key: cord-0756609-rsv0hido
authors: Baiden, Philip; LaBrenz, Catherine A.; Findley, Erin
title: Social distancing and anxiety among female caregivers of children ages zero-to-five during coronavirus disease (COVID-19) lockdown in the United States
date: 2021-05-05
journal: J Affect Disord Rep
DOI: 10.1016/j.jadr.2021.100154
sha: 0d7ccc7d66df77a9676e01d2454709037da5917b
doc_id: 756609
cord_uid: rsv0hido

BACKGROUND: Past studies have linked measures of social isolation to mental health among caregivers of children. As people across the world adjust to social distancing measures, there is a need to understand consequences of social distancing measures on mental health. Thus, the objective of this study is to examine the association between adherence to social distancing measures and feeling worried/anxious among female caregivers of children ages zero-to-five. METHODS: Data for this study came from an online survey that was administered between May and June 2020 to understand stress and mental health among caregivers of children during the COVID-19 pandemic. A sample of 358 female caregivers was analyzed using binary logistic regression with feeling worried/anxious as the outcome variable. RESULTS: More than a third of the female caregivers (35.2%) reported feeling worried/anxious during the past month and about 42% reported strictly adhering to social distancing measures. Controlling for the effect of other factors, caregivers who reported strictly adhering to social distancing had 1.86 times higher odds of feeling worried/anxious when compared caregivers who were not strictly adhering to social distancing (AOR=1.86, 95% C.I.=1.07–3.24). Caregivers who felt bothered by withdrawal from activities of interest had 4.11 times higher odds of reporting feeling worried/anxious (AOR=4.11, 95% C.I.=2.32–7.24). CONCLUSIONS: As COVID-19 pandemic continues to evolve, it is important to build community response to better support caregivers of infants and young children. Implications for practice, policy, and research as they relate to caregiver's mental health are discussed.

Since March 2020, millions of Americans across the US have been impacted by the novel Coronavirus Disease 2019 (COVID-19) and its subsequent restrictions and disruptions to daily life. As people across the world adjust to social distancing, shelter-in-place, or even more extreme quarantine measures, experts have been tasked with weighing physical health risks of opening too soon with the risks to mental health, economic stability, and overall well-being. Considering that widespread measures have only been implemented since March 2020, there are few studies that have empirically examined mental health and well-being during COVID-19. Nonetheless, there have been recent calls to better understand mental health and how to mitigate negative mental health outcomes, such as anxiety or depression, during the pandemic ( Brooks et al., 2020 ; Holmes et al., 2020 ; Pfefferbaum and North, 2020 ; parental burnout ( Lindström et al., 2011 ; Norberg, 2010 ; Roskam et al., 2017 ) . These studies have shown that similar to job burnout, parental burnout is stress-related and can manifest in three forms: emotional exhaustion, emotional distance, and emotional disengagement ( Sánchez-Rodríguez et al., 2019 ) . Emotional exhaustion refers to the state of feeling emotionally drained and exhausted. Emotional distance refers to the parent's emotional distance from the child. Emotional disengagement refers to a lack of motivation and fulfillment by a parent in performing their role as a parent ( Sánchez-Rodríguez et al., 2019 ) .

Parental burnout may be more common during early childhood, given the level of dependence and need that children present during the first years of life . In parallel, infants and young children may be particularly vulnerable to the impacts of parental stress and burnout, given the rapid brain formation and development that occurs during the first few years of life ( Tierney and Nelson III, 2009 ). In addition, infants and younger children are often not visible in other systems, such as schools, and therefore may not have a regular check-in from a teacher or counselor. Thus, it is particularly important to understand how families with infants and young children are faring during the pandemic.

Epidemics and pandemics have short-and long-term adverse effects on survivors' mental health ( Holmes et al., 2020 ; Mitchell et al., 2016 ) . Evidence from past epidemics such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS; Amare et al., 2018 ; Betancourt et al., 2013 ; Catalan et al., 2011 ; Ebuenyi et al., 2018 ; Hartog et al., 2020 ) , severe acute respiratory syndrome (SARS; Yi-Ching et al., 2006 ) , influenza A virus subtype H1N1 ( Page et al., 2011 ), Zika ( de Souza et al., 2018 , and Middle Eastern Respiratory Syndrome (MERS; Jeong et al., 2016 ) , suggest increases in rates of mental health symptoms such as anxiety, depression, and posttraumatic stress disorder (PTSD). More recently, studies have found an increase in rates of anxiety following the Ebola outbreak in the general population ( Cénat et al., 2020 ; James et al., 2019 ; Waterman et al., 2018 ) . With respect to COVID-19, there is emerging evidence of widespread fear of infection accompanied by psychological distress, particularly during the initial phase of the pandemic ( Ahorsu et al., 2020 ; Harper et al., 2020 ; Rauch et al., 2020 ; Satici et al., 2020 ; H. Wang et al., 2020 ) . Qiu et al. (2020) examined psychological distress among Chinese people and found that more than a third of adults experienced severe levels of anxiety and stress-related symptoms as a result of COVID-19.

With the advent of COVID-19, a number of non-pharmaceutical measures were put in place to prevent the spread of COVID-19. One such measure adopted by the Centers for Disease Control and Prevention (CDC) ( Centers for Disease Conrol and Prevention 2020 ) was social distancing, with the goal of "flattening the curve " to avoid overwhelming the health system. Social distancing is a community infection control measure that seeks to reduce the frequency and intensity of close contact with other humans by closing public places, avoiding large gatherings, and staying at least six feet apart from members who are not from one's household. Previous empirical research provides us with rich data on the adverse effects of social distancing on physical and overall mental health well-being ( Hawthorne, 2008 ; Perissinotto et al., 2012 ; Smith and Victor, 2019 ; Smith and Christakis, 2008 ; Valtorta et al., 2016 ; Wang et al., 2019 ; Ypsilanti et al., 2020 ) . Holt-Lunstad et al. (2010) and Ikeda and Kawachi (2010) have also provided a detailed review of the impact of social isolation on health and mental health outcomes.

Conversely, social support has been found to buffer the effect of many health and mental health problems (see e.g., Baiden et al., 2017 ; Berkman et al., 2014 ; Holt-Lunstad et al., 2010 ; Kawachi and Berkman, 2014 ; LaBrenz et al., 2019 ) . Social support has been posited to affect health and mental health through two main pathways: 1) as a direct effect on health and mental health and 2) as a buffer against stressful life events ( Cohen and Wills, 1985 ) . As a direct effect on health and mental health, the perception of the availability of support offers protection to individuals. The source, quantity, or quality of the amount of resources available to individuals could go a long way in determining the mental health and well-being of an individual, especially in times of crisis ( Cohen and Wills, 1985 ) . As a buffer, social support acts to protect the mental health of individuals, particularly individuals who are faced with adverse life events such as maltreatment or the loss of a loved one ( Cohen and Wills, 1985 ) . Systematic reviews and metaanalyses have documented the positive effect of social support in enhancing mental health well-being ( Bigby, 2012 ; Casale and Wild, 2013 ; Holt-Lunstad et al., 2010 ) .

To the best of our knowledge, the consequences of social distancing measures on mental health among caregivers with infants and young children have not been investigated. A study that examined distress and mental health symptomatology among pregnant women from Quebec, Canada, found that women who were pregnant during COVID-19 had higher rates of depressive or anxiety symptoms than their counterparts who were pregnant prior to COVID-19 ( Berthelot et al., 2020 ) . Griffith (2020) called for strategies to support caregivers during COVID-19, given that caregiver stress has been linked to child maltreatment. Thus, the primary objective of this paper is to examine the association between adherence to social distancing measures and feeling worried/anxious among female caregivers of children ages zero-to-five. We hypothesized that: 1) caregivers who strictly adhere to social distancing measures would report higher odds of feeling worried/anxious when compared to caregivers who do not strictly adhere to social distancing measures; 2) caregivers who felt bothered by withdrawal from activities of interest would report higher odds of feeling worried/anxious when compared to caregivers who do not feel bothered by withdrawal from activities of interest.

Data were utilized from an online survey that was developed and administered by the authors of this study to examine caregiver stress among caregivers of children ages zero-to-five during the COVID-19 pandemic. The survey consisted of questions the authors developed related to adherence to social distancing, challenges since COVID began, service utilization, and parenting stress. Participants were recruited via social media and childcare centers to target caregivers with children under six years of age. The survey was completed online between May and June 2020 using Qualtrics. The analysis presented in this study focuses on female caregivers of children ages zero-to-five in the US. A total of 496 female full-time/primary caregivers (most of whom were the biological mother) with at least one child between the ages of zero-to-five years completed the online survey between May and June 2020. However, the analysis presented in this study focuses on respondents with complete data on all the variables included in the multivariable logistic regression analysis. This resulted in an analytic sample of 358 respondents. Demographic characteristics of the analytic sample ( N = 358) are presented in Table 1 . The study was approved by the Institutional Review Board at the first author's institution.

In the US, most states started implementing measures against COVID-19 after the US president declared a national emergency on March 13, 2020. On March 15, 2020, the CDC cautioned against holding or attending large gatherings of more than 50 people, including sporting events, festivals, conferences, concerts, weddings, and religious services for the next eight weeks. Individuals were advised to cancel or postpone these events in order to avoid community spread of COVID-19. To practice social distancing, individuals were advised to limit face-to-face contact with others and stay at least six feet away from other people who are not from the same household.

The outcome variable examined in this study was feeling worried/anxious and was measured as a binary variable. The original variable asked caregivers "Over the past month, how often have you felt worried/anxious " with the following response options " 0 = None of the time ", "1 = A little of the time ", "2 = Some of the time ", "3 = Most of the time, and "4 = All of the time. " For the purposes of this study, caregivers who reported feeling worried/anxious "most of the time " or "all of the time " were grouped together and coded as 1; otherwise, they were coded as 0.

The main explanatory variables examined in this study were adherence to social distancing measures and being bothered by withdrawal from activities of interest. Adherence to social distancing measures was measured based on the question "On a scale of 1-5, with 5 being "very strict " and 1 being "not at all strict, " please rate your level of adherence to social distancing measures during COVID-19. " Caregivers who indicated "strictly adhering to social distancing measures " were recoded as 1; otherwise, they were recoded as 0. Being bothered by withdrawal from activities of interest was measured as a binary variable based on response to the question "Over the past month, how often have you been bothered by withdrawal from activities of interest -e.g., long-standing activities, being with family/friends etc. " Caregivers who reported being bothered by withdrawing from activities of interest "most of the time " or "all of the time " were grouped together and coded as 1; otherwise, they were coded as 0.

Other covariates examined in this study included education, household income, problems with childcare during COVID-19, lack of support during COVID-19, mental health issues during COVID-19, and parenting stress. Level of education was measured as a nominal variable into the following categories: "0 = High school or less ", "1 = Some college or associate degree ", "2 = Bachelor's degree ", "3 = Graduate or professional degree ", and "4 = Doctorate ". Household income was measured as a nominal variable into the following categories: "0 = Less than $20,000 ", "1 = $20,000-$39,999 ", "2 = $40,000-$59,999 ", "3 = $60,000-$79,999 ", and "4 = $80,000 and above ".

Caregivers were asked "On a scale of 1-5, with 5 being "very much a problem " how much of an issue have the following been in your household from March 2020 on (during COVID-19 pandemic): Childcare, lack of support, and mental health issues. For the purposes of this study, caregivers who indicted "often a problem " or "very much a problem " were recoded as 1; whereas, parents who indicated "not a problem at all ", "a little bit of a problem ", or "somewhat a problem " were recoded as 0.

Caregiver stress was measured as a continuous variable using the Parenting Stress Scale (PSS; Berry and Jones, 1995 ) . The PSS is an 18item self-report measure designed to assess parenting stress across domains of rewards, stressors, lack of control, and satisfaction ( Berry and Jones, 1995 ) . Caregivers were asked to indicate on a five-point Likert scale ranging from "1 = Strongly Disagree " to "5 = Strongly Agree " the extent to which they agree or disagree with the following statement, e.g., "I am happy in my role as a parent ", "There is little or nothing I wouldn't do for my child(ren) if it was necessary ", "Caring for my child(ren) sometimes takes more time and energy than I have to give ", "The behavior of my child(ren) is often embarrassing or stressful to me ", "If I had it to do over again, I might decide not to have child(ren) ", "I am satisfied as a parent ", etc. Some items were reverse-scored so that high scores would indicate higher levels of caregiver stress. Scores on the PSS are then summed to arrive at a total score ranging from 18 to 90, with higher scores indicating severe caregiver stress. The PSS has been used in various studies and has been found to have strong psychometric properties ( Berry and Jones, 1995 ; Louie et al., 2017 ; Zelman and Ferro, 2018 ) . In the present study, Cronbach's alpha coefficient for the PSS was = 0.87, indicating high internal consistency among the 18 items, and the results indicate that deleting items from the scale would not improve the overall Cronbach's alpha coefficient.

The following demographic variables were also taken into account: age, race/ethnicity, and number of children in household. Age was measured as a nominal variable into "0 = 18-24 years ", "1 = 25-34 years ", "2 = 35-44 years ", and "3 = 45 years and above ". Race/ethnicity was also measured as a nominal variable into the following categories "0 = non-Hispanic White ", "1 = Black/African-American ", "2 = Hispanic ", "3 = Asian ", and "4 = Other race/ethnicity ". Lastly, number of children in household was measured as a continuous variable.

Descriptive statistics were first performed using percentages for the categorical variables and mean and standard deviation for number of children in household and PSS. The main analysis involved the use of binary logistic regression to examine the association between adherence to social distancing and being bothered by withdrawal from activities of interest and feeling worried/anxious while controlling for the effects of other covariates. Binary logistic regression was chosen as it is more robust in predicting binary outcome variables (in this study, feeling worried/anxious) with independent variables that could be measured as continuous or categorical variables (Tabachnick & Fidell, 2007) . In the logistic regression, we present the adjusted odds ratios (AOR) to indicate the likelihood of reporting anxiety based on the explanator variable or each covariate in the model. For odds ratio, any number greater than one signifies that the factor increases the likelihood of anxiety, while any number less than one signifies that the factor decreases the likelihood of anxiety. All variables were entered into the model using the enter procedure. Model fitness was assessed using the Wald chi-square and the pseudo R square. Variables were considered significant if the pvalue was less than .05. Adjusted odds ratios (AOR) and 95% C.I. were reported. All statistical analyses were executed using Stata 14. Table 1 shows the general distribution of the variables examined in this study. More than a third of the caregivers (35.2%) reported feeling worried/anxious during the past month. About 42% of the caregivers reported strictly adhering to social distancing measures. About one in four caregivers (24.6%) reported being bothered by withdrawal from activities of interest. Most of the caregivers self-identified as White (80.7%), 10.9% self-identified as Hispanic, 4.2% as Asian, 1.7% as Black/African American, and 2.5% as "other race/ethnicity ". The sample was highly educated, with a third of the caregivers having bachelor's degree, 30.2% having graduate or professional degree, and 13.4% having a doctorate degree. Close to two-third of the caregivers (65.9%) had a household income of $80,000 and above. Approximately one in three (29.6%) caregivers reported problems with childcare during, 17% reported a lack of support, and 13.4% reported mental health issues during COVID-19. The average number of children per household was 2.91 (SD = 0.86), and the average PSS score was 42.02 (SD = 8.60). Table 2 shows the results of the multivariable logistic regression examining the association between adherence to social distancing and being bothered by withdrawal from activities of interest and feeling worried/anxious. Both model fitness indices indicated that the logistic regression model was fit. The Wald chi-square test statistic was significant ( 2 = 80.69, df = 22, p < .001). Together, all the variables explained 26.36% of the variance in feeling worried/anxious. Compared to caregivers who were not strictly adhering to social distancing, caregivers who reported strictly adhering to social distancing had 1.86 times higher odds of feeling worried/anxious (AOR = 1.86, p = .029, 95% C.I. = 1.07-3.24). Caregivers who felt bothered by withdrawal from activities of interest had 4.11 times higher odds of reporting feeling worried/anxious when compared to their counterparts who were not bothered by withdrawal from activities of interest (AOR = 4.11, p < .001, 95% C.I. = 2.32-7.24).

Age, race/ethnicity, education, and number of children in the household were not significantly associated with feeling worried/anxious. With respect to household income, caregivers who made $60,000-$79,999 had 92% lower odds of feeling worried/anxious when compared to their counterparts who made less than $20,000 (AOR = 0.08, p = .042, 95% C.I. = 0.01-0.91). No other income category was significantly associated with feeling worried/anxious. Caregivers who reported having problems with childcare during COVID-19 had more than three-fold higher odds of feeling worried/anxious when compared to their counterparts who had no problem with childcare during COVID (AOR = 3.10, p < .001, 95% C.I. = 1. 64-5.86 ). Caregivers who reported having problems with mental health issues during COVID-19 had almost ten-fold higher odds of feeling worried/anxious when compared to their counterparts who had no problem with mental health issues during COVID (AOR = 9.50, p < .001, 95% C.I. = 4.00-22.57). Lastly, each one-unit increase in PSS score increased feeling worried/anxious by a factor of 4% (AOR = 1.04, p = .040, 95% C.I. = 1.01-1.08).

This study examined the association between adherence to social distancing measures and maternal anxiety. These findings can contribute to our knowledge of caregivers' mental health during the COVID-19 pandemic. As the debate continues about opening up or easing restrictions, it is important to weigh physical health with caregivers' mental health and overall well-being. Indeed, over one-third of the sample reported feeling worried/anxious recently, almost one-third reported issues with childcare during COVID-19, and over one in ten reported mental health issues during COVID-19. This is congruent with a recently released report from the CDC that found high rates of mental health issues, including almost one-third that reported anxiety or depression, with the highest mental health issues among unpaid adult caregivers and young adults ( Czeisler et al., 2020 ) . Thus, there is a need to support families, especially those in caregiving roles and with additional childcare responsibility during the current crisis.

The result from our study supported our main hypothesis, in that adherence to social distancing was positively associated with feeling anxious. Although few other empirical studies have been conducted of caregivers' mental health during COVID-19, some experts have called for policies to mitigate negative mental health issues that could develop or be exacerbated by social distancing ( Venkatesh and Edirappuli, 2020 ) . As the number of caregivers reporting mental health problems increases during the pandemic ( Patrick et al., 2020 ) , it is important to provide support and enhance family resilience. Moreover, participants who reported being bothered by withdrawal from activities of interest were more likely to report feeling worried/anxious. This withdrawal from activities of interest has the tendency to lead to boredom, frustration, and a sense of isolation ( Watson and Nesdale, 2012 ) . It is important that public health messages focus on reminding individuals about what they can do to ease off boredom with practical advice on stress management and coping techniques. Utilizing one's social network, even remotely, has the potential to ease boredom and anxiety ( Manuell and Cukor, 2011 ) . The use of mobile technology such as Skype, FaceTime, Zoom, and the ubiquitousness of social media could play a significant role in communicating with friends and family members far away. Therefore, providing reliable and free Wi-Fi and internet access where individuals can communicate directly with their friends and loved ones and reassure them that they are doing well could go a long way in reducing stress and anxiety ( Brooks et al., 2020 ) .

In addition to adherence to social distancing, overall caregiver stress and childcare issues during COVID-19 were also linked to feeling worried/anxious. Notably, the average caregiver stress score among mothers in this sample was slightly higher than the average in prior clinical samples of mothers whose infants presented with sleep disturbances ( Ford, 2011 ) , but slightly lower than a prior clinical sample of mothers screened into an intervention because of preschool behavioral or developmental difficulties ( Griffin et al., 2010 ) . Thus, although caregivers in our sample were stressed, the average caregiver stress was not greater than some samples in prior literature. Concerning childcare, Patrick and colleagues (2020) also found that childcare issues impacted a substantial proportion of families during COVID-19. Indeed, prior literature has found that access to childcare can provide caregivers with other resources, such as community or neighborhood connections ( Small, 2006 ) , as well as formal or informal networks ( Dolan and Sherlock, 2010 ) . Prior research has found that parental satisfaction with daycare decreases overall caregiver stress ( Bigras et al., 2012 ) . Already, there have been reports of the disparate impact of COVID-19 and childcare on females ( Burki, 2020 ) . Indeed, gendered differences and challenges with access to childcare and disruptions to work have been exacerbated and made more visible during the current pandemic. Thus, it is important to continue to support childcare accessibility and provide options for mothers who may not have other support networks readily available.

The findings of this study are not without limitations. First, the data come from a small convenience sample and therefore are not necessarily generalizable to the entire US population. Second, the sample was largely homogenous, with a high proportion of White, well-educated, most of whom were in heterosexual relationships with two full-time professional incomes. Thus, it is also possible that the resources available to this sample may not be representative of all caregivers in the US. Third, we only collected caregiver-reported information. Future research could include reports of child behavior or mental health, as well as reports from other sources such as teachers. Lastly, the cross-sectional nature of the data does not allow for any causal inferences; thus, only an association can be inferred. One possibility to explore in future research is whether mothers with previously high levels of anxiety are more likely to adhere strictly to social distancing measures in the first place. Having at least one measurement time point before COVID-19 lockdown and another measurement time point during COVID-19 lockdown would have afforded us a much better opportunity to understand the association between social distancing measures and feeling worried/anxious.

The current study contributes towards a burgeoning number of international studies calling for a multidisciplinary approach to better understand the economic, social, and psychological impact of COVID-19 ( Brooks et al., 2020 ; Pieh et al., 2020 ; C. Wang et al., 2020 ) . Specifically, a recent review of the psychological impact of social distancing measures underscores the wide-ranging and long-lasting impact of social distancing and calls for enhanced monitoring of reported rates of mental health problems such as depression, anxiety, substance use, and suicidal behaviors so as to better inform global responses to the pandemic ( Brooks et al., 2020 ) . In the current study, we found that adherence to social distancing measures, having childcare and mental health difficulties, and being bothered by withdrawal from activities of interest were salient factors associated with feeling worried/anxious during COVID-19. The findings of this study are not to imply that nonpharmacological interventions such as social distancing should not be used, as the ultimate consequences of not using social distancing measures and allowing the virus to spread might be more devasting. However, the long-term economic, mental health, and developmental impact of strict social distancing should be weighed with the physical health benefits.

The findings from this study can help inform policy, practice, and future research to better understand how to support families during COVID-19, as well as coping with the pandemic. From a policy standpoint, as local communities, states, and the federal government continue to monitor COVID-19 cases, it could be beneficial to include resources that could decrease caregiver stress and allow for continued access to quality childcare. Policies at the federal, state, and individual workplace levels should also recognize the disparate impact of childcare duties or other caregiving responsibilities on women ( Burki, 2020 ) . Policies should also seek to balance prioritization of physical health with men-tal health and to reduce forms of stress that negatively impact family well-being.

From a practice standpoint, the percentage of respondents who reported mental health issues, including feeling worried/anxious, during COVID-19, suggests an increase in preventative mental health services for families is warranted. One suggestion is for mental health agencies to be provided training and support to provide virtual mental health support for parents, including counseling, support groups, and perhaps even case management support for families experiencing the most difficulty. This could be particularly useful for caregivers of infants and young children, given that often they are not enrolled in schools that may be conducting more outreach or periodic check-ins. Thus, local community agencies and organizations could conduct outreach to target caregivers of children zero-to-five and provide support as needed.

While the findings of this study guide our knowledge about maternal mental health during the COVID-19 pandemic, it also identifies gaps for future research. One area research should continue to focus on is understanding family mental health and well-being during this unprecedented time. Emphasis should be placed on identifying factors that detract from, and contribute to, family mental health and well-being, so that effective prevention and intervention strategies can be implemented. Additionally, research should expand these findings to track changes in anxiety over time, including factors that contribute to these changes, such as specific services, increased access to childcare, or the like. Other research could target those not adhering to social distancing guidelines, specifically to understand whether their report of lower anxiety translates to a lower experience of stress. Finally, longitudinal research should investigate the link between caregiver's mental health and future child outcomes.

In conclusion, the findings of this study suggest that adherence to measures of social distancing and being bothered by withdrawal from activities of interest are associated with feeling anxious among female caregivers of children ages zero-to-five. As the pandemic continues to evolve, it is important to build community response to better support caregivers of infants and young children. Adapting to caregiving can produce feelings of isolation and anxiety even during normal times; and during a pandemic, it is crucial to provide support and check-ins to ensure that mothers feel supported and connected.

The authors declare that they have no conflicts of interests with respect to the authorship and/or the publication of this paper.

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Philip Baiden would like to gratefully acknowledge support received from the Jillian Michelle Smith Professorship in Family Violence Research at the University of Texas at Arlington, School of Social Work.