Caregiving is a process by which one person attends to the needs or concerns of another person while the latter is experiencing dependency, either temporary or permanent, due to an illness, injury, or disability (Sherman, Reference Sherman2019). Given the complex and generally protracted nature of the caregiving role, individuals who provide care to others, either on a formal or informal basis, are often exposed to intense physical, psychological, and social distress. The caregiving role is associated with caregiver burden; a multidimensional bio-psycho-social reaction that results from an imbalance of care demands that are relative to caregivers’ personal time, social roles, physical and emotional states, and financial resources, and other role responsibilities. Further, caregiver burden is not static, as caregivers experience transitions, such as changes to their health, roles, and responsibilities, during the process of caring.
With increasing lifespans, population aging, and increasing prevalence of dementia, it is expected that the already considerable need for caregiving, both formal and informal, will increase over time (Nguyen et al., Reference Nguyen, Hoang, Zhou, Harvey, Dam and Meyer2022). Correspondingly, it is expected that caregiver distress and therefore the need for biopsychosocial interventions addressing caregiver welfare will also increase over time. This necessitates a better understanding of sociocultural factors and how they contextualize the experiences of caregiving over time and space.
The caregiving experience often includes acculturation, as caregivers adapt to cope with migration that occurred either before or during the caregiving process. This exposes caregivers to acculturation stress, which can be conceptualized as the psychological strain individuals experience as they transition from one culture to another (Ren and Jiang, Reference Ren and Jiang2021). Cultural incongruity, that is the individuals’ own perception that they do not fit in with the culture around them, is linked to their experience of acculturation stress, the overall sense of the stress related to the process of assimilation. Acculturation stress has been demonstrated to be associated with health decline over time, which is linked to socioeconomic deprivation, aspiration attenuation, income instability, and discrimination.
Understanding the epidemiology of acculturation stress requires an appreciation of the scale of modern migration. While the vast majority of people continue to live in the countries in which they were born, the estimated number of international migrants has increased over the past five decades (World Migration Report, 2022). For context, the World Migration Report, 2022 estimated that there were around 281 million international migrants in the world in 2020, which equates to 3.6 per cent of the global population. However, the great majority of people do not migrate across borders; much larger numbers migrate within countries.
The overwhelming majority of people migrate internationally for reasons related to work, family, and study— involving migration processes that largely occur without fundamentally challenging either migrants or the countries they enter (World Migration Report, 2022). As migration occurs, it is expected that most people would carry their caregiving role and caregiving burden with them. Thus, these two large-scale sociocultural phenomena— dependency/caregiving and migration/acculturation—can be expected to substantially impact societal health and well-being over time.
Nguyen et al., in their paper “Associations Between Caregiving Status, Acculturation, and Psychological Distress in a Diverse Sample” have explored the impact of caregiving and acculturation experiences on psychological distress among Latina/o/x (LX) and Asian American and Pacific Islanders (AAPI) (Nguyen et al., Reference Nguyen, Hoang, Zhou, Harvey, Dam and Meyer2022). The respondents formed part of a population-based sample that was a subset of the 2009 California Health Interview Survey (CHIS).
The study compared psychological distress among first-, second-, and third-generation LX and AAPI respondents who were categorized as caregivers or non-caregivers. Acculturation stress was measured using acculturation proxy models—generational status, language of interview, and English language proficiency. The authors hypothesized that higher levels of acculturation would be associated with greater levels of psychological distress and that the caregiving experience would further accentuate this psychological distress.
Rather than considering higher levels of acculturation as indicative of better cultural assimilation, the authors examined acculturation as a vulnerability factor contributing to psychological distress (Nguyen et al., Reference Nguyen, Hoang, Zhou, Harvey, Dam and Meyer2022). With these hypotheses, the authors approached the assumption of Finch et al., that higher levels of acculturation may serve as proxies for higher levels of exposure to the host society. Higher levels of exposure were postulated to carry with them higher levels of social stress, discrimination and exposure to health problems.
This secondary analysis, by Nguyen et al., of data obtained from LX and AAPI respondents as during the 2009 CHIS yielded mixed, and somewhat unexpected, conclusions. Among the first and second generation of respondents, caregivers demonstrated higher levels of psychological distress when compared to non-caregivers. However, among the third generation of respondents, caregivers reported lower levels of psychological distress when compared to non-caregivers.
Further, among caregivers, levels of psychological distress rose from the first to the second generation and then fell from the second to the third generation. Among non-caregivers, however, the trend was more straightforward, with levels of psychological distress rising steadily from the first to second and second to third generation.
Thus, as the authors predicted, there was a tendency for psychological distress to be higher in caregivers than non-caregivers and for psychological distress to rise over consecutive generations. This may be attributed to the effect of caregiver burden and acculturation stress, respectively, upon the mental health and well-being of CHIS respondents. However, third-generation caregivers demonstrate lower levels of psychological distress than expected. The authors have suggested that the healthy immigrant effect associated with self-selection and the salmon bias, may explain this discrepancy. However, it could also indicate the presence of resilience and adaptive coping strategies built up over time with successful acculturation and a salutary experience of the caregiving role (Palacio et al., Reference Palacio, Krikorian, Gómez-Romero, M. and Limonero2020).
With regard to language of interview, caregivers who were interviewed in a language other than English demonstrated higher levels of psychological distress than caregivers who were interviewed in English. However, non-caregivers interviewed in a language other than English demonstrated lower levels of psychological distress than non-caregivers who were interviewed in English.
Similarly, with regard to language proficiency, caregivers with low English proficiency demonstrated higher levels of psychological distress than caregivers with high English proficiency. Again, counterintuitively, non-caregivers low English proficiency demonstrated lower levels of psychological distress than non-caregivers with high English proficiency.
Thus, when language of interview and English proficiency are used as acculturation proxy models; higher levels of acculturation appear to mitigate psychological distress in caregivers and accentuate psychological distress in non-caregivers. As with generation status, the impact of acculturation stress appears far more straightforward among non-caregivers. However, acculturation stress appears to interact with caregiver burden in a manner which suggests the development of resilience and adaptive coping strategies among caregivers (Palacio et al., Reference Palacio, Krikorian, Gómez-Romero, M. and Limonero2020).
Understanding the sociocultural context of caregivers is fundamental to addressing caregiver burden and reducing the direct and indirect costs associated with caregiving. A systematic review from NICE Guideline, by Pelone et al., previously published in International Psychogeriatrics, evaluated the cost-effectiveness of interventions intended to support adult caregivers and address caregiver burden (Pelone et al., Reference Pelone, Jacklin, Francis and Purchase2022). The authors found that interventions were more likely to be cost effective when they were tailored to the specific circumstances of caregivers. The authors also recommended the development and implantation of programs to provide caregivers with support and advice to help with entering into, remaining in or returning to paid work.
Targeted interventions of this nature would have to take into account the ethnic identity, migration status, socioeconomic status, and language proficiency of caregivers in order to be truly effective. This would be important not just to deliver psychosocial support and training but also to help caregivers maintain find and maintain employment in order meet the economic cost of caregiving (Pelone et al., Reference Pelone, Jacklin, Francis and Purchase2022).
The consequences of failing to address the health and well-being of caregivers can be enormous. A recent longitudinal study, by Zwar et al., also published in International Psychogeriatrics analyzed data from the Survey of Health, Ageing, and Retirement in Europe to demonstrate that a transition to caregiving within the household was significantly associated with increased odds of suicidal ideation by 36% (Zwar et al., Reference Zwar, König and Hajek2023). Further, care-specific aspects such as the location of caregiving, age and gender of caregivers, relationship to the care recipient, and model of welfare system were found to significantly affect suicidal ideation among caregivers.
In this context, it can be anticipated that acculturation stress and language proficiency would contribute to caregiver burden and mediate access to welfare systems (Zwar et al., Reference Zwar, König and Hajek2023). Migration status and acculturation stress may also be significantly associated with suicidal ideation, though as with the CHIS study, there might be scope for mitigation by the development of resilience and adaptive coping strategies (Palacio et al., Reference Palacio, Krikorian, Gómez-Romero, M. and Limonero2020).
Nguyen et al., acknowledged the possibility of considerable within-group heterogeneity within the CHIS study and that ethnic populations may vary considerably in their perception of and response to the caregiver role (Nguyen et al., Reference Nguyen, Hoang, Zhou, Harvey, Dam and Meyer2022). The examination of sociocultural heterogeneity among caregivers and their interaction with both acculturation stress and the caregiving experience is an important potential area for further investigation. It is conceivable that economic indicators of caregiver well-being may mediate several of the relationships between sociocultural factors, migration, acculturation, caregiving, and mental health within the community (Pelone et al., Reference Pelone, Jacklin, Francis and Purchase2022).
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Caregiving is a process by which one person attends to the needs or concerns of another person while the latter is experiencing dependency, either temporary or permanent, due to an illness, injury, or disability (Sherman, Reference Sherman2019). Given the complex and generally protracted nature of the caregiving role, individuals who provide care to others, either on a formal or informal basis, are often exposed to intense physical, psychological, and social distress. The caregiving role is associated with caregiver burden; a multidimensional bio-psycho-social reaction that results from an imbalance of care demands that are relative to caregivers’ personal time, social roles, physical and emotional states, and financial resources, and other role responsibilities. Further, caregiver burden is not static, as caregivers experience transitions, such as changes to their health, roles, and responsibilities, during the process of caring.
With increasing lifespans, population aging, and increasing prevalence of dementia, it is expected that the already considerable need for caregiving, both formal and informal, will increase over time (Nguyen et al., Reference Nguyen, Hoang, Zhou, Harvey, Dam and Meyer2022). Correspondingly, it is expected that caregiver distress and therefore the need for biopsychosocial interventions addressing caregiver welfare will also increase over time. This necessitates a better understanding of sociocultural factors and how they contextualize the experiences of caregiving over time and space.
The caregiving experience often includes acculturation, as caregivers adapt to cope with migration that occurred either before or during the caregiving process. This exposes caregivers to acculturation stress, which can be conceptualized as the psychological strain individuals experience as they transition from one culture to another (Ren and Jiang, Reference Ren and Jiang2021). Cultural incongruity, that is the individuals’ own perception that they do not fit in with the culture around them, is linked to their experience of acculturation stress, the overall sense of the stress related to the process of assimilation. Acculturation stress has been demonstrated to be associated with health decline over time, which is linked to socioeconomic deprivation, aspiration attenuation, income instability, and discrimination.
Understanding the epidemiology of acculturation stress requires an appreciation of the scale of modern migration. While the vast majority of people continue to live in the countries in which they were born, the estimated number of international migrants has increased over the past five decades (World Migration Report, 2022). For context, the World Migration Report, 2022 estimated that there were around 281 million international migrants in the world in 2020, which equates to 3.6 per cent of the global population. However, the great majority of people do not migrate across borders; much larger numbers migrate within countries.
The overwhelming majority of people migrate internationally for reasons related to work, family, and study— involving migration processes that largely occur without fundamentally challenging either migrants or the countries they enter (World Migration Report, 2022). As migration occurs, it is expected that most people would carry their caregiving role and caregiving burden with them. Thus, these two large-scale sociocultural phenomena— dependency/caregiving and migration/acculturation—can be expected to substantially impact societal health and well-being over time.
Nguyen et al., in their paper “Associations Between Caregiving Status, Acculturation, and Psychological Distress in a Diverse Sample” have explored the impact of caregiving and acculturation experiences on psychological distress among Latina/o/x (LX) and Asian American and Pacific Islanders (AAPI) (Nguyen et al., Reference Nguyen, Hoang, Zhou, Harvey, Dam and Meyer2022). The respondents formed part of a population-based sample that was a subset of the 2009 California Health Interview Survey (CHIS).
The study compared psychological distress among first-, second-, and third-generation LX and AAPI respondents who were categorized as caregivers or non-caregivers. Acculturation stress was measured using acculturation proxy models—generational status, language of interview, and English language proficiency. The authors hypothesized that higher levels of acculturation would be associated with greater levels of psychological distress and that the caregiving experience would further accentuate this psychological distress.
Rather than considering higher levels of acculturation as indicative of better cultural assimilation, the authors examined acculturation as a vulnerability factor contributing to psychological distress (Nguyen et al., Reference Nguyen, Hoang, Zhou, Harvey, Dam and Meyer2022). With these hypotheses, the authors approached the assumption of Finch et al., that higher levels of acculturation may serve as proxies for higher levels of exposure to the host society. Higher levels of exposure were postulated to carry with them higher levels of social stress, discrimination and exposure to health problems.
This secondary analysis, by Nguyen et al., of data obtained from LX and AAPI respondents as during the 2009 CHIS yielded mixed, and somewhat unexpected, conclusions. Among the first and second generation of respondents, caregivers demonstrated higher levels of psychological distress when compared to non-caregivers. However, among the third generation of respondents, caregivers reported lower levels of psychological distress when compared to non-caregivers.
Further, among caregivers, levels of psychological distress rose from the first to the second generation and then fell from the second to the third generation. Among non-caregivers, however, the trend was more straightforward, with levels of psychological distress rising steadily from the first to second and second to third generation.
Thus, as the authors predicted, there was a tendency for psychological distress to be higher in caregivers than non-caregivers and for psychological distress to rise over consecutive generations. This may be attributed to the effect of caregiver burden and acculturation stress, respectively, upon the mental health and well-being of CHIS respondents. However, third-generation caregivers demonstrate lower levels of psychological distress than expected. The authors have suggested that the healthy immigrant effect associated with self-selection and the salmon bias, may explain this discrepancy. However, it could also indicate the presence of resilience and adaptive coping strategies built up over time with successful acculturation and a salutary experience of the caregiving role (Palacio et al., Reference Palacio, Krikorian, Gómez-Romero, M. and Limonero2020).
With regard to language of interview, caregivers who were interviewed in a language other than English demonstrated higher levels of psychological distress than caregivers who were interviewed in English. However, non-caregivers interviewed in a language other than English demonstrated lower levels of psychological distress than non-caregivers who were interviewed in English.
Similarly, with regard to language proficiency, caregivers with low English proficiency demonstrated higher levels of psychological distress than caregivers with high English proficiency. Again, counterintuitively, non-caregivers low English proficiency demonstrated lower levels of psychological distress than non-caregivers with high English proficiency.
Thus, when language of interview and English proficiency are used as acculturation proxy models; higher levels of acculturation appear to mitigate psychological distress in caregivers and accentuate psychological distress in non-caregivers. As with generation status, the impact of acculturation stress appears far more straightforward among non-caregivers. However, acculturation stress appears to interact with caregiver burden in a manner which suggests the development of resilience and adaptive coping strategies among caregivers (Palacio et al., Reference Palacio, Krikorian, Gómez-Romero, M. and Limonero2020).
Understanding the sociocultural context of caregivers is fundamental to addressing caregiver burden and reducing the direct and indirect costs associated with caregiving. A systematic review from NICE Guideline, by Pelone et al., previously published in International Psychogeriatrics, evaluated the cost-effectiveness of interventions intended to support adult caregivers and address caregiver burden (Pelone et al., Reference Pelone, Jacklin, Francis and Purchase2022). The authors found that interventions were more likely to be cost effective when they were tailored to the specific circumstances of caregivers. The authors also recommended the development and implantation of programs to provide caregivers with support and advice to help with entering into, remaining in or returning to paid work.
Targeted interventions of this nature would have to take into account the ethnic identity, migration status, socioeconomic status, and language proficiency of caregivers in order to be truly effective. This would be important not just to deliver psychosocial support and training but also to help caregivers maintain find and maintain employment in order meet the economic cost of caregiving (Pelone et al., Reference Pelone, Jacklin, Francis and Purchase2022).
The consequences of failing to address the health and well-being of caregivers can be enormous. A recent longitudinal study, by Zwar et al., also published in International Psychogeriatrics analyzed data from the Survey of Health, Ageing, and Retirement in Europe to demonstrate that a transition to caregiving within the household was significantly associated with increased odds of suicidal ideation by 36% (Zwar et al., Reference Zwar, König and Hajek2023). Further, care-specific aspects such as the location of caregiving, age and gender of caregivers, relationship to the care recipient, and model of welfare system were found to significantly affect suicidal ideation among caregivers.
In this context, it can be anticipated that acculturation stress and language proficiency would contribute to caregiver burden and mediate access to welfare systems (Zwar et al., Reference Zwar, König and Hajek2023). Migration status and acculturation stress may also be significantly associated with suicidal ideation, though as with the CHIS study, there might be scope for mitigation by the development of resilience and adaptive coping strategies (Palacio et al., Reference Palacio, Krikorian, Gómez-Romero, M. and Limonero2020).
Nguyen et al., acknowledged the possibility of considerable within-group heterogeneity within the CHIS study and that ethnic populations may vary considerably in their perception of and response to the caregiver role (Nguyen et al., Reference Nguyen, Hoang, Zhou, Harvey, Dam and Meyer2022). The examination of sociocultural heterogeneity among caregivers and their interaction with both acculturation stress and the caregiving experience is an important potential area for further investigation. It is conceivable that economic indicators of caregiver well-being may mediate several of the relationships between sociocultural factors, migration, acculturation, caregiving, and mental health within the community (Pelone et al., Reference Pelone, Jacklin, Francis and Purchase2022).
Conflict of interest
None.
Description of author’s role
The author, Migita M. D’cruz, is the sole contributor to this manuscript.
Acknowledgements
None.