Impacts of the COVID-19 pandemic on carer-employees’ well-being: a twelve-country comparison

Abstract

The aim of this analysis is to assess the potential ways that the COVID-19 pandemic has impacted Canadian carer-employees (CEs) and identify the needs CEs feel is required for them to continue providing care. We assess the similarities and differences in the stresses CEs faced during COVID-19 globally across countries in the G7, Australia, Spain, Brazil, Taiwan, India, and China. We aim to compare Canada against global trends with respect to the challenges of the COVID-19 pandemic, as well as the supports in place for CEs. The study utilized 2020 Carer Well-Being Index at the country level. Descriptive data on Canadian CEs is first reviewed, followed by comparisons, by country, on responses relating to: (a) time spent caring; (b) sources of support; (c) impact on paid work and career, and; (d) emotional/mental, financial, and physical health. The relationship between government support and emotional/mental health is also explored. When compared to pre-pandemic times, CEs in Canada on average spent more time caregiving, with 34% reporting more difficulty balancing their paid job and caring responsibilities. Seventy-one percent of CEs feel their mental health has deteriorated. Thirty-four percent of Canadian CEs received support from the government, and only 30% received support from their employers. Globally, there was a similar trend, with CEs experiencing deteriorating mental health, work impacts, and unmet needs during the pandemic. Comparing the well-being of Canadian CEs with other countries provides an opportunity to evaluate areas where Canadian policies and programs have been effective, as well as areas needing improvement.

Introduction

According to the United Nations, population aging is a global trend and “virtually every country in the world is experiencing growth in the size and proportion of older persons in their population” (United Nations, 2019, p.1). It is projected that the number of people 65 years and older will double from 703 million people in 2017 to over 1.5 billion in 2050 (United Nations, 2019). As the global population dramatically ages, with greater demands being made on limited health and long-term care systems, unpaid carers, such as close family, relatives, and friends, will need to take on more responsibility (WHO, 2016). Consequently, more carer-employees will need to balance the responsibilities of paid work with unpaid caring. Those who provide unpaid care to family or friends with a long-term health condition, a physical or mental disability, or problems related to aging while working paid jobs are referred to as carer-employees (CEs) (Ireson et al., 2018). Globally, CEs are referred to differently; in Europe, the term worker-carer is more frequently used.

CEs typically have worse stress and physical health compared to the general population and are associated with higher rates of mood disorders, such as depression, anger, distress, fatigue, and anxiety (Ramesh et al., 2017; Williams et al., 2016; Sethi et al., 2017; Adelman et al., 2014). Balancing caring with job responsibilities can be an area of challenge that leads to family-role overload, damaging wellbeing and workplace productivity (Halinski et al., 2020). CEs often relegate paid work responsibilities to outside the regular work week, causing them to give up on leisure activities like hobbies, social gatherings, and vacations (Wang et al., 2018). Additionally, CEs often do not choose to disclose their caring responsibilities in the workplace for fear of being seen as uncommitted, which causes feelings of isolation and loneliness (Sherman, 2018). In worst cases, stress from managing two difficult positions can cause CEs to leave the workforce altogether (Wang et al., 2018).

In 2020, the emergence of the COVID-19 pandemic and subsequent lockdowns disrupted hundreds of thousands of businesses and put high amounts of strain on healthcare systems globally. Since CEs occupy the double-role of employee and unpaid carer, they are particularly vulnerable to the massive disruption caused by COVID-19 in both areas. The onset of the COVID-19 pandemic caused widespread business closures and mass layoffs internationally (Bartik et al., 2020; Crayne, 2020). In June 2020, Statistics Canada reported that 12.4% of Canadian workers had been laid off on a monthly basis since February 2020, although the number of permanent layoffs was unclear (Winnie et al., 2020). Health-care systems were put under strain globally by influxes of COVID-19 cases as hospitals had shortages of personal protective equipment, and in some cases, inadequate capacity for ICU beds and ventilators (McMahon et al., 2020). In Ontario, the COVID-19 pandemic caused an estimated backlog of 16 million health-care services, including MRIs, CT scans, and various surgeries (Ontario Medical Association, 2020). During the COVID-19 pandemic, many CEs, an already vulnerable population, were and continue to be exposed to additional stresses from two directions as they faced both job insecurity and increased caregiving demands (Carers UK, 2020; Heilman et al., 2020; Ontario Caregivers Organization, 2020; Hughes et al., 2021).

Using data from the Carer Well-Being Index from Embracing Carers (2021) and framed within stress model (Pearlin et al., 1990), the purpose of this paper is to report the impact of caring and COVID-19 on Canadian CEs and compare these results across the twelve participating countries. Embracing Carers is a global initiative led by pharmaceutical manufacturer Merck KGaA; it is focused on improving the health and well-being of carers globally and aims to support carer initiatives by collaborating with other organizations. Specifically, this paper seeks to examine the impact of caring and COVID-19 by contextualizing changes in the following areas: (a) time spent caring; (b) sources of support; (c) impact on paid work and career, and (d) emotional/mental, financial, and physical health. The relationship between government support and emotional/mental health is also explored. Specific interest will be placed on countries in the G7 and Australia due to these countries having similar levels of economic development as Canada, as well as having somewhat similar strategies, goals, and policy initiatives with respect to CEs, particularly around flexible work (Yeandle et al., 2017). Contextualizing these results will provide opportunities to evaluate both areas where Canada is doing well and where it can improve, with respect informing new policy directions by way of other countries who are doing better than Canada.

Literature review

Pearlin et al. (1990) stress process model identifies carer stress as comprising a number of interrelated conditions, such as the resources of carers, together with a range of stressors to which they are exposed. In the process model, primary stressors are defined as hardships and problems stemming directly from caring, whereas secondary stressors are understood as either the intrapsychic strains which involve the diminishment of self-concept, or the strains experienced in roles/activities external to caring, such as paid work. The COVID-19 pandemic would be both a primary stressor, given the impact it has had on caring, as well as a secondary stressor, given the impact on work and most every other aspect of life. Pearlin et al. (1990) emphasize the positive impact of social support as a protective factor, as well as the negative impact of role conflict as a secondary stressor.

There is a growing body of literature surrounding the experience of CEs during COVID-19 which consistently shows the pandemic's negative impact, specific to: (a) time spent caring; (b) sources of support; (c) impact on paid work and career, and; (d) health, broadly defined. With respect to time spent caring, a qualitative study interviewing a sample of 52 diverse unpaid carers found that many had increased caring responsibilities with inadequate supports, while having to adjust to changes like homeschooling or working from home (Lightfoot, 2021). The literature suggests that, overall, sources of support for CEs decreased as a result of the COVID-19 pandemic. In the UK, a June 2020 survey found that, due to public health restrictions imposed by COVID-19, nearly all social support services–such as peer support groups, had stopped face-to-face arrangements, and the inability to access pre-pandemic activities significantly contributed to fear, sadness, uncertainty, and anger; however, in a qualitative study exploring the perspectives of carers on COVID-19, many described the importance of resilience, adaptation, and coping (Simblett et al., 2021). Additionally, while most carers were not connected to any formal support pre-pandemic, the majority reported having an informal support network which they chose to forgo due to concerns about COVID-19 (Lightfoot, 2021). Many shared caring responsibilities with family members which had to be rearranged due to COVID-19, with some taking on a larger workload during the pandemic than before (Lightfoot, 2021). This impacted CEs paid work and career given that boundaries between paid work, much of which had moved into the home given lockdown orders, and care work became progressively blurred; this presented a range of new challenges for family carers (Lafertty et al., 2022; Ding et al., 2022), with some leaving the workforce altogether. For those leaving the workforce or having to cut their paid work hours due to increasing care responsibilities, their financial wellbeing was compromised and worry about their financial situation increased, as noted in the UK (Carers UK, 2020) and Ireland (Lafferty et al., 2022).

With respect to health, broadly defined, CEs were also negatively impacted. According to one U.S. study, unpaid carers reported adverse mental health, such as depression, more frequently than non-carers; nearly two-thirds of unpaid carers experienced deteriorated mental health or behavioral symptoms early in the COVID-19 pandemic compared to one-third of non-carers (Czeisler et al., 2021). In the United States, among those who were both carers of adults and children, 85% experienced adverse mental health symptoms, and approximately half reported serious suicidal ideation in the past month; this was eight times greater than non-carers/non-parents (Czeisler et al., 2021). A separate U.S. study investigating carers’ mental and physical health during the COVID-19 pandemic found unpaid carers were more likely to have worse mental health and fatigue than non-carers (Park, 2020). In addition, long term carers were more likely to experience “headaches, body aches, and abdominal discomfort” than both short-term carers and non-carers (Park, 2020). Deteriorated mental and physical health outcomes were likely caused by isolation and additional stressors from the COVID-19 pandemic. A survey done by the University of Pittsburgh (2020) found that 56% of carers found caring to be more emotionally difficult during the COVID-19 pandemic, with 63% reporting more caring duties due to factors such as an inability to access health-care services, and/or increased needs of their care recipients. Based on the Pearlin et al. (1990) stress process model, as well as the available literature related to the health and support in family caregiving, our study proposed two hypotheses: (1) COVID-19 had negative impacts on carer-employees, evident in: (a) time spent caring; (b) sources of support; (c) impact on paid work and career, and; (d) emotional, financial, and physical health across twelve countries, and; (2) During COVID-19, carer-employees across 12 countries experienced deteriorating emotional/mental health in those countries characterized as having less support from government and/or employers.

Policy background

Given the objective of the paper, specific to informing policies and programs for CEs in Canada, a representative review of policies and programs supporting CEs in the six of the countries represented in the Carer Well-Being Index (representing the G7 and Australia), are outlined. Financial support (approximations provided only), flexible work, and both paid and unpaid leaves are a specific focus given that they are well-known policies that support CEs. We will start with the Canadian context, followed by five of the countries represented in the Carer Well-Being Index: Australia, UK, Italy, France and Germany, and the USA. In Canada, the Canada Caregiver Credit is a tax credit available for carers with relatives who are dependent due to mental or physical impairment (International Alliance of Carer Organizations [IACO], 2018). The Compassionate Care Benefit (CCB) is financial support payable to carers who have 600+ hours of insured work in the past year and whose earnings have fallen by at least 40%. The CCB is paid at 55% of the carer's average earnings, up to CAD $51,300. In addition, the Canadian Family Caregiver Leave is unpaid job-protected leave, available for up to 8 weeks, for carers of relatives with a serious medical condition (Yeandle et al., 2017). Additionally, Family Medical Leave is available for 26 weeks for relatives significantly at risk of dying and can be combined with the CCB to reduce the financial burden of job leave (Yeandle et al., 2017). Many other countries, including Australia, the United Kingdom, and Italy offer forms of direct allowances for carers that meet specific criteria. In Australia, the Carer Allowance is a biweekly income of $131.90 AUD paid to carers that meet a certain family income threshold, provide daily care to a disabled or frail elderly person, and who's care recipient has had an illness or disability for 6 months or is terminal (IACO, 2018; Yeandle et al., 2017). An additional Carer Supplement of $600 AUD for each care recipient is available per annum (IACO, 2018; Yeandle et al., 2017). Further, the New National Employment Standards in Australia give unpaid carers 10 days of paid leave per annum with the additional option of two days short term unpaid leave (Yeandle et al., 2017). Additionally, Australian CEs have the right to request flexible work with the business grounds for refusing clearly defined in law (Yeandle et al., 2017). In the UK, carers aged 16 and older who meet specific criteria are able to receive £67.60 weekly through the Carer's Allowance, although carer's are not paid more if they care for many people (IACO, 2018; Government of the UK, 2014). In the UK, employees who have worked for 26 weeks have the right to request flexible working (RTRFW) which employers must review fairly (Yeandle et al., 2017). However, employers can reject requests on the grounds of specific business reasons laid out in the Advisory, Conciliation and Arbitration Service code of practice including, for instance: the burden of additional costs, an inability to reorganize work among/recruit staff, a detrimental impact on performance/quality (Advisory, Conciliation and Arbitration Service, n.d.). In Italy, the Companion Allowance (Indennità di Accompagnamento) is accessible to all carers caring for someone who is unable to perform day-to-day activities without assistance and is paid out at a flat rate of about €500 monthly (IACO, 2018; Istituto Nazionale Previdenza Sociale, 2021). In Italy, carers supporting a severely disabled or ill family member are entitled to a care leave; however, it is only available for one member of the care recipient's household (Eurocarers 2020b; Yang et al., 2013). Recipients are entitled to three days paid leave per month, as well as two years paid leave once in their lifetime at 100% salary up to a maximum of €47,446 (Eurocarers 2020b; Yang et al., 2013).

In France and Germany, the personalized independence and care allowance are indirect forms of financial support for carers that are first paid out to care recipients who can then pass it on to their carers; however, there is no guarantee that carers will be reimbursed by their care recipients (IACO, 2018). In France, the Family Solidarity Leave (FSL) offers carers the ability to take up to three months of unpaid job-protected leave to assist a relative who is dying (Yeandle et al., 2017). A Daily Support Allowance is available at a maximum of €55.15 for 21 days during FSL (Yeandle et al., 2017). In Germany, short term care leave is available at 90% of net earnings for 10 days. Further, six months of unpaid leave is available for carers spending 90 minutes a day on caring duties, and three months of unpaid leave are available for carers of family at end-of-life (Eurocarers 2020a; Yang et al., 2013). In the United States, there are forms of financial assistance and tax breaks available to carers, however, support is very limited, waitlists are long, and policies are inconsistent between states (IACO, 2018). In response to the COVID-19 pandemic, a wide range of short-term stop-gap measures were put in place across the world to support community-based care; unfortunately few provided support for unpaid carers as the primary focus was on care recipients (Dawson et al., 2020).

Methods

We obtained data from the Carer Well-Being Index, a global study commissioned by Embracing Carers in twelve countries including: United States, Canada, United Kingdom, France, Germany, Italy, Spain, Australia, Brazil, Taiwan, India and China. The dataset is nationally representative of each country. The study was conducted in 2020 online or over the phone, from September 3 to October 27; it included questions related to carer well-being and possible ways unpaid carers are harmed during COVID-19. Unpaid carers were defined as those caring for someone with a long-term illness, physical disability, or cognitive/mental condition. According to The Global Carer Well-Being Index report (Embracing Carers, 2021) “outgoing sample collected was balanced to the Census of each respective country to then allow qualifying respondents to fall out naturally” (p.53). Light weighting was applied to select countries based on individual country data. As well, each individual country has an estimated margin of error of +/- 3.58% at the 95% confidence level. The survey length was approximately 20-25 minutes and included aggregated responses from 9,044 unpaid carers across the 12 countries, or approximately 750 unpaid carers per country. As this paper is focused on the effects of COVID-19 on CEs, only the aggregated responses from employed carers were considered, which included 6,313 respondents.

Data analysis

McMaster Research Ethics Board approved the study to analyze the secondary data of Carer Well-Being Index (MREB#: 5688), which included a broad range of variables which were not all relevant for the purposes of this paper. As such, variables focusing on CEs were selected based on their relevance to four categories which included: (a) time spent caring; (b) sources of support; (c) impact on paid work and career, and; (d) emotional/mental, financial, and physical health. Selected variables are presented in Table 1 . Variables related to (a) time spent caring included: percentage of first-time carers as a result of COVID-19; time spent caring per week before, at the peak, and at the time of data collection, and; estimate of future time spent caring per week. Variables related to (b) sources of support included: percentage of CEs that received support before and during the COVID-19 pandemic from the federal government, from local/state governments, from employers, and; percentage of CEs that never received support. Variables related to (c) impact on paid work and career included: percentage of CEs who felt caring negatively affected their paid responsibilities; percentage of CEs who felt caring negatively affected their long-term goals, and; percentage of CEs who felt balancing paid job with caring was more difficult due to COVID-19. Finally, variables related to (d) emotional/mental, financial, and physical health included: percentage of CEs that felt caring negatively affected emotional/mental, financial, or physical health, and; percentage of CEs that felt COVID-19 negatively affected emotional/mental, financial, or physical health.

Table 1.

Questions and selected variables.

Question	Variables
Time spent caring
On average, how many hours did/do you spend per week on caregiving during each of the following timeframes?	Time spent caring before the Coronavirus/COVID-19 hit/entered carer's country
	Time spent caring during the height/peak of the Coronavirus/COVID-19 pandemic in carer's country
	Time spent caring now
Did you become a caregiver/carer for the first time as a result of the Coronavirus/COVID-19 pandemic?	First time carer status
In general, would you say the Coronavirus/COVID-19 pandemic has made caregiving harder or easier?	Difficulty of caring as a result of the pandemic
Sources of support
Which, if any, of the following organizations did/have you received any caregiving support from (including financial or non-financial support)?	Rate of support from federal/national government before and during the COVID-19 pandemic
	Rate of support from local/state government before and during the COVID-19 pandemic
	Rate of support from employers before and during the COVID-19 pandemic
In your opinion, are caregiver/carers currently receiving too much, the right amount, or not enough support from each of the following entities?	Opinion on level of support from federal/national government
	Opinion on level of support from local/state government
	Opinion on level of support from employers
Impact on paid work and career
How, if at all, does being a caregiver/carer impact each of the following aspects of your life currently?	Caring has a negative impact on paid work responsibilities
	Caring has a negative impact on career
Which, if any, of the following statements is true for you as it relates to how the Coronavirus/COVID-19 pandemic has impacted your ability to provide care? - I am having more difficulty balancing my professional/paid job responsibilities with my caregiving responsibilities.	Difficulty balancing paid job responsibilities and caring responsibilities due to the pandemic
Emotional, financial, and physical health
In general, do you feel the Coronavirus/COVID-19 has improved or worsened each of the following aspects of your health/wellbeing?	Worsened emotional health due to the pandemic
	Worsened financial health due to the pandemic
	Worsened physical health due to the pandemic
How, if at all, does being a caregiver/carer impact each of the following aspects of your life currently?	Worsened emotional health as a result of caring
	Worsened financial health as a result of caring
	Worsened physical health as a result of caring

The listed variables of interest were compared between twelve countries. The Carer Well-Being Index included all G7 countries other than Japan. Specific interest was placed on Canada, relative to the G7 countries and Australia, given the stated hypotheses and overall objective specific to evaluating Canada's policy and program initiatives for supporting CEs. However the carer-index data we used in this study is not individual data but, rather, the data aggregated at the country level. Thus, we cannot compare the variables of interest among more specific CE groups, such as age, sex, income, ethnicity or other socio-economic variables across twelve countries. Also, the inferential stats were unable to be estimated. Thus, the analysis solely focused on the descriptive statistics.

In the Carer Well-Being Index, the Canadian sample included 479 CEs. The mean age of Canadian CEs in the sample was 43.1, with 60% of respondents being female. Sixty two percent of primary care recipients were 65+ years old. Eighty-four percent of CEs resided in urban/suburban areas, and 16% resided in rural areas. Sixty-six percent were either married or in a partnership, 25% were single, and 10% were formerly married (divorced, separated, or widowed). Forty-four percent had a medium income (50-100K), 32% had a high income (100K+), and 24% had a low income (<50K). The majority of CEs (56%) had either: completed high school or at least some college, CEGEP, or trade school, or some university (did not finish). Further, 44% completed a university undergraduate degree or higher, and only 1% did not complete high school.

In addition to reporting the number of CEs involved in the study, by country, Table 2 presents the socio-demographic data for each of the twelve countries making up the Carer Well-Being Index. The mean age of CEs in G7 countries and Australia was between 39.5 and 43.1. China, India, Taiwan, and Brazil had mean ages that were relatively lower at 34.6 to 37.2. Canadian CEs were the oldest on average among the twelve countries. Between 52% and 66% of CEs were women. Over 50% of care recipients in nearly all countries were 65+ years old. Care recipients aged 65+ made up a very large portion in Italy (77%), Spain (75%), and Taiwan (74%). In India, on the other hand, only 29% of care recipients were aged 65+. Australia had the highest proportion of CEs in urban areas (95%), while India had the lowest (40%). In the other ten countries, between 77% and 90% of CEs lived in urban areas. China had the highest percentage of married CEs (88%), while the United States had the least (59%). It is worth noting that with regards to income, countries had different ranges for what was considered medium, high, or low income. Considering this, China had the largest proportion of CEs with high income (54%) and France had the highest proportion with low income (39%). India had the largest proportion of CEs with a higher education (72%), but also the largest proportion of CEs with a lower education (19%). In Canada, the United States, Germany, and Taiwan, more people had a middle education than a higher education. In the other eight countries, more people had a higher education than a middle education.

Table 2.

Socio-demographics of CEs in the Carer Well-Being Index.

Country	Canada	USA	United Kingdom	France	Germany	Italy	Spain	Australia	Brazil	Taiwan	India	China
Total Respondents	479	415	448	578	573	499	562	512	597	625	492	534
Age group
18-24	6%	8%	8%	4%	5%	4%	6%	8%	12%	13%	11%	8%
25-34	20%	27%	24%	25%	22%	19%	24%	21%	31%	34%	38%	42%
35-44	28%	39%	26%	34%	35%	33%	35%	40%	28%	32%	35%	37%
45-54	25%	15%	23%	24%	23%	32%	24%	15%	22%	17%	12%	9%
55-64	17%	7%	15%	11%	13%	12%	11%	11%	6%	5%	4%	2%
65+	4%	4%	3%	1%	1%	1%	-	4%	1%	-	-	1%
Age (Mean)	43.1	39.5	41.9	41	41.4	42.7	40.2	40.5	37.2	36.4	35.4	34.6
Gender
Male	40%	42%	38%	44%	43%	39%	40%	34%	34%	39%	48%	41%
Female	60%	58%	62%	56%	57%	61%	60%	66%	66%	61%	52%	59%
Age of Care Recipient
Less than 18	8%	11%	7%	8%	14%	4%	7%	10%	10%	6%	23%	13%
18-24	2%	2%	3%	2%	3%	1%	2%	3%	2%	-	2%	2%
25-34	5%	7%	7%	2%	3%	3%	2%	4%	3%	2%	5%	4%
35-44	5%	7%	4%	8%	5%	6%	2%	4%	5%	3%	8%	5%
45-54	5%	10%	9%	7%	7%	8%	6%	8%	7%	5%	14%	8%
55-64	17%	19%	17%	13%	15%	6%	9%	19%	17%	15%	27%	23%
65+	62%	52%	57%	64%	57%	77%	75%	55%	60%	74%	29%	56%
Urban/Surburban/Rural
Urban/Suburb	84%	87%	85%	82%	82%	77%	85%	95%	84%	90%	40%	82%
Rural	16%	13%	15%	17%	17%	23%	15%	5%	16%	10%	60%	17%
Marital Status
Married/Partner	66%	59%	64%	76%	73%	76%	73%	74%	60%	63%	82%	88%
Single	25%	29%	27%	19%	20%	18%	20%	21%	32%	35%	17%	11%
Divorced	5%	9%	6%	3%	4%	3%	5%	4%	4%	2%	1%	1%
Separated	3%	2%	2%	1%	2%	3%	1%	1%	2%	1%	-	-
Widow/widower	2%	2%	1%	-	1%	-	-	-	2%	-	-	-
Income
Low	24%	37%	25%	39%	15%	24%	23%	12%	28%	13%	34%	9%
Medium	44%	44%	50%	29%	52%	43%	46%	31%	23%	42%	36%	36%
High	32%	18%	23%	31%	28%	28%	30%	55%	46%	44%	28%	54%
Education
Lower	1%	1%	4%	-	14%	3%	3%	4%	8%	1%	19%	12%
Medium	56%	52%	26%	31%	46%	39%	25%	43%	33%	61%	9%	36%
High	44%	47%	70%	68%	40%	58%	71%	53%	59%	38%	72%	51%

Results

Variables from the Carer Well-Being Index data set were selected based on their relevance, which included: (a) time spent caring; (b) sources of support; (c) impact on paid work and career, and; (d) emotional/mental, financial, and physical health. We also examined the relationship between government support and (d) emotional/mental, financial, and physical health. In each of these categories, the results specifically pertaining to Canadian CEs will first be described, followed by an international comparison of the twelve countries.

Time spent caring

As noted in Fig. 1 , 70 of the 479, or roughly 15% of Canadian CEs were first time carers as a result of the COVID-19 pandemic. Excluding first time carers, Canadian CEs on average spent: 17.1 hours caring per week prior to the pandemic; 19.3 hours caring per week at the peak of the pandemic, and; 19.4 hours caring per week in Fall of 2020 (time of data collection). On average, Canadian CEs were caring for 2.2 hours longer at the peak of the pandemic, and 2.3 hours longer during Fall of 2020 (Fig. 2 ). At the peak of the pandemic, first time carers typically spent more time caring (20 hours/week), on average, than CEs who had been caring prior to the pandemic, but spent less time caring during Fall of 2020 at 18.7 hours/ week. Overall, the majority (68%) of Canadian CEs found caring to be more difficult due to COVID-19. On average, Canadian CEs feel they will have to spend more time caring in the future and estimate they will spend 22.3 hours a week caring.

Fig. 1.

Percent of first time CEs by country as a result of COVID-19.

Fig. 2.

Mean hours spent caring per week over the course of COVID-19 *in color*.

A number of CEs across twelve countries were first time carers (Fig. 1). Most countries, with the exception of India, had fewer (12% to 30%) first time CEs. On the contrary, over half of all CEs in the India sample were first time carers as a result of COVID-19 (51%).

Globally, excluding first time carers, the general trend exhibited by most countries was a sharp increase of mean hours caring per week at the peak of the pandemic, which decreased in Fall of 2020 (Fig. 2). CEs in Canada and Taiwan were exceptions, as time spent caring was slightly higher in Fall of 2020 than the peak of the pandemic. Despite decreases in time spent caring relative to the peak of the pandemic, levels were still higher in Fall 2020 when compared to pre-pandemic.

As noted in Fig. 3 , among CEs who provided care prior to the COVID-19 pandemic in G7 countries and Australia, Canadian CEs spent the third shortest time caring prior to the pandemic, and the second shortest time caring both at the peak of the pandemic and in Fall of 2020. Overall, CEs in Italy, the United Kingdom, and the United States spent more time caring relative to other G7 countries and Australia. CEs in Italy, the United Kingdom, and the United States spent between 19.6 and 22 hours caring per week on average prior to the pandemic, while CEs in all other G7 countries and Australia spent between 16 and 17.8. During the peak of the pandemic, CEs in Italy, the United Kingdom, and the United States spent between 23.6 and 26.2 hours caring per week on average, and in Fall of 2020, spent between 22.3 and 25.5 hours, while comparatively, CEs in all other G7 countries and Australia spent less than 20 hours a week caring in both periods. Overall, CEs in the United States spent the most time caring, while CEs in France spent the least time caring. Among G7 countries and Australia, Germany was the only country where CEs anticipated spending less time caring in the future.

Fig. 3.

Mean hours spent caring per week over the course of COVID-19 - G7 and Australia.

In addition to spending the most hours per week caring on average, CEs in Italy, the United Kingdom, and the United States also had the largest increase in time spent caring in Fall of 2020, when compared to prior to the pandemic, at 2.7 hours, 3 hours and 3.5 hours respectively (Fig. 4 ). Canadian CEs had the 3rd lowest increase among G7 countries and Australia.

Fig. 4.

Increase in mean hours caring/week: before COVID-19 vs. Fall 2020 - G7 & Australia.

Sources of support

As noted in Fig. 5 , 66% of Canadian CEs reported having never received support from the federal government, 68% from local/provincial governments, and 70% from their employers. During the pandemic, 27% of Canadian CEs were receiving support from the federal government, 24% were receiving support from the local/provincial government, and 21% were receiving support from their employers compared to the 13%, 16%, and 13% of Canadian CEs who were receiving support prior to the pandemic from the federal government, local/provincial governments, and employers respectively (Fig. 7). Thirty-two percent feel they are receiving enough support from the federal government, 28% feel they are receiving enough support from local/provincial governments, and 39% feel they are receiving enough support from their employers before and during the pandemic.

Fig. 5.

Percent of CEs that received support by organization.

Fig. 7.

Percent of CEs receiving support before and during COVID-19: G7 and Australia.

Globally, the only countries where over half of all CEs reported having received support, both financial and non-financial, at some point from either the government or their employers were Australia, China, and India (Fig. 5). Canada ranked sixth for federal government support, sixth for local/provincial government support, and last for employer support among the 12 countries.

In Fig. 6 we observe that, among G7 countries and Australia, Australia was notable in having the highest percentage of CEs receiving support at some point from the government and employers, with over 50% of Australian CEs receiving support from their federal government, 44% receiving support from local/state governments, and 49% receiving support from their employers. The highest federal and local/state support was then distantly followed by the United States at 42% and 38% receiving support from federal and local/state governments respectively. Other G7 countries were relatively weaker in the amount of government support given, although Canada was third for both federal and local/provincial support. With respect to CEs receiving employer support, Germany, the United Kingdom, and the United States had comparatively higher rates at 36% to 39%. Canada, France, and Italy each had 30% to 31% of CEs receiving support, with Canada having the lowest levels.

Fig. 6.

Percent of CEs that received support by organization: G7 and Australia*in color*.

During COVID-19, the percentage of CEs receiving support from governments and employers increased across all countries (Fig. 7 ). The percentage of CEs receiving federal government support increased the most in Australia, the United States, and Canada, with a 16-percentage point increase in Australia and a 14 percentage point increase in Canada and the United States. Other G7 countries saw increases between 7 to 13 percentage points. France had the highest increase in support from local governments at 11 percentage points compared to 8 to 9 percentage point increases in other G7 countries and Australia. Germany and Italy had the highest increase in employer support at 16 and 15 percentage points respectively. Australia, France, and the United Kingdom had increases of 12 to 13 percentage points, and Canada and the United States were relatively behind at increases of 7 to 8 percentage points. Interestingly, among G7 countries and Australia, while Canada was 5th in terms of CEs receiving employer support prior to COVID-19, they were last during the pandemic.

Impact on paid work and career

As noted in Fig. 8 , 57% of Canadian CEs feel their paid work responsibilities are negatively affected by being a carer, and 55% feel their careers are negatively affected in the long term (Fig. 9 ). As well, due to COVID-19, 34% of CEs feel they have additional difficulty balancing professional job responsibilities with their caregiver duties (Fig. 10 ).

Fig. 8.

Percent of CEs that feel paid responsibilities are negatively affected by being a carer.

Fig. 9.

Percent of CEs that feel their long-term career is negatively affected by being a carer.

Fig. 10.

Percent of CEs having difficulty balancing job responsibilities and caring due to COVID-19.

CEs in India and France less often feel that their paid work responsibilities are negatively affected by caring duties at 36% and 41%, respectively (Fig. 8). China has comparatively more CEs with paid responsibilities that are negatively affected by caring at 68%. Among countries in the G7 and Australia, Canada and the United Kingdom have more CEs reporting that paid work responsibilities are negatively affected at 57% and 62%, while Australia, Italy, the United States, and Germany have rates between 48% and 52%.

In terms of long-term career, CEs in India again report being negatively affected less often at 36% (Fig. 9). CEs in China also have more CEs negatively affected at 69%. Among CEs in G7 countries and Australia, Canada, Germany, and the United Kingdom have higher proportions of CEs who have long term careers that are negatively affected at 55% to 61% while the United States, France, Australia, and Italy have relatively lower proportions at 47% to 50%.

Globally, among the twelve countries, 21% to 36% of CEs in each country felt more difficulty balancing their paid jobs and caring responsibilities because of COVID-19 (Fig. 10). Among G7 Countries and Australia, Canadian CEs most often reported more difficulty balancing paid jobs and caring responsibilities due to COVID-19 (34%). This was followed by Germany (29%), the United States (27%), the United Kingdom and Australia (25%), Italy (24%), and France (22%).

Emotional/mental, financial, and physical health

Sixty-two percent of Canadian CEs felt caring negatively impacted emotional/mental health, 57% felt it negatively impacted financial health, and 52% felt it negatively impacted physical health (Fig. 11 ) during the period of caring. Additionally, 71% of Canadian CEs felt COVID-19 had worsened their mental health, 56% felt their financial health worsened, and 50% felt their physical health worsened (Fig. 12 ).

Fig. 11.

Percent of CEs that report caring has negative impact on health outcomes.

Fig. 12.

Percent of CEs that report COVID-19 has negative impact on health outcomes.

In developing countries like India, Brazil, Taiwan, and China, financial health was typically negatively impacted more often or as often as emotional health while the developed countries which include Australia, Italy, France, Germany, the United States, Canada, Spain, and the United Kingdom more commonly reported a negative impact on emotional/mental health (Fig. 11). Among G7 countries and Australia, Canada had the 2nd highest proportion of CEs reporting a negative impact on emotional/mental health and financial health, and the 3rd highest proportion of CEs reporting a negative impact on physical health.

Except for China and India, which reported higher amounts of deteriorated financial health, CEs from other countries in the Carer Well-Being Index found COVID-19 deteriorated emotional/mental health more often than financial health or physical health (Fig. 12). Of the G7 countries and Australia, Canadian CEs reported deteriorated emotional/mental health due to COVID-19 most frequently (71%), followed by the United Kingdom (70%), the United States (68%), Italy (63%), France (58%), Germany (57%), and Australia (56%). Additionally, Canadian CEs reported the 4th highest percentage of deteriorated financial health, and the 2nd highest percentage of deteriorated physical health among the G7 and Australia.

Relationship between government support and emotional/mental health

Globally, when plotting rates of government support during COVID-19 against rates of deteriorated emotional/mental health during COVID-19 among the twelve countries (Fig. 13 ), there appears to be a negative relationship between level of government support and deteriorated emotional/mental health. Government support in this case was taken as the maximum of the federal government support and local government support rates.

Fig. 13.

Deteriorated emotional/mental health versus level of government support.

CEs in countries with more government support during COVID-19 appear less likely to report deteriorated emotional/mental health during COVID-19 (Fig. 13).

Additionally, level of support from employers during COVID-19 also appeared to have a negative relationship with deteriorated emotional/mental health (Fig. 14 ). Of the twelve countries, countries where a higher proportion of CEs received employer support during COVID-19 typically had lower rates of deteriorated emotional/mental health as well. Additionally, as reflected in Figs. 13 and 14, employer support appears to have a stronger relationship than government support, with lower rates of deteriorated emotional/mental health. Smaller increases to the level of employer support translated to larger decreases in rates of deteriorated emotional/mental health when compared to government support.

Fig. 14.

Deteriorated emotional/mental health versus level of employer support.

Discussion

Based on the Pearlin et al. (1990) stress process model, as well as the available literature related to the health and support in family caregiving, our study confirmed both hypotheses to be true: (1) COVID-19 had negative impacts on CEs, evident in: (a) time spent caring; (b) sources of support; (c) impact on paid work and career, and; (d) emotional, financial, and physical health across twelve countries, and; (2) During COVID-19, CEs across 12 countries experienced deteriorating emotional/mental health in those countries characterized as having less support from government and/or employers. Numerous factors, such as a country's COVID-19 response, the time of data collection relative to the peak of COVID-19 in each country, existing government legislation surrounding support for carers, and recognition of carers, all need to be considered to contextualize the results of the twelve-country comparison. Overall, all countries saw spikes in the amount of time CEs spent caring (Fig. 2). In a qualitative study on the concerns of carers during COVID-19, interviewed carers described how social isolation deteriorated the mental health of their care recipients as family members could not visit and social activities were restricted (Lightfoot, 2021). In cases of dementia, care recipients felt distress and confusion, sometimes feeling like their family was deliberately making them isolated (Lightfoot, 2021). Aligning with this perspective, the area of responsibility that increased most in the Carer Well-Being Index was providing emotional support, which ranged from 50% to 71% of carers, except for Taiwan at 34%. This suggests that CEs are predominantly spending more time providing emotional support due to the worsening mental health of care recipients. This suggests that supports addressing the social isolation of those being cared for would meaningfully ease the burden of CEs. Another reason time spent caring may have increased is due to the inability to access pre-pandemic informal help and supports, such as friends and family, as many carers report being concerned about letting informal supports into their homes due to COVID-19 (Lightfoot, 2021). Lacking these supports may have contributed to increased complexity of caring, reflected in 68% of Canadian CEs feeling caring is more difficult during COVID-19. Time spent caring was lower in Fall 2020 than in the peak of the pandemic for most countries; however, it was still higher than pre-pandemic levels, suggesting that there had yet been a return to normalcy.

Specific interest has been placed on countries in the G7 and Australia, due to these countries having similar levels of economic development as Canada, as well as having somewhat similar strategies, goals, and policy initiatives with respect to CEs, particularly around flexible work (Yeandle et al., 2017). Over half of all CEs felt paid work responsibilities were negatively affected by caring in the UK, Canada, Germany, and the United States, while less than half felt they were negatively affected in Italy, Australia, and France (Fig. 8); in particular, the UK and Canada stood out at 57% and 62% respectively. This divide seems loosely associated with the strength of available flexible work arrangements in each of the countries concerned. In the UK, there is a question of accessibility to flexible work, as the RTRFW allows CEs to request care leave, but can be rejected on business grounds (Yeandle et al., 2017); consequently, this may deter CEs from utilizing it. In Canada, while Family Caregiver Leave and Family Medical Leave are available (Yeandle et al., 2017), policies are focused more on leaves for end-of-life care; this ignores CEs engaged in long-term caring responsibilities that are not end-of-life. In Australia and Italy, carers are entitled to regular short-term leave, which is more versatile and allows carers to decide how to split time between work and caring (Yeandle et al., 2017; Eurocarers 2020a).

During the COVID-19 pandemic, 34% of Canadian CEs reported having more difficulty balancing their job responsibilities with caring, higher than other G7 countries and Australia which ranged from 22% to 29% (Fig. 10). Several factors may have contributed to this, such as heightened difficulty of care demands, increased time spent caring, and difficulties adjusting to work from home arrangements; however, the data suggest that the main cause may have been the lack of support Canadian CEs received from employers. Seventy percent of Canadian CEs did not receive support from their employers, representing the lowest amount of support among all 12 countries in the Carer Well-Being Index. CEs account for approximately 35% of the Canadian workforce (Wang et al., 2018). The fact that 55% of Canadian CEs feel their careers are negatively affected in the long term as a result of caring should cause serious concern, as this likely contributed to many Canadian CEs choosing to leave the workforce permanently post-pandemic. Employers in Canada have been reporting vacant positions caused by labour shortages, partly due to employees choosing to leave the workforce during the COVID-19 pandemic (Ericaalini, 2021). Now, more than ever, there is urgency for employers to recognize and support CEs through a range of different supports, which can be laid out in a carer-friendly workplace policy.

As previously mentioned, 70% of CEs in Canada did not receive any support from their employers (Fig. 6). As well, only 39% of CEs felt that they were receiving enough from their employers. It should be noted that during the pandemic, employers tried to take a more flexible approach towards work given the numerous lockdowns caused by the pandemic. However, based on data from the Carer Well-Being Index, employers did not meet the needs of CEs. This demonstrates that a systemic approach needs to be taken to support CEs, where employers create carer-friendly practices and policies, as suggested in the complimentary CSA Carer-Inclusive and Accommodating Organizations Standard (B701-17 Carer-inclusive and accommodating organizations - CSA Group) and accompanying complimentary handbook, Helping worker-carers in your organization (B701HB-18 Helping worker-carers in your organization - CSA Group); both these resources provide ready guides to inform this critical need. In Canada and the United States, employer support increased the least during the pandemic, at 7 to 8 percentage points (Fig. 7). In contrast, other G7 countries and Australia had increases of 12 to 16 percentage points. This suggests that working from home arrangements are not the best solution to supporting CEs. Instead, a range of options need to be available based on the specific needs of CEs. It should also be noted that while employer supports can help CEs, the ability to provide support is not always possible or economically feasible for many small and medium sized businesses (Vuksan, 2012a; Vuksan, 2012b).

Despite the various financial and non-financial supports available across G7 countries and Australia, as outlined in the literature review, the number of CEs receiving support from governments was incredibly low. Pre-pandemic, Australia had by far the highest rate of federal support at 25%, followed by the United States at 17%, with all other G7 countries at 10% to 13% (Fig. 7). As well, Australia had the highest percentage of CEs receiving support from both local/state governments and employers. There are a few reasons why CEs may not be accessing this government support, including not meeting eligibility criteria due to many supports being means-tested; it is also likely that CEs may not be aware of the available social programs, as has been well documented in the case of the Canadian Compassionate Care Benefit (Giesbrecht et al., 2012; Williams et al., 2011; Crooks et al., 2007; Giesbrecht et al., 2010a; Giesbrecht et al., 2010b; Giesbrecht et al, 2009; Williams et al., 2006; Crooks et al., 2008; Crooks et al., 2012). In Australia, where double the number of CEs have received support than most G7 countries, there is a concerted effort to recognize the contribution of carers, as well as publicize the available supports. National Carers Week is an initiative of Carers Australia that is funded by the Australian Government; this initiative not only raises community awareness, but also serves to direct carers towards avenues of support (IACO, 2018). The low rates of CEs receiving support from government in Canada indicates that there is a critical gap in information and access to information regarding existing policies and programs.

With the exception of India and China, caring, especially during COVID-19, predominantly deteriorated emotional/mental health (Figs. 9 and 10). In Canada, 71% of CEs felt their emotional/mental health was negatively impacted by COVID-19, the most among G7 countries and Australia. This is likely due to a range of factors, including: social isolation, increased burden of care responsibilities, difficulties adjusting to working from home arrangements, and inadequate support. Data from the twelve countries show that countries with more support for CEs during the pandemic, both government and employer, are less often to have high rates of deteriorated emotional/mental health (Figs. 13 and 14). This reinforces the notion that government and employer supports work in better managing the burden of care for CEs. Additionally, the benefit of employer support also appears stronger than government support, suggesting that the immediate work environment provides a critically important social, financial and support network for CEs that needs to be prioritized.

Limitations

As noted in the Methods section above, one of the major limitations of the study is the Carer-Index data is aggregated at the country level only; that is, individual data were not available.  As a result, our study has a few limitations. First, we were unable estimate inferential statistics so were unable to examine the changes experienced over the course of COVID-19 in each country, nor were we able to examine any differences across the twelve participating countries. Second, the data would not allow us to more specifically compare a range of variables of interest, such as sex, gender, income or ethnicity, etc. Third, although the characteristics of participating respondents may be significantly different, we were unable to conduct more sophisticated analysis, such as controlling for potential confounders, such as sex and gender (given what is known about the unequal distribution of caring responsibilities across these variables). Thus, this may have led to a degree of bias in the relationship between support of caregiving and the emotion/mental health, as the samples compared do not have similar characteristics in critical variables. Nevertheless, the findings in this study provide additional insight into the impact of the COVID-19 pandemic on carer-employees’ well-being. This is especially important given, to our knowledge, that this is the first global comparison of the carer-employee experience.

Conclusion

The aim of this analysis is to assess the potential ways that the COVID-19 pandemic has comparatively impacted Canadian CEs, while identifying the needs and assistance CEs feel is required for them to continue providing care. Certain steps need to be taken to improve the well-being of Canadian CEs during and after the COVID-19 pandemic. Federal, provincial, and local governments in Canada should best learn from the pandemic and both create and build on policies and programs that increase support for CEs, either through new legislation or increased awareness of existing supports. The CSA Carer-Inclusive and Accommodating Organizations Standard (B701-17 Carer-inclusive and accommodating organizations - CSA Group) and accompanying handbook, Helping worker-carers in your organization (B701HB-18 Helping worker-carers in your organization - CSA Group) provide complimentary, ready resources to guide and inform this critical need. As suggested elsewhere (Ireson et al., 2018; Ding et al., 2020a; Ding et al., 2020b; Williams et al., 2017; Lorenz et al., 2021; Ramesh et al., 2017; Wang et al., 2018; Sethi et al., 2017), large employers with the means necessary need to take a systemic approach to providing supportive work arrangements, such as non-contiguous paid and unpaid leave, flexible hours, and supportive technology for employees providing care. Finally, the social isolation of dependent care recipients also needs to be addressed and, if done, will help ease the growing responsibility of providing emotional support by CEs.

Funding

Funding was provided via a CIHR/SSHRC Healthy, Productive Work Partnership Grant: "Scaling up the Carer Inclusive Accommodating Organizations Standard" FRN: HWP - 146001 (CIHR); 890-2016-3018 (SSHRC)

Authors contribution

Jerry Wu wrote the manuscript and performed the data analysis. Dr. Williams supervised the team, oversaw the data acquisition, led the study design, initiated and managed research ethics approval, managed and assisted with writing and manuscript preparation. Nadine Henningsen provided access to the survey data and contributed feedback on the data analysis. Dr. Kitchen contributed to the data analysis and assisted with writing of the paper. Dr. Wang supervised the statistical analysis.

Ethics approval

Approved by the McMaster Research Ethics Board (MREB); Ethics Clearance Certificate #5688.

Declaration of Competing Interest

The authors declare that they have no conflict of interest.