Health Impact of Caring for Elderly Disabled Spouse:
Multiple Mediation Model
Yimeng Zhou and Peiqi Xu
School of Literature, Law and Economics, Wuhan University of Science and Technology, China
Keywords: Spouse Caregivers of Disabled Elderly, Physical Health, Mediating Effect.
Abstract: This study aimed to examine the health impact of caring on caregivers who take care of old disabled spouse
in the context of aging population and increasing empty-nest families. With the data of China Health and
Retirement Longitudinal Study in 2015 and 2018, linear regression and logistic regression were used to
testify the relationship between care provision and physical health of the spouse carers, and a multiple
mediation model was employed to explore its formation mechanism. The results verified that caring for
elderly disabled spouses is negatively associated with the physical health of the caregivers, and life pattern
and mental health had significant mediating effects in this relationship. This article argued that appropriate
supports and health promotion plans for the spouse caregivers of disabled elderly were needed in
communities to improve their physical and mental health.
1 INTRODUCTION
Family is the first liable person who is responsible
for the care for the elderly, which is also the main
nursing resource in the face of challenges of aging.
While family caregivers make contributions to their
families and society, they suffer various pressures
caused by care provision, which has raised concern
of more and more scholars. Faced with burdensome
care tasks, heavy economic burdens and relatively
isolated living environments, many caregivers are
exhausted and exposed to the risk of declining
health. Studies have shown that caregivers are more
likely to self-report poorer health status than non-
caregivers. (Vitaliano, 2003; Chan, 2013; Berglund,
2015) Because caring requires a lot of physical
labor, it is easy to cause physical pain in caregivers
and affect their quality of life. (Hughes, 1999; Ho,
2009) In terms of objective physical indicators, the
stress response system, immune system and
cardiovascular system status of caregivers are also
inferior to those of non-caregivers. (Vitaliano, 2003;
Lovell, 2011; Känel, 2008) Accumulated high
intensity care stress also increases the probability of
visiting a doctor or taking medicine. (Vitaliano,
2003) In order to further explain the health effect of
care activity, Vitaliano constructed a theoretical
model of care stress and physical health based on
stress-coping theory and psychosomatic diseases
theory. It was believed that the burden of care
activities caused physical reactions by changing the
psychological distress and life pattern of the
caregivers, thereby affecting the rate of illness and
even mortality. (Vitaliano, 2003; Vitaliano, 2004)
In China, the tradition of raising children to
prevent aging is facing challenge with the changes
of family structure and family functions. Fewer
children, empty nests and the growing pressure of
work and life on adult children have weakened the
role of adult children in parental care and therefore
spouses play an increasingly important role in care
for disabled elderly. According to the data from
China Longitudinal Healthy Longevity Survey
(CLHLS), in the ten years from 2005 to 2014, the
proportion of disabled elderly who were taken care
of mainly by their spouses increased from 7.5% to
15.7%. However, research on health effects of care
provision in China still focuses on child caregivers.
Studies showed that married women who care for
their parents were more likely to report poorer
health outcomes in both urban and rural China. (GU,
2016; CHEN, 2016; SONG, 2021) However, the
authors hadn’t found studies examining the impact
of care activities on health of spouse carers using
nation-wide sample. In fact, the impact of care
provision on health of older spouse caregivers is
probably much greater than that of child caregivers,
Zhou, Y. and Xu, P.
Health Impact of Caring for Elderly Disabled Spouse: Multiple Mediation Model.
DOI: 10.5220/0012041200003620
In Proceedings of the 4th International Conference on Economic Management and Model Engineering (ICEMME 2022), pages 641-647
ISBN: 978-989-758-636-1
Copyright
c
2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)
641
mainly for two reasons: Firstly, spouse caregivers
tend to provide longer term care and the burden of
care is much heavier; secondly, spouses of the
elderly tend to be older and have fewer resources for
coping with stress, thus, their ability to alleviate the
negative impact of the care burden on health is
relatively weak. (Pinquart, 2003) A study completed
by Schulz and Beach in the last century has received
much attention, because they found that spouse
caregivers who reported care stress had a 63%
higher mortality rate than non-caregivers at four-
year follow-up. (Schulz, 1999)
In view of this, in China, where traditional
endowment culture and endowment pattern have
been impacted, it is necessary to pay attention to
spouse caregivers of elderly. It shows a concern for
the individual well-being of this group as well as
provides a dimension to evaluate the sustainability
of this significant caring resource. Therefore,
selecting the spouse caregivers of the disabled
elderly as the research object and using national
micro data, this study would explore the relationship
between care provision and health of caregivers and
analyze the possible generating mechanism of this
relationship.
2 DATA AND METHODS
2.1 Data and Sample
This paper used data provided by the China Health
and Retirement Longitudinal Study (CHARLS),
which adopted multiple stage sampling to ensure
unbiased and representative samples, with PPS
sampling method used at the level of county and
village and randomly selection method at the level
of household and individual. The sample covered
450 communities in 150 counties and 28 provinces
(autonomous regions and municipalities) across the
country. By 2015, the samples were consisted of
23,000 respondents in 12,400 households.
This study selected the sample from the 2015
survey data according to the following procedures:
First of all, the research compared caregiver and
non-caregiver in elderly families, so we selected
families with at least one person who is not less than
60 years old, and retained the individual sample in
these families; Secondly, the non-caregivers
mentioned in this paper do not include the care
recipients, so the care recipient samples in the
elderly family were excluded; Finally, the missing
values of the control variables were cleaned up.
Then 11,059 valid samples were retained, of which
1,635 were caregivers.
2.2 Variables
2.2.1 Explained Variable: Health
Health was measured by three indicators: self-rated
health, whether you have visited a doctor or taken
medicine due to illness in the past month and
whether your body is in pain. Self-reported health
was the respondent’s subjective evaluation of their
own physical health, including five options: “very
good”, “good”, “average”, “not good” and “very
bad”, which were coded from 1 to 5 respectively in
CHARLS data. For easily explaining and
understanding, the variable was coded in reverse
order in this study, so that the higher the score
meant the better health status. At the same time, this
paper selected the symptoms of whether the body
felt pain and the fact of whether he or she had
visited a doctor or taken medicine due to illness in
the past month to reflect the objective evaluation of
physical health status.
In addition to the health status of the respondents
in the current period, this study was also concerned
about the changes in the health status of the
respondents in the follow-up survey. In 2018
interview, respondents were asked that “compared
to the last visit, do you feel your health has
improved, about the same, or worse”. The case
responding “worse” was assigned the value of 1, the
one with “about the same” or “better” was assigned
the value of 0.
2.2.2 Main Explanatory Variable: Caring
for Disabled Spouses
Caring for disabled spouses includes two meanings:
first, the elderly in the family have physical
dysfunction; second, the spouse is the main
caregiver of the disabled spouse. In the CHARLS
questionnaire, the ADL and IADL scales were used
to collect the relevant information of the
respondents’ physical dysfunction, including six
basic activities and five instrumental activities of
daily life. All respondents who reported difficulty or
inability to complete one or more of them were
defined as physical dysfunction in this study. The
CHARLS questionnaire further asked, “Who help
you the most in the above difficulties?” The
respondents who answered “spouse” were
considered to be disabled elderly cared for by their
spouses. And their spouses were identified by their
ICEMME 2022 - The International Conference on Economic Management and Model Engineering
642
family ID, thereby forming a sample of spouse
caregivers caring for disabled elderly who were
assigned a value of 1 to the care-giving variable.
Excluding the disabled elderly being cared for, the
care-giving variable of all other samples was set to
be 0.
2.2.3 Mediating Variable: Life Pattern and
Mental Health
Life pattern was mainly considered in two aspects of
sleeping time and social activity participation in this
study. The CHARLS survey included an item:
“Have you done any of these activities in the last
month? Interacted with friends; Played chess,
Played cards or went to the community club;
Provided help to others who do not live with you or
did not pay you for help; Went to a sport, social or
other kinds of club; Took part in a community-
related organization; Done voluntary or charity
work; Attended an educational or training course;
Other.” The number of categories selected by
respondents was the value of social activities
variable.
This paper used the self-rating depression scale
to measure the mental health of respondents. The
CHARLS questionnaire employed 10 items of
depressive symptoms and asked respondents how
often these symptoms occurred in the last week. The
items of “little or no (<1 day)”, “not too much (1-2
days)”, “sometimes or some half of the time (3-4
days)”, “most of the time (5-7 days)” were
respectively marked as 0, 1, 2, 3 points in turn. 10
item scores were summed up as a depression
assessment score with two positive emotion items
scored in reverse. The higher the score represented
the greater the likelihood of depression.
2.2.4 Control Variables
According to health production model proposed by
Grossman (Grossman, 1972), this paper selected
control variables from four aspects: basic
demographic characteristics, health care services
and health habits and health foundation. In terms of
basic demographic characteristics, this study
controlled gender, age, education level and working
status. In terms of health care services, two
variables, whether they have medical insurance and
whether they have had routine physical
examinations in the past year, were controlled.
Explanatory variables for healthy habits included
smoking and drinking. Following the previous
literature (Chan, 2013; CHEN, 2016), this study
used the presence of chronic diseases to control the
health base of the sample.
2.3 Methods
First of all, this study established a general linear
model to analyze the relationship between care-
giving of disabled elderly and the self-assessed
health of spouse caregivers, and binary logistic
regression analysis was used to verify the
relationship between caring for disabled spouses and
the likelihood of sickness, bodily pain, and
worsened health in the next period of caregivers .
Then multiple mediator models was used to
further discuss the path of the impact of care
activities on physical health, and bootstrap method
was employed to test the mediating role of mental
health and life pattern, which were done by the
SPSS plug-in provided by Preacher and Hayes.
3 RESULTS
3.1 Descriptive Statistic and Health
Difference Between Caregivers and
Non-Caregivers
Generally speaking, descriptive statistic in table1
showed that the health condition of spouse
caregivers were worse than non-caregivers. From
the perspective of subjective indicator, caregivers
(M=2.95, SD=0.98) were apt to report poorer health
than non-caregivers (M=3.12, SD=0.95), which was
a significant difference testified by independent
sample T test (t (10483) =-6.697, p<0.001). The
proportion of caregivers who assessed their health
condition as "bad" and "very bad" was 5.6% (F
(1,10483) =18.978, P<0.001) and 2.3% (F (1,10483)
=29.193, p<0.001) higher than that of non-
caregivers respectively. Moreover, 59.5% of the
caregivers reported that their health got worsen, and
the proportion was significantly higher than that of
non-caregivers (F (1, 9573) =44.819, p<0.001). In
terms of objective indicator, compared with non-
caregivers, more caregivers saw a doctor or took
medicine for an illness in a month prior to the visit
(F (1, 11046) =28.256, p<0.001). And the rate of
caregivers who felt bodily pain was higher than that
of non-caregivers (F (1, 10482) =62.397, p<0.001).
Health Impact of Caring for Elderly Disabled Spouse: Multiple Mediation Model
643
Table 1: Descriptive statistics.
variables N
Caregivers (1)
N=1635
non-caregivers (2)
N=9424
difference
N
(
M
)
%
(
SD
)
N
(
M
)
%
(
SD
)
(
1
)
-
(
2
)
self-re
p
orted health 10485 2.95 0.98 3.12 0.95 -0.17
***
5-very good
157 9.9% 1034 11.6% -1.7%
*
4-
g
ood
152 9.6% 1174 13.2% -3.6%
***
3-average
824 51.9% 4855 54.6% -2.7%
2-not
g
ood
355 22.4% 1492 16.8% 5.6%
***
1-very bad
99 6.2% 343 3.9% 2.3%
***
sic
k
11048 1099 67.2% 5675 60.3% 6.9%
***
p
ain 10484 591 37.2% 2445 27.5% 9.7%
***
health worsen 9575 858 59.5% 4067 50.5% 9.0%
***
depression 9490 9.50 6.92 7.53 6.18 1.97
***
slee
p
in
g
time 11059 6.22 2.05 6.36 1.95 -0.14
**
social activities 11059 0.65 0.93 0.82 1.03 -0.17
***
male 11059 905 55.4% 4343 46.1% 7.4%
***
age 11059 66.72 8.02 64.87 9.66 1.85
***
education 11059
primary and below
1267 80.2% 6650 70.6% 9.6%
***
j
unio
r
249 13.5% 1739 18.5% -5.0%
**
high and above
119 6.3% 813 10.1% -3.8%
***
wor
k
11059 985 60.2% 5516 58.5% 1.4%
insurance 11059 1487 90.9% 8420 89.3% 1.6%
examination 11059 753 46.1% 4024 42.7% 3.4%
*
smoke 11059 854 52.2% 4039 42.9% 9.3%
***
drin
k
11059 464 28.4% 2355 25.0% 2.6%
**
chronic disease 11059 1297 79.3% 6841 72.6% 6.7%
***
Note:
***
p ≤ 0.001;
**
p ≤ 0.01;
*
p ≤ 0.05. Independent sample T test was used to verify the difference of self-reported health, depression,
sleeping time, types of social activity and age between caregivers and non-caregivers, and one-way ANOVA was for other variables.
3.2 Health Effect of Care-Giving Based
on Regression Results
Table2 presented the results of regression of health
variables when basic demographic variables, health
care service conditions, health habits and health
base of sample were controlled. Care-giving was a
significantly negative predictor for self-reported
health (β =−0.126, t = −5.095, p < 0.001). Compared
with non-caregivers, odds of sick, pain and
worsened health for caregivers respectively
increased by 25.4% (=e
0.226
-1), 51.8% (=e
0.417
-1),
39.0% (=e
0.059
-1).
Table 2: Regression results of health variables.
self-reported health sic
k
p
ain health worsen
care-giving -0.126
***
(0.025) 0.226
***
(0.059) 0.417
***
(0.060) 0.330
***
(0.059)
male 0.038
(
0.027
)
-0.217
**
(
0.063
)
-0.647
***
(
0.070
)
-0.143
*
(
0.064
)
age -0.001(0.001) 0.006
*
(0.002) 0.006
*
(0.003) 0.015
***
(0.003)
p
rimar
y
and below -0.203
***
(
0.030
)
-0.034
(
0.071
)
0.860
***
(
0.093
)
0.253
**
(
0.073
)
junior -0.113
**
(0.034) 0.060(0.08) 0.385
***
(0.105) 0.139(0.082)
wor
k
0.097
***
(
0.020
)
-0.118
*
(
0.047
)
0.051
(
0.050
)
0.077
(
0.047
)
insurance 0.022(0.029) 0.219
**
(0.067) -0.046(0.074) -0.116(0.071)
examination 0.014
(
0.018
)
0.262
***
(
0.042
)
-0.102
*
(
0.047
)
-0.114
**
(
0.043
)
smoke -0.019(0.026) 0.145
*
(0.060) 0.144
**
(0.067) 0.029(0.061)
drin
k
0.168
***
(
0.022
)
-0.105
*
(
0.052
)
-0.229
***
(
0.061
)
-0.066
(
0.053
)
chronic disease -0.644
***
(
0.020
)
1.217
***
(
0.046
)
1.233
***
(
0.063
)
0.529
***
(
0.048
)
constant 3.700
***
(0.081) -1.020
***
(0.185) -2.696
***
(0.221) -1.379
***
(0.192)
-2Lo
g
Likehoo
d
13765.339 11620.364 12985.136
R² 0.117
N 11485 11048 10484 9575
Note: Estimated coefficient and standard error were reported.
***
p
≤ 0.001;
**
p
≤ 0.01;
*
p
≤ 0.05.
ICEMME 2022 - The International Conference on Economic Management and Model Engineering
644
3.3 Mediating Effect of Lifestyle and
Mental Health Based on Multiple
Mediating Model
As the estimation results in Figure1 showed, when
controlling for basic demographic variables, health
care service conditions, health habits and health
base of sample, care provision had a negative
influence on spouse caregivers’ health (β =−0.132, t
= −5.083, p < 0.001), while care-giving was not
significantly related to self-reported health after
mediating variables of sleeping time, social
activities, depression were added in the model (β
=−0.042, t==-1.685, p>0.05). Thus, it was a
complete mediating model with significant total
mediating effect.
Note: N=9487, adjusted R²=0.212. ***p ≤ 0.001;**p ≤ 0.01;*p ≤ 0.05。
Figure 1: Regression results of each path of mediation model.
Among the mediators of life pattern, caregivers
had shorter sleeping time (β =−0.132, t==-2.329,
p<0.05) and less social activity types (β =−0.137, t =
−4.773, p < 0.001). Meanwhile, sleeping time (β
=0.021, t =4.528, p < 0.001) and social activity
types (β =0.036, t = 4.049, p < 0.01) were both
positively associated with self-reported health.
Bootstrapping test showed the mediating effects of
sleeping time and social activity participation were
both significant with the 95% confidence interval, as
showed in table3.
In term of mental health, caregivers got higher
score in depression test (β =1.739, t==10.087,
p<0.001) than non-caregivers, which represented
more severe depression symptoms and led to poorer
self-reported health (β =−0.048, t==-31.751,
p<0.001). Thus, depression was a significant
mediator between the relationship of care-giving
and health, which was verified by bootstrapping test
with 95% confidence interval.
Table 3: Mediating effect of life pattern and mental health and its bootstrapping test.
variables
estimated
coefficient
(standard error)
bootstrapping
p
ercentile 95% CI BC 95% CI BC a 95% CI
lower upper lower upper lower upper
sleeping time -0.0027 (0.0014) -0.0060 -0.0004 -0.0062 -0.0006 -0.0062 -0.0006
social activities -0.0049 (0.0016) -0.0081 -0.0022 -0.0083 -0.0023 -0.0083 -0.0023
depression -0.0831 (0.0093) -0.1018 -0.0659 -0.1022 -0.0659 -0.1022 -0.0659
total -0.0907 (0.0098) -0.1098 -0.0726 -0.1095 -0.0724 -0.1095 -0.0724
Note: BC, bias corrected; BC a, bias corrected and accelerated. 1000 bootstrap samples.
-0.132
***
(0.026)
care giving
self-reported health
-0.042
(0.025)
sleeping time
-0.132
*
(0.057)
0.021
***
(0.005)
-0.137
***
(
0.029
)
0.036
**
(
0.009
)
social activities
depression
1.739
***
(0.172)
-0.048
***
(0.002)
care giving
self-reported health
Health Impact of Caring for Elderly Disabled Spouse: Multiple Mediation Model
645
4 RESEARCH CONCLUSIONS
AND POLICY IMPLICATIONS
4.1 Conclusion
This paper used the data of China Health and
Retirement Longitudinal Study in 2015 and 2018 to
study the relationship between care provision and
health of spouse caregiver for disable elderly, and
demonstrated the impacting path. The results of
independent samples t test and one-way ANOVA
showed that there was a significant difference in the
health status between caregivers and non-caregivers,
and the spousal caregivers of the disabled elderly
were in a relatively disadvantaged state. Further
general linear regression and logistic regression
analysis showed that the spouse caregivers of the
disabled elderly were more likely to report poorer
health status than other elderly people without
physical dysfunction, and they were also more likely
to experience pain in the body and got medical help
due to illness in the past month. Using tracking data
in 2018, it was found that those who cared for
disabled spouses were also more likely to report
worse health status in the next period than that of
non-caregivers. The results of multiple mediation
model analysis supported the theoretical model of
care stress and physical health proposed by
Vitaliano. Mental health and life pattern had
significant mediating effects between caring for a
disabled spouse and the physical health of
caregivers. Spouse caregivers of the disabled elderly
had shorter sleeping time, less social activities and
higher scores in depression test, which all
significantly associated with lower levels of self-
rated health.
4.2 Policy Implications
This paper examined the impact of elderly care on
health of spouse caregivers in the context of aging,
empty nesting, and declining of traditional elderly
care culture in China. And it demonstrated a hidden
cost that caregivers beard while creating value for
their families and society. The health of caregivers
is not only a reflection of their own well-being, but
also an important resource for care provision. When
the health of caregivers is seriously overstretched,
family care may be in the risk of quality reduction
and even early termination. Therefore, appropriate
support from society and community is needed.
In western countries, as the focus of endowment
policies has shifted from institutions to
communities, the support policies for family
caregivers in developed countries have gradually
developed and improved, such as care allowances,
respite services, individual consultation, mutual aid
groups, work support, statutory caring vacation,
which provide salutary experience for us to learn
from, combining with China’s national condition.
By these supporting policies and services to ensure
necessary rest time as well as social interaction time
and to relieve psychological stress for caregivers of
the disabled elderly, care burden will be
appropriately reduced and family care will be better
and sustainable. In the process of policy
implementation, priority should be given to the
spouse caregivers of disabled elderly who are
having heavier caring tasks but fewer resources.
ACKNOWLEDGMENTS
Financed by National Social Science Foundation
“Support policy on family care for disabled elderly
from the perspective of spill-over need theory”
(Project ID: 21BRK027).
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