The association between caregiving and the self-reported health status of caregivers varied by sociodemographic factors, including number of children present within a household, race/ethnicity, and income. We found that the association between caregiving and poor health generally increased with the number of children present within a household. This finding suggests that there may be increased caregiver stress among the sandwich generation of adults that care for both their elderly family members or friends and underage children simultaneously. Such observations are consistent with past studies  suggesting that members of the sandwich generation may be at higher risk for impaired health behaviors compared to caregivers who provide care only for an older adult.
Regarding differences by race/ethnicity in the association between caregiving and health status, there was a statistically significant association between caregiving and health among Whites and Others. This association was not observed for Blacks, Asians, or Hispanics, indicating that cultural differences may exist influencing the association between caregiving and health status. Cultural differences may influence perceptions of caregiving, as they relate to the availability and use of coping strategies by caregivers to manage their situations . For example, other studies examining this association have identified cultural expectations , identity , family functioning , social support [27, 30], and spirituality  as potential factors influencing perceptions of caregiving. These factors may help to explain some of the observed individual differences in stress response to the caregiving burden  and may be interesting topics to explore in future research.
The association between caregiving and health also varied by income. Curiously, the association tended to be strongest in the intermediate income group earning between $50,000 and $75,000 per year and in those earning $75,000 or more, although these findings were not observed for Hispanics. The directionality of the interaction with income changed as the number of children increased for the overall sample. The nonlinear function between health and income has also been observed previously. In one study, stroke rates and income had a non-linear association, with high rates for low and high income groups, and low rates for middle income groups in one study .
The overall trends by income were more difficult to detect within the race/ethnicity subgroups. In Whites, the association between caregiving and health was inconsistently significant as income increased. However, for Whites with at least two children, the association between caregiving and poorer health increased significantly (p < 0.001) as income decreased. This finding suggests that, in Whites, caregiving for both elderly relatives and children may be more burdensome in individuals with fewer economic resources than in individuals with higher socioeconomic status. Although the specific reason for the observed trends remains unclear, one potential explanation is that the variability in health among lower income individuals was slightly higher than in those with higher incomes. Those in the lowest quartile of income had approximately 20% higher variability in the health status outcome variable compared to those in the highest income quartile. Therefore, there is the potential to observe a stronger relationship in the lower income groups due to the increased variability of the outcome, which may account for some of the observed trends by income.
An interesting paradox was found, as well. In the models that contained interaction terms (Table 2), the interactions between race and caregiving, and income and caregiving were not statistically significant. However, in the stratified models, there were substantial differences in the association between caregiving and health by both race and income categories. The reasons for this are unclear and require further investigation. Such findings could be due, in part, to the overall magnitude of the effect modification occurring, as well as the observation that the direction and strength of the effect modification by income did not occur uniformly within all race categories, and therefore would not be detected as significant in the interaction models.
Study limitations and future research directions
Although our study contributes to the growing literature on caregiving burden experienced by the sandwich generation, results should be interpreted with caution, given its limitations. First, the use of cross-sectional data limited the study’s ability to make causal claims regarding the association of caregiving and health status. Second, we only used one measure of self-reported health status as our outcome of interest. Future studies should examine multiple outcomes to allow for a more comprehensive assessment of caregiver health. Third, income thresholds were limited by those provided by the survey questionnaire. Missing data could also bias the observed results somewhat. The relatively small amount of missing data for health status (0.7%), number of children in the households (0.1%), and race/ethnicity (0.9%) should not affect the results meaningfully. However, 12.7% of eligible respondents did not report income. Among those not reporting income, their average self-reported health status was between those in the lowest and second-lowest income categories. Therefore, people who were less healthy were slightly less likely to report income than healthier respondents, which may bias the observed results. Finally, despite having a large sample size, the observed associations between caregiving and health were clinically quite modest in magnitude, although many were statistically significant.
Directions for future research could include other health outcomes, such as emotional, mental, and physical health measures. Additionally, future studies should examine the potential for the observed associations varying by gender. Previous studies have found that female caregivers experience significantly greater strain in family relationships and declines in health than males . Among caregivers to older adults with dementia, females had significantly more caregiver burden than males . Male caregivers to individuals with dementia have a higher desire to institutionalize their relatives with dementia than females when the quality of the relationship between caregiver and recipient is low, but such differences were negligible when quality of the relationship was high . Thus, there is a distinct need to understand the roles, responsibilities, and effects of caregiving, which might also be explained by gender.
Future studies could also examine, among caregivers, how the overall intensity of caregiving, defined by length of time spent caregiving, hours per week caregiving, and specific activities of daily living and instrumental activities of daily living with which the caregiver assists the care recipient, are associated with caregiver burden with respect to health and well-being. These associations could also be assessed by whether or not the caregiver is a “sandwiched” caregiver. Promising new data sets, such as the National Study of Caregiving, a subset of the new National Health and Aging Trends Study (NHATS) , could assist in providing detailed data on both the caregiver and the care recipient to better understand these associations.