epubs.surrey.ac.ukepubs.surrey.ac.uk/849109/1/ethesis Sarah Warrell... · Web viewThe study used secondary data from the Understanding Society study. Cross-sectional analysis of how

What factors affect the mental health and well-being of Middle-Aged Male

Carers?

Sarah Warrell-Phillips

Submitted for the Degree of

Doctor of Psychology(Clinical Psychology)

School of Psychology

Faculty of Health and Medical Sciences

University of Surrey

Guildford, Surrey

United Kingdom

September 2018

Abstract

Although males constitute a substantial proportion of carers until recently

there has been little focus on the impact of caring on their mental well-being. This

study aimed to examine the extent to which a variety of contextual, caring related

and protective factors predicted the mental well-being of middle-aged male carers

informed by Pearlin’s Stress Process Model.

The study used secondary data from the Understanding Society study. Cross-

sectional analysis of how factors relating to the role of caring, interferences of caring

on employment and social participation and leisure predict mental well-being

measured by the GHQ-12 was undertaken. Longitudinal analysis following those that

became carers and potential changes in social participation, satisfaction with leisure

and mental well-being was also undertaken. Data from 8,063 middle-aged men

(1,612 carers and 6,451 non-carers) was used for the cross-sectional element and data

from 4,665 (614 carers and 4,051 non-carers) was used for the longitudinal element.

An estimated 20% of middle-aged men were carers. Carers had significantly

poorer mental well-being (p = 0.014), measured by their scores on the GHQ-12,

compared to non-carers but the difference was very small (η² = 0.001). At the cross-

sectional level, three predictors were identified to most strongly impact mental well-

being: subjective financial status; satisfaction with leisure time; and employment

status (partial eta squared = 0.053; 0.046; 0.051 respectively). Longitudinal analysis

suggested that carers’ mental well-being was poorest prior to undertaking caring.

However, there was no evidence that mental well-being became worse for those that

became carers relative to those who remained non-carers.

Middle-aged male carers who were under financial stress, unable to pursue

leisure activities and unemployed or long term sick were found to be particularly

vulnerable to poorer mental well-being. Providing support to this group of middle-

aged men both in practical and therapeutic terms would help meet their mental well-

being needs.

Acknowledgements

I would like to thank my principle research supervisor Linda Morison for her

unending support and guidance through the long process of completing my research.

Her dedication has been pivotal in supporting this process. I would like to thank my

research co-supervisor Dr Dawn Querstret for her support and fresh perspective. I

would also like to thank Dr Alison Yeung for her guidance in academic writing.

I would like to thank the amazing placement supervisors who have helped shape my

knowledge and understanding during training.

A special thanks goes to Angela Clarke who has provided much appreciated peer

supervision and support throughout training.

I would also like to thank my husband who has given me the support to complete

what has at times seemed an impossible task.

Finally, this thesis is dedicated to the memory of Sophie Parke whose compassion,

courage and strength inspired me throughout the journey to becoming a clinical

psychologist.

Table of Contents

Part 1. Empirical Paper.................................................................................................6

Statement of Journal choice................................................................................................7

Abstract...............................................................................................................................8

Introduction......................................................................................................................10

Method.............................................................................................................................17

Results...............................................................................................................................32

Discussion..........................................................................................................................54

References........................................................................................................................63

List of Appendices.............................................................................................................72

Appendix A Ethical approval..........................................................................................73

Appendix B Copies of questions used from the Understanding Society Questionnaires......................................................................................................................................77

Appendix C Original Understanding Society study variables and variables used in this study..............................................................................................................................88

Appendix D Normality Histograms................................................................................93

Appendix E Non-parametric tests results....................................................................113

Appendix F Journal guidelines for authors..................................................................115

Part 2. Literature Review..........................................................................................117

Statement of Journal Choice...........................................................................................118

Abstract...........................................................................................................................119

Introduction....................................................................................................................120

Method...........................................................................................................................123

Results.............................................................................................................................128

Discussion........................................................................................................................153

References......................................................................................................................159

Appendix A Journal guidelines....................................................................................167

Part 3. Clinical Experience.......................................................................................169

Part 4. Assessments..................................................................................................172

Part 1. Empirical Paper

What factors affect the mental health and

well-being of Middle-Aged Male Carers?

Word Count – 9,998

Statement of Journal choice.This paper will be submitted to Psychology of Men and Masculinity. The journal is

devoted “to the dissemination of research, theory, and clinical scholarship that

advances the psychology of men and masculinity” (“Psychology of Men &

Masculinity,” n.d.). The journal welcomes papers and the website states that it invites

exploration into various topics including “the impact on men’s health” (“Psychology

of Men & Masculinity,” n.d.). Psychology of Men and Masculinity would be a

suitable journal for submission for the following reasons; firstly, the paper focuses on

male carers and the impact the caring role has on their mental health and well-being,

and secondly, the paper covers care recipients who are experiencing a variety of

conditions and diseases and therefore a disease or condition specific journal would

not be suitable. Psychology of Men & Masculinity has an Institute for Scientific

Information (ISI) impact factor of 2.947.

AbstractAlthough males constitute a substantial proportion of carers until recently



and protective factors predicted the mental well-being of middle-aged male carers

informed by Pearlin’s Stress Process Model.

The study used secondary data from the Understanding Society study. Cross-

sectional analysis of how factors relating to the role of caring, interferences of caring

on employment and social participation and leisure predict mental well-being

measured by the GHQ-12 was undertaken. Longitudinal analysis following those that

became carers and potential changes in social participation, satisfaction with leisure

and mental well-being was also undertaken. Data from 8,063 middle-aged men

(1,612 carers and 6,451 non-carers) was used for the cross-sectional element and data

from 4,665 (614 carers and 4,051 non-carers) was used for the longitudinal element.

An estimated 20% of middle-aged men were carers. Carers had significantly

poorer mental well-being (p = 0.014), measured by their scores on the GHQ-12,

compared to non-carers but the difference was very small (η² = 0.001). At the cross-

sectional level, three predictors were identified to most strongly impact mental well-

being: subjective financial status; satisfaction with leisure time; and employment

status (partial eta squared = 0.053; 0.046; 0.051 respectively). Longitudinal analysis

suggested that carers’ mental well-being was poorest prior to undertaking caring.

However, there was no evidence that mental well-being became worse for those that

became carers relative to those who remained non-carers.

Middle-aged male carers who were under financial stress, unable to pursue

leisure activities and unemployed or long term sick were found to be particularly

vulnerable to poorer mental well-being. Providing support to this group of middle-

aged men both in practical and therapeutic terms would help meet their mental well-

being needs.

IntroductionInformal Carers

In the UK there is a significant population of informal carers, defined as those

that give unpaid support or assistance to a spouse/partner, family members, friends or

neighbours (Robards, Vlachantoni, Evandrou & Falkingham, 2015). The Office for

National Statistics (ONS) data collected from the 2011 national census indicated that

the number of informal carers in the UK had risen substantially in the previous ten

years (ONS, 2013). Recent indications estimate that one in five people aged 50–64

are carers in the UK (Carers Trust, 2018). With an aging population this number may

rise in the future which may have implications for governmental policies on the

provision of support for carers.

The traditional gendered view of the carer

Caring has often been viewed as traditionally a female role and as an

extension to the nurturing activities of a mother or wife (Neno, 2004). Previous

studies on middle-aged carers have often focused on or assumed carers to be female

(Riley & Bowen, 2005). However, there is evidence that men form almost half of

carers, as evidenced in a US study which found that 43% of the carers in their study

were male (Do, Cohen & Brown, 2014). Livingston, Manela and Katona (1996)

found that 46% of carers in their UK based study were male and a more recent

survey also conducted in the UK estimated that 42% of carers are male (Slack &

Fraser, 2014). Neno (2004) reported that there has been an increase in the number of

older male carers in the UK and that this trend is likely to continue due to

demographic and sociological factors. Recent research has found that the largest

cohort of those providing care in the UK is middle-aged (Holzhausen, 2017). A

recent study (Brown & Goodman, 2014) based on The 1958 National Child

Development Study age 55 survey in the UK found 14% of the middle-aged men in

their study were carers. Taken together these studies show that although the

perception is that the majority of carers are female there are already a significant

number of male carers and a trend towards an increasing number. There also appears

to be a growing number of middle-aged men who are ‘sandwich generation’ carers

(dual carers for parents/parents-in-law, as well as children). Whilst a definitive

definition of the age range of these caregivers has not been found in the literature, a

number of previous studies have given a lowest age of 40 years to an uppermost age

of 65 years as the most common for ‘sandwich generation’ caregivers (Do, et al.,

2014; Künemund, 2006; Miller, 1981; Oulevey Bachmann et al., 2015; and Riley &

Bowen, 2005). ‘Sandwich generation’ carers face competing demands placing them

under increased stresses (Riley & Bowen, 2005). A recent study based in the US

(Friedman et al., 2015) found that both men and women were equally likely to be

‘sandwich generation’ carers, contradicting the traditional view that women are more

likely to be ‘sandwich generation’ carers. The traditional gendered view may lead to

male carers’ needs being overlooked, an opinion supported by male carers in a UK

study who felt that there was a lack of recognition of their role by society and

professionals (Slack & Fraser, 2014).

Mental well-being and being a carer

The role and responsibilities of being an informal carer can have a

detrimental impact on the carer’s mental health or well-being (Carers Trust, 2018;

Molyneux, McCarthy, McEniff, Cryan, & Conroy, 2008; Stansfeld et al., 2014).

Whilst there is no universally accepted definition of mental well-being the World

Health Organisation (WHO) suggests that it is not just the absence of

disease/condition but on a continuum and includes coping with everyday stresses and

and being able to contribute to the individuals’ community (WHO, 2014).

The Stress Process Model (Pearlin, Lieberman, Menaghan, & Mullan, 1981;

Pearlin, 2010, see Figure 1.) has been widely used to study the mechanisms which

may affect the mental well-being of carers (Bookwala, 2000; Chumbler, Grimm,

Cody & Beck, 2003; Papastavrou, Kalokerinou, Papacostas, Tsangari & Sourtzi,

2007; Stansfeld et al., 2014). The model suggests that although the caring role itself

brings about primary stressors (such as the number of hours spent caring a week),

contextual factors (such as socioeconomic status) and secondary stressors (such as

the interference with employment) influence the carers mental well-being and that

these effects may be mitigated by protective factors such as social support (Pearlin,

2010).

Figure 1. The Stress Process Model (Pearlin et al., 1981; Pearlin, 2010)

Male carers and mental well-being

There is evidence that, as the stress process model predicts, higher primary

stressors will negatively impact male carers’ mental well-being. Buchanan, Radin

and Huang (2010) found increased hours spent caring per week was associated with

poorer mental well-being among male carers. This was supported by Schwartz

(2012) who found that those who were low or medium level carers reported lower

levels of emotional stress compared to those with a high level of care intensity.

Previous research has evidenced contextual factors, such as education level

and financial status, impact on the mental well-being of male middle-aged carers,

however, there has been contradictory findings between studies. For example, Durkin

and Williamson (2013) found that a higher level of education was associated with

better mental well-being in middle-aged male carers, whilst Zhu et al. (2014) found

those with a higher level of education had poorer mental well-being. However, both

studies found that better financial status was associated with better mental well-being

in middle-aged male carers.

There is evidence that there are gender differences in the impact on mental

well-being that being a carer may have, such as the higher impact of caring on

employment leading to reduced mental well-being for male carers (Slack & Fraser,

2014). The effect of the caring role may be different for those that are also working

and may impact on their working patterns (Buck et al., 1997) and thus be a factor in a

decline in mental well-being in carers (Kenny, King & Hall, 2014). Previous research

has found that male carers are more likely to be employed than female carers (Carers

Trust, 2018; Delgado & Tennstedt, 1997). Slack and Fraser (2014) reported that over

a quarter of the males in their study who were caring for over 60 hours a week were

also working. They also found that for those male carers that were employed, over a

quarter would not describe themselves as a carer to others, which may reduce the

level of support that they could receive, particularly from employers (Slack & Fraser

2014). This same survey found that male carers felt that their needs may be different

from female carers, with balancing work and caring highlighted as an area of

particular concern (Slack & Fraser, 2014). As previous research has evidenced that

interference with working is a stressor to carers’ mental well-being (Kenny et al.,

2014) and male carers are more likely to be employed (Delgado & Tennstedt, 1997),

research would be beneficial to explore the relationship between caring role and

interference with employment and their impact on male carers mental health.

The need for leisure time for carers has been identified particularly for those

with a high level of caring responsibilities (Coen, O’Boyle, Coaklet & Lawlor, 2002;

Mannion, 2008) and that the negative impact of caring on social participation and

connection can have a marked effect on mental well-being (Croog, Burleson,

Sudiloysky & Baume, 2006; Stansfeld et al., 2014). Gender differences have been

seen in strategies that carers employ to cope with the impact of caring, with male

carers more likely to suffer from social isolation (Delgado & Tennstedt, 1997;

Harris, 1993; Slack & Fraser, 2014). Male carers have been found to be less likely to

report that they had someone to turn to for assistance or emotional support (Delgado

& Tennstedt, 1997) which would contribute to their feelings of isolation. Male carers

were also reported to have identified social and leisure time as a protective factor to

their mental well-being (Pretorious et al., 2009) with activity restriction having a

negative effect on their mental well-being (Bookwala, 2000) . Previous research

suggests that for carers higher levels of leisure time and social support can have

beneficial effects on mental well-being and any interference with these can have

detrimental effects. The research described above suggests that male carers may have

less social connection than their female counterparts and therefore may be

particularly vulnerable to social isolation leading to poorer mental well-being.

Research Aims

Given the increase in the numbers of middle-aged male carers and the dearth

of research focusing specifically on middle-aged male carers, this study aimed to

describe the prevalence and type of caring undertaken by these men in a sample

representative of the UK using secondary data from The Understanding Society

study (University of Essex, 2017). Previous research has demonstrated limited

exploration of the how impact of the caring role on mental well-being of middle-aged

male carers may vary due to primary stressors (e.g. combined informal caring and

caring for children) and secondary stressors (e.g. interference with employment)

whilst also accounting for contextual factors (e.g. socioeconomic status) and the

mitigating effects of protective factors (e.g. social support and participation).

Therefore this research aimed to explore what factors (particularly: primary stressors;

interference with employment; social support; and satisfaction with leisure time)

predicted the mental well-being of the participants guided by the Stress Process

Model (see Figure 2 for the operationalised Stress Process Model with the factors

used in this study).

Figure 2. Operationalised Stress Process Model with the factors used in this study

Hypotheses

1. Middle-aged men with informal caring responsibilities will have poorer

mental well-being than those without caring responsibilities.

2. Mental well-being of middle-aged male carers will be predicted by the Stress

Process Model (Pearlin et al., 1981). Specifically:

a. Mental well-being will be poorer with higher Primary and Secondary

stressors

b. Mental well-being will be better with higher protective factors

c. Contextual factors will impact male carers’ mental well-being

3. The Stress Process Model (Pearlin et al., 1981) will inform changes in men’s

mental well-being due to becoming a carer:

a. Middle-aged males who become carers will experience poorer mental

well-being

b. Middle-aged men who become carers will have decreases in

Protective factors of the Stress Process Model (Pearlin et al., 1981)

MethodDesign

A cross-sectional design was used as it allowed several variables to be

examined at the same point of time. In addition a longitudinal design was undertaken

to examine factors for a group of men prior to and after they became carers with a

comparison group of men who remained non-carers at the same time points.

Secondary analyses of existing data from the Understanding Society study

(University of Essex, 2017) was conducted for this study. The Understanding Society

study is a longitudinal sample of individuals which aims to be representative of the

whole UK population (as at 2009) interviewed annually within a household context.

As individuals are followed in each ‘Wave’ (year) of the study, data is available from

the first year the Understanding Society study started in 2009 (Wave 1) to the most

recently released, Wave 7 (2015). The majority of the data collection for the

Understanding Society study takes place face-to-face via computer aided personal

interview. To encourage high participation an inter-wave mailing to adult members is

conducted to maintain contact and an e-newsletter is sent quarterly. Interviewers for

the Understanding Society study are required to have prior experience of working on

random probability sampling projects in addition to the standard and survey-specific

training that interviewers go through (Lynn & Knies, 2016).

The data for this study was obtained under End User Licence from the UK

Data Service following registration with them as a researcher requesting access to the

Understanding Society study datasets for non-commercial research purposes.

Following registration the required datasets for all Waves of the Understanding

Society study (University of Essex, 2017) were downloaded for processing.

Participants

Participants were those who were part of the Understanding Society study.

Full details of the Understanding Society design are reported elsewhere (Buck &

McFall, 2012). In brief the Understanding Society study in its household panel

design drew samples across the UK to represent the whole UK population in 2009.

At the start of the Understanding Society study in Wave 1 in 2009, 39,802

households completed the survey totalling responses from 59,436 adults (aged 16 or

over), with response rates in subsequent years being maintained at around 70%

(Buck & McFall, 2012). The participants for this study were individuals who

completed the survey at Wave 3 (2011) and Wave 6 (2014).These particular Waves

were chosen as they provided all of the required variables which were not available

in other Waves of the survey. As the selection process for the participants varied in

the two different aspects of the study (the cross sectional element and the

longitudinal element), they have been detailed separately:

Cross sectional element

In the cross sectional element of the research a total of 10,154 males between the

ages of 40 and 65 years old were initially identified from the Understanding Society

study Wave 3 dataset (University of Essex, 2017). Of these a total of 2,088 were

excluded due to not meeting inclusion criteria or critical missing data (see Figure 3).

Following the exclusion process 8,063 participants (1,612 carers and 6,451 non-

carers) remained for inclusion in this study. A G*Power (Faul, Erdfelder, Lang, &

Buchner, 2007) calculation for the comparison of mental well-being between carers

and non-carers was conducted with a medium effect size. The sample size to detect a

medium effect size with 80% power resulted in a minimum sample size of 210

participants which is well below the number of participants. In relation to the

comparison of mental well-being between different groups of carers further G*Power

(Faul et al., 2007) calculations were conducted to detect a medium effect size of 80%

power resulting in minimum sample sizes of 252 (for three groups), 280 (for four

groups), 305 (for five groups) and 324 (for six groups) which is well below the

number of participants.

Longitudinal element

In the longitudinal element of the study the aim of the participant selection

process was to establish firstly participants who were non-carers in Wave 3 of the

Understanding Society study and then to establish from these who had become a

carer by/in Wave 6 of the Understanding Society study (see Figure 4 for flow chart

showing selection process). Of the 10,154 males aged between 40 and 65 years old in

Wave 3 of the Understanding Society study dataset (University of Essex, 2017) a

total of 5,489 were excluded. Of those that remained after the selection process

(N=4,665) 4,051 were non-carers in both Waves and 614 had become carers in/by

Wave 6.

A G*Power (Faul et al., 2007) calculation for the comparison of mental well-

being between non-carers and those that became carers by/in Wave 6 was conducted

and with a medium effect size. The sample size to detect a medium effect size with

80% power resulted in a minimum sample size of 158 participants which is well

below the number of participants.

Ethical Considerations

At each Wave of The Understanding Society study an ethical review of the

entire study is undertaken by the University of Essex Ethics Committee with the

most recent reviews in December 2010 and August 2013 with further amendments

approved July 2014 and July 2015 (Lynn & Knies, 2016).

Ethical approval was confirmed for this study at the University of Surrey in

December 2016 by completion of an online self-assessment form. This confirmed

that the study did not meet the criteria for ethical review, and a submission to the

University Ethics Committee was not required (see Appendix A).

The Understanding Society study ensures that the respondents’ participation

is informed and voluntary using a number of strategies, including; sending an

advance letter in each Wave giving the respondents the opportunity to withdraw or

make enquiries prior to interviews; at the beginning of each Wave’s interview

respondents are advised that each question is completely voluntary; respondents are

kept fully informed about the Understanding Society study through a variety of

channels (Lynn & Knies, 2016). Respondents are also made fully aware that their

anonymised data is made available to genuine researchers via the UK Data Service.

Figure 3. Cross sectional participant selection process

Removed those that responded ‘Refusal’ or ‘Don’t Know’ in variable asking if respondent cared for

someone in the home. N=3

Removed those that said they care for more than 5 people outside of the home. N=5

-Removed those that responded ‘other’ in number of care hours per week. N=11

Removed those who had missing data in derived GHQ-12 variable. N=957

Total Males Aged 40-65 left in Wave 3

N=8063

Removed those that had missing data in variable asking

if respondent cared for someone outside the home.

N=1


N=9040

Removed those where care recipient is client of

voluntary organisation N=10

Males aged 40-65 Total Carers

N=1612

Removed those that had missing data in variable asking if

respondent cared for someone in the home. N=2

Males aged 40-65

Non Carers

N=6451

Males aged 40-65. Carers in the both household and

outside the household

N=104

Males aged 40-65. Carers

outside the household

N=1059

Males aged 40-65. Carers

in the household

N=449

Total Males aged 40-65 left in Wave 3

N=9050

Removed those that had proxy respondents in all

variables. N=1102

Total Males aged 40-65 in Wave 3.

N=10154

Figure 4. Longitudinal participant selection process

Removed those that said that care recipient is client of a

voluntary organisation. N= 14

Removed those that said they care for more than 5 people

outside the home. N=2

Removed if those that responded ‘other’ or ‘don’t

know’ in number of care hours per week. N=10

Total Males Aged 40-65 who were non-carers in Wave 3 but carers in

Wave 6. (home n=115, outside n=482, both n=17)

N= 614

Removed those that had missing, proxy or inapplicable in the GHQ-12

variable for Wave 3 or Wave 6. N=1778

Total Males Aged 40-65 who were non carers in Wave 3

N=4665

Non-carers in both Waves

N=4051

Removed respondents who answered that there were carers inside the

home or outside the home. N=2583


Who are non-carers

N=6469

Total Males aged 40-65 left in Wave 3

N=9052

Removed those that had proxy respondents. N=1102

Total Males aged 40-65 in Wave 3

n=10154

Variables and Measures

Participants were asked a large number of questions for the Understanding

Society study at each Wave from various questionnaires, but for the purpose of this

study data was required for only two of the questionnaires; the ‘Mainstage

Questionnaire’ and the ‘Adult Self-Completion Questionnaire’ (University of Essex,

2017). For copies of the original Understanding Society questions used in this study

see Appendix B. In the following sections the relevant questions from these

questionnaires are outlined.

Variables used to describe the sample

Age Ranges

The age given by the Understanding Society study was used to categorise

each participant into five categories of 40 to 44 years old, 45 to 49 years old, 50 to 54

years old, 55 to 59 years old and 60 to 65 years old in order to describe different age

groups within the broader middle-aged range.

Marital/relationship status

The Understanding Society study questionnaire asked each participant their

legal marital status. This was then combined with a variable identifying those who

were ‘living as a couple’ and formed a derived variable which was the basis for a

recoded variable used in this present study. The recoded variable consisted of three

categories of: single/never married, married/civil partner/living as a couple and

separated/divorced/former civil partner/widowed used to characterise the sample.

Ethnicity

Participants were asked ‘What is your ethnic group?’ at Wave 1 (or a later

Wave if they joined the study at a later point). The Understanding Society study

created a derived variable for each participant for their ethnicity which was recoded

for this study to five categories (see Appendix C for full details). The five categories

were based on the ONS five sub-headings describing ethnicity used in the 2011

Census in England and Wales (ONS, 2014).

Contextual factors

Socioeconomic status background: education level

Each participant was asked the highest educational or school qualification

that they had obtained. These were then recoded for this study into reduced

categories of: degree or other higher degree, A Level, GCSE/other qualification or no

qualification/missing (see Appendix C for full details).

Current socioeconomic status: employment status

Participants were asked in the Understanding Society study questionnaire

‘Which of these best describes your current employment situation?’ and shown a list

of occupations (see Appendix C for full details and list of occupations). These were

then recoded for this study into reduced categories of: employed or self-employed,

unemployed, retired, looking after family, long term sick or disabled, and other (e.g.

student or government training).

Current socioeconomic status: subjective financial status

Subjective financial status was assessed by using The Understanding Society

study question which asked each participant ‘How well would you say you yourself

are managing financially these days?’. Participants were given the options of: ‘living

comfortably’, ‘doing alright’, ‘just about getting by’, ‘finding it quite difficult’, or

‘finding it very difficult’ forming a Likert type scale.

Primary Stressors

Carer status

The Understanding Society study questionnaire had two questions designed

to ascertain participants’ carer status: ‘Is there anyone living with you who is sick,

disabled or elderly whom you look after or give special help to (for example, a sick,

disabled or elderly relative/husband/wife/friend etc.)?’ and ‘Do you provide some

regular service or help for any sick, disabled or elderly person not living with you?’.

Participants who answered yes to either or both of these questions were coded as

carers and those who answered no to both of these questions were coded as non-

carers in a new variable created for this study.

Hours of care per week

Those that had answered that they were carers were asked ‘Now thinking

about everyone who you look after or provide help for both those living with you and

not living with you - in total, how many hours do you spend each week looking after

or helping (him/her/them)?’ and responses were coded into nine different care hour

ranges (see Appendix C for full details). These were recoded into a new variable for

this study with two categories of under 20 hours per week (coded 1) and 20 or more

hours per week (coded 2). The cut off criteria was set at 20 hours to allow each of the

responses/categories given in the Understanding Society study to be correctly

recoded into reduced categories. This criteria has also been used in previous studies

(e.g. Kenny et al., 2014) and was used in this study to reflect that caring for relatively

more hours per week has a higher stress load than relatively less hours per week

(Buchanan et al., 2010).

Dependent children in household

Participants were asked how many dependent children were in the household.

This variable was then recoded into a new variable for this study into a yes/no

response.

Help given to adult children

Each participant was asked whether they gave practical help to their adult

children in the question: ‘Nowadays, do you regularly or frequently do any of these

things for your children aged 16 or older who are not living here?’ with seven

options offered of: giving them lifts in your car; shopping for them; providing or

cooking meals; looking after their children; washing, ironing or cleaning; dealing

with personal affairs (e.g. paying bills or writing letters); or decorating, gardening or

house repairs. This created seven separate variables with participants potentially

answering yes to between zero and seven categories. For the purpose of this study a

new variable was created to establish the level of help given to adult children with

levels of ‘None’ coded 0 (where participants had said that they did not given help in

any of the categories), ‘Low’ coded 1 (where participants had said they helped in one

to three categories) and ‘High’ coded 2 (where participants had said that they helped

in four or more categories).

Secondary Stressors

Interference with employment

Whether caring interferes with the participants employment was assessed by

the Understanding Society study which asked ‘Thinking about everyone who lives

with you that you look after or provide help for - does this extra work looking after X

prevent you from doing a paid job or as much paid work as you might like to do?’.

Participants were given the options of ‘Unable to work at all’, ‘Unable to do as much

paid work as you might’ or ‘This doesn't prevent you from working’. There was also

a category of ‘Inapplicable’ for those that this question did not apply to, for example

they were either not carers in the household, not working or they could not work for

another reason.

Interference with social life

Each participant was asked if they went out socially. If they answered that

they did not they were asked the reason including an option that it was due to caring

responsibilities. The Understanding society study variable (see Appendix C) was

used to determine if carers did not go out socially due to caring responsibilities.

Protective factors- Social Support and Participation

Satisfaction with the amount of leisure time

As part of the Understanding Society study participants were asked how

satisfied they were with the amount of leisure time that they had with responses in

seven categories on a scale from ‘Completely dissatisfied’ to ‘Completely satisfied’.

These responses were recoded for the purpose of this study into reduced categories

(see Appendix C) with a Likert type scale ranging from ‘Very dissatisfied’ to ‘Very

Satisfied’ comprising of five categories.

Go out socially

Participants were asked in the Understanding Society study questionnaire ‘Do

you go out socially or visit friends when you feel like it?’ with responses coded

either 1 for yes or 2 for no for this study.

Has a partner

In order to determine whether participants had social support in the form of

having a partner (i.e. that they were married, living as a couple or in a civil

partnership) a new variable was created for this study derived from the

Understanding Society variable which determined marital status (see Contextual

Factors section and Appendix C). Participants were coded as 1 if they had a partner

or 2 if they did not have a partner.

Mental Health/well-being

GHQ-12 (General Health Questionnaire 12 item, Goldberg, 1972).

Participants’ mental health/well-being was assessed using the GHQ-12

(Goldberg, 1972) which is a 12 item questionnaire. Items include questions around

concentration, sleep, making decisions, being constantly under strain, being unhappy

or depressed and overcoming difficulties. Responses are given on a Likert scale. The

Understanding Society variable (used in its original form in this study) converts valid

answers to the 12 questions of the GHQ to a single scale by recoding so that the scale

runs from 0 to 3 instead of 1 to 4, and then by summing all 12, giving a scale running

from 0 (the least distressed) to 36 (the most distressed) (see Appendix C).The use of

the GHQ-12 as a continuous measure allowed for examining even small differences

between groups. However, to enable examination into ‘psychiatric caseness’ (i.e.

those individuals who if presented to a medical professional would be likely to

receive further attention) a GHQ-12 caseness variable was also used. The

Understanding Society variable used for this converts valid answers to 12 questions

of the General Health Questionnaire (GHQ) to a single scale by recoding 1 and 2

values on individual variables to 0, and 3 and 4 values to 1, and then summing,

giving a scale running from 0 (the least distressed) to 12 (the most distressed). This

variable was then recoded for the purpose of this study into a dichotomous variable

of caseness (value of 4 or more) or non caseness (value of under 4). This cut off

point has been used in numerous previous studies (Damey et al., 2014: Goodwin et

al., 2015; Hamer, Biddle & Stamatakis, 2017; and Murphy & Lloyd, 2007).

GHQ-12 (Goldberg, 1972) has been seen to be a valid measure of the mental

well-being in carers in previous research (Cuéllar-Flores, Sánchez-López, Limiñana-

Gras & Colodro-Conde, 2014). Internal consistencies for the measure in the

participants in this study were excellent (α=.90 (for cross-sectional element), α=.90

(Wave 3 longitudinal element) and α=.90 (Wave 6 longitudinal element)).

Statistical Analysis

Data sets for each Wave of the Understanding Survey were downloaded and

analysed using IBM SPSS Statistics (version 24). Analysis for the prevalence of

carers in the cross sectional element was conducted by calculating frequencies, the

proportion and exact 95% confidence interval using an online calculator (Pezzullo,

2018).

The data was examined to assess normality. Visual inspection of the

histograms (see Appendix D for histograms) indicated that there was some positive

skew. Considering the large sample sizes in this study, and that central limit theorem

means that the sampling distribution of the sampling means approaches a normal

distribution as the sample size gets larger (Field, 2009), parametric tests were

considered valid. However, non-parametric tests were also conducted to examine the

robustness of the results (see Appendix E).

For Hypothesis 1 the main dependent variable, scores on the GHQ-12, were

compared between carers and non-carers using analysis of variance (ANOVA).

Assumptions of this model were examined and due to some concerns about

normality, an equivalent non-parametric test (Mann-Whitney U) was conducted.

Comparisons between the non-parametric test and analysis of variance allowed an

assessment of the robustness of the parametric results. In addition chi-squared test

http://www.statisticshowto.com/probability-and-statistics/find-sample-size/

http://www.statisticshowto.com/probability-and-statistics/normal-distributions/

http://www.statisticshowto.com/probability-and-statistics/normal-distributions/

was used to determine whether there were significant differences between carers and

non-carers in relation to GHQ-12 caseness.

For Hypothesis 2a firstly the main dependent variable of scores on the GHQ-

12 were compared between carers for three independent variables of Primary

Stressors: number of hours spent caring per week, whether there were dependent

children, and level of help given to adult children. Each of the variables were

analysed separately using ANOVA and then all three variables were entered into a

model and analysed together using ANOVA. Then the main dependent variable was

compared between carers for three independent variables of Secondary Stressors:

subjective financial status, interference with employment, and interference with

social life. As with Hypothesis 2 each of the variables were analysed separately using

ANOVA and then all three variables were entered into a model and analysed together

using ANOVA. Non-parametric tests were also conducted to examine the robustness

of the results due to concerns about normality.

For Hypothesis 2b the main dependent variable of scores on the GHQ-12

were compared between carers for three independent variables for Social Support

and Participation: go out socially, having a partner, and satisfaction with the amount

of leisure time. Each variable was analysed separately using ANOVA and then all

three variables were entered into an ANOVA model.

For Hypothesis 2c the main dependent variable of scores on the GHQ-12 was

compared between carers for three independent variables for Contextual factors:

education level; employment status; and subjective financial status. Each variable

was analysed separately using ANOVA and then all three variables were entered into

an ANOVA model.

In order to examine the predictor variables in the Stress Process Model

together further analysis using models of ANOVA were conducted to explore the

variance in GHQ-12 scores that could be accounted for by all of the variables. This

was accomplished by entering all Primary Stressor and Secondary Stressors variables

into a model. Following this Protective factor (social support and participation)

variables were added into the model. A third model comprised of the variables from

the second model with the addition of the Contextual variables.

To test Hypothesis 3a a repeated measures ANOVA was conducted to test

whether there was a significant difference in the main dependent measure of scores

on the GHQ-12 for carers and non-carers between the two time points. An interaction

between carer group and time was included to examine whether changes over time

were different for the two groups. In addition to test if there were significant

differences between GHQ-12 caseness over time McNemar’s tests were undertaken

for both groups. In relation to Hypothesis 3b firstly in order to examine changes in

going out socially for those that became carers a McNemar’s test was undertaken as

this allows comparison for paired binary data. McNemar’s tests were completed

separately for carers and non-carers to understand if there was a significant change

over time in going out socially in either groups. In the final analysis for Hypothesis

3b, to examine changes in satisfaction with the amount of leisure time a repeated

measures ANOVA was conducted to test whether there was a significant difference

in satisfaction with the amount of leisure time for carers and non-carers between the

two time points.

ResultsCross sectional element

Participants included in the analysis

In the cross sectional element of the research a total of 10,154 males between

the ages of 40 and 65 years old were initially identified from the Understanding

Society study dataset. Of these a total of 2,091 were excluded due to critical missing

data (see methods). Of the remaining 8,063 participants, 1,612 were carers and 6,451

were non carers. This provided sample sizes of 8,063 for Hypothesis 1 and 1,612 for

Hypothesis 2. The samples sizes were substantially above the desired number of

participants to achieve reasonable statistical power (see methods).

Characteristics of the participants

In the total sample of 8,063 the majority of men were of a white background,

in relationships and working (see Table 1). Of the total sample 1,612 were carers.

This means that 20% (1612/8063) of these men were acting as informal carers. The

95% confidence interval for this proportion was 19.12%-20.88% meaning that if the

sample is reasonably representative of the UK population we can be reasonably

confident that the true proportion lies within these limits.

Characteristics of carers

Table 1 shows that carers were significantly older than non-carers (p<.001)

with 24.9% in the higher age bracket of 60 to 65 years compared to 20.6% in non-

carers. There were no significant differences in marital status, ethnic background or

education level between carers and non-carers. In considering the employment status

of the participants there was a significant difference (p<.001). Whilst in both carers

and non-carers the majority of men were working, in carers there was a higher

percentage of men who were retired. A significantly (p<.001) higher percentage of

non-carers had dependent children in the household compared to carers.

In relation to carers a description of the factors and characteristics relevant to

the role of caring are shown in Table 2. The majority of carers cared for someone

who did not live in the same household (65.6%). The vast majority for carers cared

for under 20 hours per week (78.8%). In considering those that may be termed as

‘sandwich generation’ carers only a small proportion of carers provided a high level

of help to adult children (6.9%). A small minority of carers stated that caring

prevented them from working at all (5.3%) or that they were unable to do as much

paid work as they might (3.2%).

Table 1.

Characteristics of Participants in cross-sectional analysis

Characteristic CarersN=1612

Non CarersN=6451 (80%)

Chi-square p value

Age Ranges40-44 yrs.45-49 yrs.50-54 yrs.55-59 yrs.60-65yrs

247 (15.3)308 (19.1)345 (21.4)311 (19.3)401 (24.9)

1478 (22.9)1362 (21.1)1244 (19.3)1041 (16.1)1326 (20.6)

<.001

Marital StatusSingle

Married, civil partnership or living as couple

Separated, divorced/former civil partnership or widowed

171 (10.6)1294 (80.3)

147 (9.1)

664 (10.3)5096 (79.0)

691 (10.7)

.171

Ethnic backgroundMissing

British, Irish or Other white backgroundMixed backgroundAsian backgroundBlack background

Other ethnic group

5 (0.3)1466 (90.9)

19 (1.2)78 (4.8)34 (2.1)10 (0.6)

13 (0.2)5738 (88.9)

69 (1.1)381 (5.9)210 (3.3)40 (0.6)

.088

Education levelDegree or higher degree

A LevelGCSE or other qualification

No qualification

578 (35.9)349 (21.7)518 (32.1)167 (10.4)

2449 (38.0)1351 (20.9)2025 (31.4)626 (9.7)

.454

Employment statusEmployed or self employed

UnemployedRetired

Looking after familyLong term sick or disabled

Other

1058 (65.6)131 (8.1)258 (16.0)55 (3.4)80 (5.0)30 (1.9)

4960 (76.9)375 (5.8)641 (9.9)30 (0.5)

409 (6.3)36 (0.6)

<.001

Dependent Children under 18 years old in household

NoYes

1141 (70.8)471 (29.2)

4088 (63.4)2363 (36.6)

<.001

How managing financially now?missing

living comfortablydoing alright

just about getting byfinding it quite difficultfinding it very difficult

3 (0.2)437 (27.1)483 (30.0)471 (29.2)161 (10.0)57 (3.5)

6 (0.1)1786 (27.7)2069 (32.1)1805 (28.0)540 (8.4)245 (3.8)

.148


Very DissatisfiedDissatisfied

241 (15.0)279 (17.3)

966 (15.0)1074 (16.6)

.730

Neither Satisfied or DissatisfiedSatisfied

Very SatisfiedMissing

242 (15.0)291 (18.1)559 (34.7)

916 (14.2)1247 (19.3)2242 (34.8)

6 (0.1)

GHQ 12 derived score Mean (SD)Caseness

11.06 (5.269)281 (17.4)

10.7 (5.234)1028 (15.9)

.145

Table 2.

Characteristics of care given and reported effects of caring in cross-sectional

analysis

N %

Where care At home only

Outside of home onlyBoth at home and outside of home

449 1059 104

27.965.66.5

Hours per week spent caringUnder 20 hrs per week

20 or more hours per week1270342

78.821.2

Level of help given to adult children NoneLowHigh

1131 370 111

70.223.06.9

Caring role interferes with employmentInapplicable

Unable to work at allUnable to do as much paid work as you might

Does not prevent you from working

114186 52 333

70.85.33.220.7

Go out sociallyYes No

1424 188

88.311.7

Caring role interferes with going out socially Inapplicable

NoYes

1424 135 53

88.38.43.3

Hypothesis 1. Informal caring responsibilities and mental well-being.

Hypothesis one was that carers would have poorer mental health, as measured

by their GHQ-12 score, compared to non-carers. Whilst there was not a significant

difference between carers and non-carers in GHQ-12 caseness there was a significant

difference in the mean GHQ-12 scores between carers and non-carers (Table 3) with

carers having a higher GHQ-12 score (M=11.06, SD = 5.269) compared to non-

carers (M = 10.70, SD = 5.234). This indicated poorer mental well-being for carers,

however the effect size (η²=0.001) was extremely small. Concerns about normality

resulted in non-parametric tests being conducted to examine robustness of the results.

In this case it gave similar results (p=.004; see Appendix E for full results).

As there were significant differences in age, employment status and dependent

children between carers and non-carers (see Table 1) these were added into the

ANOVA model as control variables. After adjusting for age, employment status and

dependent children, carer status was still significant at p =.018 (F(1,8062)= 5.643)

indicating that carer status is a predictor of scores on the GHQ-12.

Table 3.

GHQ-12 score by carer status

Carer status N Mean GHQ-12 score

SD Eta squared η² F (df) p

Carer 1612

11.06 5.269 0.001 5.995 (1,8061) .014

Non-carer 6451

10.70 5.234

Adjusted model 0.001a 5.643 (1,8062) .018

a partial eta squared for carer status after adjusting for age, employment status and dependent children

Hypothesis 2a. Primary Stressors and mental well-being

Hypothesis 2a predicted that the higher the ‘Primary stressors’ (defined as:

number of hours spent caring per week, whether there are dependent children, and

help given to adult children), the poorer the mental well-being among carers. Table

4 shows that each of the Primary Stressors had an overall statistically significant

effect on GHQ-12 scores with results from the Mann-Whitney U Test indicating the

robustness of this finding (see Appendix E). The GHQ-12 means in Table 4 show

that those who cared for 20 hours or more a week had worse mental well-being than

those who cared for fewer hours, with a small effect size (η² =0.02). Table 4 also

shows that those who had dependent children had significantly (p=0.002) higher

GHQ-12 scores than those who did not but the effect size (η²=0.006) was below the

criteria for small effect size (Cohen, 1969 cited in Richardson, 2010). For help given

to children the results were complicated with the highest GHQ-12 scores found for

those who gave no help and those who gave high amounts of help. The Primary

Stressor variables were also all entered into a model to analyse how much variance

of GHQ-12 score may be explained by all three Primary Stressor variables combined

(Table 4). Each Primary Stressor still explained a significant amount of variability in

GHQ-12 scores. Although the overall model (combined Primary Stressor variables)

was significant (p<.001) it only accounted for 3.7% of the variation in GHQ-12

scores (R² =.037).

Table 4.

GHQ-12 score by Primary Stressors variables

Variables analysed separately Combined variables

Primary Stressor N Mean GHQ-12 score

SD Eta squared η²

F (df) p F (df) p ES

Hours of caring per weekUnder 20 hours per week


10.6712.48

4.9736.048

0.020 32.143 (1,1610)

<.001 13.327 (1,1610)

<.001 0.020 a

Dependent children No

Yes1141471

10.7911.70

5.1455.512

0.006 9.935 (1,1610)

.002 7.953 (1,1610)

.005 0.005 a

Level of help given to adult children

None LowHigh

1131370111

11.2710.2911.41

5.4034.7535.327

0.006 5.119 (2,1609)

.006 3.181 (2,1609)

.042 0.005 a

Overall Model 5.553 (11,1601)

<.001 0.037 b

Note. ES = effect size

a partial eta squaredb r² for overall model

Hypothesis 2a Secondary stressors and mental well-being

Hypothesis 2a predicted that the higher the Secondary Stressors (interference

with employment and interference with social life) the poorer the male carers’ mental

well-being measured by the GHQ-12 score. Table 5 shows both Secondary Stressor

variables had a statistically significant effect on GHQ-12 scores. The results from the

Kruskal-Wallis H tests were similar indicating robustness of the ANOVA results

(Appendix E). Table 5 shows that whilst interference with employment was

statistically significant (p<.001) with those unable to work at all experiencing the

worse mental well-being, the amount of variance explained by this variable was

small (η² =0.022). For caring interfering with the social life of the carer interestingly

the highest GHQ-12 scores were found for those who did not go out due to a reason

other than caring responsibilities.

The Secondary Stressors variables were also all entered jointly into a model

to analyse how much variance of GHQ-12 score may be explained by both

Secondary Stressor variables combined (Table 5). The results showed that the

variation explained by the model was small (R²=0.025). When entered into the joint

model caring interfering with the social life of the carer was no longer a significant

predictor (p=.051).

Table 5.

GHQ-12 score by Secondary Stressor variables

Variables analysed separately Combined Variables

Secondary Stressor N Mean GHQ-12 score

SD Eta squared η²


Caring prevents paid employmentInapplicable

Unable to work at allUnable to do as much paid work as you

mightDoesn’t prevent you from working

11418652

333

10.7414.0012.52

11.14

5.0556.4835.638

5.332

0.022 11.881 (3,1608)

<.001 5.792 (3,1608)

.001 0.020 a

Caring interferes with social lifeDoes not interfere as goes out socially

Does not go out socially due to another reason

Caring interferes with going out socially

1424135

53

10.9212.31

11.51

5.1876.025

5.045

0.006 4.516 (2,1609)

.011 2.020 (2,1610)

.051 0.004 a


<.001 0.025 b

Note. ES = effect sizea partial eta squaredb r² for overall model

Hypothesis 2b Protective Factors (social support and leisure) and mental

well-being

Hypothesis 2b predicted that those carers who had higher levels of social

support (defined as whether they go out socially and whether they have a partner)

and satisfaction in the amount of leisure time that they had would have better mental

well-being than those with lower levels of social support and satisfaction in the

amount of leisure time they have.

The results for all three Protective factor variables analysed separately by

ANOVA, can be seen in Table 6. Those who reported that they did go out socially

had lower GHQ-12 scores than those who reported that they did not (indicating better

mental well-being for those who did go out socially) but the effect size did not reach

the criteria for small (η²=0.005). A Mann-Whitney U test was also conducted for

robustness and gave similar results (see Appendix E). Whether participants had a

partner showed significant (p=.006) differences in GHQ-12 scores with better mental

well-being for those with a partner. However the effect size was below the criteria

for small (η²=0.005). A Mann-Whitney U test was also conducted for robustness and

gave similar results (see Appendix E). In terms of the satisfaction with leisure time

there were significant differences (p<.001) between the results, indicating poorer

mental well-being for those reporting decreased satisfaction with the amount of

leisure time, with a medium effect size (Cohen, 1969, cited in Richardson, 2010,

η²=0.066). The social support and satisfaction with the amount of leisure time

variables were also all entered into a model to analyse how much variance of GHQ-

12 score may be explained by all three Protective factor variables combined (Table

6). The results show that this was significant (p<.001) with a medium effect size

(R²=0.074).

Table 6.

GHQ-12 score by Protective factors (social support and satisfaction with the amount of leisure time).


Protective factor (Social support/ leisure variables)

N Mean GHQ-12 score

SD Eta squaredη²

F (df) p F(df) p ES

Go out sociallyYesNo

1424188

10.9212.09

5.1875.764

0.005 8.147 (1,1610)

.004 4.838 (1,1610)

.028 0.003 a

Have a partnerYesNo

1294318

10.8811.79

5.1595.644

0.005 7.695 (1,1610)

.006 6.327 (1,1610)

.012 0.005 a



Neither Satisfied or Dissatisfied

SatisfiedVery Satisfied

241279242

291559

12.5812.2012.46

10.689.42

6.1985.2735.572

4.9474.286

0.066 28.342 (4,1607)

<.001 27.522 (4,1607)

<.001 0.064 a

Overall model 21.232 (6,1605)

<.001 0.074 b

Note. ES = effect size

a partial eta squaredb r² for overall model

Hypothesis 2c. Contextual Factors

The Stress Process Model (Pearlin et al, 1981) predicts that contextual factors

will affect mental well-being. To examine this separate ANOVAs were conducted

for each of the individual variables in relation to contextual factors: education level,

employment status, and subjective financial status (for results see Table 7).

Education level was a significant predictor of mental well-being (p=0.010)

and indicated that those with no qualifications have poorer mental well-being than

those with qualifications. However, the amount of variance of GHQ-12 scores by

education level was below the criteria for small (η² = 0.007).

Employment status was also a significant predictor of mental well-being

(p<.001) with the highest GHQ-12 scores (poorer mental well-being) obtained by

those carers who classed themselves as long term sick or disabled and the lowest

GHQ-12 scores obtained by those who were retired. Employment status accounted

for 9.7% of the variance of GHQ-12 scores in carers (η² = 0.097).

The means in Table 7 show that those who had worse subjective financial

status had significantly (p<.001) worse mental well-being than those with better

subjective financial status, with a medium effect size (Cohen, 1969 cited in

Richardson, 2010, η²= 0.117).

All three of the Contextual factor variables were entered into an ANOVA

model to examine how much of the variance in GHQ-12 scores could be explained

by Contextual factors (see Table 7). The results show that the combined Contextual

factors were significant (p<.001) accounting for 16.6% of the variance in GHQ-12

(R²=0.166). Kruskal-Wallis tests were also conducted for robustness (see Appendix

E) and these also showed significant differences in GHQ-12 scores for all of the

Contextual variables.

Table 7. GHQ-12 score by Contextual Factors


Contextual Factor variable N Mean GHQ-12 score

SD Eta squared η²


Education LevelDegree or other higher degree

A LevelGCSE or other qualificationNo qualification or missing

578349518167

10.7910.5911.3612.01

5.2954.4095.5035.917

0.007 3.830 (3,1608)

.010 2.012 (3,1608)

.110 0.004 a

Employment statusEmployed

UnemployedRetired

Looking after familyLong term sick/disabled

Other (e.g. student or government training scheme)

1058131258558030

10.4013.3910.3112.2917.0912.03

4.6326.3974.9294.8417.0715.678

0.097 34.452 (5,1606)

<.001 17.108 (5,1606)

<.001 0.051 a

Subjective financial statusLiving comfortably

Doing alrightJust about getting by

Finding it quite difficultFinding it very difficult

43748347116157

9.12 10.39 11.85 14.15 16.28

4.0644.7035.2206.2236.753

0.117 53.33 (4,1609)

<.001 33.464 (4,1609)

<.001 0.077 a


<.001 0.166 b

Note. ES = effect sizea partial eta squared

b r² for overall model

Hypothesis 2 The full Stress Process Model

In order to explore the variance in GHQ-12 accounted for by all variables in

the Stress Process Model (Pearlin et al, 1981) a sequence of ANOVAs were

conducted for different sets of the factors ((i.e. Primary Stressors and Secondary

Stressors, Protective factors (social support and participation) and Contextual

Factors)).

In Model 1 all Primary Stressors and Secondary Stressors variables were

added. In Model 2 all Protective factors variables were added to the variables in

Model 1 except the ‘Go out socially’ variable as this had multicollinearity with the

‘Interference with social life’ variable. Model 3 comprises of all of the variables

from Model 2 along with the addition of the Contextual Factors. The results from

Models 1, 2 and 3 can be seen in Table 8.

Model 1 results showed that all of the Primary Stressor and Secondary

Stressor variables were significant predictors of mental well-being but the model

only accounted for 4.3% of the variation in GHQ-12 scores in carers (R²= 0.043).

Model 2 added Protective factors to the variables in Model 1 and accounted

for a higher amount of the variation in GHQ-12 scores than Model 1 (R²= 0.102).

Model 3 included all variables from Model 2 with the addition of Contextual

factor variables. The results for Model 3 show that the model accounts for 21.7% of

the variation in GHQ-12 scores. Several factors in Model 3 were not significant

predictors (help given to adult children; interference with employment; interference

with social life; have a partner; and education level). Of the variables in Model 3 five

(hours spent caring per week, dependent children, satisfaction with leisure time,

employment status and subjective financial status) remained significant (p=.004,

p=.048, p<.001, p<.001 and p<.001, respectively) predictors of mental well-being.

However, the effect sizes for only three variables (satisfaction with leisure,

employment status, and subjective financial status) reached small effect size (partial

eta squared= 0.046, 0.051 and 0.053, respectively).

Table 8.

Stress Process Models

Variables Model 1 Model 2 Model 3

p partial eta squared



Primary Stressors

Hours spent caring per week <.001 0.008 <.001 0.008 .004 0.005

Dependent children .003 0.005 .019 0.003 .048 0.002

Help given to adult children .033 0.004 .369 0.001 .519 0.001

Secondary Stressors

Interference with employment .005 0.008 .004 0.008 .297 0.002

Interference with social life .034 0.004 .107 0.003 .654 0.001

Social Support and Participation

Satisfaction with leisure time a a <.001 0.550 <.001 0.046

Have a partner a a .002 0.006 .092 0.002

Contextual factors

Education level a a a a .055 0.005

Employment status a a a a <.001 0.051

Subjective financial status a a a a <.001 0.053

R² for Model 0.043 0.102 0.217

a Variable not included in this Model

Longitudinal element

The longitudinal element of the study aimed to determine whether those that

became carers experienced changes in their mental well-being, social support and

satisfaction with the amount of leisure time that they had. Those that remained non

carers were included as a comparison group to control for the effects of time.

Participants included in the analysis

For the longitudinal element of the research a total of 10,154 males between

the ages of 40 and 65 were initially identified from the Understanding Society study

dataset of the first time period (Wave 3), of these 2,583 were excluded as they were

already carers leaving 7,571. Of these 7,571 a total of 2,906 were further excluded

(see Methods). Of the remaining 4,665 a total of 4,051 remained non-carers and 614

became carers in the second time period (Wave 6). This provided a sample size of

4,665 substantially above the desired number of participants to achieve reasonable

statistical power (see Methods).

Characteristics of the participants

In the total sample of 4,665 the majority of men were of a white background,

in relationships and working (see Table 9). Of the total sample 13.2% (n=614) had

become carers by the second time period approximately three years later. There was

a significant (p=0.014) difference in ages between carers and non-carers with more

carers in the older age range. Not surprisingly in both groups of men there was a

substantial increase in the percentage that were retired in the second time period.

Education level was similar between the groups. In both groups the majority of men

did not have dependent children as measured at Time 1 with a significant (p=0.028)

higher percentage of those in the group that remained non-carers having dependent

children.

Table 9.

Characteristics of participants in longitudinal analysis

Those that became carers

Those that remained non-carers

Chi-square p value for

Time 1 figuresn=614 (%)

Time 2figuresn=614 (%)

Time 1 figuresn=4051 (%)

Time 2figuresn=4051 (%)

Time 1

Age Ranges40-44 yrs.45-49 yrs.50-54 yrs.55-59 yrs.60-65yrs

105 (17.1)130 (21.2)124 (20.2)119 (19.4)136 (22.1)

a 932 (23.0)837 (20.7)786 (19.4)653 (16.1)843 (20.8)

a .014

Marital StatusSingle

Married/ civil partnership/living as couple

Separated/divorced/former civil partnership/widowed

Missing

64 (10.4)490 (79.8)

60 (9.8)

0

63 (10.3)487 (79.3)

64 (10.4)

0

416 (10.3)3180 (78.5)455 (11.2)

0

423 (10.4)3163 (78.1)464 (11.5)

1 (<0.0)

.561

Ethnic backgroundMissing

British/Irish/Other white background

Mixed backgroundAsian backgroundBlack backgroundOther ethnic group

0575 (93.6)

5 (0.8)22 (3.6)8 (1.3)4 (0.7)

a 7 (0.2)3688 (91.0)

43 (1.1)199 (4.9)93 (2.3)21 (0.5)

a .272

Employment statusEmployed or self employed

UnemployedRetired

Looking after familyLong term sick or disabled

Other

471 (76.7)

35 (5.7)63 (10.3)5 (0.8)36 (5.9)4 (0.7)

423 (68.9)

23 (3.7)126 (20.5)11 (1.8)28 (4.6)3 (0.5)

3159 (78.0)

212 (5.2)429 (10.6)16 (0.4)212 (5.2)23 (0.6)

2959 (73.0)152 (3.8)733 (18.1)12 (0.3)179 (4.4)15 (0.4)

.711

Education levelDegree or higher degree

A LevelGCSE or other qualification

No qualification

243 (39.6)145 (23.6)175 (28.5)51 (8.3)

a 1617 (39.9)

841 (20.8)1249 (30.8)344 (8.5)

a .385

Dependent Children under 18 years old in household

NoYes

420 (68.4)194 (31.6)

a 2586 (63.8)1465 (36.2)

a .028

a figures not obtained for this time period

Hypothesis 3. The Stress Process Model will inform changes in men’s

mental well-being due to becoming a carer.

Hypothesis 3a. Middle-aged males who become carers will experience

poorer mental well-being

In relation to Hypothesis 3a, a repeated measures ANOVA was conducted to

compare the GHQ-12 scores between carer status groups and time periods. An

interaction term was included to examine whether the two groups changed differently

over time. The results can be seen in Table 10a. In addition McNemar's tests were

completed for both those that became carers and those that remained non-carers to

determine if there was a significant change in GHQ-12 caseness (see Tables 10b and

10c).

For both groups of men mean GHQ-12 scores reduced from Time 1 to Time

2. Overall, GHQ-12 was higher in carers, and interestingly the highest mean was

obtained in the group who became carers in the wave before they became carers. The

repeated measures analysis revealed that there was no significant interaction between

carer group and time (F(1,4663)=1.588, p=.208) indicating that there was no

evidence that GHQ-12 scores became worse in the group who became carers relative

to those who remained non-carers. As there were significant difference in the ages

and dependent children between carers and non-carers these were entered into the

model. After adjusting for age and dependent children there was still no significant

interaction between carer group and time (F(1,4665)= 2.177, p=.140).

The results from the McNemar’s tests showed that the difference in the

proportion of GHQ-12 caseness at Time 1 and Time 2, for both those that became

carers and those who remained non-carers, was not statistically significant (p=.702;

and p=.090 respectively).

Table 10a.

Repeated Measures ANOVA for GHQ-12 change by carer status

Group Time 1 GHQ-12 Mean

SD Time 2 GHQ-12 Mean

SD Mean change between Time 1 and Time 2

partial eta squared

p value for interaction between time and carers status


10.80 5.264 10.77 5.246 -0.03 <.001 .208


10.52 5.087 10.21 4.872 -0.31

Adjusted model a <.001 b .140

a adjusted for age and dependent childrenb partial eta squared for carer status

Table 10b.

McNemar’s test results for carers for GHQ-12 caseness for Time 1 and Time 2

Time 2

Tim

e 1

Below GHQ-12 Caseness

GHQ-12 Caseness Total observed


Observed n=50 (8.1%)

Observed n=57 (9.3%)Hypothesized n=54.5 (8.9%)

n=107 (17.4%)

GHQ-12 Caseness



n=507 (82.6%)

Total observed

n=102 (16.6%) n=512 (83.4%) n=614 (100%)

Table 10c.

McNemar’s test results for non-carers for GHQ-12 caseness for Time 1 and Time 2

Time 2

Tim

e 1


GHQ-12 Caseness Total observed


Observed n=3,129 (77.2%)

Observed n=329 (8.1%)Hypothesized n=352 (8.7%)

n=3,458 (85.4%)

GHQ-12 Caseness



n= 593 (14.6%)

Total observed

n= 3504 (86.5%) n=547 (13.5%) n=4051 (100%)

Hypothesis 3b. Middle-aged men who become carers will have decreases in

Protective factors (social support measured by whether they go out socially).

In relation to Hypothesis 3b of those that had become carers by Time 2

(n=614) the majority reported that they went out socially at Time 1 (88.1%) and at

Time 2 (87.3%) (see Table 11a). The number that reported that they did not go out

socially rose slightly at Time 2, the time that they reported to be carers, from 11.9%

to 12.7%. McNemar's test showed that the difference in the proportion of those that

went out socially at Time 1 and Time 2 was not statistically significant (p=.657).

To compare those that became carers with those that remained non-carers a

McNemar’s test was then undertaken for non-carers (n=4051) to determine if there

was a difference in the proportion of those that went out socially at Time 1 and Time

2 (see Table 11b). The McNemar’s test for non-carers was also not statistically

significant (p=.602).

In summary, there was a very slight fall in the proportion going out among

those who became carers whilst there was a very slight increase for those who

remained non-carers. However, McNemar’s tests showed that the differences

between the two time points was not significant for either group.

Table 11a.

McNemar’s test results for carers for ‘Go Out Socially’ for Time 1 and Time 2

Time 2

Tim

e 1

Yes No Total observed

Yes Observed n=498 (81.1%)


n=541 (88.1%)

No Observed n=38 (6.2%)Hypothesized n=40.5 (6.6%)

Observed n=35 (5.7%) n=73 (11.9%)

Total observed

n=536 (87.3%) n=78 (12.7%) n=614 (100%)

Table 11b.

McNemar’s test results for non-carers for ‘Go Out Socially’ for Time 1 and Time 2

Time 2

Yes No Total observed

Tim

e 1

Yes Observed n=3237 (79.9%)


n=3541 (87.4%)

No Observed n=318 (7.8%)Hypothesized n=311 (7.7%)

Observed n=192 (4.7%) n=510 (12.6%)

Total observed

n=3555 (87.8%) n=496 (12.2%) n=4051 (100%)

Hypothesis 3b. Middle-aged men who become carers will have decreases in

Protective factors (satisfaction with the amount of leisure time).

For Hypothesis 3b a repeated measures ANOVA was conducted to compare

the amount of satisfaction with leisure time between groups and time periods. An

interaction term was included to examine whether the two groups changed differently

over time. The results can be seen in Table 12.

Although ‘satisfaction with the amount of leisure time’ was a Likert type

variable it was treated as a continuous variable (scale one to five) in this analysis

with higher scores indicating higher satisfaction with the amount of leisure time.

For both groups mean satisfaction with leisure time scores increased slightly

from Time 1 to Time 2. Interestingly those that became carers had a slightly lower

mean than those that remained non-carers in the Wave before they became carers. In

the group that became carers the satisfaction with leisure mean was 3.39 at Time 1

(SD 1.453) and rose to 3.66 (SD 1.404) at Time 2. For those who remained non-

carers the satisfaction with leisure mean rose from 3.46 (SD 1.477) at Time 1 to 3.72

(SD 1.395) at Time 2. However the repeated measures analysis revealed that there

was no significant interaction between carer group and time (F(1,4656)=0.003,

p=0.953) indicating that there was no evidence that satisfaction with leisure scores

became worse in the group who became carers relative to those who remained non-

carers.

Table 12.

Repeated Measures ANOVA for change in Satisfaction with the amount of leisure

time by carer status

Group Time 1 Satisfaction with the amount of leisure timemean

SD Time 2 Satisfaction with the amount of leisure timemean

SD Mean change between Time 1 and Time 2

partial eta squared

p value for interaction between change in satisfaction with the amount of leisure time and carers status


3.39 1.453

3.66 1.404 +0.27 <.001 .953


3.46 1.477

3.72 1.395 +0.26

Discussion

Although males constitute a substantial proportion of carers until recently



and protective factors predict the mental well-being of middle-aged male carers.

The study found a higher of prevalence of middle-aged male carers then

found in previous studies in the UK. In the current study, 20% of middle-aged men

were carers, higher than the figure of 14% found in Brown & Goodman (2014).

The findings supported the hypothesis that middle-aged male carers have

poorer mental well-being than non-carers as found in previous research such as

Stansfeld et al.’s (2014) study which found that carers had an increased risk of

common mental disorders and Phillips, Gallagher, Hunt, Der and Carroll’s (2009)

study which found increased anxiety and depression symptoms among carers.

However, the difference in mental well-being, measured by mean GHQ-12 scores, in

this study was extremely small between carers and non-carers with only 0.1% of the

variance in GHQ-12 scores explained by carer status (η²=0.001). In addition, the

longitudinal analysis revealed no evidence that GHQ-12 scores became worse in the

group who became carers relative to those who remained non-carers. This finding

also remained unchanged when adjusted for age and dependent children. An

interesting finding was that those that became carers had poorer GHQ-12 scores prior

to actually commencing caregiving. Whilst this finding has not been found in the

literature (to the author’s knowledge) an unpublished dissertation also using the

Understanding Society study data had a similar finding for female carers (Clarke,

2018).

In relation to ‘sandwich generation’ carers and dual caring the study found

that carers were less likely to have dependent children than non-carers and the

majority of carers did not provide help to adult children. Whilst the study did find

that carers with dependent children had poorer mental well-being, supporting

previous research which has found increased burden for duel carers (Do et al., 2014),

the effect size (η²=0.006) did not reach the criteria for a small effect (Cohen, 1969

cited in Richardson, 2010). The study found in line with the Stress Process model

(Pearlin et al., 1981) that increased primary stressors (hours spent caring per week,

dependent children and help given to adult children) negatively impacted on carers’

mental well-being. However, the amount of the variance in mental well-being by the

combined primary stressors was small (r²= 0.03) indicating that there are other

factors influencing mental well-being.

Within carers the results from the cross sectional analysis showed a number

of predictors of male carers’ mental well-being. One of the strongest predictors was

the subjective financial status of the carer with those experiencing financial

difficulties with poorer mental well-being reaching the criteria for medium effect size

(η²=0.117, Cohen, 1969 cited in Richardson, 2010). This supports previous research

in middle-aged male carers which found higher income inadequacy was associated

with poorer mental well-being in a US study (Durkin & Williamson, 2013) and

higher family income was associated with better mental well-being in a study in

China (Zhu et al., 2014).

Previous research has found that caring can interfere with the social activities

of carers, in turn negatively impacting their mental well-being, in line with the Stress

Process model (Bookwala, 2000; Croog et al., 2006; Stansfeld et al., 2014). Male

carers have reported social and leisure activities as protective to their mental well-

being (Pretorious et al., 2009). In this study, in line with predictions, satisfaction with

the amount of leisure time accounted for variance in mental well-being, with a

medium (Cohen, 1969 cited in Richardson, 2010) effect size (η²= 0.066). In

considering the Secondary Stressor of caring interfering with social life, whilst this

study found only 3.3% of carers reported they did not go out due to caring

responsibilities, this group of carers did have poorer mental well-being. However,

those who said that they did not go out due to a different reason had worse mental

health overall. This could indicate that further factors are involved in the relationship

between caring and social activity, such as the carers’ financial status or own

personal physical health. Whilst the study found that those that go out socially had

better mental well-being than those who did not, the ability to go out socially may

not solely be impacted through caring responsibilities. Considering this finding in

relation to the results for satisfaction with leisure time could indicate that perceived

quality of leisure time is a stronger predictor of mental well-being than whether the

carer goes out socially. The longitudinal aspect of the study found no significant

change in going out socially or satisfaction with leisure for those that became carers

relative to before caring, further indicating that caring responsibilities may not solely

predict an impact on social/leisure activities.

The study predicted that higher Secondary Stressors, such as interference

with employment, would predict poorer mental well-being among middle-aged male

carers. Whilst the study found only 5.3% of carers reported that caring prevented

them from working at all, this group of men had poorer mental well-being than those

who reported no interference with employment consistent with previous research

(Kenny et al., 2014; Marks, 1998).

The findings generally supported the hypothesis that Contextual factors

(education level, employment status and subjective financial status) impacted the

mental well-being of carers, with the exception of education level. Whilst education

level was significant (p=.010) when analysed separately, the effect size was below

the small criteria (η²=0.007) Furthermore, when added with the other Contextual

factors into a combined model it was no longer significant (p=.110). Employment

status and subjective financial status remained significant (p<.001 and p<.001

respectively) accounting for 5.1% and 7.7% of the variance in GHQ-12 scores,

respectively. These findings may indicate that current socioeconomic status

(employment status and subjective financial status) are stronger predictors of mental

well-being amongst male carers than background socioeconomic status (education

level).

Limitations

A limitation of the study was that it was unable to consider some factors

which may affect the mental well-being of male carers due to the data being

unavailable from the Understanding Society study (University of Essex, 2017). For

example, it was not possible to determine the carer’s relationship to the care recipient

and therefore unable to establish the proportion of those who were caring specifically

for parents/parents-in-law. This means that the study was unable to determine the

level of those that may be defined as ‘sandwich generation’ carers in which carers

are faced with competing demands placing them under increased stress (Riley &

Bowen, 2005). However, this study incorporated some factors which define

‘sandwich generation’ carers, namely dependent children and help given to adult

children, and therefore to some extent examine competing demands.

In addition due to availability of variables the study was only able to use one

measure for mental well-being, GHQ-12. Whilst this measure has been extensively

used in previous research a potential limitation is that it is often viewed as two or

three dimensional (Campbell, Walker, & Farrell, 2003). The GHQ-12 measures

overall psychological distress and is therefore not suitable to identify those that may

reach diagnostic criteria for a psychiatric disorders such as depression and anxiety.

The study was also unable to determine coping strategies used by carers, such

as emotion-focused and avoidance-focused coping strategies which have been

associated with poorer mental health in male carers (Geiger, Wilks, Lovelace, Chen

& Spivey, 2015). A further factor that the study was unable to explore was the

quality of the relational behaviours between the carer and the care recipient which

previous research has found to be associated with the carer’s mental well-being

(Crevier, Marchand, Nachar & Guay, 2015).

A potential limitation of this study was concerns about whether assumptions

for the parametric tests were fully met. However, the results from the nonparametric

tests (Appendix E) were consistent with the parametric findings indicating robustness

of the results of the parametric tests.

Following careful consideration it was decided to not add a matching variable

to the analysis models. Whilst this led to comparison groups of uneven sizes it was

considered selecting a matching variable may have led to over-matching and missing

key results.

Policy and Clinical Implications

Overall the results from the cross-sectional analysis indicate that carers have

poorer mental well-being than non-carers. However, when taking account of the

results from the GHQ-12 casesness analysis, whilst there was a higher proportion of

carers in the caseness category, this was not statistically different to non-carers.

Taken together these results indicate that middle aged male carers are experiencing

psychological distress, but at a level which may not be identified as reaching a

threshold for intervention. This could have implications of the management of

mental well-being for middle-aged male carers, as whilst they may not reach the

threshold for treatment, they are experiencing an impact on their mental well-being,

and in turn their ability to undertake activities including the role of being a carer. As

middle-aged men have been seen to have less access to support, this coupled with

psychological distress below a threshold for intervention could place them at greater

risk of going ‘under the radar’.

Carers experiencing financial difficulties were found in this study to have

poorer mental well-being. Support for this group of carers both in terms of

interventions to lessen financial difficulties (such as financial aid and access to the

appropriate benefit agencies) and in therapeutic terms would help meet their mental

well-being needs. Clinicians working with male carers should be aware of the

potential stressor of financial difficulties and incorporate this into their assessment

and formulation, aiding an appropriate person-centred intervention. Providing

support to such carers in developing resources both internal, such as effective coping

strategies and external, such as social support may help minimise stressors.

The study found those with the highest level of satisfaction with leisure time

had better mental well-being, consistent with previous research for carers of both

genders (Coen et al., 2002; Mannion, 2008) and specifically for male carers

(Pretorious et al., 2009). As male carers have been found to be more likely to suffer

from social isolation (Delgado & Tennstedt, 1997; Harris, 1993; Slack & Fraser,

2014) supporting male carers to undertake valued leisure pursuits, whilst balancing

the demands of the carer role, could play an important part in supporting better

mental well-being. Leisure has been found to have a buffering effect against the

negative effects of stressors (Iwasaki & Smale, 1998). Leisure activities also have the

potential to reduce social isolation thereby promoting better mental well-being (Iso-

Ahola & Park, 1996). As men have been found to have increased life satisfaction and

satisfaction with leisure more from physical activities than other types of leisure

pursuits (Brown & Frankel, 1993), providing access to such activities could hold

important implications for their mental well-being.

Three factors were found to be consistently associated with the mental well-

being among middle-aged male carers: subjective financial status, satisfaction with

leisure time and employment status in line with the Stress Process Model (Pearlin et

al., 1981). Therefore these factors are important to consider in identifying middle-

aged male carers whose mental well-being may be at higher risk or whom may

require additional support. Those carers who are under financial stress, dissatisfied

with their leisure time and unemployed or long term sick were found to be

particularly vulnerable to poor mental well-being. The stressors of caring coupled

with financial stress and unemployment appear to be outweighing the resources (such

as leisure time) male carers have available to minimise these stressors resulting in

poor mental well-being (Lazarus & Folkman, 1984). For clinicians working with

carers, either directly or indirectly via care recipients, it would be beneficial to

consider factors, such as satisfaction with leisure time, as protective factors to mental

well-being.

Future Research

An interesting finding of this study was that carers had poorer mental well-

being, compared to those who remained non-carers, prior to actually commencing

caring. A limitation of this study was that potential factors explaining this finding

could not be explored. Previous research has found factors in the process to

becoming a carer effect mental well-being such having an autonomous motive to

provide care (Kim, Carver & Cannady, 2015) or the carers’ own health or

employment status (Kenny et al., 2014). Further longitudinal research following men

prior to undertaking caring responsibilities and exploring the process to becoming a

carer may be beneficial to explain the potential negative impact on mental well-

being.

Conclusions

For middle-aged male carers, current socioeconomic status (subjective

financial status and job status) and satisfaction with leisure impacted their mental

well-being. This has implications both for the individual carer, but also at a local and

national service provision level.

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https://www.understandingsociety.ac.uk/documentation

List of Appendices

Appendix A: Ethical approval

Appendix B: Copies of questions used from the Understanding Society

Questionnaries

Appendix C: Original Understanding Society study variables and variables used in

this study

Appendix D: Normality Plots

Appendix E: Non-parametric tests results

Appendix F: Journal guidelines for authors

Appendix A Ethical approval

Appendix B Copies of questions used from the Understanding Society Questionnaires

The full copies of these questionnaires can be accessed at https://www.understandingsociety.ac.uk/documentation/mainstage/questionnaires

Below are the questions used within this study-

Contextual Factors-

Education level

https://www.understandingsociety.ac.uk/documentation/mainstage/questionnaires

Working status

Subjective financial status

Primary Stressors

Carer status

and


Dependent children – derived variable therefore not a specific question(s) on

questionnaire


Secondary Stressors

Interference with employment


Social support and participation


Go out socially

Mental health- GHQ-12 –derived from the following questions

Appendix C Original Understanding Society study variables and variables used in this studySection Area Understanding Society

Question(s) asked Understanding Society variable code(s)

Understanding Society responses and response codes

My variable code(s)

My variable responses and response codes

Contextual (SES background)

Education level

Can you tell me the highest educational or school qualification you have obtained?

c_hiqual_dv Missing -9 Inapplicable -8 Degree 1 Other higher degree 2 A-level etc. 3 GCSE etc. 4 Other qualification 5 No qualification 9

NEWHiQual 1= no qualification or missing2= degree or other higher degree3= A Level 4= GCSE or other qualification

Contextual (current SES)

Working status

Which of these best describes your current employment situation?

c_jbstat Refusal -2 Don't know -1 Self-employed 1 In paid employment (full or part-time) 2 Unemployed 3 Retired 4 On maternity leave 5 Looking after family or home 6 Full-time student 7 Long term sick or disabled 8 On a government training scheme 9 Unpaid worker in family business 10 Working in an apprenticeship 11 Doing something else 97

NEWJBStat 1=employed or self-employed2=unemployed 3=retired 4=looking after family 5=long term sick or disabled 6= other e.g. student or government training

Secondary Stressors

Subjective financial status

How well would you say you yourself are managing financially these days?

c_finnow living comfortably 1 doing alright 2 just about getting by 3 finding it quite difficult 4 finding it very difficult? 5

c_finnow same as Understanding Society responses and response codes

Primary Stressors

Carers status Is there anyone living with you who is sick, disabled or elderly

c_aidhh missing -9 NEWCarer 1= Carer

whom you look after or give special help to (for example, a sick, disabled or elderly relative/husband/wife/friend etc.)?and

Do you provide some regular service or help for any sick, disabled or elderly person not living with you?

c_aidxhh inapplicable -8 refusal -2 don't know -1 yes 1 no 2

2= Non-carer

Primary Stressors


Now thinking about everyone who you look after or provide help for both those living with you and not living with you - in total, how many hours do you spend each week looking after or helping (him/her/them)?

c_aidhrs proxy -7 refusal -2 don't know -1 0 - 4 hours per week 1 5 - 9 hours per week 2 10-19 hours per week 3 20-34 hours per week 4 35-49 hours per week 5 50-99 hours per week 6 100 or more hours per week/continuous care 7 varies under 20 hours 8 varies 20 hours or more 9 other 97

NEWCareHrsReduced

1= under 20 hours per week2= 20 or more hours per week

Primary Stressors

Dependent children under 18 years old

derived variable c_ndepchl_dv inapplicable, living alone -8 then 0 for no children, 1 for one child etc.

NEWChildrenDepinHH

0=no1=yes

Primary Stressors


Nowadays, do you regularly or frequently do any of these things for your children aged 16 or older who are not living here?

c_chaid1c_chaid2c_chaid3 c_chaid4 c_chaid5

for all variables-not mentioned 0 mentioned 1

NEWTotalChaid

0= none (provides no help to adult children)1= low (provides help in 1-3 areas)2= high (provides help in 4

Options1 Giving them lifts in your car (if you have one)2 Shopping for them3 Providing or cooking meals4 Looking after their children5 Washing, ironing or cleaning6 Dealing with personal affairs e.g. paying bills, writing letters7 Decorating, gardening or house repairs

c_chaid6c_chaid7

or more areas)

Secondary Stressors

interference with employment

Thinking about everyone who lives with you that you look after or provide help for - does this extra work looking after [NAME(S)] prevent you from doing a paid job or as much paid work as you might like todo?

c_aideft inapplicable -8 proxy -7 don't know -1 unable to work at all 1 unable to do as much paid work as you might 2 this doesn’t prevent you from working? 3

NEWAidEFT 1= unable to work at all2= unable to do as much paid work as you might3= doesn’t prevent you from working

Secondary Stressors


What stops you from going out socially or visiting friends when you want to?

c_visfrndsy14 inapplicable -8 proxy -7 don't know -1 not mentioned 0 mentioned 1

c_visfrndsy14 -8= inapplicable (Does not interfere as goes out socially) 0= not mentioned (Does not go out socially due to another reason)1= mentioned (Caring interferes with going out socially)



satisfaction with the amount of leisure time

c_sclfsat7 completely dissatisfied 1 mostly dissatisfied 2 somewhat dissatisfied 3 neither satisfied or dissatisfied 4 somewhat satisfied 5

NEWSatLeisure

1=Very Dissatisfied (Understanding variable response codes 1 and 2) 2=Dissatisfied (Understanding Society

mostly satisfied 6 completely satisfied 7

response code 3) 3= Neither Satisfied or Dissatisfied (Understanding Society response code 4)4= Satisfied (Understanding Society response code 5)5= Very Satisfied (Understanding Society response codes 6 and 7)


Go out socially

‘Do you go out socially or visit friends when you feel like it?’

c_visfrnds yes 1no 2

c_visfrnds same as Understanding Society responses and response codes


Has a partner derived variable from legal marital status question ‘What is your legal marital status?’ and information of those who are living as a couple

c_mastat_dv Single and never married/in civil partnership 1 Married 2 In a registered same-sex civil partnership 3 Separated but legally married 4 Divorced 5 Widowed 6 Separated from civil partner 7 A former civil partner 8 A surviving civil partner 9 Living as couple 10

NEWPartner 1= yes (Understanding Society responses codes 2, 3 or 10)2= no (Understanding Society responses codes 1, 4, 5, 6, 7, 8 or 9)

Mental health/well-being

GHQ-12 derived variable c_scghq1_dv from the 12 GHQ questions-‘Have you recently been able to concentrate on whatever you're doing?’Options 1 Better than usual 2 Same as usual 3 Less than usual 4 Much less than usual‘Have you recently lost much sleep over worry?’Options 1 Not at all 2 No more than usual 3 Rather more than usual 4 Much more than usual‘Have you recently felt that you were playing a useful part in things?’Options 1 More than usual 2 Same as usual 3 Less so than usual4 Much less than usual‘Have you recently felt capable of making decisions about things?’Options 1 More so than usual 2 Same as usual 3 Less so than usual 4 Much less capable

same as Understanding Society responsesscale of 0 to 36

‘Have you recently felt constantly under strain?’Options 1 Not at all 2 No more than usual 3 Rather more than usual 4 Much more than usual ‘Have you recently felt you couldn't overcome your difficulties?’Options 1 Not at all 2 No more than usual 3 Rather more than usual 4 Much more than usual‘Have you recently been able to enjoy your normal day-to-day activities?’Options 1 More than usual 2 Same as usual 3 Less so that usual 4 Much less than usual‘Have you recently been able to face up to problems?’Options 1 More so than usual 2 Same as usual 3 Less able than usual 4 Much less able‘Have you recently been feeling unhappy or depressed?’Options 1 Not at all 2 No more than usual 3 Rather more than usual 4 Much more than usual‘Have you recently been losing confidence in yourself?’Options 1 Not at all 2 No more than usual 3 Rather more than usual 4 Much more than usual‘Have you recently been thinking of yourself as a worthless person?’Options 1 Not at all 2 No more than usual 3 Rather more than usual 4 Much more than usual‘Have you recently been feeling reasonably happy, all things considered?’Options 1 More so than usual 2 About the same as usual 3 Less so than usual 4 Much less than usual

98

Appendix D Normality Histograms

Below are the histograms for the main measure of GHQ-12 for each variable used in the cross sectional analysis.Hypothesis 1 GHQ-12 by carer status

99

Hypothesis 2a Primary stressors

100

101

102

Hypothesis 2a Secondary Stressors

103

104

105

106

107

108

Hypothesis 2b Protective factors (Social support and participation)

109

110

111

112

Hypothesis 2c. Contextual Factors

113

114

115

116

117

118

Appendix E Non-parametric tests results

GHQ-12 score by carer status

Carer status

N Mean GHQ-12 score

SD Median Mann-Whitney U

Mann-Whitney U P value

Carer 1612 11.06 5.269 10.00 4,960,484.500 0.004

Non-carer

6451 10.70 5.234 9.00

GHQ-12 score by Primary Stressors variables

Primary Stressor N Mean GHQ-12 score


Mann-Whitney U p value

Kruskal-Wallis H test p value

Hours of caring per weekUnder 20 hours per week


10.6712.48

4.9736.048

1011

257,404 <0.001 n/a

Dependent children No

Yes1141471

10.7911.70

5.1455.512

1011

300,733 <0.001 n/a

Level of help given to adult children

None LowHigh

1131370111

11.2710.2911.41

5.4034.7535.327

10910

n/a n/a 0.002

GHQ-12 score by Secondary Stressors variables

Secondary Stressor N Mean GHQ-12 score

SD Median Kruskal-Wallis H test p value

Caring prevents paid employmentInapplicable

Unable to work at allUnable to do as much paid work as you

might

11418652

10.7414.0012.52

5.0556.4835.638

101211.50

<0.001

119

Doesn’t prevent you from working 333 11.14 5.332 10

Caring interferes with social lifeDoes not interfere as goes out socially

Does not go out socially due to another reason

Caring interferes with going out socially

1424135

53

10.9212.31

11.51

5.1876.025

5.045

101110

0.018

GHQ-12 score by Protective factors (social support variables and satisfaction with

the amount of leisure time).

Social support/ leisure variable

N Mean GHQ-12 score


Mann-Whitney U p value

Kruskal-Wallis H test p value

Go out sociallyYesNo

1424188

10.9212.09

5.1875.764

1011

150,701 0.005 n/a

Have a partnerYesNo

1294318

10.8811.79

5.1595.644

1011

226,020 0.006 n/a



Neither Satisfied or Dissatisfied

SatisfiedVery Satisfied

241279242

291559

12.5812.2012.46

10.689.42

6.1985.2735.572

4.9474.286

111111

108

n/a n/a <0.001

GHQ-12 score by Contextual Factors

Contextual Factor variable N Mean GHQ-12 score

SD Median Kruskal-Wallis H test p value

Education LevelDegree or other higher degree

A LevelGCSE or other qualificationNo qualification or missing

578349518167

10.7910.5911.3612.01

5.2954.4095.5035.917

10.0010.0010.0011.00

0.036

Employment statusEmployed

UnemployedRetired

1058131258

10.4013.3910.31

4.6326.3974.929

10.011.009.00

<0.001

120

Looking after familyLong term sick/disabled

Other (e.g. student or government training scheme)

558030

12.2917.0912.03

4.8417.0715.678

11.0016.0011.00

Subjective financial statusLiving comfortably

Doing alrightJust about getting by

Finding it quite difficultFinding it very difficult

43748347116157

9.12 10.39 11.85 14.15 16.28

4.0644.7035.2206.2236.753

89111315

<0.001

121

Appendix F Journal guidelines for authors from http://www.apa.org/pubs/journals/men/call-for-papers.aspx obtained 02/03/2018

Call for Papers

Psychology of Men & Masculinity ® — the official journal of APA Division 51 (Society for the Psychological Study of Men and Masculinity) — is among the world's leading scholarly publications devoted to the dissemination of research, theory, and clinical scholarship that advances the discipline of the psychology of men and masculinity. Psychology of Men & Masculinity (PMM) is part of the Thomson Reuters' Journal Citation Reports (JCR), with an Impact Factor of 1.679, and is among top sex- and gender-related journals.

We are interested in work that arises from applied fields, such as health, clinical, counseling, and school psychology, and foundational areas such as social, developmental, and cognitive psychology, and the study of emotions. We welcome research using diverse methodologies, including both quantitative and qualitative approaches.

Examples of relevant topics include, but are not limited to

men's health behaviors and outcomes biological factors influencing male development men's utilization of health services body image and muscularity sexual development, health, and dysfunction addictive behaviors

Because APA publishes PMM, authors benefit from exceptional support, knowledge, and resources and enjoy a worldwide exposure: All articles published in PMM are included in PsycINFO® and PsycARTICLES®, the most comprehensive and widely used psychological databases in the world. Through print and electronic access, articles published in PMM are available to a global audience of over 3,000 institutions and 60 million potential readers.

Additional information about PMM is available on the journal's homepage.

Submitted manuscripts must be written in the style outlined in the Publication Manual of the American Psychological Association (6th Ed.).

PPM will accept both regular-length submissions (7,500 words) and brief reports (2,500 words).

http://www.apa.org/pubs/journals/men/call-for-papers.aspx

122

Manuscripts should be submitted electronically through the journal's Manuscript Submission Portal. See the Instructions to Authors for details.

123

Part 2. Literature Review

What Factors are Associated with the Mental Health and Well-being of Male

Middle-Aged Carers? A Systematic Review

Word Count 6782

124

Statement of Journal Choice

This review will be submitted to Psychology of Men and Masculinity. The journal is

devoted “to the dissemination of research, theory, and clinical scholarship that

advances the psychology of men and masculinity” (“Psychology of Men &

Masculinity,” n.d.). The journal welcomes literature reviews and the website states

that it invites exploration into various topics including “the impact on men’s health”.

Psychology of Men and Masculinity would be a suitable journal for submission for

the following reasons; firstly, the review focuses on male carers and the impact the

caring role has on their mental health and well-being, and secondly, the review

covers care recipients who are experiencing a variety of conditions and diseases and

therefore a disease or condition specific journal would not be suitable. Psychology

of Men & Masculinity has an Institute for Scientific Information (ISI) impact factor

of 2.947.

125

AbstractThe impact of the caring role on carers’ mental well-being has been explored

in previous research. However, the impact and the factors which may relate to it

among middle-aged, male carers has not been specifically examined in previous

reviews. This review addresses a need to understand the impact of being a carer on

middle-aged men. Electronic and hand searches for published studies which explored

the factors which may affect the mental well-being of middle-aged male carers

identified a total of 16 studies. Half of the studies were conducted in the US with

two of the remaining studies from Japan and one each from Australia, Austria,

Canada, China, the Netherlands and the UK. The majority of the studies were

quantitative, cross-sectional and used convenience samples. Three broad categories

of factors associated with mental health/well-being were ascertained: practical

characteristics of care (such as hours of care giving), support (both social and

professional) and the characteristics of the carer (including demographic

characteristics, intrinsic and life events). The findings suggest a number of influences

on the mental health of middle-aged male carers, a consistent factor being that

reduced social support is associated with worse mental well-being. Limitations of the

review are discussed.

126

Introduction

In the UK there is a significant population of informal carers, defined as those

that give unpaid support or assistance to a spouse/partner, family member, friend or

neighbour (Robards, Vlachantoni, Evandrou & Falkingham, 2015). The Office for

National Statistics (ONS) data collected from the 2011 national census indicated that

the number of carers in the UK was 5.8 million and had risen substantially in the

previous ten years (ONS, 2013). With an aging population it is likely that this

number will rise in the future which may have implications for governmental policies

on the provision of support for carers.

The role of carer has often been viewed as traditionally a female role and as

an extension to the nurturing activities of a mother or wife (Neno, 2004), or

feminised through its emphasis on nurturing (Campbell & Carroll, 2007). The aging

population along with other demographic trends such as later child rearing has

resulted in a rise in the number of ‘sandwich generation’ caregivers. Whilst a

definitive definition of the age range of these caregivers has not been found in the

literature, a number of previous studies have given a lowest age of 40 years to an

uppermost age of 65 years as the most common for ‘sandwich generation’ caregivers

(Do, et al., 2014; Künemund, 2006; Miller, 1981; Oulevey Bachmann et al., 2015;

and Riley & Bowen, 2005). These middle-aged caregivers have the competing

demands of caring for aging parents/parents-in-law whilst raising children (Boyczuk

& Fletcher, 2016). Previous studies on middle-aged carers (who may also be

‘sandwich generation’ caregivers) have often focused on or assumed carers to be

female as the perception is that the majority of carers are women (Riley & Bowen,

2005). However, there is evidence that almost half of all carers are male, as

127

evidenced in a US study which found that 43% of the carers in their study were male

(Do, Cohen, & Brown, 2014). This is not just found in the US as Livingston, Manela

and Katona (1996) found that 46% of carers in their UK based study on middle-aged

carers were male and a more recent survey also conducted in the UK estimated that

42% of all carers were male (Slack & Fraser, 2014). Neno (2004) reported that there

was an increase in the number of older male carers during the 1990’s in the UK and

that this trend is likely to continue due to demographic and sociological factors. A

more recent study (Brown & Goodman, 2014) based on the UK “1958 National

Child Development Study age 55 survey” found that 14% of the middle-aged men in

their study spent 10 hours a week caring for others (not including children at home).

Taken together these studies show that although the perception is that the

majority of carers are female, the literature suggests that male carers may make up

almost half of the carer population and there is a trend towards an increasing number.

A traditional gendered view may lead to male carer’s needs being overlooked. This

opinion was supported by male carers in a UK study who felt that there was a lack of

recognition of their role by society and professionals (Slack & Fraser, 2014). A lack

of recognition of male carers could lead to their needs not being addressed.

The role and responsibilities of being an informal carer can have a

detrimental impact on the carer’s mental health or well-being (Molyneux, McCarthy,

McEniff, Cryan, & Conroy, 2008). Whilst there is no universally accepted definition

of mental well-being the World Health Organisation (WHO) suggests that it is not

just the absence of disease/condition but on a continuum and includes coping with

everyday stresses, having the ability to work productively and being able to

contribute to the individuals’ community (WHO, 2014). Stansfeld et al. (2014) found

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in their study using a nationally representative survey (N=5170), that the prevalence

of mental health difficulties was higher in carers than non-carers. Brown and

Goodman (2014) recommended that further research should be undertaken to explore

how caring responsibilities may affect the mental well-being of male carers due to a

lack of research in this area. Do et al. (2014) suggest that members of the ‘sandwich

generation’ may be at even higher risk for impaired health behaviours since

caregiving for more than one person reduces the amount of time available for

engaging in personal health activities even more.

Several studies have considered how gender might impact the well-being of

carers. For example, Delgado and Tennstedt (1997) reported that the likelihood of

experiencing negative effects such as reduced leisure time, negative impact on health

and interference with employment as a carer of parents were the same for sons and

daughters, but that sons on average spent fewer hours on caring activities than

daughters. Chumbler, Grimm, Cody and Beck (2003) reported that the burden (which

the study defined as subjective views of stress and anxiety) felt by carers was the

same for both female and male carers. However, the study did not explore within the

genders if there were differences in the time spent completing caring activities or the

impact of caring on employment or social activity which may themselves have

gendered differences. There is evidence that among carers with a high level of caring

responsibility, male carers have poorer mental wellbeing (measured by the mental

health component of the SF-36 Health Survey), compared to their female

counterparts (Kenny, King & Hall, 2014). This shows that studies need to consider

many aspects in combination which may affect the mental well-being of carers.

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More recently, research has emerged from studies considering the issues

which may affect male carers’ mental health (e.g., Dihmes, 2013; Kenny, King &

Hall, 2014). Despite a growth in the number of middle-aged male carers, which

could have implications both at individual/familial level and at a wider society level

in the provision of support, there has not been a review of literature for middle-aged

male carers. This review attempts to address this gap.

The primary question posed by this review is: “What are the factors which are

associated with the mental health/well-being of middle-aged male carers?”. The aim

is therefore to identify and synthesise previous research studies which have explored

the mental health/well-being of middle-aged male carers and the factors associated

with their mental health/well-being.

MethodInformation sources and search strategy

In November and December 2016 searches of electronic databases Psychinfo,

PsychArticles and Web of Science were completed for peer reviewed papers. No date

restrictions were applied.

Keywords were selected in the two concept areas of male carers (“male

carers” OR “male caregivers”) and mental well-being (“mental health” OR “mental

well-being” OR “carers well-being” OR “resilience”). For details of the search terms

and search fields used for each database please see Table 1. A hand search of the

reference section of the included articles was also conducted to identify any

potentially additional relevant articles.

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Table 1.

Search terms and search fields for each database

Date Database Search term Search field Number of

results

15/11/2016 Psychinfo male carers AND mental

Health OR mental wellbeing

Title 191

25/11/2016 Psychinfo male carers OR male

caregivers AND mental health

OR mental wellbeing

Title 200

15/11/2016 Psychinfo male carers Abstract 71

06/12/2016 Web of Science male carers OR male

caregivers

Title 73

25/11/2016 Psychinfo male carers OR male

caregivers

Abstract 630

06/12/2016 Web of Science male carers Title 11

06/12/2016 PsychArticles male carers OR male

caregivers

Title 2

06/12/2016 PsychArticles male carers OR male

caregivers

Abstract 22

06/12/2016 PsychArticles male carers Abstract 1

06/12/2016 Psychinfo carers wellbeing Abstract 36

06/12/2016 Web of Science carers AND resilience Title 7

06/12/2016 Web of Science male carers AND resilience Topic 7

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Eligibility criteria

Papers were eligible for inclusion if the study explored male middle-aged

(defined as between 40 and 65 years old) carers and the factors which are associated

with their mental health/well-being. Studies were eligible if they included male only

or both male and female participants with a breakdown of findings specifically for

males. Studies were excluded if they did not investigate the factors associated with

mental well-being or did not include any males within the specified age range. To

meet the inclusion criteria regarding the age range the mean age of participants

within the studies was required to be between 40 and 65 years, therefore articles

which did not report the mean age of participants or whose mean age was outside of

this parameter were excluded. Articles were also excluded if they were not available

in English or if they did not report original data (e.g. if they were a literature review).

Articles were not excluded based on geographical location of the study due to the

limited number of studies from any one particular country/culture. It is

acknowledged that culture is a contextual factor and is likely to impact the

relationship between caregiving and mental well-being. This relationship is also

likely to be impacted by the health and social care systems which vary between

countries. Given these likely variations between countries and cultures the decision

was taken to not restrict to a particular culture or country but to include all papers

and consider the cultural and national context.

Articles were eligible for inclusion whether they were of a quantitative or

qualitative research design.

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The articles underwent an initial screening and were full-text reviewed if they

appeared eligible or if eligibility was unclear from an initial screening (see Figure 1

PRISMA flow diagram, Moher, Liberati, Tetzlaff & Altman, 2009,).

Quality assessment

Quality assessment was completed using the QualSyst quality appraisal tool

(Kmet, Lee & Cook, 2004). This tool was selected as it allows scoring for both

qualitative and quantitative studies. Studies were not excluded based on the quality

scores but the quality assessment allowed consideration of the confidence that could

be placed on the studies’ findings.

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Figure 1. PRISMA (Moher et al., 2009) flow diagram showing the process of including and excluding retrieved articles

Records identified through database

searching

1251

Additional records identified through hand searching of

reference lists

1

Records after duplicates removed

961

Records screened

961

Records excluded as not relevant on the basis of the title

or abstract

826

Full-text articles assessed for eligibility

135

Full-text articles excluded

Reason N=

Does not report on MH/well-being 5

Out of age range 18

No breakdown of findings

for males only 76

Not available in English 3

Poster presentations 14

No original data 2

No results for carers 1Articles included in

literature review

16

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ResultsDescription of Included Studies

The search resulted in sixteen papers which met the inclusion criteria, of

which fourteen were of a quantitative design and two of a qualitative design. Details

of the included studies can be found in Table 2. Eight of the studies were conducted

in the US (Buchanan, Radin & Huang, 2010; Coe & Van Houtven, 2009; Dihmes,

2013; Durkin & Williamson, 2013; Geiger, Wilks, Lovelace, Chen & Spivey, 2015;

Kim, Carver & Cannady, 2015; Mays & Lund, 1999; Schwartz, 2012). Two of the

remaining studies were from Japan (Arai, Nagatsuka & Hirai, 2008; Oshio, 2015)

and one each from Australia (Kenny et al., 2014), Austria (Schrank et al., 2016),

Canada (Crevier, Marchand, Nachar, & Guay, 2015), China (Zhu et al., 2014), the

Netherlands (Hagedoorn, Sanderman, Buunk, & Wobbes, 2002) and the UK (Lopez,

Copp, & Molassiotis, 2012). Included studies were published between 1999 and

2016 with a combined total of 8,716 participants. The mean ages of the male

participants ranged from 41.8 to 63.4 years. Of the included studies nine (Arai et al.,

2008; Coe & Van Houtven, 2009; Crevier et al., 2015; Hagedoorn et al., 2002;

Kenny et al., 2014; Kim et al., 2015; Oshio, 2015; Schrank et al., 2016; Schwartz,

2012) had both male and female participants but were included as they reported

results separately for men. The remaining seven (Buchanan et al., 2010; Dihmes,

2013; Durkin & Williamson, 2013; Geiger et al., 2015; Lopez et al., 2012; Mays &

Lund, 1999; Zhu et al., 2014) had only male participants.

Design of Included studies

In terms of design, within the quantitative studies nine used a cross-sectional

design and all of these except one (Schwartz, 2012) used a convenience sample. The

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remaining five quantitative studies were all longitudinal with three (Coe & Van

Houtven, 2009; Kenny et al., 2014; Oshio, 2015) using nationally representative

samples and two (Durkin & Williamson, 2013; Kim et al., 2015) using convenience

samples. Of the quantitative studies the vast majority used regression analysis to

examine the relationship between carers and mental well-being. In the two

qualitative studies one study (Lopez et al., 2012) was longitudinal with a

convenience sample of participants being interviewed at four time periods. The other

study used a purposive sample (Mays & Lund, 1999). Both of the qualitative studies

used content analysis.

Care recipients’ characteristics within the studies

As the literature review encompassed male middle-aged carers of those with

any condition there was a broad range of conditions that the care recipients had

including cancer (Dihmes, 2013; Hagedoorn et al., 2002; Kim et al., 2015; Lopez et

al., 2012; Schrank et al., 2016; Zhu et al., 2014), Dementia (Geiger et al., 2015),

Multiple Sclerosis (Buchanan et al., 2010), elderly (Coe & Van Houtven, 2009;

Durkin & Williamson, 2013), Post-Traumatic Stress Disorder (Crevier et al., 2015)

and mental ill health (Mays & Lund, 1999).

Characterization and measurement of mental health/well-being in the studies

There were a number of different mental health/well-being measures used

within the quantitative studies. Five of the studies (Zhu et al., 2007; Kim et al., 2015;

Kenny et al., 2002; Buchanan et al., 2010; Arai et al., 2008) used versions of the

Short Form Survey (SF) (Ware, Snow, Kosinski & Gandek, 1993, also known as the

Medical Outcomes Studies MOS) which is a generic quality of life measure. Two

studies used the Zarit Burden Interview (Bedard et al., 2001; Zarit, 1990) or a

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shortened version (the Zarit Burden Interview 12) (Geiger et al., 2015; Schrank et al.,

2016) which rates burden within caregivers. Burden in this context is defined as

combined stress, emotional strain, impact on the carer’s health, impact on the carer’s

social life and the carer’s perceived competence in the carer role. The concept of

burden in this measure is as an outcome of the carer role and therefore for the

purpose of this review it was felt that it was appropriate for inclusion under mental

health/well-being. The Center for Epidemiological Studies Depression Scale (CES-

D, Blazer, Burchet, Service & George, 1991) or shorter versions of the measure were

used in three further studies (Hagedoorn et al., 2002; Durkin & Williamson, 2013;

Coe & Van Houtven, 2009). Other depression or depressive symptoms measures

were used in other studies such as the Beck Depression Inventory II (Beck, Steer &

Brown, 1996), which assesses the symptoms associated with typical depression, in

Dihmes (2013) and Crevier et al. (2015) and the Masculine Depression Scale

(Magovcevic & Addis, 2008), which is designed to assess symptoms of ‘masculine’

depression such as anger, substance abuse, withdrawal from family or social

interactions and an over-focus on work, in Dihmes (2013). Two studies used

measures specifically for anxiety: Crevier et al. (2015) which used the Beck Anxiety

Inventory (Beck & Steer, 1990) and Durkin and Williamson (2013) which used the

Spielbergers’s Stat-Trait Anxiety Inventory (Spielberger, 2010). Oshio (2015) was

the sole study to use The Kessler Psychological Distress Scale (Kessler et al., 2002)

which aims to measure psychological distress. One study (Schwartz, 2012) used a

measure derived by the author to capture ‘emotional stress’.

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Table 2.

Included studies methods and aims.

Author (year); country

Study type, design & sampling


(N/Gender/Age/Relationship to care

recipient)

Disability/condition of

care recipient

Study aims How mental health/well-

being defined

Outcome measure(s) used

Factors to mental health/well-being

Arai et al. (2008); Japan

QuantitativeCross-sectionalConvenience sample

N =1763 (male 663, female 1100)Age mean 63.06, range >30 years Family

Disabled To examine health related quality of life depending whether participants have family members with disabilities and examine the relationship between quality of life and social networks

Mental Health Medical Outcomes Survey Short Form-8 (Japanese version).

Social support

Buchanan et al. (2010); US


N =225 (all male)Age mean 60.7, range 29 to 83 years Various (92.4% spouse of care recipient)

Multiple Sclerosis

To identify the characteristics of male caregivers

Mental Health Short Form-8 Hours of caregiving a week.Caregiving affects caregiver’s ability to perform important activities.

Coe & Van Houtven (2009); US

QuantitativeLongitudinalNationally representative sample

N =1467 (male 563, female 904)Age mean 57.69, range not givenAdult children

Elderly To examine the long term effects of caring for an elderly mother

Depressive symptoms

Center for Epidemiological Studies Depression Scale 8

Marital status.Continued caregiving.

Crevier et al. (2015); Canada


N =65 (male 36, female 29)Age mean 41.83, range not given Various relationships.

PTSD To explore and assess links between individuals with PTSD, caregivers symptoms and observed social support behaviours

Anxiety and depressive symptoms

Beck Anxiety Inventory. Beck Depression Inventory -II

Social support behaviours of caregiver.

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recipient)


care recipient


being defined



Dihmes (2013); US


N= 69 (all male)Age mean 56.30, range 26-82 years Spouses

Breast cancer

To investigate background factors, primary stressors secondary stressors and mediating variables and understand impact on mental and physical health of caregivers

Depressive symptoms,

Masculine distress

Beck Depression Inventory -II Masculine Depression Scale.

Role strainSatisfaction with marital relationship

Durkin & Williamson (2013);US

QuantitativeLongitudinalSecondary data analysis

N= 64 (all male)Age mean 63.4, range 21- 87 yearsVarious relationships

Older adults To understand the impact of quality of relationships, activity restriction and social support on prototypical depression, masculine distress, and physical health

Depressive symptoms, Anxiety

Center for Epidemiological Studies Depression scale.Spielberger’s State-Trait Anxiety Inventory

Pre-illness relationship.Activity restriction.Social SupportIncome adequacy

Geiger et al. (2015);US

QuantitativeCross-sectionalSecondary data analysis of convenience sample

N= 138 (all male)Age mean 61, range not given Various relationships

Dementia To examine the effects of coping strategies on burden among male dementia caregivers

Burden Zarit Burden Interview (shortened 4-item)

Coping strategies

Hagedoorn et al. (2002);Netherlands

QuantitativeCross-sectionalConvenience

N= 68 (male 36, female 32)Age mean 54, range not given Spouses

Cancer To explore associations between carers feelings of competent and lower levels of distress

Depressive symptoms

Center for Epidemiological Studies Depression scale

Feeling competent as a carer

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recipient)


care recipient


being defined



Kenny et al. (2014);Australia

QuantitativeLongitudinalSecondary data analysis

N= 424 (male 170, female 254)Age mean 48.9, range not givenVarious relationships

Various conditions

To explore the impact of caregiving before caregiving commenced to 2 and 4 years after caregiving commenced

Mental Health Short Form-36. Number of hours caregiving.

Kim et al. (2015);US

QuantitativeLongitudinalConvenience sample

N= 369 (male 136, female 233)Age mean for men 56.1 mean for women 54.4, ranges not given Various relationships

Cancer To investigate the extent to which caregiving motives predict caregiver's longer term spirituality and Quality of Life (mental and physical health)

Mental Health Medical Outcomes Scale Short Form-12.(12-item).

Earlier caregiving motives.Spirituality.

Lopez et al. (2012); UK

Qualitative, longitudinal, convenience sample

N=15 (all male) Age mean 60, range 27-74 years Spouses

Cancer To explore male spouses/partners experiences of caring for their spouse/partner over a one year period

Psychological impact

N/A Support, coping strategies, adapting, knowledge of the disease/treatment.

Mays & Lund (1999);US

QualitativeCross-sectionalPurposive sample

N= 10 (all male)Age mean 59.9, range 36–70 years Spouse or parent

Mental illness

To describe the lived experiences of male caregivers of severely mentally ill relatives

Emotional impact,burden

N/A Lack of understanding of the illness and the care required.Improvement over time/ adjustment.

Oshio (2015);Japan

QuantitativeLongitudinalSecondary data analysis of national survey

N= 2243 (male)Age mean 58.1 for men, range not givenVarious relationships

Various conditions

To examine how informal caregiver's psychological distress is associated with prolonged caregiving

Psychological distress

Kessler 6 (K6) Hours of care (>14 h per week)Residing with a care recipientCaring for a spouse orparent(s)-in-lawCaring for others

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Not working





recipient)


care recipient


being defined



Schrank et al. (2016);Austria


N= 308 (male 179 and female 129)Age mean 57 for men, range not givenVarious relationships

Cancer To assess the correlates and determinants of caregiver burden in family caregivers of advanced cancer patients

Burden Zarit Caregiver Burden Interview (ZBI-12).

Hope.Coping style.Perceived support.

Schwartz (2012);US

QuantitativeCross-sectionalSecondary data analysis of a national random sample of caregivers

N= 821 (male 270, female 551)Age mean 53.35 for men, range 18-90 years Various relationships

Various conditions

To examine if there are there differences in male and female carers and what factors impact carers health

Emotional stress

Author derived 5-point Likert scale.

Care intensity.Use of websites.Seeking of respite services.

Zhu et al. (2014);China


N= 243 (all male)Age mean 49.5, 26-80 years Spouses

Breast cancer

To describe the characteristics of male spouse caregivers of breast cancer patients, assess their quality of life and investigate influencing factors.

Mental health Short Form-36 Life events.Patient’s symptoms.Family income.Education level of carer. Sharing caring.

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Quality assessment of the studies

Quality assessment was completed using the QualSyst quality appraisal tool

(Kmet et al., 2004). The results for this can be seen in Table 3a for the quantitative

studies and Table 3b for the qualitative studies.

Considering the quantitative studies, the majority of the studies did not

provide sufficient estimate of the variance (e.g. confidence intervals, standard errors)

within their results. A further common limitation of the quantitative studies was

inappropriate sample sizes with four of the quantitative studies (Crevier et al., 2015;

Dihmes, 2013; Durkin & Williamson, 2013; Hagedoorn et al., 2002) having fewer

than 100 male participants. A further limitation of many of the quantitative studies

was the method of selection of the participants with many using convenience

samples and three identified by the QualSyst quality appraisal tool (Kmet et al.,

2004) as only partially meeting the criteria for ‘subject selection’ (Arai et al., 2008;

Hagedoorn et al., 2002; Schrank et al., 2016).

In considering the quality of the qualitative studies (Lopez et al., 2012; Mays

& Lund, 1999) neither study provided evidence of reflexivity in the study report.

Therefore any potential author influences on the data were not explored.

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Table 3a.

Quantitative studies quality ratings

Criteria a Arai et al. (2008)

Buchanan et al. (2010)

Coe & Van Houtven (2009)

Crevier et al. (2015)

Dihmes (2013)

Durkin& Williamson (2010)

Geiger et al. (2015)

Hagedoorn et al. (2002)

Kenny et al. (2014)

Kim et al. (2015)

Oshio (2015)

Schrank et al. (2016)

Schwartz (2012)

Zhu et al. (2014)

1. Question/objective sufficiently described?

2 2 1 2 2 2 2 1 2 2 1 2 2 2

2. Study design evident and appropriate? 2 2 2 2 2 2 2 2 2 2 1 2 2 23. Method of subject/comparison group selection or source of information/input variables described and appropriate

1 2 2 2 2 2 2 1 2 2 2 1 2 2

4. Subject (and comparison group, if applicable) characteristics sufficiently described?

0 2 2 2 2 2 2 2 2 2 2 2 2 2

5. If interventional and random allocation was possible, was it described?

n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

6. If interventional and blinding of investigators was possible, was it described?


7. If interventional and blinding of subjects was possible, was it reported?


8. Outcome and (if applicable) exposure measure(s) well defined and robust to measurement/misclassification bias? Means of assessment reported?

2 2 2 2 2 2 2 2 2 2 2 2 2 2

Criteria a Arai et al. (2008)

Buchanan et al.

Coe & Van Houtve

Crevier et al. (2015)

Dihmes (2013)

Durkin & Willia

Geiger et al. (2015)

Hagedoorn et al.

Kenny et al. (2014)

Kim et al. (2015)

Oshio (2015)

Schrank et al. (2016)

Schwartz (2012)

Zhu et al. (2014)

Note. n/a = not applicable. Scores for each criteria are Yes (2), Partial (1), No (0).

a from Kmet et al., 2004. B

b figures have been calculated on a percentage (out of 100) to aid comparison between papers.

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(2010) n (2009)

mson (2013)

(2002)

9. Sample size appropriate? 2 2 2 1 1 2 1 1 2 2 2 1 2 210. Analytic methods described/justified and appropriate?

2 2 2 2 2 2 2 2 2 2 2 2 2 2

11. Some estimate of variance is reported for the main results?

0 2 2 1 2 2 0 0 2 0 2 2 1 0

12. Controlled for confounding? 0 n/a 1 1 n/a 2 n/a 2 2 1 2 2 2 n/a13. Results reported in sufficient detail? 2 2 2 2 2 2 2 2 2 2 1 2 2 214. Conclusions supported by the results?

2 2 2 2 2 2 2 2 2 2 2 2 2 1

Total score 15/22 20/20 20/22 19/22 19/20 22/22 17/20 17/22 22/22 19/22 19/22 20/22 21/22 17/20Final quality rating b 68% 100% 90% 86% 95% 100% 85% 77% 100% 86% 86% 90% 95% 85%

Note. n/a = not applicable. Scores for each criteria are Yes (2), Partial (1), No (0).

a from Kmet et al., 2004.

b figures have been calculated on a percentage (out of 100) to aid comparison between papers.

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Table 3b.

Qualitative studies quality ratings

Criteria a Lopez et al. (2012) Mays & Lund (1999)

1. Question/ objective sufficiently described? 2 12. Study design evident and appropriate? 2 23. Context for the study clear? 2 24. Connection to a theoretical framework/wider body of knowledge? 2 15. Sampling strategy described, relevant and justified? 2 26. Data collection methods clearly described and systematic? 2 27. Data analysis clearly described and systematic? 2 28. Use of verification procedure(s) to establish credibility? 2 29. Conclusions supported by the results? 2 210. Reflexivity of the account? 0 0Total score 18/20 16/20

Final quality rating b 90% 80%

Note. Scores for each criteria are Yes (2), Partial (1), No (0).

a from Kmet et al., 2004.

b Figures have been calculated on a percentage (out of 100) to aid comparison between papers.

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Factors which may contribute to mental health/well-being

The factors which the studies examined that may contribute to a carer’s

mental well-being were broad and included social support, duration and hours of

caregiving, relationship dynamics, coping strategies , spirituality , knowledge of the

condition/disease , gender identity, negative life events and income. Results for

these factors are further explained below in the following broad categories: practical

characteristics of care (such as number of hours spent care giving a week and the

length of time that the carer has been in the role), support (both social and

professional) and the characteristics of the carer (intrinsic, extrinsic and demographic

characteristics).

Practical characteristics of care

A commonly examined factor amongst the studies was the impact of the

practical characteristics of care, such as the number of hours spent care giving a

week and the length of time that the carer has been in the role.

In relation to the length of time that the carer has been in the role, the impact

of continued caregiving was seen to vary in Kenny et al.’s (2014) longitudinal study

depending on the number of hours that the carer spent caring a week. Worse mental

well-being for longer duration carers was seen for those who were moderate (five to

nineteen hours a week) or high (twenty plus hours a week) level carers but this

pattern was not seen for those caring at the lower level of numbers of hours (Table

3a). However, in Mays and Lund’s (1999) qualitative study of male caregivers, of

those with mental health problems, the majority of caregivers described decreased

levels of ‘stress’ the longer the carer was in the carer role, although the study did not

146

elaborate on what participants described as ‘stress’ and had a characteristically small

number of participants (N=10).

In terms of the number of hours spent care giving a week Buchanan et al.’s

(2010) large (N=225) cross-sectional study of male carers in the US, showed an

association between hours of care giving and poorer mental well-being amongst the

male care givers in their study. Higher hours were associated with poorer mental

well-being (Buchanan et al., 2010). However the association was weak (see Table

4a.) and the sample arose from those who were members of a voluntary register. This

registration may have come about through the carer identifying that they require

additional support which could be indicative of, and therefore have, over-represented

those with poorer mental well-being.

A further study found an association between the number of hours spent

caregiving a week and mental well-being. In a large, cross-sectional study using a

national random sample of caregiver’s Schwartz (2012) found that those who were

low or medium level carers (based upon a calculation based on the number of hours

caregiving and the number of activities of daily living performed) were also reported

to have lower levels of emotional stress compared to those with a high level of care

intensity (Table 4a). However, this study used a Likert scale measure of well-being

devised by the author which has not been validated. Also, as Schwartz (2012)

incorporated care hours with the number of activities of daily living forming a care

intensity rating, care hours solely cannot be separated as a factor in this study.

The association between number of hours spent care giving and mental well-

being was not established in all studies. A longitudinal study based in Japan (Oshio,

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2015) used secondary analysis of a national survey and did not find evidence of any

association between the number of hours in the care role and mental well-being for

male carers who had been caring for over one year (see Table 4a.).

So in summary higher hours spent care giving a week were generally

consistently associated with poorer mental well-being but this was not statistically

significant in all of the studies which explored this factor.

Another aspect of the practical characteristics of care is the effect the role has

on the caregiver’s ability to undertake previous activities. In a relatively small

(N=64) longitudinal study of male carers of older adults in the US (Durkin &

Williamson, 2013) the care giver’s need to give up previous activities (such as

hobbies and social contacts) due to the caring role was associated with anxiety and

depression. Buchanan et al.’s (2010) study supported this as they found the

perception of whether the caring role impacts on important day-to-day activities was

highly associated with poorer mental well-being for carers.

A further aspect of the practical characteristics of care was role strain defined

in Dihmes (2013) as interference to the carer’s original role (i.e. prior to commencing

caring), both inside and outside the home, due to the responsibilities of the care role.

In a relatively small (N=69) cross-sectional study of male spouse carers of those with

breast cancer, Dihmes (2013) found that increased role strain and reduced

satisfaction in the marital relationship were both associated with masculine

(measured by the Masculine Depression Scale, Magovcevic & Addis, 2008) and

prototypical (measured by the Beck Depression Inventory-II, Beck et al., 1990)

depression symptoms but with role strain having a stronger association (Table 3a).

However, the definition of role strain, which was measured using the PAIS-SR

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(Psychosocial Adjustment to Illness Scale-Self-Report Derogatis & Derogatis, 1990),

had a broad definition within this study. The PAIS-SR measures the quality of the

carer’s psychosocial adjustment to illness or its residual effects and assesses changes

made as a result of the illness. Whilst changes made as a result of illness can be

viewed as practical characteristics of care the measure incorporates a number of

aspects including health care orientation, vocational environment, domestic

environment, relationships and social environment. The measure therefore combines

a number of separate factors in a number of environments.

A final area in the practical characteristics of care which was identified in this

review was the care recipient’s symptom severity. A relatively large (N=243) cross-

sectional study of male spouse carers of those with breast cancer in China (Zhu et al.,

2014) found a small association between higher care recipient’s symptom severity

and poorer carer’s mental health (Table 4a).

Support

Support in both the social and professional context emerged from the review

as a major factor associated with middle-aged male carers’ mental well-being.

Social Support

In terms of social support, four of the studies (Arai et al., 2008; Durkin &

Williamson, 2013; Lopez et al., 2012; Zhu et al., 2014) found a positive association

between higher levels of support and better mental well-being. Arai et al.’s (2008)

large cross-sectional study in Japan found an association between higher social

support that carers had (defined by how many people around them they had to help

and how many friends or family would listen if the carer had worries), and better

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mental well-being, although the association was quite weak (Table 4a). This positive

association between social support and mental health was also highlighted in a US

study by Durkin and Williamson (2013) who found that more social support was

associated with reduced depressed affect (and therefore better mental well-being) in

their male carers. In their UK qualitative study of male spouses/partners caring for

those with cancer Lopez et al. (2012) also highlighted a link between social support

and mental well-being as they found that their male carers reported a negative impact

on their well-being and lifestyle as a result of a lack of social support, particularly in

the early post-diagnosis stage. This highlights that social support has been seen to

have consistent importance across a variety of cultures/countries.

This is also supported in Zhu et al.’s (2014) large study of male spouse carers

in China which found that ‘having someone to share caregiving’ positively impacted

caregivers’ mental health (Table 4a). However, ‘having someone to share caregiving’

may go beyond social support and actually change the intensity of the care giving

role such as the number of hours spent caregiving, but this was not reported on in the

study.

Professional support

In terms of professional support only one study (Schwartz, 2012) explored

this as a factor associated with male carers’ mental well-being. Schwartz (2012)

found that the men in their study who did not seek professional support through

respite services reported lower levels of emotional stress, although they may have

provided a lower intensity of care (defined in this study as combined hours of care

per week and activities of daily living undertaken by the carer) which was not

accounted for by the study. The seeking of respite services may be impacted on by

150

the informal or social support that a carer may also be receiving but this was not

reported within the study. The motive to seek respite services may result from the

carer’s feelings of being overwhelmed and a lack of adequate support and/or high

intensity care given may impact this, although this was also not explored in the

study.

In summary in considering support there was consistency among the studies

included in the review that increased social support is associated with better mental

health/well-being.

Characteristics of the carer

Characteristics of the carer were consistently found to be associated with

mental well-being. The characteristics of the carer can be further split into two

subcategories of intrinsic (such as relation behaviours and coping styles) and

extrinsic or demographic characteristics (such as social economic status and marital

status).

Intrinsic Characteristics

A number of studies highlighted an association between the carer’s relational

behaviours and the carer’s mental well-being, for example in Crevier et al. (2015). In

their relatively small sample size (N=65) of both male and female carers to those

with PTSD they examined care dyads using The Social Support Interaction Global

Coding System (Pizzamiglio et al., 2001 cited in Crevier et al., 2015) which is a

validated behavioural observation system. They found that higher social support

behaviours (from the carer towards the care recipient) such as validation, listening

and positive solution suggestions in male carers were associated with lower levels of

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both depressive symptoms and anxiety symptoms (see Table 4a). Male carers in their

study who displayed less validation and positive solutions social behaviours towards

the care recipient were more likely to have depressive symptoms. They also found

that male caregivers who were more withdrawn and displayed less validation social

behaviours towards the care recipient were more likely to show anxiety symptoms.

However, this should be interpreted with a high level of caution as the direction of

causation is not known as it is plausible that those carers with higher levels of

anxiety or depression have a reduced ability to show higher levels of social support

behaviours. A further limitation of this study is that it was formed of a small number

(N=36) of male carers of those with PTSD.

Another intrinsic characteristic evident in a number of studies to be

associated with the mental well-being of male carers was coping styles and

approaches. Coping styles and approaches has received coverage in previous

literature (see Spendelow, Adam & Fairhurst, 2017). Geiger et al.’s 2015 cross-

sectional study of male carers explored coping styles (assessed by the Coping

Inventory for Task Stressors) adopted by male carers and their relationship with

burden as measured by two scales: a shortened Zarit Burden Interview (Zarit, 1990)

and the Revised Memory and Behaviour Problems Checklist (Teri et al., 1992). They

found that emotion-focused (such as a high rating on ‘worried about what I would do

next’) and avoidance-focused (such as a high rating on ‘staying detached from the

situation’) coping strategies were associated with higher levels of burden (negative

mental well-being). However, they found no significant effect on burden in the use of

task-focused coping strategies such as ‘working out a strategy for successful

performance’ (see Table 4a).

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An additional intrinsic characteristic explored in the studies included in this

review was autonomy or agency in particular in respect to the motive to provide care.

In Kim et al.’s (2015) study an autonomous motive, as measured by responses to the

autonomous motive subscale in the Reasons for Providing Care, to initially provide

care was associated with better mental well-being as measured by the Medical

Outcomes Survey Short Form-12 (MOS-SF-12;Ware et al., 1993) mental component

score.

A further intrinsic characteristic explored in the studies relating to agency

was the carers’ feelings about being a carer. The feelings of personal

accomplishment in the role of a carer (measured with a subscale of the Maslach

Burnout Inventory; Maslach, Jackson & Leiter, 1996) was not found to have a

significant association with the male carer’s mental well-being (measured by the

CES-D) in Hagedoorn et al. (2002). However, Mays and Lund (1999) found as a

theme in their qualitative study that male carers reported that their mental well-being

improved with adjustment to the role and becoming more self-efficient, although this

should be viewed with caution due to the characteristically small sample size of male

carers (N=10). Kim et al. (2015) found in exploring spirituality in carers that a

measure of greater peace and meaning (measured by subcomponents in the 12-item

Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being Scale)

were correlated with increased mental wellbeing measured by the mental functioning

score of the MOS SF-12 among male carers. The concept of having ‘hope’, measured

by The Integrative Hope Scale (Schrank, Woppmann, Sibitz & Lauber, 2011), was

also associated with reduced levels of burden (measured by the Zarit Burden

Interview) in carers in the study by Schrank et al. (2016).

153

A further intrinsic characteristic which was explored in the studies centred on

the carer’s knowledge about the illness/condition that the care recipient had. Carers

expressed frustration at a lack of knowledge in Lopez et al.’s (2012) qualitative study

of male spousal carers of those with cancer. In Mays and Lund’s (1999) qualitative

study of male caregivers of those with mental health difficulties a major theme

described a lack of understanding about the illness and the care required negatively

impacted on the carer’s mental health.

Extrinsic and Demographic Characteristics

An area which was explored as a predictor of mental well-being in some of

the studies was socioeconomic status. This was defined in various ways in the

different studies such as education level (Durkin & Williamson, 2013; Zhu et al.,

2014) and income (Durkin & Williamson, 2013; Zhu et al., 2014). An interesting

finding in Zhu et al.’s, 2014 study in China was that male carers with a higher level

of education tended to have poorer mental well-being as measured by the mental

component of the Short Form-36. The authors of the study suggested this could be an

indication that those with higher education levels are more likely to have higher

expectations for a healthy life and family and the conflict between this expectation

and reality could cause emotional distress. In contrast, a study in the US (Durkin &

Williamson, 2013) found that a lower level of education was associated with

increased anxiety and increased depressed affect among male carers. Durkin and

Williamson (2013) also found that higher income inadequacy (where participants

perceived their income was inadequate to meet their needs) was associated with

increased anxiety and depressed affect. This finding was supported by Zhu et al.

(2014) who found that a higher level of family income was associated with better

154

mental well-being for the carers in their study. However, the authors did not suggest

an explanation for this finding or how it may be understood in relation to their

findings that higher education was associated with poorer mental well-being. A

possible explanation of this could be that education level is related to historic

socioeconomic status and income to current socioeconomic status which may impact

differently on mental well-being.

Another demographic factor explored in one study was the marital status of

the carer. A large, longitudinal US study of those caring for an elderly mother (Coe

& Van Houtven, 2009) found that there were increased depressive symptoms (as

measured by the CES-D8 index) for married men who continued caregiving after two

years but for single men who continued caregiving after two years there was a

decrease in depressive symptoms (Table 4a).

An extrinsic characteristic explored in one of the studies (Zhu et al., 2014)

was the presence of negative ‘life events’. The presence of negative ‘life events’ was

shown to strongly associate with poorer mental health of carers in Zhu et al. (2014)

although the definition of negative ‘life events’ was not given in the study and they

were measured in only a yes/no format.

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Table 4a.

Quantitative Study findings

Authors Results for each factor reported Narrative Conclusions

Arai et al. (2008); Japan

Social support β 0.25 p<0.05 Higher social support predicted better mental health as measured by the MCS (mental components of health) scores of males.

Buchanan et al. (2010); US

Hours of caregiving (Ave. no of hours/week). β 0.273 (SE 0.103) p =0.009Caregiving affects caregiver’s activities β 0.923 (SE 0.237) p<0.001

More hours of caregiving associated with poorer mental health.The more caregivers perceived that assisting the person with MS limited their ability to perform important activities in their daily lives the poorer their mental health.

Coe & Van Houtven (2009); US

Continued caregiving (after 2 years) and marital statusMarried men β 0.6463 (SE =0.3063) p<0.05Single men β -0.3725 (SE= 0.7735) p value not given

Increased depressive symptoms for married men who continue to care, but decreased depressive symptoms for single men who continue to care.

Crevier et al. (2015); Canada

Behaviours towards care recipient - Problem description. Depression r=-0.11;Anxiety r=-0.22Expression of emotions. Depression r=0.19;Anxiety r=0.23Listening. Depression r=-0.30; Anxiety r=-0.23Validation. Depression r=-0.31; Anxiety r=-0.34**Positive solutions. Depression r=-0.42**;Anxiety r=-0.35**Negative solutions. Depression r=-0.30; Anxiety r=-0.14Dysphoria. Depression r=0.09;Anxiety r=0.10Counter-validation. Depression r=-0.01;Anxiety r=0.05Withdrawal. Depression r=0.16; Anxiety r=0.36Behavioural implication (e.g. voice intonation and facial expressions). Depression r=-0.35*;Anxiety r=-0.38

*p<0.05 **p<0.01.

Male caregivers who display more validation and positive solutions behaviours towards the care recipients are less likely to show depressive symptoms.Male caregivers who display less validation and are more withdrawn towards the care recipient are more likely to show anxiety symptoms.

Note. ns = not significant, SE= Standard Error, B= unstandardised coefficents

156


Dihmes (2013); US

Role strain. Masculine Depression Symptoms β 0.647 p<0.001 ; Prototypical Depression Symptoms β 0.790 p<0.001Satisfaction with marital relationship. Masculine Depression Symptoms β -0.321 p<0.01 ; Prototypical Depression Symptoms β -0.221 p<0.05

Increased role strain and lower levels of satisfaction with a marital relationship are associated with symptoms of both masculine and prototypical depression

Durkin & Williamson (2013);US

Caregiver education. Anxiety β -1.92 (SE 0.36) p<0.001 ; Depressed affect β -1.24 (SE 0.36) p=0.001Social support. Anxiety not given ; Depressed affect β -0.60 (SE 0.18) p=0.002Activity restriction. Anxiety β 0.71 (SE 0.12) p<0.001 ; Depressed affect β 0.62 (SE 0.14) p<0.001Pre-illness relationship. Anxiety β -0.50 (SE 0.14) p<0.001 ; Depressed affect β 4.64 (SE 1.78) p=0.011Income Adequacy. Anxiety r = .28, p<0.01; Depressed affect r = .26, p<.01

A lower level of education, greater perceived incomeinadequacy, increased activity restriction and a worse pre-illness relationship are associated with increased anxiety.A lower level of education, greater perceived incomeinadequacy, worse pre-illness relationship, less social support and more activity restriction associated with increased depressed affect.

Geiger et al. (2015);US

Task focused coping strategy nsEmotion focused coping strategy β 0.523 p<0.01Avoidance focused coping strategy β 0.233 p<0.01

No significant effect of task-focused coping on burden. Emotion-focused and avoidance-focused coping strategies associated with higher levels of burden.

Hagedoorn et al. (2002);Netherlands

Carer’s feelings of self-efficacy r=-0.20 nsCarer’s feelings of personal accomplishment r= 0.07 nsCare recipient’s perception of carer’s supportive behaviour r=0.17 nsCare recipient’s perception of carer’s unsupportive behaviour r=-0.13 ns

Male carer’s feelings of self-efficacy and personal accomplishment were not associated with their psychological distress.Care recipient’s perception of the carer’s supportive or unsupportive behaviour were not associated with the carer’s psychological distress.

Kenny et al. (2014);Australia

Moderate caregivers 7.2 point decline in mental health(t=-2.02, p=0.045)High caregivers Non-significant 6.6 point decline in mental health (t=-1.49, p=0.14)

After 4 years of caregiving the deterioration in mental health was worse for moderate and high care-giving males than low care-giving males.

Kim et al. (2015);US

Autonomous motive for providing care. r=0.20 p<0.05Spirituality domains-

Peace r=0.66 p<0.001Meaning r=0.61 p<0.001

Male carers’ mental health is positively correlated with an autonomous motive for providing care and with peace and meaning components of spirituality.

157


Oshio (2015);Japan Hours of care (>14 h per week) β -0.06,ns,95% CI (-0.20,0.08)

Residing with a care recipient β 0.07,ns, 95% CI (-0.05,0.19)Caring for a spouse β -0.19,ns, 95% CI (-0.59,0.21)Caring for parent(s)-in-law β 0.06,ns, 95% CI (-0.08,0.20)Caring for others β 0.09,ns, 95% CI (-0.10,0.29)Not working β 0.01,ns, 95% CI (-0.17,0.19)

Hours of care (>14 hr per week), residing with a care recipient, caring for a spouse, caring for parent(s)-in-law, caring for others and not working were not significantly associated to the mental health of male carers.

Schrank et al. (2016);Austria

Multivariate analyses resultsAge. β -0.0091 p<0.05Hope. β -0.3603 p=0.001Emotion-oriented coping. β 0.1511 nsPerceived fulfilment of support needs. β -0.5044 p<0.05

Hope is associated with lower level of burden in men accounting for 36% of the variance.Perceived fulfilment of support needs is associated with lower levels of burden in men accounting for 50% of the variance.

Schwartz (2012);US

Significant difference (chi-square test statistic)Care intensity. 24.90 p≤0.001Use of websites. 31.24 p≤0.01Seeking of respite services. 13.94 p≤0.01

Men who provide a low/medium level of care intensity have lower emotional stress compared to men providing a high level of care intensity.Men who use websites sometimes or often have higher levels of emotional stress than men who never or rarely use websites. Men who did not seek respite services reported lower levels of emotional stress.

Zhu et al. (2014);China

Life events. B-8.119, p<0.01Patient’s symptoms. B-0.314, p<0.01Average monthly family income. B3.875, p<0.01Education level of carer. B-5.236, p=0.011Sharing caring. B2.099, p=0.018

Life events and the education of the carer negatively impacted on the mental well-being of male carers. Patients’ symptom severity also had a negative impact on the mental well-being of male carers but to a lesser extent.Family income had a beneficial effect on the mental well-being of carers along with having someone to share caregiving.

Note. ns = not significant, SE= Standard Error, B= unstandardised coefficients

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Table 4b.

Qualitative study findings

Authors Themes/categories Findings

Lopez et al. (2012);UK

Searching for information about the disease.Difficulty expressing emotions.Fear of losing wife/partner.Fear of the unknown/uncertainty.Lack of social support and limited social contacts.

Male carers reported frustration with lack of knowledge and difficulty expressing their fears and concerns to others. They also reported a lack of social support and an impact on their social contacts particularly at the beginning following diagnosis.

Mays & Lund (1999);US

Caregiver’s lack of understanding of the illness and the care required.Improvement over time/adjustment.

Caregiver’s mental well-being negatively impacted by a lack of understanding of the illness/care required.Caregiver’s mental well-being improves with adjustment to the role.

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DiscussionThe review aimed to synthesise and critique research into the factors

associated with the mental well-being of middle-aged male carers. Sixteen papers

were critically reviewed. Eight of the studies were conducted in the US with two of

the remaining studies from Japan and one each from Australia, Austria, Canada,

China, the Netherlands and the UK showing a broad geographical and cultural

variation.

Fourteen of the studies were of a quantitative design and of these eleven were

cross-sectional. A limitation of all of these cross-sectional quantitative studies was

that they used convenience samples with the exception of one (Schwartz, 2012)

which used a national random sample of caregivers. Another common limitation

within the quantitative studies was the relatively small sample sizes. Along with the

use of convenience samples this raises concerns about how representative the

samples are of the wider population of male carers. The dearth of longitudinal studies

also revealed a gap in the research relating to possible long-term effects on male

carers’ mental health and well-being.

The findings from the review were broadly in line with previous research into

the effect of the role of being a carer on an individual’s mental well-being. The

studies examined in this review which compared male carers with male non-carers or

followed those who became carers (Kenny et al., 2014; Oshio, 2015), found poorer

mental well-being for carers which is in line with previous research which has

consistently found worse mental well-being among carers (e.g. Molyneux et al.,

2008; Stansfeld et al., 2014). Although it should be noted that in the reviewed study

of Kenny et al. (2014) the male carers group were significantly older on average than

the male non carers group which could affect the relevance of those results.

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A consistent finding from the review was the impact that social support or the

absence of it can have on male carers’ mental well-being. Several studies (Arai et al.,

2008; Durkin & Williamson, 2013; Lopez et al., 2012; Schrank et al., 2016;

Schwartz, 2012; Zhu et al., 2014) found that better social support was associated

with better mental well-being. Within the reviewed studies the definition of support

varied from social contacts (Lopez et al., 2012) and social support from family and

friends (Durkin & Williamson, 2013), to carers viewing that their support needs were

fulfilled (Schrank et al., 2016) and ‘sharing caring’ (Zhu et al., 2014). In addition,

masculine identity has been suggested to influence male carers’ ability to express

their own feelings leading to them not seeking the support that they require (Lopez et

al., 2012), which may impact their mental well-being. While the results here suggest

that social support is an important factor in the mental well-being of male carers, the

results for professional support were more difficult to interpret as this was only

explored within one study (Schwartz, 2012). Although Schwartz (2012) found an

association between not seeking professional support through respite services and

better mental well-being the study did not account for the level of intensity of care

that may be provided.

There were consistent findings that the carer role restricts the ability of the

male carer to undertake activities, negatively impacting their mental well-being

(Buchanan et al., 2010; Durkin & Williamson, 2013; Lopez et al., 2012). This

supports previous research on male and female middle-aged carers which suggested

that middle-aged carers could be at even higher risk for impaired health behaviours

due to conflicting demands on their time (Do et al., 2014). A possible mechanism

through which it may operate is that the restriction of activity could reduce the social

support and contacts which a carer may have which has also been found to have a

161

negative impact on male carers’ mental well-being (Durkin & Williamson, 2013;

Lopez et al., 2012).

In relation specifically to factors which may be more pertinent to middle-aged

male carers or ‘sandwich generation’ carers, such as the combined demands of being

a carer and having dependent children (Boyczuk & Fletcher, 2016), a clearer

conclusion was harder to establish from the findings of the review. Of the studies

examined only one (Kenny et al., 2014) explored factors which may be specific to

those of the ‘sandwich generation’ such as dependent children, which has been seen

as a contributing factor to poor mental health in carers in the US (Do et al., 2014).

Whilst Kenny et al. (2014) explored the effect of having dependent children the

study did not report the findings specifically in relation to males and therefore the

results were not included in this review. The review highlighted the lack of research

into this group of carers and future research would be beneficial to explore the needs

of middle-aged male carers particularly those which are defined as in the ‘sandwich

generation’.

Of the sixteen studies explored within this review there was a broad

geographical range. A number of cultural and social factors may influence the carer’s

role and factors contributing to their well-being, for example the level of state

support provided to carers. The cultural expectations placed on male carers may also

vary, such as in Eastern cultures sons may be seen as the main carer but they may

undertake this role with assistance from their wives (McDonnell & Ryan, 2013).

Limitations

The review had a number of limitations. A limitation, due to the dearth of

studies solely on middle-aged male carers, was that it was necessary to include a

162

broader age range than exclusively middle-aged (40 to 65 years) carers but it was

hoped that by including the location of the data for age (i.e. mean age) as between 40

to 65 years the results do pertain largely to this age group. The second limitation was

that the quality assessment completed using the QualSyst quality appraisal tool

(Kmet et al., 2004) indicated that many of the studies had relatively small sample

sizes (see Table 2a.) with four of the quantitative studies having fewer than 100 male

participants.

A further potential limitation of this review was that the broad geographical

range of studies included has meant the inclusion of various countries and cultural

and societal factors of which the individual studies have not specifically reported on.

However, there was consistency in the findings of studies from different cultures

such as the impact of income on carer’s mental well-being in the US in Durkin and

Williamson (2013) and in China in Zhu et al. (2014).

Another limitation of this review was that there was a broad

operationalisation of mental health/well-being ranging from stress, burden, to anxiety

and depression. Subsequently there was a broad range of measures used to capture

the various operationalisations of mental health/well-being from a measure derived

by the author to capture ‘emotional stress’ (Schwartz, 2012) to specific mental health

condition standardised outcomes measures such as The Center for Epidemiological

Studies Depression Scale (CES-D; Blazer et al., 1991) in three studies (Hagedoorn et

al., 2002; Durkin & Williamson, 2013; Coe & Van Houtven, 2009). Further

standardised measures were used for depressive symptoms such as the Beck

Depression Inventory II (Beck et al., 1990, in Dihmes, 2013; Crevier et al., 2015)

and the Masculine Depression Scale (Magovcevic & Addis, 2008, in Dihmes (2013).

163

There were few studies which used the same definition or outcome measure and

therefore the review could not establish consistency by comparing studies together

based on a particular outcome measure/definition of mental well-being. The factors

which influence different definitions of mental well-being (e.g. stress, burden,

depression, anxiety), may vary and therefore future research should be mindful to

acknowledge and operationalise this through clearly defined and theoretically based

terms of mental well-being.

Future Research and Conclusions

Whilst previous research in the US (Do et al., 2014) and the UK (Livingston

et al., 1996) has indicated that almost half of all carers are male the review

highlighted the lack of current research with sufficient samples sizes for this group of

carers. Future research into the factors which are associated with middle-aged male

carers’ mental well-being might be indicated as previous research has suggested that

males carers’ needs may be overlooked (Slack & Fraser, 2014). Due to the broad

geographical range of the included studies future research into middle-aged male

carers in a specific country could help to address some of the social and cultural

influences which may be relevant in a particular country. Future research would also

need to be mindful of the target population and how they can get a representative

sample of it, as a limitation within many of the included studies in this review was

the use of convenience samples.

The review’s aim was to identify and synthesise previous studies which have

explored the mental health/well-being of middle-aged carers and the factors

associated with their mental health/well-being. Of the 16 studies identified in the

review three broad categories of factors associated with mental health/well-being

164

were ascertained: practical characteristics of care, support and the characteristics of

the carer. The review found that a consistent factor identified in a number of studies

(Arai et al., 2008; Durkin & Williamson, 2013; Lopez et al., 2012; Zhu et al., 2014)

was that reduced social support is associated with worse mental well-being.

165

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Appendix A Journal guidelines

Literature Review Guidelines

Developed by James O'Neill with assistance from Ronald Levant, Rod Watts, Andrew Smiler, Michael Addis, and Stephen Wester.General Considerations

A good review should summarize the state of knowledge on a well-defined topic in the psychology of men and masculinity in concise and clear ways. This means that the review is written with exceptional clarity, cohesiveness, conciseness, and comprehensiveness.

A good review should describe in detail the systematic process or method that was used in doing the literature review. There are articulated ways to do "narrative reviews" just as there are ways of doing experiments or meta-analyses (Baumeister & Leary, 1997; Bem, 1995).

Essential Elements for a Review

Focus on an important, relevant, and operationally defined topic in the psychology of men and masculinity, and make a strong case for why a literature review of this topic is important.

Include a critical and inclusive review of previous theory related to the relevant topic. "Critical" means that the literature review reveals problems, contradictions, controversies, strengths, next steps, and potentials in the theories. "Inclusive" means that there is an active evaluation of all of the theory relevant to the topic.

Include a critical and inclusive review of previous empirical research related to the relevant topic.

Critically analyze the distinction between authors' interpretation of their data and the actual empirical evidence presented. A good review critically analyses how accurately previous authors have reported their findings and whether they have refrained from asserting conclusions not supported by data

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Discuss the methodological diversity of studies reported in the literature review and the implications of this diversity for new knowledge or future research

Raise provocative and innovative questions on the topic not discussed before in the literature.

Write the review so that theoretical knowledge and empirical research is significantly advanced in the psychology of men and masculinity, and that there is an overall contribution to the field's theory, research, and clinical practice.

Include many "take home messages" (Sternberg, 1991) that generate new theories and empirical research.

Sections That Might Be Included in a Review

Provide a historical account or background of the development of the theory or research program reviewed.

Include persuasive arguments and articulated points of view on the topic from both theoretical and empirical perspectives.

Propose novel conceptualizations or theories based on reviews of previous theories and empirical research.

Propose new research paradigms or testable hypotheses that advance future research.

Propose new therapeutic paradigms or testable hypotheses that advance clinical practice/psychoeducational programming with men.

Address the frequent gap between reporting theory/research and interpreting the meaning of the theory and research.

It is not expected that reviews will be able to meet all of the above-listed criteria but authors should meet many of them.

References

Bem, D. J. (1995). Writing a review article for Psychological Bulletin. Psychological Bulletin, 118, 172–177.

Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews. Review of General Psychology, 1, 311–320.

Sternberg, R. J. (1991). Editorial. Psychological Bulletin, 109, 3–4.

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Retrieved on 16/05/2017 from

http://www.apa.org/pubs/journals/men/literature-review-guidelines.aspx

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Part 3. Clinical Experience

Adult Mental health Placement: Community Mental Health Recovery Service

(CMHRS)

On this placement I worked with adults aged between 18 and 64 from a variety of

backgrounds, with severe and enduring mental health difficulties. I offered

assessment and intervention for adults with diagnoses of Depression, Anxiety,

Borderline Personality Disorder, Obsessive Compulsive Disorder and Psychosis.

Therapeutic interventions included Cognitive Behaviour Therapy (CBT), Acceptance

and Commitment Therapy (ACT), Behavioural Activation and Exposure and

Response Prevention (ERP). I also provided teaching to non-clinical staff on working

with clients with a diagnosis of Borderline Personality Disorder. I developed

experience and skills in neuropsychological assessment using the BADS, WAIS-IV,

WMS-IV and TOPF.

Child Placement: Tier 2 Child and Adolescent Mental Health Service and

Paediatric outpatient department of an acute hospital

On this placement I worked with children and young people from the ages of 3 to 17

years old presenting with mental health and/or developmental difficulties including

Anxiety, Depression, Obsessive Compulsive Disorder, ASD, ADHD and behavioral

difficulties. I worked with outside agencies including schools, nurseries, inpatient

paediatric department and social care to develop person-centred care including

contributing to a TAC meeting. I used an integrative approach utilising CBT, ERP,

Systemic and Narrative approaches. I also conducted neuropsychological assessment

177

for children using the WISC-IV. In addition I delivered CBT training for non-

psychologists within the service.

Learning Disability Placement: Community Mental Health Learning Disability

Team

On this placement I worked with adults between the ages of 18 and 68 with a

learning disability who also had mental health difficulties including Depression,

anger difficulties, Anxiety and Bipolar Disorder. I also worked with a number of

clients who had a diagnosis of probable Dementia. I provided interventions with

clients, their families, carers and staff teams using a number of approaches including

Cognitive Analytic Therapy, Positive Behavior Support and integrative approaches

employing Systemic ideas. I worked closely with other professionals both within the

team and outside agencies to provide personal centered care to clients. I gained

further experience and skills in neuropsychological assessment using tools such as

WAIS-IV, NAID, CAMCOGS, ABAS and Vineland to assess cognitive ability and

adaptive behavior as appropriate. I also delivered teaching to a staff team on

‘Dementia in Learning Disabilities’. In addition I co-developed a CAT outcome

measure tool to be used in research.

Specialist Placement: Health Psychology Service at an acute hospital and Pain

Management Clinic

This placement I worked with adults aged from 21 to 70 years old with physical

health difficulties and mild-moderate mental health difficulties. In addition I worked

with adults with chronic pain. I offered assessment and interventions for adults with

a range of physical health difficulties including cancer, cardiac health problems,

multiple sclerosis and chronic pain and mental health difficulties including health

178

anxiety, anxiety and depression. I used an integrative approach utilizing CBT and

systemic approaches. In addition I delivered Pain Management Programmes working

closely with other medical professionals such as specialist nurses and

physiotherapists. I also delivered teaching and consultation to other professionals

such as physiotherapists within the Pain Management Clinic.

Older People Placement: Older People’s Community Mental Health

Service/Memory Assessment Clinic

On this placement I worked with older people from the ages of 65 to 81 with mental

health difficulties and/or memory/cognitive difficulties. I offered assessment and

intervention for older people with depression, adjustment difficulties and anxiety

often with co-morbid physical health and/or cognitive difficulties. I developed

further my neuropsychological assessments skills in the assessment of memory and

other cognitive domains using tests including subtests from the WAIS-IV, WMS-IV,

BADS, TOPF, KNBA and DKEFS. I also delivered teaching to clients with a

diagnosis of Parkinson’s disease on “Anxiety and How to Manage It”. In addition I

delivered training to other professionals within the service on neuropsychological

testing. I also undertook CBT supervision of other professional’s clinical work.

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Part 4. AssessmentsPSYCHD CLINICAL PROGAMME

TABLE OF ASSESSMENTS COMPLETED DURING TRAINING

Year I Assessments

Assessment title

WAIS WAIS Interpretation (online assessment)

Practice Report of Clinical Activity

Assessment and formulation for ‘Miss Smith’*, a woman in her mid 40’s with Schizophrenia and anxiety.

Audio Recording of Clinical Activity with Critical Appraisal

Acceptance and Commitment Therapy (ACT) session with ‘Anna’*.

Report of Clinical Activity N=1

Cognitive Behavioural Therapy intervention with ‘Cathy’*, a woman in her mid-twenties with depression

Major Research Project Literature Survey

Literature Survey on Factors affecting the mental health and well-being of male carers of the elderly.

Major Research Project Proposal

What factors affect the mental health and wellbeing of Middle Aged Male Carers?

Service-Related Project An audit of Crisis and Contingency Plans for people with Personality Disorders in Community Mental Health Recovery Services.

Year II Assessments

assessment title

Report of Clinical Activity/Report of Clinical Activity – Formal Assessment

A neuropsychological assessment of a girl of infant school age with behavioural and academic difficulties.

PPLD Process Account PPLDG Process Account

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Year III Assessments

assessment title

Presentation of Clinical Activity

Individual Cognitive Analytic Therapy (CAT) with ‘David’*, a man in his early 50’s with a learning disability and difficulties with ‘anger’.

Major Research Project Literature Review

What Factors are Associated with the Mental Health and Well-being of Male Middle-Aged Carers? A Systematic Review

Major Research Project Empirical Paper

What factors affect the mental health and well-being of Middle-Aged Male Carers?

Report of Clinical Activity/Report of Clinical Activity – Formal Assessment

Cognitive Behavioural Therapy with ‘Martin’*, a middle-aged man experiencing anxiety and distress following a myocardial infarction.

Final Reflective Account On becoming a clinical psychologist: A retrospective, developmental, reflective account of the experience of training

*please note that all names given are pseudonyms.

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