Abstract
Objectives:
Older adults providing unpaid care to a relative or friend during the COVID-19 pandemic may have diminished self-efficacy in managing their own chronic illness, especially in the context of more complex self-management. We evaluated whether adults aged 50 and older with caregiving roles are more likely to report reduced illness self-efficacy since the pandemic, and whether this link is exacerbated by a higher number of conditions.
Methods:
Participants (105 caregivers and 590 noncaregivers) residing in Michigan (82.6%) and 33 other U.S. states completed one online survey between May 14 and July 9, 2020.
Results:
Controlling for sociodemographic and health characteristics, stressors related to COVID-19, and behavioral and psychosocial changes since the pandemic, caregivers were more likely than noncaregivers to report reduced illness self-efficacy when they had a higher number of chronic conditions.
Conclusion:
These findings highlight the importance of maintaining caregivers’ self-care during the COVID-19 pandemic and in future public health crises.
Keywords: caregiving, chronic disease, chronic illness, coronavirus
Introduction
The COVID-19 pandemic has had a substantial and ongoing public health impact in the United States. In particular, older adults with chronic conditions are at heightened risk for severe illness and mortality from the coronavirus (Van Orden et al., 2020). Many of these individuals also serve as unpaid caregivers to other people with mental and/or physical health conditions (Liu & Lou, 2019; Polenick et al., 2020). Caregivers often report compromised health and well-being relative to noncaregivers (Bom et al., 2019, and this might be amplified by the pandemic (Cohen et al., 2020; Greenberg et al., 2020; Lightfoot & Moone, 2020; Park, 2021). Notably, older adults with caregiving responsibilities may feel less able to effectively manage and care for their own health. Given the additional challenges of providing unpaid care, it is important to consider how caregivers differ from noncaregivers in their perceptions of illness self-efficacy (i.e., beliefs in one’s own capacity to engage in behaviors necessary to manage chronic conditions) during the COVID-19 pandemic. In this study, we evaluated the association between caregiver status and perceptions of reduced illness self-efficacy in a U.S. sample of adults aged 50 and older with chronic conditions. We also considered whether this association is intensified for individuals with a higher number of chronic conditions.
Self-efficacy in managing chronic illness is a key factor in shaping health outcomes (Lorig et al., 2001; Wilson et al., 2019). For example, illness self-efficacy has been associated with medication adherence (Gonzalez et al., 2015; Shiyanbola et al., 2018), engagement in self-care behaviors (e.g., exercise) related to illness management (ALAboudi et al., 2016; Zhang et al., 2015), health-related quality of life (Selzler et al., 2020), and biological indicators including glycemic control (ALAboudi et al., 2016; Gonzalez et al., 2015). Illness self-efficacy has also been found to mediate the association between illness severity and depression (Greco et al., 2014). The COVID-19 pandemic poses barriers to illness management that may erode illness self-efficacy. Indeed, social distancing recommendations have made it more difficult to access health care (NORC, 2020) and have had a negative impact on self-care behaviors (e.g., physical activity, diet, sleep) that are crucial to managing chronic conditions (Beck et al., 2021; Phillipou et al., 2020; Son et al., 2020).
Caregivers may be more likely than noncaregivers to report reduced illness self-efficacy during the COVID-19 pandemic. Stress process models posit that caregiving can be stressful and may interfere with activities that are unrelated to care provision, including the management of one’s own health and well-being (Aneshensel et al., 1995). Providing care diverts time and resources from illness self-management (Jowsey et al., 2013; Tommis et al., 2009). Caregivers also commonly experience emotional distress and some degree of physical exertion related to caregiving (e.g., lifting care recipients) that might exacerbate their chronic conditions or related symptoms such as pain (Liu & Lou, 2019; Pinquart & Sörensen, 2007; Tommis et al., 2009). Further, care-related stress may contribute to cognitive problems that hinder one’s capacity to manage everyday tasks (Vitaliano et al., 2011) and self-monitor (Vitaliano et al., 2017). These care-related challenges can make it harder to manage one’s own chronic conditions both within and outside the context of a widespread public health crisis. In turn, caregivers may have lower illness self-efficacy than noncaregivers, particularly when they manage a higher number of conditions that increase self-management complexity. This may especially have been the case during the early months of the COVID-19 pandemic because of reduced social contact (Son et al., 2020; Van Orden et al., 2020) that also limited access to care-related support resources (e.g., family assistance, respite care). Identifying people at increased risk of reduced illness self-efficacy would help target interventions and services to those in greatest need.
This study extends the literature by examining the association between caregiver status and perceptions of reduced illness self-efficacy during the first 2-4 months of social distancing due to COVID-19 in a sample of U.S. adults aged 50 and older with chronic conditions. We hypothesized that caregivers would be more likely than noncaregivers to report reduced illness self-efficacy since the pandemic, controlling for sociodemographic and health characteristics, stressors related to COVID-19, and behavioral and psychosocial changes since the pandemic. We further hypothesized that this link would be exacerbated by a higher number of conditions.
Methods
Sample and Procedures
We recruited 788 adults for this cross-sectional study between May 14 and July 9, 2020. To recruit, we used the UMHealthResearch.org opt-in database; the Healthier Black Elders Center Participant Resource Pool of African American adults aged 55 and older; social media posts; emails with the study team’s contacts; and word of mouth. People were eligible if they were aged 50 or older, currently lived in the United States., and reported a current diagnosis of at least one chronic mental or physical condition.
Participants were asked to complete an anonymous online survey using the Qualtrics platform that took about 20 minutes. Only individuals who gave electronic informed consent were able to take the survey. Participants were not compensated. This study was performed in line with the principles of the Declaration of Helsinki and was approved by the Institutional Review Board at the University of Michigan.
Of 788 adults recruited, we removed 11 who did not respond to any survey questions and 13 who reported that they did not have a diagnosis of any chronic conditions in the survey and did not have any other health problems. Of the 764 remaining, we removed 40 with no data on chronic conditions and 29 with missing data on one or more other study variables. The final analytic sample included 105 caregivers and 590 noncaregivers. Compared with the 69 individuals who were removed because of missing data, the 695 participants were less likely to be a person of color (χ2 (1, N = 761) = 10.06, p = .002) and more likely to have a bachelor’s degree or higher (χ2 (1, N = 761) = 8.59, p = .003) but did not differ on other study variables.
Measures
Reduced illness self-efficacy since the pandemic.
Using an adapted item (Lorig et al., 2001), participants separately reported, before and since the COVID-19 pandemic, overall, how confident did/do they feel that they could/can do the different tasks and activities needed to manage their condition(s), from 1 being “not at all confident” to 10 being “totally confident”? We created a binary variable to assess reports of reduced illness self-efficacy since the pandemic relative to before (1 = yes, 0 = no).
Caregiver status.
Participants were asked: “Do you currently provide unpaid care to one or more family members or friends with mental and/or physical health conditions and with difficulties in performing everyday activities?” Responses included a child under age 18, an adult aged 18-64, and/or an adult aged 65 or older (1 = caregiver, 0 = noncaregiver).
Chronic conditions.
Participants reported whether (1 = yes, 0 = no) they currently had a physician diagnosis of 21 chronic conditions (see Table 1). We summed the conditions.
Table 1.
Chronic Conditions Among Caregivers and Noncaregivers.
| Condition | Caregivers n = 105 |
Noncaregivers n = 590 |
|---|---|---|
| Anxiety disorder: % | 24.8 | 24.7 |
| Arthritis: % | 65.7 | 59.8 |
| Asthma: % | 31.4** | 20.0 |
| Bipolar disorder: % | 5.7 | 4.4 |
| Cancer (all except non-melanoma skin): % | 9.5 | 10.5 |
| Cardiac arrhythmias: % | 13.5 | 10.7 |
| Chronic kidney disease: % | 6.7 | 5.1 |
| Chronic obstructive pulmonary disease (COPD): % | 10.5 | 7.6 |
| Chronic pain condition: % | 37.5 | 34.2 |
| Congestive heart failure: % | 1.9 | 3.6 |
| Coronary artery disease, coronary heart disease, or ischemic heart disease: % | 6.7 | 7.3 |
| Dementia (including Alzheimer’s disease and other types): % | 0.0 | 0.7 |
| Diabetes: % | 21.9 | 17.8 |
| Hepatitis: % | 1.0 | 1.2 |
| High blood pressure or hypertension: % | 50.5 | 46.1 |
| Human immunodeficiency virus (HIV): % | 0.0 | 0.3 |
| Hyperlipidemia or high cholesterol: % | 42.3 | 43.2 |
| Osteoporosis: % | 22.9 | 19.0 |
| Schizophrenia: % | 0.0 | 0.3 |
| Stroke, cerebrovascular disease, or transient ischemic attack: % | 3.8 | 4.1 |
| Substance use disorder (including drug and alcohol disorders): % | 1.0 | 2.5 |
| Other mental or physical health problems:a % | 55.8 | 45.8 |
Note.
Endorsement of having other current mental or physical health problems not listed in the survey.
N = 695 adults.
Significant difference at p < .01.
Sociodemographic characteristics.
We assessed age in years, gender (1 = female, 0 = male or other), race/ethnicity (1 = people of color, 0 = non-Hispanic White), education (1 = bachelor’s degree or higher, 0 = less than a bachelor’s degree), work status (1 = currently employed full-time or part-time, 0 = other), marital status (1 = currently married/cohabiting with a partner, 0 = not currently married/cohabiting with a partner), and household size (number of adults and children currently living in the household).
Health characteristics.
Participants reported whether a doctor or other care provider has said they currently have depression (1 = yes, 0 = no). Participants reported their overall physical health before the pandemic (1 = excellent, 2 = very good, 3 = good, 4 = fair, 5 = poor), with the item reverse-coded (Merikangas et al., 2020; Ware, 1999). Participants reported how much they were currently limited (1 = yes, limited a lot, 2 = yes, limited a little, 3 = no, not limited at all) in ten activities to assess functional limitations (Ware, 1999): vigorous activities; moderate activities; lifting or carrying groceries; climbing several flights of stairs; climbing one flight of stairs; bending, kneeling or stooping; walking more than a mile; walking several blocks; walking one block; bathing or dressing. Items were reverse-coded and summed. Participants also reported how much bodily pain they usually have since the pandemic (0 = none, 1 = very mild, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe) using an adapted item (Ware, 1999).
Pandemic-related stress.
Participants separately reported the extent (1 = not at all, 2 = a little, 3 = somewhat, 4 = quite a bit, 5 = a great deal) that they have had difficulty obtaining (a) medication and (b) routine care since the COVID-19 pandemic (Cawthon et al., 2020), and that they or their families have had (c) financial problems created by changes related to the pandemic (Merikangas et al., 2020). We also summed reports (1 = yes, 0 = no) of 13 pandemic-related stressors using items from prior research (Merikangas et al., 2020). Participants reported whether they are an essential worker (e.g., healthcare, delivery worker, store worker, security, building maintenance); have a household member who is an essential worker; have lost their job or been laid off because of COVID-19; have been suspected of having COVID-19; have had a household member diagnosed with COVID-19; and have had a family member outside their household diagnosed with COVID-19. Participants also reported whether any of the following happened to their family members because of the COVID-19 pandemic: fallen physically ill; hospitalized; put into self-isolation with symptoms (i.e., presumed infection); put into self-quarantine without symptoms (e.g., due to possible exposure); passed away; lost job or been laid off; and had reduced ability to earn money.
Behavioral and psychosocial changes since the pandemic.
Participants separately reported, before and since the COVID-19 pandemic, in an average week, how many minutes per day (a) on weekdays and (b) on weekends did/do they spend physically active (i.e., walking, jogging, swimming, gardening, household chores): 1 = 0-30, 2 = 30-60, 3 = 60-90, 4 = 90-120, 5 = more than 120 (Pennington Biomedical Research Center, 2020). We averaged reports on weekdays and weekends and created a binary variable to assess reports of reduced physical activity since the pandemic relative to before (1 = yes, 0 = no). Participants were asked how their eating habits have changed compared to before the pandemic: 1 = eating less healthy now, 2 = eating more healthy now, 3 = eating about the same now (Pennington Biomedical Research Center, 2020). We created a binary variable to ascertain perceptions of a less healthy diet since the pandemic (1 = yes, 0 = no). Participants reported how the quality of their sleep has changed since the pandemic: 1 = improved, 2 = worsened, 3 = stayed the same, 4 = have not noticed (Pennington Biomedical Research Center, 2020). We created a binary variable to obtain reports of worse sleep quality since the pandemic (1 = yes, 0 = no).
Anxiety symptoms were measured with an adapted scale (Kroenke et al., 2007). Participants were separately asked, before and since the pandemic, in an average week: (a) how often did/do they feel nervous, anxious, or on edge?, and (b) how often were/are they not able to stop or control worrying? (0 = not at all, 1 = several days, 2 = over half the days, 3 = nearly every day). We summed scores and created a binary variable to examine reports of increased anxiety symptoms since the pandemic relative to before (1 = yes, 0 = no). Participants separately reported how often they received emotional support from family members or friends (e.g., being available to listen to your concerns) before and since the pandemic (1 = daily, 2 = a few times per week, 3 = once a week, 4 = a few times per month, 5 = once a month, 6 = less than once a month, 7 = never). We created a binary variable to evaluate reports of reduced emotional support since the pandemic relative to before (1 = yes, 0 = no).
Statistical Analysis
In preliminary analyses, we tested differences between caregivers and noncaregivers for study variables using independent t tests and chi-square tests. We conducted logistic regressions to evaluate the association between caregiver status and perceptions of reduced illness self-efficacy since the pandemic and the moderating effects of number of chronic conditions. Step 1 included caregiver status and number of chronic conditions as predictors and controlled for sociodemographic and health characteristics, pandemic-related stress, and behavioral and psychosocial changes since the pandemic. Step 2 added an interaction term (caregiver status X number of chronic conditions). To evaluate the nature of the interaction, we estimated simple slopes for the odds of perceiving reduced illness self-efficacy at one standard deviation above and below the mean number of conditions. Continuous covariates were grand mean centered. Models were estimated using SPSS version 27.
Results
Nearly one in seven (15.1%) participants reported being a caregiver, with 2.0% caring for a child, 3.6% caring for an adult aged 18-64, and 10.2% caring for an adult aged 65 or older. Table 1 displays the prevalence of chronic conditions among caregivers and noncaregivers. Caregivers were more likely to report an asthma diagnosis (χ2 (1, N = 695) = 6.85, p = .009) but did not differ from noncaregivers in other reported conditions.
Table 2 presents scores on study variables among caregivers and noncaregivers. In bivariate analyses, caregivers were more likely to report reduced illness self-efficacy since the pandemic compared with noncaregivers (χ2 (1, N = 695) = 5.61, p = .018). Caregivers were also more likely than noncaregivers to be female (χ2 (1, N = 695) = 6.72, p = .010), married or cohabiting with a partner (χ2 (1, N = 695) = 7.39, p = .007), and have a larger household (t(127.06) = 4.83, p < .001). Additionally, relative to noncaregivers, caregivers reported worse physical health (t(151.49) = −2.76, p = .007), greater pain intensity (t(693) = 2.27, p = .023), more financial strain related to the pandemic (t(693) = 1.98, p = .048), more total stressors related to the pandemic (t(693) = 1.99, p = .047), a less healthy diet since the pandemic (χ2 (1, N = 695) = 10.56, p = .001), and reduced emotional support since the pandemic (χ2 (1, N = 695) = 4.42, p = .035).
Table 2.
Sociodemographic and Health Characteristics Among Caregivers and Noncaregivers.
| Variable | Caregivers n = 105 |
Noncaregivers n = 590 |
|---|---|---|
| Sociodemographic characteristics | ||
| Age in years: M(SD) | 63.48(7.63) | 64.77(9.09) |
| Female gender: % | 83.8* | 71.7 |
| People of color: % | 21.9 | 15.3 |
| Bachelor’s degree or higher: % | 65.7 | 72.9 |
| Currently working part-time or full-time: % | 38.1 | 33.1 |
| Spouse or cohabiting partner: % | 71.4** | 57.3 |
| Household size: M(SD) | 1.90(1.48)*** | 1.16(1.14) |
| Michigan resident:a % | 83.8 | 82.4 |
| Health characteristics | ||
| Depression diagnosis: % | 33.3 | 35.6 |
| Self-rated physical health:b M(SD) | 2.95(0.85)** | 3.20(0.92) |
| Functional limitations:c M(SD) | 16.22(4.80) | 15.81(5.27) |
| Pain intensity:d M(SD) | 2.31(1.08)* | 2.03(1.18) |
| Number of chronic conditions:e M(SD) | 3.56(2.01) | 3.23(1.96) |
| Pandemic-related stress | ||
| Perceived difficulty getting medication:f M(SD) | 1.31(0.59) | 1.22(0.48) |
| Perceived difficulty getting routine care:f M(SD) | 1.93(0.88) | 1.82(0.86) |
| Perceived financial strain related to COVID-19:g M(SD) | 2.10(1.22)* | 1.86(1.11) |
| Total stressors:hM(SD) | 1.79(1.67)* | 1.45(1.63) |
| Behavioral and psychosocial changes since the pandemic | ||
| Reduced physical activity: % | 32.4 | 35.8 |
| Less healthy diet: % | 44.8** | 28.8 |
| Worse sleep quality: % | 45.7 | 42.4 |
| Increased anxiety symptoms: % | 61.9 | 52.7 |
| Reduced emotional support: % | 29.5* | 20.3 |
| Reduced illness self-efficacy since the pandemic: % | 60.0* | 47.5 |
Note.
Includes a total of 34 U.S. states and the District of Columbia.
Range = 1 – 5, higher scores indicate better health.
Range = 10 – 30, higher scores indicate greater limitations.
Range = 0 – 5, higher scores indicate greater pain intensity.
Range = 0 – 21.
Range = 1 – 5, higher scores indicate greater difficulty.
Range = 1 – 5, higher scores indicate greater strain.
Range = 0 – 13.
N = 695 adults.
Significant difference at p < .05.
Significant difference at p < .01.
Significant difference at p < .001.
Table 3 shows results from the logistic regression models. Although caregiver status and number of chronic conditions were not independently linked to perceptions of reduced illness self-efficacy since the pandemic controlling for covariates in Step 1, there was a significant interaction between these two variables in Step 2 (OR = 1.39, p = .023, 95% CI: [1.05, 1.84]). Simple slopes tests revealed that caregivers reported higher odds of perceiving reduced illness self-efficacy since the pandemic relative to noncaregivers when their number of chronic conditions was high (OR = 2.31, p = .035, 95% CI: [1.06, 5.00]) but not low (OR = 0.64, p = .242, 95% CI: [0.30, 1.36]).
Table 3.
Logistic Regressions Examining the Link Between Caregiver Status and Reduced Illness Self-Efficacy Since the COVID-19 Pandemic.
| Reduced Illness Self-Efficacy Since the Pandemic |
||||
|---|---|---|---|---|
|
| ||||
| Step 1 | Step 2 | |||
|
|
||||
| Predictors | OR | 95% CI | OR | 95% CI |
| Caregiver status | 1.22 | 0.73, 2.05 | 1.21 | 0.71, 2.06 |
| Number of chronic conditions | 0.99 | 0.89, 1.09 | 0.94 | 0.84, 1.05 |
| Caregiver status X Number of conditions | 1.39* | 1.05, 1.84 | ||
| Sociodemographic characteristics | ||||
| Age in years | 0.99 | 0.97, 1.02 | 0.99 | 0.96, 1.01 |
| Gender (female) | 1.09 | 0.70, 1.68 | 1.07 | 0.69, 1.66 |
| Race/ethnicity (person of color) | 0.66 | 0.39, 1.11 | 0.64 | 0.38, 1.08 |
| Education (bachelor’s or higher) | 1.30 | 0.86, 1.97 | 1.31 | 0.86, 1.98 |
| Work status (currently working) | 1.30 | 0.85, 2.00 | 1.24 | 0.81, 1.91 |
| Marital status (spouse or cohabiting partner) | 1.06 | 0.70, 1.63 | 1.04 | 0.68, 1.59 |
| Household size | 1.09 | 0.92, 1.29 | 1.10 | 0.92, 1.30 |
| Health characteristics | ||||
| Depression | 1.58* | 1.07, 2.35 | 1.55* | 1.04, 2.30 |
| Self-rated physical health | 0.77* | 0.60, 0.99 | 0.77* | 0.60, 0.99 |
| Functional limitations | 1.00 | 0.95, 1.04 | 1.00 | 0.95, 1.05 |
| Pain intensity | 1.38** | 1.14, 1.68 | 1.39** | 1.14, 1.69 |
| Pandemic-related stress | ||||
| Perceived difficulty getting medication | 1.93** | 1.28, 2.92 | 1.90** | 1.26, 2.87 |
| Perceived difficulty getting routine care | 1.51*** | 1.20, 1.90 | 1.50** | 1.19, 1.89 |
| Perceived financial strain | 1.09 | 0.92, 1.29 | 1.10 | 0.92, 1.31 |
| Total stressors | 1.01 | 0.90, 1.14 | 1.01 | 0.90, 1.14 |
| Behavioral and psychosocial changes since the pandemic | ||||
| Reduced physical activity | 1.91** | 1.29, 2.81 | 1.94** | 1.32, 2.87 |
| A less healthy diet | 1.38 | 0.91, 2.09 | 1.37 | 0.90, 2.08 |
| Worse sleep quality | 1.16 | 0.79, 1.70 | 1.14 | 0.77, 1.68 |
| Increased anxiety symptoms | 2.33*** | 1.60, 3.39 | 2.39*** | 1.63, 3.49 |
| Reduced emotional support | 1.24 | 0.80, 1.94 | 1.23 | 0.79, 1.92 |
| −2 Log Likelihood | 755.10 | 749.53 | ||
| Change in −2 Log Likelihood | 5.57* | |||
Note. COVID-19 = coronavirus disease 2019.
N = 695 adults.
p < .05.
p < .01.
p < .001.
Discussion
This study contributes to the literature by indicating that, in the early months of social distancing recommendations during the COVID-19 pandemic, caregivers may be more likely than noncaregivers to report reduced illness self-efficacy when they manage a higher number of chronic conditions. The models controlled for sociodemographic and health characteristics, along with pandemic-related stress and changes to daily life. Hence, the findings appear to be robust when accounting for a range of potential confounding factors. Reduced illness self-efficacy during the pandemic may have detrimental consequences both for caregivers’ health and for the quality of care they provide to care recipients. The current findings suggest that clinical care and interventions should incorporate strategies to support caregivers in their own illness management throughout the pandemic.
Caregivers may have higher odds of perceiving reduced illness self-efficacy in the context of a higher number of chronic conditions for several reasons. First, caregivers with multiple chronic conditions report greater difficulties related to caregiving and self-care (Liu & Lou, 2019; Polenick et al., 2020). Second, the COVID-19 pandemic has made it more difficult to access care-related services that provide respite and allow time for self-care (Greenberg et al., 2020; Lightfoot & Moone, 2020). Third, the pandemic may contribute to elevated caregiver stress (Cohen et al., 2020), adding to the complexity of illness self-management and potentially exacerbating mental and physical health symptoms. The adverse implications for illness self-efficacy may be magnified among caregivers with a greater number of chronic conditions because multimorbidity is linked to worse illness management and poorer health outcomes (Fabbri et al., 2015).
Of note, caregivers in this study had poorer overall health, greater stress, and less resilient coping since the COVID-19 pandemic. More specifically, in bivariate analyses, caregivers were more likely than noncaregivers to report reduced illness self-efficacy since the pandemic and reported worse physical health, greater pain intensity, more pandemic-related financial strain and other pandemic-related stressors, less healthy eating since the pandemic, and reduced emotional support since the pandemic. This indicates that pandemic-related changes may have resulted in more stress and fewer social resources among older caregivers with greater multimorbidity, which might lead to unhealthy dietary behavior and other self-care deficits that make it harder to manage multiple chronic conditions. Greater stress and diminished resources since the pandemic may also make it more difficult for older people with multiple chronic conditions to provide care. For example, caregivers with reduced illness self-efficacy may similarly feel less able to manage their care recipients’ health conditions. This could lead to ineffective care that places care recipients at an increased risk of poor health outcomes.
Future research should consider how the intensity of caregiving (e.g., hours per week), relationship to the care recipient, and specific care situations (e.g., dementia care) impact the current findings. It will also be imperative to conduct longitudinal studies that evaluate the long-term association between caregiver status and illness self-efficacy during the pandemic and identify possible mechanisms. Difficulty with obtaining medical care for care recipients due to the COVID-19 pandemic may have particularly strong implications for caregivers’ illness self-efficacy. For instance, delays or cancelations of in-home assistance with medical/nursing tasks (e.g., ostomy care, injections) may require caregivers to take on the primary responsibility for care activities that might be stressful or challenging. In turn, these caregivers may have less available time and energy to devote to their own illness self-management.
Considering the continued surges of COVID-19 in Michigan and in many other U.S. states, future research should consider other factors linked to illness self-efficacy during the pandemic among caregivers and noncaregivers. For example, one study of Spanish older adults found that those who regularly engaged in vigorous (VPA) and moderate-vigorous physical activity (MVPA) during the COVID-19 pandemic were found to report greater self-efficacy in general (Carriedo et al., 2020), which may also translate to greater illness self-efficacy. Greater self-efficacy has been associated with critical health outcomes among older adults with chronic conditions outside of a pandemic or other collective crisis, including lower psychological distress and lower odds of pre-frailty or frailty (Hladek et al., 2020; Wu et al., 2004). Consequently, more nuanced knowledge of how the pandemic may impact illness self-efficacy would facilitate targeted approaches to improve and sustain effective chronic condition self-management.
In addition, it is important to consider the applicability of the current findings to future widespread public health risks. The increased odds of reduced illness self-efficacy found among older caregivers with a greater number of chronic conditions during the COVID-19 pandemic may signal unmet needs among these individuals that should be addressed at an early point in the crisis. Targeting resources and support to caregivers with greater multimorbidity might help to prevent or attenuate challenges with illness self-management. For instance, early interventions that include strategies for overcoming crisis-related barriers to effective illness management in this subgroup of older adults (e.g., difficulty getting food for a special diet) may be beneficial.
We acknowledge several limitations. First, the self-selected convenience sample may introduce bias. Second, a number of study variables used single items or dichotomized items that may be better operationalized with validated scales. Third, the analyses are cross-sectional and there may be some recall bias in participant reports; however the models controlled for self-reported diagnosis of depression, which helps to mitigate these concerns. Fourth, for some individuals, the illness self-efficacy item used in this study may reflect more of a trait than a state; as such, this item might not have fully captured perceived changes in illness self-efficacy before and since the pandemic. Fifth, participants all had online access and were mostly women, non-Hispanic White, highly educated, and Michigan residents, limiting generalizability to broader samples of older U.S. adults living with chronic conditions. Further limiting generalizability, the sample also included a wider age range (i.e., aged 50 and older) than some studies of older adults, and only about two-thirds of caregivers cared for an adult aged 65 or older. Finally, the findings may not apply beyond 2-4 months after the initial social distancing recommendations in the United States. Nevertheless, this study highlights the need for additional research to develop strategies to support older caregivers in their own illness self-management during this pandemic and in future public health crises.
Acknowledgments
Funding:
This work was supported by the National Institute on Aging at the National Institutes of Health (K01AG059829 and P30 AG015281), the National Center for Advancing Translational Sciences (grant number UL1TR002240), and the Michigan Center for Urban African American Aging Research.
Disclosure of Interest
The authors report no conflict of interest. This work was supported by the National Institute on Aging under Grants [K01 AG059829] and [P30 AG015281]; the National Center for Advancing Translational Sciences under Grant [UL1TR002240]; and the Michigan Center for Urban African American Aging Research.
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