Changes in Health Indicators Among Caregivers — United States, 2015–2016 to 2021–2022

Caregivers provide support to persons who might otherwise require placement in long-term care facilities. Approximately one in five U.S. adults provides care to family members or friends who have a chronic health condition or disability. Promoting the well-being of this large segment of the population is a public health priority as recognized by the 2022 National Strategy to Support Family Caregivers. Although negative associations between caregiving and caregiver health are known, changes in the health status of caregivers over time are not. Data from the 2015–2016 and 2021–2022 Behavioral Risk Factor Surveillance System were analyzed to compare changes in the prevalence of 19 health indicators among cross-sectional samples of caregivers and noncaregivers at different time points. Caregivers experienced improvements in prevalence of four health indicators, whereas six worsened. Some health indicators, such as cigarette smoking, improved for both caregivers and noncaregivers, although smoking prevalence remained higher for caregivers (16.6% versus 11.7%). Prevalence of lifetime depression increased for both groups and remained higher among caregivers (25.6%) than among noncaregivers (18.6%). During 2021–2022, age-adjusted estimates for caregivers were unfavorable for 13 of the 19 health indicators when compared with noncaregivers. Strategies for supporting caregivers are available, and integrating these with existing programs to address mental health and chronic diseases among this population might improve caregiver well-being. For example, many community organizations support caregivers by offering interventions designed to relieve caregiver strain, including skills training, support groups, and care coordination.

Caregivers provide support to persons who might otherwise require placement in long-term care facilities. Approximately one in five U.S. adults provides regular care or assistance to a friend or family member with a health condition or disability (1). Promoting the long-term well-being of this large segment of the population is a public health priority as recognized by the first National Strategy to Support Family Caregivers (2). The time commitment and responsibilities of caregiving can place an undue emotional, economic, and physical burden on caregivers (2). During 2015–2017, caregivers in the generation born during 1946–1964 had more chronic health conditions and more frequent mental distress than noncaregivers of the same age (3). Although studies have described differences in health indicators between caregivers and noncaregivers (4,5), this report compares changes in the prevalence of 19 health indicators among caregivers and noncaregivers from 2015–2016 to 2021–2022.

Data Source

The Behavioral Risk Factor Surveillance System (BRFSS) is an annual, state-based, random-digit–dialed telephone survey of the noninstitutionalized U.S. adult population aged ≥18 years in all 50 states, the District of Columbia, and U.S. territories.* In addition to core questions administered to all participants, states can include optional modules. Data from the core BRFSS questionnaire and the optional caregiver module during 2015–2016 and 2021–2022 were assessed for 35 states and Puerto Rico, where the optional caregiver module was included at least once in both periods.^† This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.^§ Among all respondents, 92,461 who responded “yes” to the question, “During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or a disability?” were classified as caregivers. Those who responded “no” or indicated that their care recipient died during the previous 30 days (353,242) were classified as noncaregivers; 2,489 who responded “did not know/not sure” or refused to answer were excluded. Estimates for both periods were available for demographic characteristics (sex, age, race and ethnicity, education level, employment status, marital status, home ownership, and annual household income) and the following 19 health indicators: 1) current cigarette smoking, 2) binge drinking,^¶ 3) heavy drinking,** 4) physical inactivity,^†† 5) fair or poor self-rated health, 6) frequent mental distress,^§§ 7) frequent physical distress,^¶¶ 8) lifetime diagnosed depression,*** 9) coronary heart disease, 10) stroke, 11) chronic obstructive pulmonary disease, 12) arthritis, 13) diabetes, 14) obesity, 15) diagnosed asthma, 16) any chronic physical health condition,^††† 17) multiple chronic physical health conditions, 18) having no health coverage,^§§§ and 19) inability to see a doctor because of cost.^¶¶¶

Statistical Methods

Percentage point changes (changes) in the unadjusted prevalence of demographic characteristics and caregiving status by state during 2015–2016 and 2021–2022 were compared using t-tests. Logistic regression, with age-adjustment using a continuous age variable, was used to measure percentage point differences in health indicators (dependent variable) between caregivers and noncaregivers (independent variable) as well as changes in health indicators (with time indicator as independent variable). Logistic regression was used to determine whether age-adjusted changes among caregivers and noncaregivers were different (i.e., time interaction). Statistical tests with p-values <0.05 were considered significant. Analyses were conducted using SAS software (version 9.4; SAS Institute) and SAS-callable SUDAAN software (version 11.0.1; RTI International) to account for complex sample design and weighting.

A positive social connection can grow between a caregiver and care recipient, providing a sense of purpose for the caregiver and less stress for the care recipient (4). However, caregivers had worse age-adjusted outcomes for 13 of the 19 health indicators examined during 2021–2022. Many of these findings are consistent with previous reports, including the association between caregiving and smoking (5,6), poor mental health (3,4,7), obesity (5), and asthma (3).

Overarching circumstances during the time of the study, including the COVID-19 pandemic and health care reform policies, affected the U.S. population. Increased prevalence of lifetime depression and frequent mental distress among both caregivers and noncaregivers is consistent with findings of population-level mental health impacts during the COVID-19 pandemic (8). Expanded eligibility for Medicaid occurred during the study period,**** and national data indicate that public health plan coverage (including Medicaid) increased among adults aged <65 years (9).

The National Strategy to Support Family Caregivers has raised awareness of the need to support the health of caregivers nationwide. Goals outlined in the strategy include strengthening services and supports for family caregivers and expanding data, research, and evidence-based practices (2). Providing relief from caregiving tasks, broadly known as “respite care,” was identified as a priority. Availability of such services can be optimized through public policies and community collaboration, resulting in high-quality, affordable, and flexible care (2). Additional strategies to ensure financial and workplace security for caregivers have been implemented in some states, and include enhancement of paid family leave and antidiscrimination laws.^††††

Limitations

The findings in this report are subject to at least four limitations. First, all measures are self-reported and might be subject to recall and social desirability bias, possibly resulting in misclassification of health indicators. Second, data were not available in all states, and estimates might not be representative of all U.S. adults. Third, the study design was cross-sectional at two time points rather than longitudinal (i.e., survey participants were not followed over time to observe changes). Finally, this study was descriptive and further adjustment might explain differences between caregivers and noncaregivers. Despite these limitations, this study is the first to examine changes in the health of caregivers from a population health perspective using a large sample.

Implications for Public Health Practice

National, state, and local public health strategies that address comprehensive chronic disease prevention and management^§§§§ could be tailored for caregivers. Many community organizations support caregivers by offering interventions designed to relieve caregiver strain, including skills training, support groups, and care coordination.^¶¶¶¶ Specialized training designed to help caregivers cope with the unique challenges of dementia care can be especially helpful for persons who care for those with memory loss or cognitive decline.***** In health care settings, professionals can take steps to identify patients who serve in a caregiving role and encourage them to seek any support they might need to prioritize their own mental and physical health. Additional critical strategies outlined in the National Strategy to Support Family Caregivers call on public and private sectors to provide resources for caregivers (2).