Does the provision of informal care matter for caregivers’ mental health? Evidence from China

Highlights

• There is no impact of informal care on caregivers’ mental health in general.

• Low-intensity care improves, while high-intensity care impairs mental health.

• Mental-health effect of informal care varies across different subgroups.

• Limitations in leisure activities and life satisfaction mediate these effects.

• The LTCI and formal care services modify the negative impact of care intensity.

Abstract

This paper investigates the causal effect of informal care on the mental health of caregivers and disentangles the mechanisms of such effect. Using 2011−2018 CHARLS data, the fixed effects and instrumental variable approaches was conducted to address fundamental endogeneity problems. This study found that there was no impact of informal caregiving on caregivers’ mental health in general. However, the intensity of caregiving was shown to negatively impair mental health. The impact of informal caregiving varied by kinship, cultural context, and residential area. Participation in social and exercise activities and life satisfaction mediated the association between the provision of informal care and caregivers’ mental health. Long-term care insurance and the provision of formal care substantially modified the negative impacts of informal caregiving.

Introduction

China is experiencing population aging on an unprecedented scale. At the end of 2021, the number of people aged 65 years and older reached more than 200.5 million and accounted for 14.2% of the total population in China.¹ This demographic change is expected to raise the demand for long-term care. China relies heavily on informal care to meet the care needs of the elderly.² Furthermore, in the context of the COVID-19 pandemic, older people have been advised to stay at home as much as possible with restricted access to formal care resources, raising concerns about the unmet needs for informal care and the increased burden of caregivers.^3,4 In China, approximately 65% of older people rely on their children for daily care, and 85% of disabled older adults received informal care.⁵ The estimated economic value of the provision of informal care to older individuals in China is over ¥420 billion per year.⁶ Yet, these cost savings to society may overshadow costs to informal caregivers’ health. Providing informal care is typically both physically and emotionally demanding, which likely put caregivers at increased risk for poor physical and mental health outcomes.^7,8 If informal caregivers suffer from health impairment due to their caregiving responsibilities, the overall utilization of health care services will inevitably increase. These hidden costs make informal care provision not as economic as often thought. Furthermore, changes in caregivers’ mental health can have numerous health and wellbeing consequences for care recipients.⁹ Understanding how informal care impacts their mental health remains an important policy issue.

It is widely known that caregiving provision is closely associated with the mental health. However, the pathways through which caregiving might affect mental health are manifold. The competing demands hypothesis proposes that caregivers may experience a decline in their mental health due to the physical and time demand involved with caregiving. Various studies suggest that providing informal care led to sleep inefficiency, decreased participation in outdoor activities and low life satisfaction,10, 11, 12, 13 which further impaired mental health.^9,14,15 Particularly, the negative effect tended to be greater for intensive and continued caregivers.^16,17 However, informal care can have positive mental health consequences due to emotional gains from taking social responsibilities and caring for loved ones, which is covered by “expansion hypothesis”. The empirical research provided evidence on that caregiving can be rewarding and make a positive contribution to caregiver's mental health in Finland, South Australia, Thailand and England.18, 19, 20 Informal caregiving has no significant impact on depression as informal care can be both a burden and a source of satisfaction simultaneously.¹³ In a summary, there is a lack of consensus because caregiving may have competing and expansion impacts on mental health through various channels of influence.

The relationship between informal care and mental health is further complicated by gender roles and different cultural norms across societies. For example, the negative impact was more pronounced among women in Europe,²¹ while informal care seems to be more detrimental to men in German.²² Also, the association is seemingly affected by kinship between caregivers and care recipients,^14,23 and cultural context as the motivation for care provision.^24,25 Yet, how these factors impact the association between informal caregiving and mental health is understudied due to a scarcity of sufficiently large samples.¹⁷

China provides a valuable test case of the impact of informal caregiving on adult children caregivers’ mental health. Adhering to the strong cultural tradition of filial piety, an essential part of Confucianism, caregiving for older parents is considered the adult children’s responsibility, obligation, and also a virtue. Caregivers feel needed and wanted from helping their older parents to derive positive mental health outcomes.²⁰ Also, favorable external evaluations from the community and society offer caregivers positive incentives (i.e., satisfaction and reward). However, such a function of informal care has been gradually weakened by the simplified family structure, fragmented residences, and labor force relocation arising from urbanization. These changes lead to time and strain conflicts for adult children caregivers when performing work and care roles, eventually adversely impairing their mental health. In response, China started to introduce the Long-term Care Insurance (LTCI) program in 2016 and invested in formal care to free caregivers from providing informal care and to reduce their care burdens as formal and informal care services are partial substitutes.²⁶ In this context, it is difficult to sign a priori for the effect of informal care on mental health. An in-depth analysis of how informal caregiving by adult children affect their mental health is necessary in order to provide evidence to support informal caregivers.

The majority of extant literature were carried out in higher-income countries, with a limited evidence from China, despite that informal care is the main source of care for older persons. The experience may not be generalizable to the Chinese case due to differences in social and cultural context, leaving it an open question as to how informal care impacts mental health of Chinese caregivers. To date, only a few, mostly cross-sectional studies, have addressed the potential endogeneous relationship between informal care provision and caregivers’ mental health, making it difficult to untangle the causal effect of informal caregiving. Also, these results fail to acknowledge differences by individual characteristics and social strata.¹⁴ Thus, it would be interesting to examine whether findings generated from advanced economies can be generalized to China where filial obligation remains a very tangible value in Chinese culture and bind adult children to accept their duty to provide care for their parents.

Therefore, based on nationally representative data from the 2011−2018 waves of China Health and Retirement Longitudinal Study (CHARLS), this study was to examine the causal impact of informal care on mental health among middle-aged and elderly persons in China. Specifically, several research hypotheses were proposed by this study:

(1) The effect of informal care on mental health depends on caregiving intensity. Higher levels of informal caregiving are likely to lead to erosions in mental health, while a lower caregiving intensity is likely to reduce the level of depression symptoms among middle-aged and older caregivers; (2) The mental-health effect of informal care provision is likely to vary by kinship, cultural context, and residential area; (3) Social activities and life satisfaction highlight possible mechanisms through which caregiving may influence the mental health of middle-aged and older caregivers; (4) The LTCI program and formal care services are likely to moderate the relationship between informal caregiving and mental health.