Mental Health Outcomes of Immigrant- and US-Born Caregivers: California Health Interview Survey, 2019–2020

Abstract

Objectives. To compare the mental health outcomes of US-born with immigrant caregivers of adult care recipients.

Methods. We conducted a cross-sectional secondary analysis of the 2019 California Health Interview Survey (CHIS), administered via web or telephone to 22 152 participants between September and December 2019. We characterized (1) caregivers and noncaregivers, and (2) US-born versus immigrant caregivers. Then, we estimated and compared (3) the relationship between caregiving status and severe psychological distress among US-born and immigrant respondents, and (4) correlates of severe psychological distress among US-born and immigrant respondents.

Results. Caregivers were more likely than noncaregivers to report severe psychological distress (P < .05). Immigrant caregivers residing separately from their care recipient were significantly more likely to experience severe psychological distress (odds ratio = 3.76; P < .01).

Conclusions. US-born and immigrant caregivers may experience different risk factors for psychological distress associated with caregiving. Clinical and community resources should be tailored to caregivers’ distinct needs with consideration of how access to resources (e.g., language), circumstances (e.g., acculturation), and cultural norms (e.g., filial piety) may be associated with exacerbation of psychological distress among immigrants. (Am J Public Health. 2024;114(S2):S189–S199. https://doi.org/10.2105/AJPH.2023.307396)

Nearly one third (28.4%) of US-born adults and 20.5% of immigrants are caregivers providing unpaid care to an adult (e.g., a spouse or partner, adult child, parent, friend, or neighbor) in a variety of tasks, such as daily activities, memory support, social support, and health care tasks.^1–3 Immigrant caregivers may, additionally, be responsible for language translation and helping their care recipient navigate social and cultural norms.⁴ Furthermore, racial and ethnic minority caregivers, including immigrants, are more likely to reside with their care recipient⁵ and have more physical health problems than White caregivers, which is exacerbated by having lower levels of social support.⁶ In particular, immigrants may face language barriers, discrimination, and other resource barriers to both formal and informal supports.⁷ Immigrants may leave behind members of their social support network or may relocate to the United States with their care recipients. As a result, they may uphold caregiving responsibilities independently or with very little social or formal support while also being the primary financial and social support for their older relatives (e.g., parents).^8,9

Caregiving responsibilities can be both physically and mentally demanding and challenging and are associated with adverse physical and mental health outcomes, including anxiety and depression.^10–12 Factors that may affect caregivers’ mental health include relationship dynamics with their care recipient, the care recipient’s health conditions and related needs, and the stage of the caregiving process.¹³ These challenges are compounded by caregivers’ limited opportunities or support for self-care or respite. In fact, immigrant caregivers from certain communities may be especially likely to neglect self-care because of cultural obligations and expectations regarding caregiving.^14–17

Interventions to support caregivers have tended to be “one-size-fits-all” approaches and are limited in their applicability to the social and cultural circumstances of minority caregivers; furthermore, they may not be accessible to immigrant caregivers in terms of language, alignment with customs and norms, or health beliefs.^4,18,19 These interventions, accordingly, also presume that the experiences and circumstances of caregivers are homogenous. However, immigrant caregivers, for instance, may identify with cultures that continue to be stigmatized and, subsequently, underdiagnosed with and undertreated for mental health conditions.²⁰

Support services for these caregivers are unlikely to be effective if they fail to consider the different contexts and circumstances of immigrants. To motivate and facilitate the development of tailored interventions, there is a need to first understand how mental health outcomes compare between immigrant and US-born caregivers of adult relatives. Accordingly, our purpose was to (1) characterize noncaregivers and caregivers and then further characterize caregivers according to immigration status, (2) evaluate the relationship between caregiving status and mental health outcomes for immigrant and US-born respondents, and (3) evaluate correlates of severe psychological distress among immigrant caregivers and US-born caregivers.

METHODS

We conducted a secondary data analysis of the publicly available 2019 California Health Interview Survey (CHIS) data set. The CHIS is the largest state health survey in the United States and provides critical data on the health and health care needs of the diverse population of California to policymakers, researchers, health experts, and the media.³ The CHIS is a biennial population-based survey that uses random-digit dial sampling of adults, adolescents, and children. The survey is conducted in several languages, including English, Spanish, Cantonese, Mandarin, Korean, Tagalog, and Vietnamese. The survey contains self-reported questions, and we applied weights to the sample data to compensate for the probability of selection bias and a variety of other factors to represent the noninstitutionalized population for each sampling stratum (i.e., caregivers vs noncaregivers and US-born vs immigrant respondent) and statewide. The overall sample is restricted to adults 18 years or older. The 2019 survey was administered between September and December 2019, and 22 152 participants completed the survey by web or telephone. The overall household response rate was 11.2%.²¹ We conducted the statistical analyses using Stata version 18 (StataCorp, College Station, TX).

Measures

Our main outcome measure was mental distress, which we assessed by the widely used Kessler K6 nonspecific distress scale to screen for severe mental distress, as defined by a K6 score of 13 or greater.²² We defined moderate mental distress as a K6 score of 5 or more and less than 13. We considered K6 scores of 4 or less as indicative of no mental health distress (i.e., clinically insignificant). This scale has been validated in diverse adult populations.^23–26

Our main predictor was caregiving status, which we determined by the response to the question assessing whether the individual provided short-term or long-term help to a family member or friend who had a serious chronic illness or disability: “During the past 12 months, did you provide short-term or long-term help to a family member or friend who has a serious chronic illness or disability? This may include things they cannot do for themselves.” Among respondents answering “yes” (= 1) to this question, we further restricted the sample to respondents caring for a person 18 years or older (n = 6023). We considered respondents answering “no” to this question noncaregivers for our analysis (n = 16 129). Among caregivers, we stratified the sample further to distinguish between US-born and immigrant caregivers based on their response to the question “In what country were you born?” Responses included the United States (i.e., US-born caregivers) or other countries (i.e., immigrant born).

Covariates

We also included information regarding participant age, self-reported gender, educational attainment, urban versus rural location, and self-reported health as covariates. We categorized age into 5 groups (18–29, 30–44, 45–59, 60–74, ≥ 75 years). We dichotomized self-reported gender as female (= 0) and male (= 1). We determined educational attainment by the response to the question “What is the highest grade of education you have completed and received credit for?” We categorized responses into 4 categories (high school or less; some college or associate’s, technical, or vocational degree; bachelor’s degree; and graduate or professional degree). We determined urban versus rural geographic designation by zip code using Claritas geographic data determination.²⁷ Self-reported health was a continuous measure, determined by the response to the survey question “Would you say that in general, your health is excellent, very good, good, fair, or poor?” (Excellent = 1 and poor = 5.) For immigrants, we included a categorical measure of the number of years living in the United States (< 5, 5–9, 10–14, or 15–19).

In addition, we evaluated several caregiving and care recipient characteristics, including the relationship between caregiver and care recipient (i.e., care recipient as the respondent’s spouse or partner, parent or parent-in-law, child or child-in-law, other relative, or friend, neighbor, or other nonrelative); a continuous variable describing hours spent caregiving per week; the care recipient’s age, categorized as 18 to 44 years, 45 to 64 years, 65 to 74 years, or 75 years or older; and the care recipient’s residence (i.e., living alone, living with the caregiver, or living elsewhere [e.g., in a facility or with another caregiver]). In addition, we categorized the care recipient’s health conditions, including chronic disease (e.g., cancer), musculoskeletal conditions, mental health or neurodegenerative conditions, aging or frailty, and acute and other conditions.

Analytic Plan

First, we applied population weights and summarized proportions of demographic and immigration characteristics for caregivers versus noncaregivers, as well as caregiving characteristics for both US-born and immigrant respondents who were caregivers in the previous 12 months. Then, we summarized the overall percentage of psychological distress outcomes, including severe, moderate, and clinically insignificant psychological distress, using population nonresponse weights. We calculated these for US-born and immigrant caregivers who provided care in the past 12 months.

Next, we employed hierarchical multivariate regression models for the full sample of US-born and immigrant participants to estimate the independent correlates of severe psychological distress (categorized as a binary variable of severe distress vs not severe distress) and to examine whether the addition of covariates improved the prediction of this mental health outcome among all participants in the sample. We ran 3 models: (1) to test the association between caregiver status and severe psychological distress; (2) to test demographic characteristics, including age, self-reported gender, and educational attainment; and (3) to test other predictors of mental health, including region (urban vs rural) and self-reported health status. For each multivariate regression, we applied population weights.

To further explore characteristics of caregiving experiences that may be associated with mental health, we estimated additional multivariate correlates of severe psychological distress, including caregiving relationship, caregiving hours, residential location (living with care recipient or not), and care recipient health condition. We conducted 2 logistic regression models, adjusting for age, gender, education, and self-reported health. The first model estimated severe psychological distress (compared with no or moderate distress) among US-born caregivers, and the second model estimated this among immigrant caregivers. We then compared the estimated odds of experiencing severe psychological distress between the 2 groups. For all models, we reported odds ratios (ORs) and 95% confidence intervals (CIs), with the P value based on 2-tailed t tests of significance.

RESULTS

Almost one quarter (23.6%) of respondents reported being a caregiver of someone 18 years or older in the previous 12 months, and 76.4% were noncaregivers. The majority of caregivers (72.6%) and noncaregivers (65.5%) were born in the United States, and a slightly larger proportion of immigrant caregivers (77.6%) had lived in the United States for at least 15 years than immigrant noncaregivers (72.2%). Noncaregivers were predominantly men (51.3%), whereas caregivers were predominantly women (58.9%). Caregivers and noncaregivers were significantly different across most characteristics (i.e., age, gender, race/ethnicity, education, and immigration status) but were not significantly different in terms of self-reported health status (P = .41) and, among immigrants, the number of years since immigrating (P = .36; Table 1).

TABLE 1—

Weighted Characteristics of Caregivers Versus Noncaregivers: 2019 California Health Interview Survey

Respondent Demographics	Caregivers Proportion	Noncaregivers Proportion	χ2 or t test; P
Age, y			158.90; < .001
18–25	12.7	16.2
26–34	13.9	17.3
35–49	23.2	25.0
50–64	29.7	22.2
≥ 65	20.5	19.3
Self-reported gender			165.12; < .001
Man	41.1	51.3
Woman	58.9	48.7
Race/ethnicity			89.64; < .001
Non-Hispanic White	44.2	37.9
Hispanic	32.4	37.3
Non-Hispanic Black	6.5	5.5
Non-Hispanic Asian	14.2	16.8
Other, American Indian/Alaska Native	2.8	2.5
Highest education attained			33.83; .05
High school or less	34.4	37.7
Some college or associate’s, technical, or vocational degree	25.4	22.0
Bachelor’s degree	23.4	24.1
Graduate or professional degree	16.8	16.2
Self-reported health status (1 = excellent; 5 = poor)	2.42 (0.99)	2.41 (1.01)	0.83; .41
Immigration status
US-born	72.6	65.5	91.01
Immigrant	27.4	34.5	< .001
No. years since immigrating			12.12; .36
< 5	5.9	8.4
5–9	7.3	9.0
10–14	9.3	10.3
≥ 15	77.6	72.2

Caregivers were predominantly born in the United States (72.6%), and 27.4% of caregivers were immigrants. Of immigrant caregivers, 77.6% had lived in the United States for 15 to 19 years. Most immigrant caregivers were in the 45 to 59 age group (41.0%), whereas the age distribution of US-born caregivers was relatively even (22.1% were 18–29 years; 22.7% were 30–44 years; 23.4% were 45–59 years; and 31.8% were 60 years or older). More than half of caregivers were women (US-born: 60.4%; immigrant: 55.1%). More than half of US-born caregivers identified as non-Hispanic White (56.0%), nearly half of immigrants (45.6%) identified as Hispanic, and more than one third (37.7%) identified as non-Hispanic Asian. Across both groups, most caregivers cared for a parent or parent-in-law (US-born: 40.9%; immigrant: 51.0%), and a slightly higher proportion of immigrant caregivers lived in the same residence as their care recipient (immigrant: 45.2%; US-born: 36.5%). Table 2 summarizes the demographic and caregiving characteristics of US-born and immigrant caregivers in our sample.

TABLE 2—

Weighted Descriptive Summary of US and Immigrant Caregivers of Adults in the Previous 12 Months: 2019 California Health Interview Survey

Demographics	Caregivers Aged ≥ 18 Years, % or Mean (SD)
	US	Immigrant Caregivers ≥ 18 y Proportion	χ2 or t statistic; P
Respondent demographics
Age, y			143.05; < .001
18–25	14.9	6.8
26–34	14.6	12.0
35–49	21.3	28.5
50–64	27.2	36.2
≥ 65	22.0	16.5
Self-reported gender			13.23; .11
Man	39.6	44.9
Woman	60.4	55.1
Race/Ethnicity			1544.18; < .001
Non-Hispanic White	56.0	12.9
Hispanic	27.4	45.6
Non-Hispanic Black	7.9	2.7
Non-Hispanic Asian	5.3	37.7
Other, American Indian/Alaska Native	3.4	1.1
Highest education			111.24; < .001
High school or less	30.6	44.4
Some college or associate’s, technical, or vocational degree	27.9	18.7
Bachelor’s degree	24.2	21.3
Graduate or professional degree	17.3	15.6
Self-reported health status (1 = excellent; 5 = poor)	2.40 (0.99)	2.53 (0.99)	−1.13; .26
Caregiving and care recipient characteristics
Relationship with care recipient			73.26; < .01
Spouse/partner	11.8	13.5
Parent/parent-in-law	40.9	51.0
Adult child/in-law	5.9	4.6
Other relative	24.1	15.8
Friend/neighbor/nonrelative	17.4	15.2
Hours spent caregiving per week	14.71 (21.88)	13.65 (19.64)	1.46; .15
Care recipient’s residence			54.24; < .01
Lives alone	20.1	12.6
Lives with caregiver	32.6	39.9
Lives elsewhere (e.g., facility, with someone else)	47.2	47.5
Care recipient’s health conditions			36.36; .22
None	7.6	11.0
Chronic disease (e.g., cancer)	13.0	14.8
Musculoskeletal	11.6	11.8
Mental health or neurodegenerative	13.0	12.8
Aging/frailty	35.4	35.1
Acute and other	19.5	14.5
Care recipient age, y			5.31; .79
18–44	14.2	12.4
45–64	22.1	21.3
65–84	39.4	42.1
≥ 85	24.2	24.2
Immigration characteristics
Years living in the US	N/A		N/A
< 5		5.9
5–9		7.3
10–14		9.3
15–19		77.6

Note. N/A = not applicable.

US-Born and Immigrant Respondents

Both US-born (OR = 1.43; 95% CI = 1.17, 1.74) and immigrant (OR = 1.58; 95% CI = 1.04, 2.38) respondents who indicated being a caregiver for someone 18 years or older in the previous 12 months were more likely to experience severe psychological distress than noncaregivers before adjusting for other respondent characteristics. This difference was significant for both US-born (P < .001) and immigrant (P < .05) respondents. After adjusting for respondent characteristics, the likelihood of experiencing severe psychological distress was amplified further for both groups (US-born: OR = 1.54; 95% CI = 1.23, 1.94; P < .001; immigrant born: OR = 1.83; 95% CI = 1.18, 2.83; P < .01). Men were less likely to experience severe psychological distress, and this difference was greater among immigrant respondents (OR = 0.52; 95% CI = 0.35, 0.79; P < .01) than US-born respondents (OR = 0.79; 95% CI = 0.64, 0.97; P < .05; Table 3; Table A, available as a supplement to the online version of this article at http://www.ajph.org).

TABLE 3—

Correlates of Severe Psychological Distress (vs Not Severe Distress) Among US-Born and Immigrant Caregivers Versus Noncaregivers: 2019 California Health Interview Survey

	Severe Psychological Distress, OR (95% CI)
	US-Born Respondents	Immigrant Respondents
Caregiving status
Noncaregivers (Ref)	1	1
Caregivers	1.54 (1.23, 1.94)	1.83 (1.18, 2.83)
Age, y	0.95 (0.94, 0.96)	0.95 (0.94, 0.97)
Race/ethnicity
Non-Hispanic White (Ref)	1	1
Hispanic	0.95 (0.74, 1.21)	0.45 (0.27, 0.76)
Non-Hispanic Black	0.93 (0.57, 1.55)	0.20 (0.02, 0.78)
Non-Hispanic Asian	0.67 (0.45, 1.01)	0.48 (0.29, 0.78)
Other, American Indian/Alaska Native	1.59 (0.93, 2.70)	0.11 (0.03, 0.37)
Gender
Woman (Ref)	1	1
Man	0.79 (0.64, 0.97)	0.52 (0.35, 0.79)
Education
High school or less (Ref)	1	1
Some college or associate’s, technical, or vocational degree	1.11 (0.84, 1.47)	1.17 (0.66, 2.07)
Bachelor’s degree	1.05 (0.79, 1.40)	1.00 (0.56, 1.78)
Graduate or professional degree	1.14 (0.82, 1.58)	0.92 (0.50, 1.69)
Geographic area
Rural (Ref)	1	1
Urban	1.36 (1.02, 1.79)	1.61 (0.83, 2.29)
Self-reported health	1.94 (1.73, 2.16)	1.87 (1.54, 2.29)
Years lived in the US	…	0.93 (0.80, 1.09)
Constant	0.17 (0.10, 0.28)	0.23 (0.06, 0.90)
Observations	17 448	4566
Pseudo R2	0.151	0.118

Note. CI = confidence interval; OR = odds ratio. For comparison of models, please refer to Table A (available as a supplement to the online version of this article at http://www.ajph.org).

US-Born Caregivers

US-born caregivers caring for a child or child-in-law (OR = 1.27; 95% CI = 0.56, 2.87) or a friend or other nonrelative (OR = 1.34; 95% CI = 0.63, 2.87) were more likely to report severe psychological distress than caregivers caring for a spouse or partner. US-born caregivers caring for a care recipient residing elsewhere (OR = 1.56; 95% CI = 1.01, 2.44; P < .05) were significantly more likely to experience severe psychological distress than respondents whose care recipient resided independently (Table 4).

TABLE 4—

Correlates of Severe (vs Not) Mental Distress Among Immigrant Caregivers: 2019 California Health Interview Survey

	US-Born Caregivers, OR (95% CI)	Immigrant Caregivers, OR (95% CI)
Caregiver relationship
Spouse/partner (Ref)	1	1
Parent/parent-in-law	0.93 (0.47, 1.83)	0.80 (0.25, 2.52)
Child/child-in-law	1.27 (0.56, 2.87)	0.63 (0.12, 3.22)
Other relative	0.76 (0.34, 1.71)	0.50 (0.13, 1.87)
Friend/neighbor/nonrelative	1.34 (0.63, 2.87)	0.81 (0.22, 2.93)
Hours spent caregiving	1.00 (0.99, 1.01)	1.01 (0.99, 1.02)
Care recipient residence
Lives independently (Ref)	1	1
Lives with caregiver	1.67 (0.96, 2.88)	1.33 (0.43, 4.17)
Lives elsewhere	1.56 (1.01, 2.44)	4.21 (1.59, 11.10)
Care recipient health condition
None (Ref)	1	1
Chronic condition	1.53 (0.66, 3.53)	0.53 (0.09, 3.12)
Musculoskeletal	1.63 (0.62, 4.29)	0.45 (0.11, 1.83)
Mental health or neurocognitive	1.67 (0.73, 3.80)	0.72 (0.18, 2.89)
Aging/frailty	2.02 (0.94, 4.36)	0.60 (0.18, 1.97)
Acute and other	2.40 (1.14, 5.05)	0.83 (0.19, 3.67)

Note. CI = confidence Interval; OR = odds ratio. Model is adjusted for age, gender, race/ethnicity, education, self-reported health status, and years in the United States (for immigrant sample).

Immigrant Caregivers

Among immigrant caregivers, after adjusting for demographic characteristics, caring for a parent or parent-in-law (OR = 0.80; 95% CI = 0.25, 2.52), a child or child-in-law (OR = 0.63; 95% CI = 0.12, 3.22), other relative (OR = 0.50; 95% CI = 0.13, 1.87), and nonrelative (OR = 0.81; 95% CI = 0.22, 2.93) were all associated with a lower likelihood of severe psychological distress than caring for a spouse or partner. Caring for a care recipient who resided elsewhere (i.e., neither with the caregiver nor by themselves) was associated with a significantly greater likelihood of experiencing severe psychological distress (OR = 4.21; 95% CI = 1.59, 11.10; P < .01). The association between more hours spent caregiving and severe psychological distress were similar for US-born (OR = 1.00; 95% CI = 0.99, 1.01) and immigrant (OR = 1.01; 95% CI = 0.99, 1.02; Table 4) caregivers.

DISCUSSION

We have reported findings from a secondary analysis of the CHIS. We evaluated psychological distress between US-born and immigrant caregivers and then compared severe psychological distress between (1) US-born caregivers and noncaregivers, (2) immigrant caregivers and noncaregivers, and (3) US-born and immigrant caregivers. We found that after adjusting for demographics and self-reported health, both US-born and immigrant caregivers were more likely to report severe psychological distress than noncaregivers. We also found that a greater proportion of US-born caregivers reported severe psychological distress than immigrant caregivers; however, in adjusted models, immigrant caregivers were significantly more likely to report severe psychological distress.

Although the relationship between caregiver and care recipient was not significantly associated with the likelihood of severe psychological distress for either US-born or immigrant caregivers, proximity to care recipient (i.e., where the care recipient resides) emerged as a key predictor of severe psychological distress among both US-born and immigrant caregivers. Among US-born caregivers, caring for a care recipient with an acute or other health condition emerged as another key predictor of severe psychological distress. This finding adds to the literature that associates caregiving for persons with dementia or other long-term chronic conditions with caregiving distress and suggests that acute or short-term health conditions can also initiate or exacerbate mental distress among caregivers.^28–30

The demands of caregiving are complex, and our finding that caregivers, in general, are more likely to report psychological distress is consistent with the literature that underscores the mental and emotional burden of caregiving.^10,12,31 Our study departs from previous studies that suggest that US-born individuals are more likely to experience psychological distress than immigrants in general; instead we found that immigrant caregivers are more likely to experience severe psychological distress than US-born caregivers.^32–36 Acculturation and navigating other social and cultural differences between country of origin and the United States (e.g., language), caregiver immigration status, and care recipient immigration status (e.g., whether undocumented) may exacerbate psychological distress among immigrant caregivers.^4,37–39 Differences in family structure, intergenerational conflict, and language and cultural differences can all contribute to mental distress among immigrants; in the context of caregiving, immigrants may be navigating these complexities both for themselves and for their care recipient.⁴⁰

It is somewhat surprising that the relationship between caregiver and care recipient did not have a significant association with psychological distress given other studies suggesting that caring for a spouse or partner or children is associated with greater self-reported stress than caring for parents, other family members, or nonrelatives.⁴¹ In our analysis, this pattern holds true for US-born caregivers, for whom caring for an adult child, compared with other relationships, was associated with a greater likelihood of psychological distress; however, for immigrant caregivers, caring for a parent or parent-in-law, adult child or child-in-law, or other relative or nonrelative were all associated with a lower likelihood of psychological distress than caring for a spouse or partner. Our findings also suggest that immigrant caregivers residing separately from their care recipient may experience greater distress. It is possible that some of these caregivers are long-distance caregivers (e.g., for relatives who are in their home country) and that this reflects an understudied group of caregivers who may not have access to resources or mechanisms for support.^42,43

Policies such as those related to bereavement or family leave may not apply to long-distance caregivers—or their availability to long-distance caregivers may be unclear—requiring further attention, given potential consequences to caregiver mental health. It is also possible that this circumstance applies to caregivers whose care recipient is residing in an institutional setting (e.g., long-term care). Given the lack of diversity in long-term care and barriers to accessing high-quality long-term care among immigrants (and especially those from racial/ethnic minority groups), it is critical to understand the mental health needs and challenges of caregivers whose care recipients are residing in institutional settings.^44,45

Recommendations for Future Research

Although beyond the scope of data available for the current analysis, future research could examine the specific circumstances in which immigrant caregivers are caring for their relatives and how those circumstances influence psychological distress. For example, studies could investigate whether immigrant caregivers are caring for relatives residing in another country or the extent to which differential access to family leave policies or health care services (e.g., because of health insurance status, linguistically or culturally tailored programs) influences mental health outcomes among these groups of caregivers. Future studies could also examine how different types of relationships are associated with psychological distress among caregivers and how the experience of caregiving for different types of relatives and nonrelatives may vary between US-born and immigrant caregivers. For example, family dynamics and cultural expectations of caregiving could perpetuate psychological distress as a caregiver anticipates their caregiving responsibilities; on the other hand, anticipating these responsibilities might lead caregivers to prepare themselves mentally.^{14,15,46–49} These recommendations could be especially helpful for tailoring resources for caregivers that consider their own position in their environment but also the context of their relationships and networks.

Recommendations for Policy and Practice

Supporting mental health and well-being among US-born caregivers and immigrant caregivers may require distinct and tailored approaches. For example, mental health services for immigrant caregivers should consider the impact of internalized stigma⁵⁰; language for diagnostics, treatment, and resources; and availability of mental health care professionals whose identities reflect the identities of immigrant caregivers being served. Current policies and programs for caregivers presume homogeneity in the cultural experiences of caregivers; these policies should include tailored resources and interventions to support immigrant caregivers. For instance, programs could employ community health workers to work with caregivers from the communities with which they identify, to disseminate mental health resources, and to serve as liaisons with the health care system and mental health services. Caregivers and their distinct circumstances should also be considered further in the health care delivery context. For instance, caregivers are often tasked with communicating with providers and navigating health and social services.^2,51

Immigrant caregivers may face challenges in upholding these responsibilities such as language barriers and navigating cultural norms and expectations. The health care system should continue to emphasize the training and hiring of diverse workers, including interpreters, social workers, community health workers, and other types of health and health care professionals who can assist immigrant caregivers in navigating the complex system with or on behalf of their care recipients. This is particularly important given that lack of information can be a primary contributor to caregiver distress.⁵²

Limitations

The results of our study should be interpreted in the context of some limitations. Our study relied on self-reported data, and it is unclear how the self-report nature of this study might yield different levels of bias between immigrant and US-born caregivers for our constructs of interest. We encourage future studies to further investigate subpopulations of immigrant and US-born caregivers and to use more refined approaches in assessing the mechanisms between caregiving and psychological distress across the intersectional identities of caregivers. This is reflected in our results, which suggests that caregiving, demographic, and health characteristics may not fully explain the variation in psychological distress, especially among immigrants; identifying other predictors of distress among immigrant caregivers requires further inquiry. Additionally, 2.7% of caregivers in our sample responded to the survey in a non-English language, including languages for which the K6 has not been validated.^25,53

We also used cross-sectional data in our investigation of caregiving, immigrant status, and psychological distress; consequently, causality among key study variables cannot be assumed. Our study was limited by the response rate (11.2%) and to survey items related to caregiving that were available in CHIS (e.g., there were no data on whether caregivers were paid). Therefore, generalizability of findings may be limited, and there may be salient caregiving experiences that were not evaluated, including duration of caregiving experiences. The survey may also be subject to underreporting of caregiving experiences, particularly among those who may not identify with the term “caregiver” despite upholding caregiving responsibilities.

Although our study was confined to the limits of the data, which did not support more sophisticated models that could resolve some potential biases and capture confounders, the relationships we found are still strong and worth exploring, especially as the extant literature is insufficient for understanding the unique experiences and mental health challenges of immigrant caregivers.

Conclusions

Addressing the mental health needs of caregivers remains a priority, but the efficacy of mental health resources and policies requires tailoring interventions to the specific needs and circumstances of caregivers. We found variation in the level of psychological distress that US-born and immigrant caregivers experience and in the way that different caregiving circumstances are associated with this psychological distress. Accordingly, supporting caregivers in an equitable manner requires ensuring that clinical and community mental health services are responsive to the distinct situations of caregivers and are informed by their experience of living in the United States.