents' COVID-19-related worry

Model 1 in Table 1 multi-regression model depicts a significant association of decreased parent worry when parents have Oceanian (p<0.05) and European (p<0.1) ethnic backgrounds compared to Indian, Asian, and Middle-Eastern (reference level). Increased parents' worry is associated with lower neighbourhood perceived safety levels (p<0.05) compared to those reported feeling very safe (reference level) and among parents with a history of daily distress symptoms. From COVID-19-related stressors, parents' worry was positively associated with increased daily exposure to pandemic news "four hours and more daily" (p<0.05). Income changes increased parents' worry, particularly for those whose salary was reduced (p <0.05).

Table1 Hierarchical multilinear regressions of parents' COVID-19 and pre- COVID-19 worry

Variable

During COVID-19

Before COVID

Model 1

Model 2

Sociodemographic

Age (ref: 25-35)

35-44

45-54

55-65

-0.045 (0.702)

-0.084 (0.139)

-0.092 (0.178)

0.430 (0.761)

-0.218 (0.153)

-0.215(0.196)

Gender (ref: female)

Male

Ethnicity(ref: Asian, Indian, Middle Eastern )

European

Oceanian

Others

-0.000 (0.141)

-0.352 ^# (0.182)

-0.275 * (0.117)

-0.477^#(0.266)

-0.260^#(0.154)

0.154 (0.199)

0.011 (0.127)

0.044 (0.284)

Education (ref: High school or less

Vocational/technical

Undergraduate

Graduate

Household (ref: $3,499 or less)

$3,500 - $6,499 (3)

$6,500 or more (4)

-0.108 (0.220)

-0.016 (0.171)

0.048 (0.175)

0.125 (0.133)

-0.133 (0.145)

0.009 (0.242)

0.083 (0.213)

-0.039 (0.216)

0.0433 (0.144)

0.054 (0.156)

Life stressors (History)

Safety perception (ref: Very Safe (1))

Quite Safe

Quite Unsafe

Not at all safe

0.321* (0.126)

-0.220 (0.152)

-0.145 (0.231)

0.059 (0.254)

-0.055 (0.166)

0.052 (0.138)

History of parents' distress (ref: Not at all)

More than half the day

Several days

Nearly every day

0.118 (0.221)

-0.041 (0.139)

0.565* (0.258)

0.213 (0.238)

0.073 (0.151)

0.231 (0.278)

History of parents' worry (ref: Not at all)

More than half the day

Several days

Nearly every day

-0.088 (0.238)

0.062 (0.151)

-0.266 (0.296)

0.478* (0.242)

0.301# (0.158)

0.459 (0.320)

Parents' Exposure to Media news before the pandemic

(ref: Less than 30 mins a day 2)

Never

Less than an hour a day

1-3 hours a day

Four hours and more

-0.613** (0.224)

-0.020 (0.130)

0.347* (0.162)

0.347 (0.162)

COVID-19-related life stressors

Income change (ref: No, it is about the same, and normally go to work)

No, it is about the same, but work from home mainly

Job-keeper

Salary is reduced

Seeking employment

Exposure to COVID-19 infection (ref: No direct exposure)

Direct exposure (being infected or someone in the family being infected)."

"Having a close relationship with someone infected in the buildings or local area."

-0.232 (0.335)

-0.162 (0.219)

-0.799* (0.373)

0.415 (0.601)

-0.043 (0.189)

-0.029 (0.198)

Parents' Exposure to Media news during the pandemic

(ref: Less than 30 mins a day)

Never

Less than an hour a day

1-3 hours a day

Four hours and more

-0.227(0.472)

0.200(0.154)

0.232(0.153)

0.460*(0.192)

Constants

3.954*** (0.302)

3.103***(0.319)

[Ref] is Reference group; ^#p < 0.1, * p < 0.05; ** p < 0.01; *** p < 0.001. Note: Model 1 includes all variables in a single model, COVID-19 worry and sociodemographic, reported pre-pandemic stressors, habits of exposure to news, and COVID-19-related stressors. Model 2 includes socioeconomic, pre-pandemic stressors, and exposure to pre-pandemic news.

Parents' pre- COVID-19 worry

Model 2, Table 1 shows that parents' worry is modified by their demographic characteristics, particularly gender. Lower worry levels were among male parents (p<0.1) compared to female parents. Less worried parents were also among those who never followed the news (p<0.01). Increased worry was among parents who reported a history of worry symptoms (several days and every day of the week) (p<0.05) and had daily exposure to the news for 1- 3 hours (p<0.01).

Parents' COVID-19-related worry by ethnic background.

Table 2 depicts variables associated with parents' worry adjusted by ethnic background. Worry among parents from "Asian, Indian and Middle-Eastern" backgrounds were positively associated with those who had a history of higher frequency of distress (p < 0.05) or worry (p< 0.1) symptoms and those with high health risk due to COVID-19 (p < 0.1). Whereas increased worry among Oceanian's parents was associated with those who perceived lower neighbourhood safety (p <0.05) and reported excessive daily attention to pandemic news of one hour and over (p < 0.05 and p < 0.01).

Table 2: Multiple regression analysis Variables associated with parents' worry after controlling for ethnic background

Variable

Asian, Indian or Middle Eastern

Oceanian

Sociodemographic

Age (ref: 25-35)

35-44 (2)

45-54 (3)

55-65 (4)

-0.180 (0.222)

0.0238 (0.288)

0.073 (0.224)

0.304 (0.299)

0.669 (0.480)

Gender (ref: female)

Male

0.224(0.246)

0.0749 (0.215)

Education (ref: High school or less)

Vocational/technical

Undergraduate

Graduate degree

Household (ref: $3,499 or less)

3,500 - $6,499

$6,500 or more

0.492 (0.740)

-0.059 (0.560)

0.0761 (0.567)

-0.115 (0.211)

-0.172 (0.247)

-0.418 (0.299)

-0.179 (0.240)

-0.049 (0.245)

0.146 (0.219)

-0.200 (0.232)

Life stressors (History)

Safety perception (ref: Very Safe)

Quite Safe

Quite Unsafe

Not at all safe

-0.286 (0.210)

-0.310 (0.315)

0.030 (0.346)

-0.409* (0.236)

-0.254 (0.228)

-0.329 (0.371)

History of parents' distress (ref: Not at all)

More than half the day

Several days

Nearly every day

0.713* (0.346)

0.470* (0.231)

0.693 (0.497)

-0.210 (0.320)

-0.241 (0.222)

0.611 (0.380)

History of parents' worry (ref: Not at all)

More than half the day

Several days

Nearly every day

-0.242 (0.497)

-0.413 (0.250)

0.813^# (0.446)

0.077 (0.416)

0.425 (0.287)

0.312 (0.562)

COVID-19-related life stressors

Income change (ref: No, it is about the same, and normally go to work)

No, it is about the same, but work from home mainly

Job-keeper

No Job

Salary is reduced

Seeking employment

Exposure to COVID-19 infection (ref: No direct exposure)

Direct exposure (being infected or someone in the family being infected)"

"Having a close relationship with someone infected in the buildings or local area"

-0.417 (0.266)

-0.549 (0.404)

-0.146 (0.267)

-0.424 (0.377)

-0.687^# (0.360)

0.001 (0.370)

0.040 (0.199)

-0.010 (0.346)

0.346 (0.982)

-0.136 (0.215)

0.178 (0.354)

0.039 (0.335)

Parents' Exposure to Media news during the pandemic

(ref: Less than 30 mins a day)

Never (1)

Less than an hour a day (3)

1-3 hours a day (4)

Four hours and more (5)

-0.383 (0.676)

0.126 (0.265)

0.168 (0.272)

0.239 (0.311)

-0.272 (0.597)

0.305 (0.597)

0.663* (0.277)

1.014** (0.354)

Constants

4.229*** (0.676)

2.839***(0.764)

[Ref] is Reference group; ^#p < 0.1, * p < 0.05; ** p < 0.01; *** p < 0.001. Note:

The variance inflation factors (VIFs) in each independent variable was 2 or below, suggesting no redundancy or overlapping among variables (Chen et al., 2021). The Q-Q plot outcome and scatter plot matrix grid in Figure 2 confirm multilinear regression assumptions. Figure 1, Additional file 1 is used to visualise the pairwise potential correlation between study variables.

Variation over geography in variables contributes to parents' worry

Some of the variable's spatial behaviour outcomes of GWR of parents' worry in pre-to-during pandemic comparison are displayed in Figures 5 & 6. As recommended in public health studies, we portrayed four quantile categorisations of the coefficient [58]. Negative significance denotes that decreased explanatory variable level increases the response variable's impact. In pre-COVID19, the perceived neighbourhood safety coefficient, the bottom three maps of Figure5, shows marginal positive significance with homogeneous coefficient values ranging from 0.06 to 0.07. During COVID-19, in the top three maps of Figure 5, the perceived neighbourhood safety coefficient explicitly shows spatial variation behaviour and a significant impact on parents' worry, going from positive to negative (0.01 – - 0.003). The strong effects are primarily in the eastern states of NWS and VIC, but WA lacked significant power.

The coefficient of exposure to news variable, not displayed in the manuscript, depicted a significant positive effect of following news on parents' COVID-19 worry, with values ranging from 0.1 - 0.01. A strong positive impact in the eastern states of NSW, VIC, and QLD is depicted, which also lacked significance in WA.

COVID-19-related stressors of income changes, Figure 6, shows coefficient values ranging from positive to negative (0.06 - -0.1). The coefficient displayed variation in the impact of income change across states revealing a significant positive effect in VIC but significantly negative in NSW and non-significant in WA.

Variables' importance

Figure 7 displays the outcome of variables' importance in predicting parents' worry employing forest-based classification, and the input was variables found significant in the multi-regression and the GWR.

In Figure 7a, the most dominant variable to predict parents' COVID-19-related worry was the financial risk of parents' income changes. The perception of neighbourhood safety equally shared the lead with media exposure in predicting parents' pre- COVID-19 worry (Figure 7b). Remaining details are in Tables 4 and 5 in Additional File 1

Examining the locality relationship between worried parents and children (Q4), Table 6 , Additional file 1 shows a value of (0.21), which indicates the positional locality of children with increased worry is primarily found within distraught parents. Examining the relation before the pandemic, the value of 0.03 (closer to 0) denotes a lack of this association, Table 7, Additional File 1.

Sample characteristics

Among the 332 included respondents, parents were about 57% females. About 41% of the parents were under 35 years old. Using Australia's Bureau of Statistics (ABS) broad ethnic grouping [57], 48% of participants were Oceanian by birth. The countries that fall under this category are in Table 2, Additional file 1. Parents' qualifications varied from vocational or technical (8.4%), high school or less (15.6%), below bachelor's degree "undergraduates" 37.9%, at or above bachelor "Graduate degrees" 37.9%. Parents from the lowest income category of $3,499 monthly are 23.4%, 38.5% of the sample fall within the median yearly income (between $3,400 to less than $6,500 monthly), and 32.8% of the high income. The general Australian population, in the majority, were represented in the study sample. Yet, parents' qualification of undergraduates was slightly underrepresented compared to 48.6% according to ABS's latest survey in 2018. Most parents reported no direct exposure to COVID-19 cases (78%). Nearly 56% reported keeping their jobs, whereas 27.4% had their salary reduced due to the pandemic at the time of the survey. Remaining descriptive statistics are in Table 3 Additional file 1.

Bivariate relationships

Figure 4 shows a significant 13.8% increase in parents who reported "very worried all the time" during COVID-19 compared to pre-pandemic. Whereas parents who reported "not worried at all" declined by 26% in a similar comparison.

Parents' exposure to news soared in the category of 1-3 hours daily to 36% during the pandemic compared to 18% before that. The percentage of "more than four hours" daily exposure has trebled, reaching 12% during the pandemic compared to 4% before that. Parents that never followed any news decreased from 7% to 1% in pre-and-during the pandemic comparison.

Regressions results

Parents' COVID-19-related worry

Model 1 in Table 1 multi-regression model depicts a significant association of decreased parent worry when parents have Oceanian (p<0.05) and European (p<0.1) ethnic backgrounds compared to Indian, Asian, and Middle-Eastern (reference level). Increased parents' worry is associated with lower neighbourhood perceived safety levels (p<0.05) compared to those reported feeling very safe (reference level) and among parents with a history of daily distress symptoms. From COVID-19-related stressors, parents' worry was positively associated with increased daily exposure to pandemic news "four hours and more daily" (p<0.05). Income changes increased parents' worry, particularly for those whose salary was reduced (p <0.05).

Table1 Hierarchical multilinear regressions of parents' COVID-19 and pre- COVID-19 worry

Variable

During COVID-19

Before COVID

Model 1

Model 2

Sociodemographic

Age (ref: 25-35)

35-44

45-54

55-65

-0.045 (0.702)

-0.084 (0.139)

-0.092 (0.178)

0.430 (0.761)

-0.218 (0.153)

-0.215(0.196)

Gender (ref: female)

Male

Ethnicity(ref: Asian, Indian, Middle Eastern )

European

Oceanian

Others

-0.000 (0.141)

-0.352 ^# (0.182)

-0.275 * (0.117)

-0.477^#(0.266)

-0.260^#(0.154)

0.154 (0.199)

0.011 (0.127)

0.044 (0.284)

Education (ref: High school or less

Vocational/technical

Undergraduate

Graduate

Household (ref: $3,499 or less)

$3,500 - $6,499 (3)

$6,500 or more (4)

-0.108 (0.220)

-0.016 (0.171)

0.048 (0.175)

0.125 (0.133)

-0.133 (0.145)

0.009 (0.242)

0.083 (0.213)

-0.039 (0.216)

0.0433 (0.144)

0.054 (0.156)

Life stressors (History)

Safety perception (ref: Very Safe (1))

Quite Safe

Quite Unsafe

Not at all safe

0.321* (0.126)

-0.220 (0.152)

-0.145 (0.231)

0.059 (0.254)

-0.055 (0.166)

0.052 (0.138)

History of parents' distress (ref: Not at all)

More than half the day

Several days

Nearly every day

0.118 (0.221)

-0.041 (0.139)

0.565* (0.258)

0.213 (0.238)

0.073 (0.151)

0.231 (0.278)

History of parents' worry (ref: Not at all)

More than half the day

Several days

Nearly every day

-0.088 (0.238)

0.062 (0.151)

-0.266 (0.296)

0.478* (0.242)

0.301# (0.158)

0.459 (0.320)

Parents' Exposure to Media news before the pandemic

(ref: Less than 30 mins a day 2)

Never

Less than an hour a day

1-3 hours a day

Four hours and more

-0.613** (0.224)

-0.020 (0.130)

0.347* (0.162)

0.347 (0.162)

COVID-19-related life stressors

Income change (ref: No, it is about the same, and normally go to work)

No, it is about the same, but work from home mainly

Job-keeper

Salary is reduced

Seeking employment

Exposure to COVID-19 infection (ref: No direct exposure)

Direct exposure (being infected or someone in the family being infected)."

"Having a close relationship with someone infected in the buildings or local area."

-0.232 (0.335)

-0.162 (0.219)

-0.799* (0.373)

0.415 (0.601)

-0.043 (0.189)

-0.029 (0.198)

Parents' Exposure to Media news during the pandemic

(ref: Less than 30 mins a day)

Never

Less than an hour a day

1-3 hours a day

Four hours and more

-0.227(0.472)

0.200(0.154)

0.232(0.153)

0.460*(0.192)

Constants

3.954*** (0.302)

3.103***(0.319)

[Ref] is Reference group; ^#p < 0.1, * p < 0.05; ** p < 0.01; *** p < 0.001. Note: Model 1 includes all variables in a single model, COVID-19 worry and sociodemographic, reported pre-pandemic stressors, habits of exposure to news, and COVID-19-related stressors. Model 2 includes socioeconomic, pre-pandemic stressors, and exposure to pre-pandemic news.

Parents' pre- COVID-19 worry

Model 2, Table 1 shows that parents' worry is modified by their demographic characteristics, particularly gender. Lower worry levels were among male parents (p<0.1) compared to female parents. Less worried parents were also among those who never followed the news (p<0.01). Increased worry was among parents who reported a history of worry symptoms (several days and every day of the week) (p<0.05) and had daily exposure to the news for 1- 3 hours (p<0.01).

Parents' COVID-19-related worry by ethnic background.

Table 2 depicts variables associated with parents' worry adjusted by ethnic background. Worry among parents from "Asian, Indian and Middle-Eastern" backgrounds were positively associated with those who had a history of higher frequency of distress (p < 0.05) or worry (p< 0.1) symptoms and those with high health risk due to COVID-19 (p < 0.1). Whereas increased worry among Oceanian's parents was associated with those who perceived lower neighbourhood safety (p <0.05) and reported excessive daily attention to pandemic news of one hour and over (p < 0.05 and p < 0.01).

Table 2: Multiple regression analysis Variables associated with parents' worry after controlling for ethnic background

Variable

Asian, Indian or Middle Eastern

Oceanian

Sociodemographic

Age (ref: 25-35)

35-44 (2)

45-54 (3)

55-65 (4)

-0.180 (0.222)

0.0238 (0.288)

0.073 (0.224)

0.304 (0.299)

0.669 (0.480)

Gender (ref: female)

Male

0.224(0.246)

0.0749 (0.215)

Education (ref: High school or less)

Vocational/technical

Undergraduate

Graduate degree

Household (ref: $3,499 or less)

3,500 - $6,499

$6,500 or more

0.492 (0.740)

-0.059 (0.560)

0.0761 (0.567)

-0.115 (0.211)

-0.172 (0.247)

-0.418 (0.299)

-0.179 (0.240)

-0.049 (0.245)

0.146 (0.219)

-0.200 (0.232)

Life stressors (History)

Safety perception (ref: Very Safe)

Quite Safe

Quite Unsafe

Not at all safe

-0.286 (0.210)

-0.310 (0.315)

0.030 (0.346)

-0.409* (0.236)

-0.254 (0.228)

-0.329 (0.371)

History of parents' distress (ref: Not at all)

More than half the day

Several days

Nearly every day

0.713* (0.346)

0.470* (0.231)

0.693 (0.497)

-0.210 (0.320)

-0.241 (0.222)

0.611 (0.380)

History of parents' worry (ref: Not at all)

More than half the day

Several days

Nearly every day

-0.242 (0.497)

-0.413 (0.250)

0.813^# (0.446)

0.077 (0.416)

0.425 (0.287)

0.312 (0.562)

COVID-19-related life stressors

Income change (ref: No, it is about the same, and normally go to work)

No, it is about the same, but work from home mainly

Job-keeper

No Job

Salary is reduced

Seeking employment

Exposure to COVID-19 infection (ref: No direct exposure)

Direct exposure (being infected or someone in the family being infected)"

"Having a close relationship with someone infected in the buildings or local area"

-0.417 (0.266)

-0.549 (0.404)

-0.146 (0.267)

-0.424 (0.377)

-0.687^# (0.360)

0.001 (0.370)

0.040 (0.199)

-0.010 (0.346)

0.346 (0.982)

-0.136 (0.215)

0.178 (0.354)

0.039 (0.335)

Parents' Exposure to Media news during the pandemic

(ref: Less than 30 mins a day)

Never (1)

Less than an hour a day (3)

1-3 hours a day (4)

Four hours and more (5)

-0.383 (0.676)

0.126 (0.265)

0.168 (0.272)

0.239 (0.311)

-0.272 (0.597)

0.305 (0.597)

0.663* (0.277)

1.014** (0.354)

Constants

4.229*** (0.676)

2.839***(0.764)

[Ref] is Reference group; ^#p < 0.1, * p < 0.05; ** p < 0.01; *** p < 0.001. Note:

The variance inflation factors (VIFs) in each independent variable was 2 or below, suggesting no redundancy or overlapping among variables (Chen et al., 2021). The Q-Q plot outcome and scatter plot matrix grid in Figure 2 confirm multilinear regression assumptions. Figure 1, Additional file 1 is used to visualise the pairwise potential correlation between study variables.

Variation over geography in variables contributes to parents' worry

Some of the variable's spatial behaviour outcomes of GWR of parents' worry in pre-to-during pandemic comparison are displayed in Figures 5 & 6. As recommended in public health studies, we portrayed four quantile categorisations of the coefficient [58]. Negative significance denotes that decreased explanatory variable level increases the response variable's impact. In pre-COVID19, the perceived neighbourhood safety coefficient, the bottom three maps of Figure5, shows marginal positive significance with homogeneous coefficient values ranging from 0.06 to 0.07. During COVID-19, in the top three maps of Figure 5, the perceived neighbourhood safety coefficient explicitly shows spatial variation behaviour and a significant impact on parents' worry, going from positive to negative (0.01 – - 0.003). The strong effects are primarily in the eastern states of NWS and VIC, but WA lacked significant power.

The coefficient of exposure to news variable, not displayed in the manuscript, depicted a significant positive effect of following news on parents' COVID-19 worry, with values ranging from 0.1 - 0.01. A strong positive impact in the eastern states of NSW, VIC, and QLD is depicted, which also lacked significance in WA.

COVID-19-related stressors of income changes, Figure 6, shows coefficient values ranging from positive to negative (0.06 - -0.1). The coefficient displayed variation in the impact of income change across states revealing a significant positive effect in VIC but significantly negative in NSW and non-significant in WA.

Variables' importance

Figure 7 displays the outcome of variables' importance in predicting parents' worry employing forest-based classification, and the input was variables found significant in the multi-regression and the GWR.

In Figure 7a, the most dominant variable to predict parents' COVID-19-related worry was the financial risk of parents' income changes. The perception of neighbourhood safety equally shared the lead with media exposure in predicting parents' pre- COVID-19 worry (Figure 7b). Remaining details are in Tables 4 and 5 in Additional File 1

Examining the locality relationship between worried parents and children (Q4), Table 6 , Additional file 1 shows a value of (0.21), which indicates the positional locality of children with increased worry is primarily found within distraught parents. Examining the relation before the pandemic, the value of 0.03 (closer to 0) denotes a lack of this association, Table 7, Additional File 1.

The study provided highly valuable insights into variables that contributed to parents' perceived worry during the pandemic and its variation across geography and time. The recent pandemic led to rising parents' worries and distress that may not have been restored to pre-pandemic levels. Furthermore, several key insight findings emerged from the current study analyses.

Variables contributing to parents' worry during abnormal health crises vary from those in everyday life. However, most notably is that ethnic background was significantly associated with parental worry during the pandemic but lacked predictive power before that time. Worried Asian, Indian, and Middle Eastern parents is explained by the history of worry, distress symptoms, and high health risk (direct exposure to the confirmed virus cases). This result is consistent with existing knowledge that ethnic minority populations will generally experience worse health outcomes than other groups during a pandemic [59]. A more prominent impact of the pandemic among black and brown communities is found in the US [10, 60, 61] and the UK [62, 63]. Health inequality is likely due to a lower chance of primary health care and Medicaid access. However, McCaffery et al. [64] suggested that Australian people with inadequate health literacy and language barriers may experience more difficulty understanding government messages about the virus. Thus, they are less likely to adopt social distancing measures. The same study also suggests a higher endorsement of misinformation related to the pandemic among people whose English is not their first language.

Exposure to stressors before COVID-19 may have helped parents develop coping strategies. Our finding of links between worry and history of distress symptoms agrees with preceding research in several parts of the world. Yet, our analysis depicted that only those who reported daily distress or worry before the outbreak were predictors of COVID-19 worried parents. In pre- COVID-19, mild to moderate symptoms of pre-existing distress were significant. Past studies suggest exposure to stressors over time may help individuals develop their competencies and coping skills that promote resilience during crises such as this pandemic [16, 65].

The increased exposure to the news during times of uncertainty and crises is found in earlier research [66]. Our study's findings on media news playing a role in parents' worries agree with previous studies on mass violence [14] and health crises like H1N1 [13]. It is also found in the recent pandemic in studies across the world [18, 37, 67]. Media news is a critical player in recent public health. However, while it is crucial to disseminate public health measures throughout the population, reliance on media news may (in)directly and inadvertently endanger public health in several ways, such as increasing people's anxiety.

Perception of neighbourhood safety contributing to parents' worry (Fig. 5) showed variation in the spatial behaviour of before-to-during the pandemic comparison. The coefficient is somewhat more homogeneous across all states before the pandemic, denoting a general marginal impact on parents' worry. However, during the pandemic, the coefficient in WA lacked significant power compared to the other two states of NSW and VIC. The negative significance values inside the city of VIC denote a low safety perception that contributed to increased parents' worry. This also matches the geographical distribution of high incident rates of COVID-19 cases reported at the same time as the survey carried out for this study. Whereas parents in WA had a lower level of pandemic cases may explain the lack of contribution of this variable to parents' worry. This may suggest that participants' responses to safety perceptions are likely influenced by their experienced COVID-19 worry in the two states.

The spatial behaviour of the income change variable will likely mirror the varying policy and individual state actions. COVID-19 has evoked a massive global unemployment crisis. Despite Australia's unemployment rate remaining among the lowest globally [68], it reached 7.5% in July 2020 (at the time of the survey), the highest since 1998. During the survey, about 1.6 million Australians were without jobs in July 2020. About 6.7% (around 871,600 people) lost their jobs between March and May 2020 [69]. The highest employment decrease between March and October 2020 was in eastern states, with − 4.1% in VIC and − 1.3% in NSW. This likely explains the spatial behaviour and the significant coefficient for income change (Fig. 6) in eastern states. The no change in the unemployment rate reported in QLD, with WA and SA being the lowest at -0.4% [69], may explain the lack of significance found in WA (Fig. 6). By May 2021, the government reported $291 billion in support of businesses impacted by the pandemic. After announcing the state of emergency, the government introduced Job Keeper (Job Saver in NSW), a wage subsidy to allow employees to remain employed during the pandemic. However, the exclusion of some businesses from being qualified for this scheme and the high mortality rates and the extended lockdown duration may have reduced the effect of these government support packages found in VIC. These temporary schemes were cut in late September 2021, with reports indicating a drastic impact on the finance of Australian families' households.

The variable importance and GWR analyses revealed essential findings about the spatial behaviour of variables contributing to parents' worry. Despite living in a health crisis, the amplified parents' worry was triggered by factors other than a health risk. Financial risk due to abrupt income changes after the pandemic was the leading variable contributing to parents' worry (Fig. 7a). Neighbourhood safety perception is a leading variable predicting parents' worry before the pandemic, aligning with preceding studies linking neighbourhood-perceived safety with mental health in adults [70] and parents [71].

During the pandemic, the positional link between worried parents and children affirms that the prevalence of worry among children is largely found among those cared for by distraught parents. This finding aligns with past works suggesting a parental role in shaping children's emotions [40, 72].

Parents' vulnerability is associated with the factors portrayed around the triangle. However, as Fig. 1 outlined, socioeconomics and other exposures unevenly impacted parents' worry. The effect, though, varies by geographical location and time. Neighbourhood safety and media exposure in everyday life, but the uncertainty in income and financial risk during the abnormal event of health crisis have contributed most to heightened parents' worries. Geography has modified the level of impact of each factor. Despite a very low percentage of the population being severely ill from the virus, living in areas with extended enforced measures of lockdown and social distancing had largely affected parents' well-being. The association of the locality of worried children among distraught parents affirms that children's mental well-being is linked to their parents, as Fig. 1 has outlined.

Study Limitation

There are limitations in this study that may restrict some of the substantive conclusions noted previously. Data collection occurred over two months but represented two points in time and thus didn't allow for causal inference. Also, the study used online self-reported questionnaires with retrospective parent reports before COVID-19. The survey may be subject to selection bias as participation requires respondents with internet access or who agreed to participate to be healthy and less likely to report stress and psychological distress. To minimise the potential recall bias, the survey was administered a few weeks after the outbreak of COVID-19. Yet some responses for pre-COVID-19 values were likely influenced by parents' COVID-19 stress or other unmeasured biased, as we suspect in the case of the perceived safety variable (Fig. 5). It is also worth noting that although the survey questionnaires used past research on health crises to develop questionnaires, they may not align with the objective assessment made by a health professional. This study also used items developed by the research team to assess factors influencing parents' worry. At the time of the study onset, measures of COVID-19-specific stressors on parents and intervention strategies did not exist, yet many are now available for future research. Despite every effort to represent the general Australian population, there is slight underrepresentation in some levels, such as parents' education variable. Undergraduate qualifications are about 10% lower than the ABS report for the general population. A larger sample size of parents and their children may have increased data skewing. Nevertheless, compared with other studies on population worries and recruited participants from the total population in the US [16], this study's sample size is well represented, considering this study recruited parents who care for children in one age group (9–11 years).

Policy And Research Implications

Despite the abovementioned limitations, current findings provide important research-based evidence that can inform future preparedness for policy and guide further research direction. Uncertainty around health risks and economic concerns led research to anticipate that significant mental health needs would emerge in public during this pandemic [73]. Yet this research depicts that some families are more prone to experience worry than others. Public policies need to pay more attention to parents targeting minority ethnic backgrounds and those with a history of distress or worry symptoms and provide awareness of the risks of excessive attention to pandemic news. Parenting-specific strategies and in-state actions, mitigating financial and health risks and providing community support to vulnerable parents may reduce unforeseen symptoms of parents' depression and increase parents' resilience. Also, increasing public health awareness to promote healthy ways of coping with increased worry and providing parents with specific information may improve families' well-being. Given the potential for an impending mental health crisis, it is critical to ensure parents have adequate access to mental health resources, including health services using the government Medicare fund. Besides urging the government to take measures for short- and long-term mental health, it is important to ensure that the public is well informed about necessary information and minimises fake news.

Identifying parents' characteristics at high risk may help reduce anxiety and stress and provide necessary resources to help mitigate this impact. The conceptual framework can be used in similar research or other contexts, including the prevalence of worry due to natural disasters such as floods and bushfires. Also, studies may examine the impact of variation in urban and rural settings on parents' association with determinants of worry and address worry among those who care for older children. There is a dire need for a coordinated effort between researchers and policy-makers to further research direction and generate parents' spatial vulnerability index that can help prioritise resources to reduce COVID-19 impact on parents and elevate family well-being.

The study has provided insights into the indirect adverse impact of the recent pandemic on parents' well-being. Factors deemed to modify parents' -who care for primary school-aged children (9–11 years)- resilience to worry and its variation during abnormal health crises compared to everyday life are examined. The efficacy of developing a framework may guide future research-based evidence in health crises or other contexts that adversely affects people's well-being. We uncovered inequality in the impact of COVID-19 beyond physical health and spatial heterogeneity in variables contributing to amplified parents' worry. A key finding is that a higher level of worry during health crises has been linked to factors other than physical health. The study depicted that parents' everyday worries are primarily predicted by neighbourhood safety. Whereas during the pandemic, financial risk was the prime factor. Excessive exposure to news remains a significant contributor to parents' worry before and during the pandemic. Yet, there is variation in the impact of the factors across geography. Such variation confirms that no one-size-fits-all model can identify vulnerable populations. Each country and state must identify target people at greater risk and take adequate steps to mitigate the impact of worry across the family structure. The outcome of this study can be used to advocate for policies that support parents' and families' well-being in current or future events. This may include access to appropriate mental health resources to mitigate the negative impact on those in need and limit exposure to unnecessary news. The conceptual framework can help in other contexts or be further modified for additional variables that can be paramount for informing policy-makers.

WHO World Health Organisation

COVID-19: Coronavirus disease 2019 SARS-COV-2

GIS Geographic Information Systems

GWR Geographic Weighted Regression

ABS Australian Bureau Statistics

NSW: New South Wales

VIC: Victoria

SA: South Australia

WA: Western Australia

QLD: Queensland

US: United States

UK: United Kingdome

VIFs: Variance Inflation Factors

No potential conflict of interest was reported by the author(s).

Ethical Approval and Consent to Participate. The authors assert that all procedures contributing to this work have been approved by university ethics committee led by Amy Bowater, Ethics Team Leader (HRE20180-0683). All methods were performed in accordance with the relevant guidelines and regulations and performed according to ethical standards. Informed written online consent was obtained from all individual participants included in the study.

Data Availability Statement. The data supporting the finding of this study are available from corresponding author upon reasonable request.

Consent of Publication. NA/Not Applicable.

Funding: The first author receives the Australian Government Research Training Program (RTP) scholarship; however, the research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Author Contributions. Primary author: literature search, the conceptualisation of the study, questionnaire construction, preparing and obtaining ethics approval, building the online survey, disseminating the survey link, data analysis, data interpretation, drafting and finalising the manuscript. Co-author1: Review and test the questionnaire after construction, giving feedback on the statistical analysis and proofreading. Co-author2 and co-author3 reviewed and provided feedback on the draft manuscript and approved the final version.

Acknowledgement. The authors are grateful to the people who participated in the test of initial questionnaire. Their feedback was invaluable in ensuring the workability and clarity of the survey. Thanks also go to all participants who voluntarily completed the survey.

The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementary materials.

*Notes: unless otherwise stated, all figures in the text were made by the authors.

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No competing interests reported.

Additionalfile1.docx

Inequality and heterogeneity of variables influencing parents' perceived worry before and during COVID-19 outbreak: evidence from a cross-sectional survey in Australia

Status:

Journal Publication

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Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Conceptualising parents worry during or before health crises

Method

Results

Discussion

Policy And Research Implications

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1